Of Hamlet and Per Diem

‘Something is rotten in the State of Denmark’ – Shakespeare’s Hamlet

ABC
Anyone who has even a superficial knowledge of HIV/AIDS in Africa will know that Uganda has an almost mythic reputation as a success story in the long war against AIDS. Long before HIV/AIDS became a global issue, years before the international community began trucking in Wells Fargo-loads of cash, encyclopedias of advice and armies of technical advisors, Uganda had embarked upon its own unique national plan.

In 1986 the new Ugandan president, Yoweri Museveni responded to the emerging HIV crisis with the speed and determination that characterized his rise to power and early years as a national ruler. He embarked on a nationwide tour to tell people that avoiding AIDS was a patriotic duty, they should abstain from sex before marriage and then go on to remain faithful to their partners and to use condoms. This message became the underpinning national strategy, known as ABC, Abstinence, Be faithful and use a Condom. The same year, Uganda's Health Minister announced to the World Health Assembly that there was HIV in Uganda, and the first AIDS control program in Uganda was established. It focused on providing safe blood products, and educating people about HIV/AIDS.

Over the next five years the national programme fought an uphill battle against the disease, which had already reached catastrophic levels. Best estimates show that by the early 1990s the national adult prevalence rate peaked at around 15% and exceeded a staggering 30% among pregnant women in the cities. There is no accurate data on mortality rates during this period but they are believed to have been very high. In 1992 the government ramped up its efforts, adopting a multi-sector approach and coordinating the response to it. The strategy appeared to pay off with surprising speed. HIV prevalence in young pregnant women in Uganda began rapidly to decrease. In 1995 Uganda announced what appeared to be declining national trends in HIV prevalence. Over the next five years, the prevalence rates continued to drop. A national program to prevent mother to child transmission, using ARVs was introduced. By 2001 UNAIDS estimated the national prevalence rate to be around 5%.

The government and international agencies attributed this remarkable success to a combination of strong leadership, open national debate and information programs, community-level prevention and treatment programs and a national strategy based on a simple message, ABC. The model and the message has now become the basis of national strategies across sub-Saharan Africa and world-wide.

AB Small c
So where are we today? Put bluntly, the national strategy is in disarray, victim of politics, religious dogma, corruption and public apathy. The crisis began some years ago with a subtle shift in government policy away from ABC towards greater emphasis on ‘A’ – abstinence. Led by President Museveni and his First Lady, government policy and social marketing strategies now stress abstinence as the cornerstone of current HIV/AIDS prevention strategy.

The result is uproar amongst the national and international AIDS activist communities. The rhetoric and action have been neither balanced nor objective. Museveni caused international consternation at the 2004 International AIDS Conference in Bangkok when he argued, policies that promote abstinence and sex within marriage are more effective in preventing AIDS than those which stress condom use. In April 2006 the Ministry of Education issued a directive banning the promotion and distribution of condoms in public schools. Also in 2006 a Human Rights Watch report claimed that information about HIV transmission, safe sex and condom use had been removed from the school curriculum in Uganda and replaced by information emphasizing abstinence.

PEPFAR
The USA is smack in the eye of ‘Hurricane Condom’, specifically the Administration’s pet project the President’s Emergency Plan for Aids Relief (PEPFAR) which aims to provide life-saving drugs to at least two million people with HIV, prevent seven million new infections, and care for the sick and orphaned in 15 countries world-wide. Critics have, from its inception, argued that the initiative is fatally flawed in that it has overtly moral strings attached and is heavily influenced by the views and mores of America’s Christian conservatives. Beneficiaries must emphasize abstinence over condoms and in some cases, condemn prostitution. As one of the first beneficiaries of PEPFAR, Uganda was given $137m for HIV prevention and treatment programmes for 2005 and an additional $170m in 2006. Critics of PEPFAR, both national and international have spent a great deal of energy and resources ensuring the Ugandan media inform the people of this moral agenda.

Matters came to a head in the Fall of 2006 when the Ugandan media launched a string of reports detailing a national shortage of condoms, which they argued had been deliberately precipitated by the government’s nationwide recall of condoms - distributed free in health clinics- on the spurious grounds that they were defective. The debate was further enflamed when the UN Secretary General’s Special Envoy for HIV/AIDS in Africa, Stephen Lewis, told a world-wide teleconference on AIDS, that Uganda’s policy shift has been influenced by the US government “which is now mainly promoting pro-abstinence programmes and less of condom use”.

The truth is far more complex. The US global AIDS coordinator, Dr. Mark Dybul, has repeatedly stated there is no change in US policy and the current emphasis on abstinence is only to ensure a more balanced ABC strategy, which in the past has mostly focused on condom use. I have no reason to doubt his veracity, but it does not really matter. Perception is reality and there is now widespread belief, in Uganda and elsewhere that the USA is attempting to inject its own moral agenda into the global HIV/AIDS debate. It is using the power of money to do so and its actions threaten to undermine what little progress has been made so far, in mitigating the impact of AIDS in Africa.

Scamming the Global Fund
In October 2006 a team from the Geneva-based Global Fund to Fight Aids, Malaria and Tuberculosis arrived to announce the immediate suspension of all grants to Uganda, after a probe revealed “gross mismanagement of its funds”. A subsequent inquiry, led by a respected Judge, revealed mismanagement and fraud on an epic scale.

The total sum granted by the Fund was $201m over two years. The initial report stated that ‘to date only (my emphasis) $45m had been disbursed’. An initial investigation by outside auditors revealed “financial, procurement, governance and management structure irregularities,” a euphemism for fraud and theft. A few examples illustrate the extent of the mess: about $300,000 was lost by poor management of exchange rates between the dollar and Ugandan shilling and $1m was misdirected from monies meant for the private sector into government departments. “Monies amounting to millions of dollars” were paid to national NGOs and private businesses with little or no record of where the money went or how spent.

Government staff were paid hugely inflated allowances for tasks ranging from out-of-hours photocopying to attending workshops and what are known in local vernacular as ‘trainings’. (I am constantly surprised at how much employees of even small local CBOs know about allowances, the term Per Diem is an essential phrase of Ugandan bureaucratic language.)
My two favorite stories from the inquiry were: One official sent his daughter off to an international program for health education using GF monies. Another official presented a series of suspect receipts for fuel spent on official travel. Such was the level of his incompetence, once receipt was made out to a vehicle whose number plate belonged to a caterpillar tractor.

Whilst I was stunned by the blatant nature of the scamming, I was not surprised by the event. The first time I visited the Ministry of Health Kampala I re-named it the Ministry of Land Cruisers – I counted 56 in the parking lot. At the end of 2006 the MOH failed to organize the purchase of 15m doses of Co-Artem – the new WHO-approved malaria treatment – for which the Global Fund had provided $28m. One national newspaper suggested it was because there was little opportunity for fraud. The Minister of Health and his two deputies were forced to resign but despite public indignation and international irritation, none of the culprits have been brought to book. I have no idea how much if any of the money was ever recovered

Root of All Evil
If there is a moral to these two stories it is the corrosive and corrupting effect of money on people and governments, particularly when it is accompanied by explicit donor agendas and is poured into countries, institutions and communities on a scale which overwhelms existing systems for accounting and distribution. I have heard senior government officials publicly state they believed Uganda would be better off without PEPFAR and Global Fund money, that they did fine before it arrived; they invented ABC without outside help and were controlling the epidemic without huge donor funding. The advent of these two funds alone as spawned over 2,500 local NGOs and CBOs, a new national industry, almost impossible to regulate, which serves more to line the pockets of 'snake- oil' salesmen than tend to the sick and needy.

Shocked, Truly Shocked
Although Ugandans are dismayed at the corruption and mismanagement of HIV/AIDS funds they are equally angry at the donor community. They feel they should be given the money, without strings attached; where there is fraud and waste, they should deal with it. They see more than a little hypocrisy in the international community’s reaction and cite international NGOs dissembling over how they spend donor monies. They have a valid point. I am no expert, but I would guess that if you 'followed the money' from K Street to a Ugandan village, of every dollar that begins its journey, only a few cents arrives. It may not be fraud or waste but it certainly smacks of dysfunctional systems.

But Ugandans reserve their greatest disdain for those ‘aid industry’ experts who express their shock and outrage at local mismanagement and corruption, from the comfort of their luxury offices in Geneva or Washington. On command, they descend in hordes by first class flight to Entebbe, issue injured-sounding rebuttals or scathing criticism from the Sheraton Kampala and jet back to their comfortable homes. Rarely is there an admission that they might be part of the problem. Surely someone in PEPFAR could have predicted the birth of a conspiracy theory over the condom shortage and taken early action? Surely someone in the Global Fund knew at least the rumors surrounding the some of the Ministry of Health staff, particularly the Minister? If not, they only had to read the local newspapers (available online) to get the picture.

Now For Something Completely Different
If, as I have argued, things are so SNAFUd, what is to be done? We cannot keep doing what we have always done and when it shows not to be working simply try harder and throw more money at it. The time has come for original thinking and novel approaches. The key is to reduce the opportunities for misappropriation, get more, of every dollar donated, onto the final target and develop long-term independence by making individual Ugandans responsible for their own health and future.

There are many original thinkers in this part of the world. My favourite is a member of the Ugandan Parliament, the Honourable Mr Madada. He launched a project which offered free university education for virgins. In short, any young women can apply for college education providing she is from Kayunaga District and a virgin, she must prove this by subjecting to a virginity test, the details of which were never made clear. Needless to say the concept failed but at least it was original thinking!


Health Savings Accounts
I offer another ‘out of the box’ idea. Somebody out there give me $1m, no strings attached. I will put it in a Ugandan bank (best exchange rates I can get). I will then advertise for 1,000 volunteers from the class of 2010 at Makrere University. All will be required to undergo an HIV test. The first 1,000 that show negative will have a bank account opened in their name, for the sake of propriety we will call it a ‘health savings account’, containing $900 in Ugandan shillings. The contract will be they remain negative until they graduate. At that time they will be tested again and those still negative will have unrestricted access to their savings account and do whatever they please with both the original sum and the interest accrued. How individuals stay healthy - ABC or any variation thereof - is a personal and private concern. If the project is a success, it will be repeated and widened, dependent on donor interest and funding ( if I had access to the $200m given to Uganda by the Global Fund I could impact on 200,000 people).

I can almost hear the howls of indignation from the politically correct. ‘This concept smacks of bribery, it has no place in respectable social science’. I offer the following for consideration:
Almost certainly more than 1,000 will volunteer; those who are positive will be able to seek treatment and long-term care, the negatives will know their status and adjust their lives accordingly
1,000 ‘at risk’ individuals will be trying to stay out of the ‘risk pool’ for three years (over time, this must have some, albeit mathematically small, impact on infection and prevalence rates)
Money spent on administration will be minimal (much less than the majority of current prevention programs).
Opportunities for mismanagement and misappropriation of funds will be very limited
The capital sum will be available for national investment in the intervening years
On successful completion of the three year term, all monies, the capital sum plus interest accrued, will go directly to the individual, without caveat.
The money saved will most probably be spent or re-invested in-country on an individual basis.
Each individual will be incentivized to make personal decisions regarding their current and future health status. Successful completion of the first period may convince them to maintain healthy behaviour.
Individuals will recognize that they are capable of determining their own future.

I doubt that, at first blush, I have convinced many that this idea is anything more than the crude use of financial reward to manipulate social behaviour. Well, that might be true, but is it any more odious than many current schemes? At least it has no moral strings attached, requires minimum administration and does not lend itself easily to misappropriation. Has anyone out there got a better idea?