With the recent media reporting of fraud in the Global Fund to Fight AIDS, TB and Malaria, ^(2,3,4) the new decade brings a reminder of the old and pervasive problem of corruption. Described as “a crime against… what many would consider the pillars of social well being,”⁽⁵⁾ corruption is a serious challenge faced by almost all donor health programmes where multi-million dollar grants are involved. Corruption is particularly critical with respect to HIV & AIDS due to the scale of the pandemic, the stigma associated with the disease, and the high cost of treatment which intensify the opportunity and potential amount of corruption involved, as well as its adverse impact.⁽⁶⁾ It is undisputable that the response to HIV & AIDS requires an increase in funds, and the sums being distributed from donor partnerships are considerable. However, corruption and misuses of such funds can slow the progress of the fight against HIV & AIDS as it may leave those who are uninfected vulnerable, while those living with HIV & AIDS may suffer even more than they would otherwise.

While it is accepted that corruption has serious effects, media exaggeration and distortion can spread rapidly and can often lead to somewhat quick decisions being made which threaten future funding grants. For example, in the case of the Global Fund, stories of corruption and misuse were picked up by a large number of media outlets, resulting in Germany withholding its contribution to the Fund, until a full investigation is complete. It is therefore important to take a step back and separate the facts from exaggeration and to identify the types of corruption that take place, how much corruption is known to be occurring and what possible solutions there are besides revoking grants. The following CAI discussion paper attempts to obtain a holistic picture of corruption that occurs in relation to HIV & AIDS resources - an area where the true scope is rarely known. It begins by reviewing where and how corruption occurs and examining the effects of such corruption. The recently reported cases of HIV & AIDS corruption are then discussed, and potential solutions based on the problems with funding are provided.

Corruption opportunities within HIV & AIDS and its effects

Similar to other health programmes, factors such as the misuse of earmarked health funds and informal payments of free services characterise HIV & AIDS corruption. Hence opportunities for many types of corruption including bribery, petty-, and grand corruption, exist in the prevention and treatment of HIV & AIDS. Within prevention, misuse occurs mostly where money is pocketed and claims are presented for prevention programmes that never took place or materials that were never used.⁽⁷⁾ This is especially true for raising awareness programmes, which are funded but do not occur. HIV awareness is imperative for prevention and such corruption means that less education is provided to societies. Money is also swindled in programmes that seek to ease the socioeconomic impact of HIV & AIDS on families. For example, in programmes that are intended to fund food or school fees, recipients are made to pay although it is supposed to be free.⁽⁸⁾ These families therefore continue to suffer from adverse consequences as a result of unaffordable household expenditure due to their earning family member being ill. Also affecting the prevention of HIV are corrupt procedures that hold up hospital supplies such as sterile needles. Even when stocks reach hospitals, health workers may demand an informal payment for the sterile needles.⁽⁹⁾ As a consequence, non-sterile usage is increased, adding to the risk of HIV transmission. As HIV prevention is essential in combating the pandemic, withholding and manipulating the necessary prevention programmes and equipment contributes to the continued spread of HIV.

Nonetheless, it is the treatment aspect of the epidemic where corruption has the greatest opportunity to occur. Highly valuable ARV drugs can be misappropriated at any point of the production, procurement and distribution chain. At the high end, ministry officials embezzle funds earmarked for treatment or in some cases the treatment drugs themselves, selling them to the informal market. In addition to this type of grand corruption, bribery flourishes in the middle of the treatment distribution chain as the demand for ARV treatment exceeds the supply. Some HIV sufferers use financial or political influence to register for free or subsidised treatment programmes, which excludes other patients whose stage of disease may be more critical, who then have to scrounge for drugs or go without them.⁽¹⁰⁾ At the lowest end, where HIV treatment is provided, health workers demand informal tips and favours for proper medication and care. Those who decline the offer are simply neglected or receive sub-standard care.⁽¹¹⁾ Finally, patients who do receive free or subsidised ARV drugs receive this valuable asset and share or trade their valuable ARV drugs to meet other family and household needs, enlarging the informal market for ARVs.⁽¹²⁾

The informal ARV drug market trades huge quantities of the drugs everyday as market vendors are supplied with ARV drugs by patients, ministry workers, and health professionals. Many people buy from informal vendors, as it is free of stigma and often cheaper with no hassle or waiting. This has implications for HIV & AIDS treatment due to the complexity of the ARV treatment regimes.⁽¹³⁾ ARV treatment is usually a combination therapy of 2 or more ARV drugs at a time and must be given in appropriate combinations. Furthermore it requires strict adherence despite the chance of several side effects. Buying from those who know little about the combinations, dosages, and side effects means that treatment is likely to be ineffective as inadequate combinations may be given or rigorous adherence not explained.⁽¹⁴⁾ Likewise, such factors also increase the speed of drug resistance, narrowing future treatment options and their success. For these reasons, the characteristics of the HIV & AIDS pandemic not only provide more opportunity for corruption but the type of corruption occurring also has severe repercussions on the lives of those living with HIV & AIDS.

Reported cases of misuse in HIV & AIDS resources

Besides cases reported by the Global Fund, very little public information on corruption with regard to HIV & AIDS resources is available. Corruption plagues many development programmes no matter which donor organisations support them.⁽¹⁵⁾ It is therefore argued that the only difference between the Global Fund and other organisations is that the Global Fund actually reports findings through its Office of the Inspector General (OIG), while other donor organisations are “reported to be highly secretive”.^(16,17,18) Nevertheless the handful of cases involving predominantly the Global Fund and the World Bank will be discussed here.

Although the media outbreak only occurred in January 2011, the Global Fund had publicly reported corruption cases totalling US$ 34 million occurring in four African countries in 2010.^(19,20) In Zambia for example, Global Fund Director of Communications, Jon Liden, reported at least US$ 8 million to be missing from the grants given to the Ministry of Health.⁽²¹⁾ The OIG then reported US$ 12 million in unaccountable expenditures and US$ 1 million in non-delivered goods of the grant.⁽²²⁾ In total, the grant was worth approximately US$ 300 million.⁽²³⁾ Despite repeated warnings being given to the Zambian Ministry of Health, Liden argued that no necessary action to tackle the corruption was taken on their behalf. As a consequence, in November 2010, Sweden suspended its contribution to the Global Fund for 2011, which amounts to US$ 25 million.⁽²⁴⁾ The Global Fund then froze the grant given to the government and transferred the management of the current amount of US$ 140 million from the Zambian government to the UN Development Programme.⁽²⁵⁾

While the absolute sum of abused funds has been calculated by the OIG, it is important to assess their representativeness by placing these figures into the context of the absolute money involved in HIV & AIDS programmes. The OIG has reported that since 2007 it has spent US$ 13 billion for health programmes while it has uncovered US$ 34 million of fraud. Calculated as a percentage, as a result of anti-corruption strategies, only 0.3% was squandered, which is not a bad result despite zero tolerance being an ideal.⁽²⁶⁾ The Global Fund should therefore be applauded for minimising corruption through the transparency it practices, openly reporting the cases and informing the public. In addition to its monitoring mechanisms put in place, the Global Fund has taken steps since 2010 to recover misused funds and ensures that those committing the fraud are bought to justice through criminal proceedings.⁽²⁷⁾ At this stage it appears as if the corruption problems are not as serious as shown in the media, but it should be noted that not all countries have yet been audited by the OIG and therefore the total percentage could be much higher – an estimation of around 1%, which is problematic.⁽²⁸⁾

Another case leaked by the Wall Street journal involved projects in Kenya funded by the World Bank.⁽²⁹⁾ Out of 21 contracts that were awarded to the Kenya Decentralised Reproductive Health and HIV & AIDS Project, 13 contracts worth US$ 5.2 million, were found to involve corruption and misuse in their implementation. The report found shortcomings in the governance and control of contracts, and alleged that ministry officials implored bribes through implementation processes.⁽³⁰⁾ Another project funded by the World Bank in which corruption and fraud occurred, was the Kenya HIV & AIDS Disaster Response Project (KHADREP) in which 72% of grant activities exhibited misuse.⁽³¹⁾ Corruption in Kenya was previously discovered in the National AIDS Control Council (NACC), which was given control over KHADREP funds to coordinate prevention and control of HIV & AIDS. In 2003, a scandal surfaced revealing that the head of the NACC had received a salary seven times higher than entitled to a civil servant upon joining the NACC, which was inflated in the following years after joining.⁽³²⁾ Reports in 2005 by the Efficiency Monitoring Unit found that for many years high-level civil servants had used the NACC as their personal cash cow. The document concluded that Kenya could not account for US$ 48 million since 2001.⁽³³⁾

In addition to the higher-level corruption, even when money left the NACC, misuse was identified in the NGOs it supported. In one example, workers in the Par Aid NGO that was intended to spend money on free medicine trials actually spent more money on trips to collect medicines and on fuel. The medicines that should have been used were sold to desperate patients thereby turning a profit.⁽³⁴⁾ Similar to the Zambian case, the NACC showed lenient behaviour, continuing to finance NGOs even when officers had expressed concerns. After the findings of the report, the NACC hired auditors and claimed that they ordered 20 NGOs to refund misused money. Further, the NACC stated that they would only provide funds to the NGOs if they prove previous funds were correctly utilised.⁽³⁵⁾ In addition to the NACC case, there is indeed ample anecdotal evidence of low-end corruption in HIV & AIDS funds. For example, a ready informal ARV drug market has been reported in Nairobi⁽³⁶⁾ while in Malawi, The Malawi Network of People Living with HIV & AIDS has found cases of hospital workers requesting monetary, sexual, and material favours in return for treatment and care.⁽³⁷⁾ While these examples may only be a taste of what is occurring, they demonstrate the levels of corruption that occur in the different areas of the epidemic.

Solutions

Critics of donor aid argue that the central problems with donor programmes include the following: firstly, it has been identified that the accountability of donor aid programmes is only to its donors and not to its receiving country citizens, which of course presents problems of transparency and country ownership – if countries feel that the money and programmes are not theirs or for them, it is questionable how much they would care about how they are used.⁽³⁸⁾ Secondly, programmes are evaluated in terms of the level and speed of disbursement and consequently the funds or goods are disbursed into corrupt hands instead of the communities and recipients that need it.⁽³⁹⁾ Thirdly, as there are a huge number of agencies and organisations addressing the HIV & AIDS pandemic, a lack of adequate monitoring can cause a blur of who is doing what in a given country.⁽⁴⁰⁾ As these problems increase the opportunity for corruption, analysing them gives an insight into the steps donors and recipient governments can take to make programmes less vulnerable to corruption and misuse.

Donors and governments need to develop better accountability arrangements and increase transparency and country ownership. While it is internationally recommended, it is not the case in practice. As accountability is only towards donors, transparency and country ownership is exceedingly important in making all key players accountable. Global HIV & AIDS programmes should ensure that the citizens in recipient countries are being educated and made aware of the programmes intended to benefit them. Donors need to be clear and specific about what, when and to whom they are contributing their resources.⁽⁴¹⁾ What countries will be receiving, in addition to the eligibility criteria for HIV & AIDS programmes and country payments should also be well publicised.⁽⁴²⁾ This should potentially make health ministries and health workers more accountable and less likely to partake in corruption activities. While donors should ensure these procedures are taking place, ultimately, the recipient countries are in the driver’s seat to tackle corruption, which is why they should play a more involved role in informing citizens and beneficiaries. Moreover, government authorities need to continuously monitor affairs and strictly enforce the law, holding perpetrators accountable. Lastly, a government and donor system could be developed that encourages health workers and recipient countries to report past and future violations without the fear of being victimised.⁽⁴³⁾

At the international donor level, transparency can be increased by communication between the various agencies and organisations that are running programmes. HIV & AIDS programmes supporting African countries from around the world could discuss their respective roles in each country epidemic and perhaps draft monitoring and accountability procedures as well as corruption policies that would then be consistent across countries. Similarly, donors should also be encouraged to openly investigate their corruption cases analysing what happened in such cases, how corruption could have been unmasked earlier and prevented altogether.⁽⁴⁴⁾ Publishing the results of such investigations and open dialogue on corruption could help other countries, donors, and systems to learn from real experiences. Full disclosure and information sharing of this kind could improve the methods to minimise corruption.

Nancy Birdsall and Bill Savedoff from the Center for Global Development have suggested an alternative to current donor arrangements that addresses accountability, transparency and the inadequacy of evaluating programmes on disbursement. Known as Cash on Delivery Aid (COD Aid),⁽⁴⁵⁾ its objective is to link aid payments directly to a specific outcome, which is set and agreed by both the recipient and the donor. This can increase accountability and build country ownership making country progress transparent and more visible to its own citizens. Moreover, funders are able to place more weight on results such as health outcomes, and rewarding this achievement instead of disbursement. Countries would hopefully spend their resources with more responsibility in order to get more funding because, if they do not produce the expected results, they would get no further aid.^(46,47) Therefore, donors have options they can pursue in order to strengthen their models and minimise as much corruption as they can.

Concluding remarks

It is clear that corruption can have devastating effects on the progress towards combating the HIV & AIDS threat, by hampering prevention and treatment efforts. It is also clear that there have been few yet important reported cases of the misuse occurring. Although it is unacceptable for corruption and misuse continue, media misrepresentation can cause unwarranted decreases in funding and undermine efforts aimed at objective reporting. Instead, transparency through raising awareness and information sharing needs to be encouraged to educate the public with well-balanced reporting. With this logic, there is a lesson to be learnt from the Global Fund on openly disseminating corruption problems and the methods taken to tackle them. Such assistance and well researched papers need to be provided to decision makers for developing and improving current donor systems and models. While it is virtually impossible to ensure corruption and misuse will not occur, well-informed steps of transparency, accountability, and country ownership can be taken to minimise the risk and threat of corruption in HIV & AIDS.

NOTES:

(1) Contact Farah Seedat through Consultancy Africa Intelligence’s HIV & AIDS Unit ( hivaids@consultancyafrica.com This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).
(2) Roger Bate, ‘Africa’s epidemic of disappearing medicine’, Foreign Policy, 11 January 2011, http://www.foreignpolicy.com.
(3) Gatonye Gatura, ‘Kenya under probe over misuse of HIV Funds’, Daily Nation, 17 January 2011, http://allafrica.com.
(4) ‘Fraud plagues Global Health Fund’, Associated Press, Businesseek, 23 January 2011, http://www.businessweek.com.
(5) Sholain Govender-Bateman, ‘Corruption Africa: A crime against development’, Inter Press Services, 9 December 2009, http://ipsnews.net.
(6) Liz Taylor and Clare Dickinson, ‘The link between corruption and HIV/AIDS’, Global Corruption Report 2006, Ch 6, p104, 8 November 2005, http://www.transparency.org.
(7) Ibid.
(8) ‘Unit 9: Corruption and HIV/AIDS’, Parliamentary Strengthening, http://www.parliamentarystrengthening.org.
(9) Ibid.
(10) Statement by CSO at the fourth ordinary African Union Summit of Heads of States, January 2005.
(11) Ibid.
(12) Liz Taylor and Clare Dickinson, ‘The link between corruption and HIV/AIDS’, Corruption and Health, 8 November 2005, http://www.transparency.org.
(13) Ibid.
(14) Ibid.
(15) Nandini Oomman, ‘What can we learn from the Global Fund’s “Massive Fraud”?’, Center for Global Development, 25 January 2011, http://www.cgdev.org.
(16) Ibid.
(17) William Savendoff, ‘Massive Corruption! (.. In Small Global Health grants?), Center for the Global Development, 24 January 2011, http://www.cgdev.org/.
(18) Bernard Rivers, ‘Corruption by Global Fund Grant Implementers’, Aidspan, 27 January 2011, http://www.aidspan.org.
(19) ‘Global Fund suspends two malaria grants, terminates TB grant to Mali’, The Global Fund, 07 December 2010, http://www.theglobalfund.org.
(20) ‘Global Fund confirms freeze on cash disbursements to Zambia’s Ministry of Health, grants to be transferred to the UNDP’, The Global Fund, 16 June 2010, http://www.theglobalfund.org.
(21) Lisa Schlein, ‘Global Fund to resume aid to Zambia’, Voice of America News, 17 June 2010, http://www.voanews.com.
(22) Dimboni Mafweto, ‘Zambia: Sweden suspends Global Fund to Zambia’, Lusaka Times, 16 November 2010, http://www.lusakatimes.com.
(23) Ibid.
(24) Ibid.
(25) Lisa Schlein, ‘Global Fund to resume aid to Zambia’, Voice of America News, 17 June 2010, http://www.voanews.com.
(26) Sarah Boseley, ‘Can the Global Fund weather the corruption storm’, Talk Afrique, 30 January 2011, http://www.talkafrique.com.
(27) Bernard Rivers, ‘Corruption by Global Fund grant implementers’, Aidspan, 27 January 2011, http://www.aidspan.org.
(28) Ibid.
(29) ‘Kenya detailed implementation review report’, The World Bank, January 2007, http://online.wsj.com.
(30) Ibid.
(31) Kipkoech Tanui and Nixon Ng’ang’a, ‘Corruption in Kenya’s National AIDS Control Council and HIV/AIDS’, Corruption and Health, 8 November 2005, http://www.transparency.org.
(32) Ibid.
(33) Ibid.
(34) Ibid.
(35) Ibid.
(36) ‘The Nation’, Kenya, 22 January 2004.
(37) ‘Voices for Equality and Dignity; Qualitative research on stigma and discrimination issues as they affect PLWHA in Malawi’, Malawi Network of People Living with HIV/AIDS, July 2003, http://www.comminit.com.
(38) Dambisa Moyo, ’Dead aid: Why Aid is not working and how there is better way for Africa’, 2009.
(39) Nandini Oomman, ‘What can we learn from the Global Fund’s “Massive Fraud”?’, Center for Global Development, 25 January 2011, http://www.cgdev.org.
(40) ‘Unit 9: Corruption and HIV/AIDS’, Parliamentary Strengthening, http://www.parliamentarystrengthening.org.
(41) Liz Taylor and Clare Dickinson, ‘The link between corruption and HIV/AIDS’, Corruption and Health, 8 November 2005, http://www.transparency.org.
(42) Ibid.
(43) Bernard Rivers, ‘Corruption by Global Fund Grant Implementers’, Aidspan, 27 January 2011, http://www.aidspan.org.
(44) Ibid.
(45) Nancy Birdsall and William D. Savedoff, ‘Cash on delivery: A new approach to foreign aid’, Center for Global Development, 16 March 2010, http://www.cgdev.org.
(46) Ibid.
(47) Nandini Oomman, ‘What can we learn from the Global Fund’s “Massive Fraud”?’, Center for Global Development, 25 January 2011, http://www.cgdev.org

Written by Farah Seedat ⁽¹⁾