Waste at the Global Fund costs lives

The litany of failure and waste revealed by World Malaria Day this week reminds us how badly we need competent policies.
The Global Fund's inefficient procurement and its promotion of dangerous drugs is working against the mission of fighting AIDS, malaria and tuberculosis in the poorest countries.
Launched in 2003, the Global Fund to Fight AIDS, Tuberculosis, and Malaria was supposed to be the solution to the problems of inadequate funding for these diseases. As a partnership among governments, the private sector and affected communities, the Global Fund represented an innovative approach to international health financing. And in the years following its inception, the Fund did not disappoint. By its second birthday, the Fund had become the largest financier of a leading malaria treatment called artemisinin combination therapies or ACTs--providing the medicine to more than 5.6 million sufferers.

But our new research finds systemic problems with the Global Fund's procurement system, including widespread delays for treatment and a preferred drug list that includes products of uncertain quality.

To call the Fund's procurement process cumbersome would be an understatement. Many months can elapse while grants are submitted, approved and forwarded on to a contracted procurement agency, then finally converted into actual medicines and shipped. Because of the duration and the haphazard pattern of the process, funds sometimes get held up by government bureaucracies (usually the target country's Finance Ministry), even further delaying the procurement process.

In one particular example, the Ghanaian government's slow bureaucratic procurement processes caused delays in getting life-saving HIV products into the field. Our new study shows this is not an isolated event. Anecdotal evidence from countries such as Chad, Nigeria, and Tanzania point to the same problem. Occasionally funds are stolen, as in Uganda.

The Global Fund was created to be responsive to the needs of poor countries and it has wanted to work with them at every level. However, providing funding to Finance Ministries has proved problematic. Some Finance Ministries have proved incompetent or corrupt, with funding not being allocated quickly (or at all in some instances) to pay for drugs.

Another important problem is that the Global Fund often pays scant attention to the quality and efficacy of the drugs it procures for treatment. Many of the drugs purchased for its three core diseases--AIDS, malaria, and tuberculosis--simply do not work. At least 16 percent of its drugs purchased in the recent past have been of indeterminate quality, since they have been purchased from companies not approved either by major national regulators or or the WHO. And the percentage of possibly unsafe drugs is set to increase as the Global Fund tries to improve competition in procurement by buying more drugs from developing-country suppliers.

The World Health Organization has censured the Global Fund for including single-drug “monotherapies” on its approved list of malaria drugs treatment. Monotherapies, which are easier to produce, have been abandoned in the past few years in favour of the more effective combination therapies (ACTs) in much of Africa. ACTs save more lives and reduce the chance of parasite resistance developing.

A plethora of available studies expose the resistance-inducing effects of monotherapies. For example, a 2005 scientific study of Kenyan children treated with amodiaquine (AQ) as a monotherapy found a “high prevalence of AQ-resistant parasites.” In continuing to support monotherapies, despite evidence to the contrary, the Global Fund is acting dangerously. It should follow WHO guidelines and drop them.

For countries without secure procurement channels, the Global Fund, in collaboration with other global health organizations, must establish a centralized procurement department to coordinate the quantities and quality of drugs needed for treatment. The Fund can then eliminate ineffective middlemen--often lazy and incompetent bureaucrats, more interested in reaping personal benefits than ensuring drugs are delivered on time.

Implementing these changes will go a long way to improving poor patients' access to treatment in the quickest way possible.

The Global Fund deserves praise for the great strides it has made in funding treatment for malaria and other diseases. In its latest rounds of grant allocations, the organization gave over US$200 million to 19 countries, mainly for ACT purchases.

However, the organization has been lackadaisical at best in its management of key problems: without addressing these problems the Global Fund will fail in its mission to save lives.

Roger Bate is a Resident Fellow at the American Enterprise Institute and author of its recent study “Reality and Rhetoric on Treating Malaria.” Kathryn Boateng is a Research Assistant at the AEI.