Living With Corruption
It is 9th December 2007 and I have just watched, for the third time in two days, a CNN special program entitiled, ‘Living With Corruption’, yet another first rate documentary on Africa by the incomparable Sorious Samora. Maybe it is just because I live in Africa and have great interest in the subjects he covers of maybe it his totally unpretentious manner, but I find him one of the best documentary producers around today.
As the title suggests, ‘Living With Corruption’ takes a hard look at corruption in Africa. Some might ask, so what’s new, it’s a subject well chewed over by the media on an almost daily basis. This film gives a new slant, it looks at how corruption rules the lives of the ordinary man and woman in the street. It demonstrates all too horribly and clearly how corruption pervades every level of society, and Samora suggests the entire Continent.
This at times infuriating film depressed and angered me on a number of levels; first because it reminds me of what I have witnessed almost every day of my past six years in east Africa and second because in many ways, Samora is ‘preaching to the choir’, the people most likely to see this film will be people who already know and have an interest in the subject. These are the same people who have witnessed the issue for years and have failed singularly to do anything to change it, I count myself amongst this group.
I doubt that the USA’s domestic CNN channel will make room in its twittering vacuous 24 hour ‘news cycle’ for a program as sober as this. Not least because CNN’s Directors have long since assumed [ or indeed created] an American audience with the attention span of a humming bird, that simply could not concentrate for almost an hour.
Of the many scenes that angered me, the shots of Samora walking at night down narrow alleys of Kibera slum in Nairobi ranked pretty high. His camera pans to the streams of raw sewage and describes the plastic bags under foot as being filled with human waste. There is such a dearth of pit latrines in Kibera, (as in most urban African slums) that the people have solved the problem by shitting in plastic bags and then hurling them as far away from their own dwellings as they can. The practice is called “The Flying Toilet”.
When I lived in Nairobi some years ago, I wrote a piece in early 2003, about HIV/AIDS and public health, essentially criticising the then ‘new’ PEPFAR initiative as being too narrow in its focus. My argument then and now is that attempting to stem the tide of AIDS by offering medicines to those in need is in many ways a pointless task. Giving medicines to people whose living conditions are so appalling they cannot find clean water with which to swallow their medications and cannot find food enough to re-generate their lost body weight, seems an exercise in futility that does no more than make the donor community feel good in the short term.
I entitled that piece The Lord’s Gift and Flying Toilets. Watching Samora’s film prompte me to revisit the piece, it is depressing to see that almost five years on so little has changed for the better and most for the worst.
I have reprised the article below…………..
Medicines for the Hungry
Even if it all comes together and “the Feds” get the money and resources to do what the President has directed, I have serious doubts about the [plan’s] overall impact on the disease, at least in East Africa, because it takes too narrow an approach to the issue and offers a single templated solution. The Harvard economist Jeffrey Sachs recently commented: “…the US administration has latched on to a simplistic vision of what to do, based on a single example, Uganda. It knows little of measures in place in other parts of the world, and that each country needs to shape the best local response”.
I think he’s right. My brief sojourn into HIV/AIDS in this part of the world has taught me that there is no template: even communities abutting each other need different plans of attack. But above all else it has taught me that it is a disease of poverty and that no plan will work unless it deals directly with the underlying social causes of poverty as key objective. A Kenyan friend puts it more bluntly. “Giving medicines to the hungry that live in shacks with no heating, lighting or toilets, consume dirty water and are illiterate will not reverse the scourge.” Another commented: “No community or government can tackle disease when its people are barely surviving on $1 a day.”
This Hecate’s brew of hunger and AIDS is impacting upon Kenya in a multitude of ways. The Country has a population of about 30 million, around 80% live in rural areas and could be broadly considered as farmers. But the demographics are changing rapidly. Farmers who once grew cash crops such as cotton and peanuts cannot find enough healthy members of their family to harvest so they have turned to subsistence crops like maize. But when disease stalks the land on a biblical scale even subsistence farming fails. So the people, particularly the young move to the cities to find security and work. HIV/AIDS is accelerating the pace of urbanization in Kenya and in doing so it is creating another dimension of social problems, which in turn must shape the way HIV/AIDS is managed in those communities.
Living in a Ditch
Kenya’s capital, Nairobi, is a city of approximately 2.2 million and growing daily. Over 60% of the population lives in slums euphemistically called temporary settlements and the numbers are growing at an unstoppable rate. The most infamous is slum is called Kibera. It has the dubious distinction of being the biggest in Africa, with about three quarters of a million people occupying 226 hectares – three-square meters per person. It was most trenchantly described by the BBC’s East Africa correspondent, Andrew Harding as, “Wood fires, fried fish, excrement, and rubbish – the rich stench of 800,000 people living in a ditch…six hundred acres of mud and filth with a brown stream dribbling in the middle…and at least one third of Nairobi lives there.”
The majority of Kibera’s residents work in and around the city, in light industry and the service sector. Most live in tin-roofed shacks connected by mud tracks, which usually double as open sewers. There is an erratic electricity supply for those who can afford it. It is a dangerous place to live. Robbery and violence is commonplace. Drugs, prostitution and heavy drinking of an illegal and potent homebrew called Chang’aa are common recreational activities. The police rarely patrol; vigilantes provide security for a price and sometimes exact terrible punishments: ‘necklacing’ is not uncommon for theft
Lord’s Gift
TB and dysentery are endemic and there are frequent outbreaks of virulent infectious diseases such as meningitis and hepatitis. Rats and other vermin are constant health risk. The HIV prevalence is estimated to be 20% (5% above the national level) but I have failed to find out how this figure was determined). Public health standards would shame a refugee camp. There is little or no running water; contractors bring in most in aging water trucks with logos such as “the Lords Gift” painted down the side. It is sold at exorbitant prices and carried home every day by women and children. Only a hardened Kibera dweller would drink it without boiling. The sewage system is a combination of open sewer and pit latrine. But as numbers multiply there are not enough latrines and in desperation, people resort to the “the Flying Toilet”. In simple terms those with no access to a latrine evacuate into plastic supermarket shopping bags and hurl them as far away from their own shack as they can. The result needs no description.
Reality Check
Now: against this medieval background lets remember our clear and simple mission is to reduce the number of new HIV infections, treat a number infected with Anti Retroviral Therapy (ART) and a considerable number more for the opportunistic diseases of AIDS. In this scenario prevention through education and behavioral change is an uphill struggle. Clinical diagnosis and medication are overshadowed by the need for clean water an adequate diet. How effective will ART be when the patient drinks water laden with cryptosporidia and eats one meal of porridge a day? For those who will never receive ART and who will spend their last days in their shacks in what is euphemistically called Home Based Care, the greatest need is a clean place to lie, a caring nurse, relief from pain and a death with dignity.
This is the reality that our “Emergency Plan for Aids Relief” must deal with. It can only succeed by a broad approach, socio-economic, educational and health. Each country stricken by this plague has unique problems and each must deal with them in an individual fashion. It requires the complete involvement of the people, communities and government. Solutions cannot be designed and imposed by even the most clever, generous and wealthy outsiders. America cannot solve this problem alone and in a way of its own choosing. To have any hope of success, we must act now, the numbers are growing inexorably. It needs huge sums of money, focused, trained human resources and a ‘coalition of the willing’.
This last cliché raises another spectre. If by the time this reaches print we are at war in Iraq, then war will eclipse every other international human priority, HIV/AIDS included. Wars divert attention; wars consume resources. Will America still be able to meet its promises?
Showing posts with label PEPFAR. Show all posts
Showing posts with label PEPFAR. Show all posts
Sunday, December 9, 2007
Wednesday, April 25, 2007
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?
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?
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