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Global Fund in new scandal

Prof Vinand Nantulya

Uganda’s reputation has been put at risk again, after it emerged that the country is failing to use or properly manage donor money meant to contain three of its leading killers – Aids, malaria and tuberculosis.

In recent months, the country has suffered acute shortages of life-saving drugs for people living with HIV/Aids, while northern Uganda is now being battered by an epidemic of malaria.

But on Friday, the Global Fund to fight Aids, Tuberculosis and Malaria released an audit report that amounts to a stinging indictment of the Ugandan government. Uganda’s capacity to promptly take up, efficaciously use, and credibly account for millions of dollars was found to be largely ineffective.

Created in 2002, the Global Fund is meant to be a rapid fund-raising and disbursing mechanism supporting initiatives to contain malaria, HIV/Aids and tuberculosis mostly in poor countries. Grants are received by the ministry of finance in Kampala, which passes them to the ministry of health that oversees the programmes, working through structures such as the Country Coordinating Mechanism (CCM) and the Focal Coordination Office.

Uganda, which had otherwise won global acclaim for containing the cureless HIV/Aids pandemics, is no stranger to scandals involving Global Fund money. In 2005, the fund suspended nearly $370 million worth of grants, after a whistleblower exposed cases of systematic theft and mismanagement. The grants were eventually reinstated, after Uganda launched a judicial probe and put in place strategies to prevent a recurrence of the graft.


However, while that scandal was largely about outright theft and misappropriation of money meant to save lives, last week’s audit exposed systemic inaction that could be just as fatal.

With an HIV prevalence rate of 7.3 per cent, the country has about 1.5 million people living with HIV, the virus that causes Aids. The Global Fund estimates that in 2014, HIV killed 33,000 Ugandans.

In a risk-oriented audit in November 2015, the Global Fund’s Office of the Inspector General (OIG) looked at grants dating back to January 2013. Auditors particularly looked at the chain for medical supplies paid for by the Global Fund, quality and timeliness of data from programmes, robustness of accountability mechanisms, and quality of governance and oversight.

In the findings, the country is accused of dawdling in procurement processes that drag on for years while patients die, deprived of critical drugs and supplies – yet money is waiting to be used.

There are cases of theft of drugs, irregular sale of condoms meant to be free, use of expired HIV test kits as well as unexplained mismatches between inventory figures on the one hand, and actual stocks and disbursements on the other – amounting to $23.7 million.


The OIG audit says that although Uganda does not have the money to fund key health activities, it has failed to organize itself to use the little money available. Of all the money sent to Uganda between January 2013 and June 2015, only 46% had been used by the time of the audit last November.

But while money lies idle, patients have no medicines. Out of 50 hospitals and health centres visited by auditors, 70 per cent had experienced shortage of HIV/Aids drugs and test kits, and 68% had reported stock-outs of malaria medicines for various periods of time.

The report blames the Uganda government for lowering the threshold for starting HIV/Aids treatment without ensuring that there is a matching increase in the funding. This reportedly led to the acute shortages of drugs in recent months.

The report also points out that several staffing positions critical to effective administration of the grants have not been filled, even where Global Fund has already committed to pay their salaries.

On the current malaria epidemic in the north, the report says that Uganda mismanaged the transition from use of indoor residual spraying to universal use of bed nets.

The phasing out was reportedly meant to be accompanied by behavior change communication but this was not done, according to the report, – leading to a surge in malaria cases.

“The epidemic has resulted in available anti-malaria commodities under the grant being ‘front-loaded’ and unless additional funding for medicines is secured, this is likely to result in national stock-outs of anti-malarial medicines in the medium term,” the report says.

The audit report concludes that Uganda’s administrative structure for the grants is way too weak and crying out for leadership. For instance, the ministry of finance, which is the principal recipient of the grants, is accused of failing to offer due oversight over what happens to the money once it is passed to the ministry of health.

Unnamed top health ministry officials are accused of even failing to attend key meetings. The implicit suggestion is that given the amount of “investment”, Global Fund grants do not get “commensurate” attention.

The report recommends a raft of interventions, including meetings to harmonise funding and HIV treatment numbers, as well as demanding specific plan of action from the CCM.


Reacting to the report, health rights activists have demanded that the ministry of health should be removed as the main implementer of Global Fund programmes. A statement sent to The Observer this week lamented that many of the flaws in the Global Fund management system had been raised earlier but no action had been taken.

Joshua Wamboga, executive director of the Uganda National Aids Services Organisations, is quoted as saying that there is “no sign that government is taking these problems seriously.”

Speaking on condition of anonymity, one of the health rights activists said that it is because of the problems between the ministries of finance and health that Professor Vinand Nantulya recently tendered his resignation as chair of Uganda Aids Commission and of the CCM. That resignation has not been yet accepted, leaving him as the outgoing chair.

On Monday, Prof Nantulya refused to comment on the report, saying he had not read it yet. By press time, the ministry of finance, the principal recipient of the grants, was yet to come back to us with a response to the issues raised in the audit report.

Key figures from the report

$1 bn

Worth of Global Fund grants agreed with Uganda since 2002


Total amount of money sent to Uganda by Global Fund since 2002


Of Global Fund money sent to Uganda between January 2013 and June 2015 has been spent


Of Global fund money goes to buying drugs and other health commodities

1.5 million

Ugandans with HIV


HIV prevalence in Uganda


Estimated number of Ugandans on anti-retroviral treatment


Health facilities reported stock-out of ARVs


Of health facilities had accumulated expired medicines


Of budget is allocated to the health sector


The year when the procurement process for food packs for TB patients started. The procurement had not been completed by November 2015


The figure by which locally-bought ARVs are more expensive than internationally-procured ones

Shs 200bn

The money in the health budget that activists want to be allocated to HIV treatment – up from the present Shs 100 billion


Cartons of malaria drugs reportedly stolen from Mulago hospital last October

$90 million

Funding gap for HIV treatment for the year 2016 created by scaling up of ARV access

16.5 million

Condoms that should have been distributed for free were sold through social marketing


Gene-Xpert machines for testing TB are in use out of the 102 that were bought.


Of the 50 facilities visited were performing HIV tests with expired test kits


Of facilities visited did not perform confirmatory tests on clients diagnosed as HIV-positive, increasing the risk of clients getting false results.


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