World Aids Day was marked around the globe on Thursday as a moment for much concern, and a small amount of hope. Tentative signs of progress in preventing the spread of HIV and treating those with it are outweighed by the failures of governments, both donors and recipients, to confront the pandemic with the urgency it deserves.
Nowhere is this more true than in Nigeria, where the dominant mood in government circles was, or at least should have been, embarrassment. The country rivals South Africa in the number of its citizens estimated to be infected with HIV. It is one of the richest states in Africa. Its president, Olusegun Obasanjo, widely respected in Brussels, London and Washington, currently chairs the African Union.
Yet Nigeria stands on the brink of having the Global Fund, the major international donor agency for fighting Aids, tuberculosis and malaria, pull the plug. According to a letter sent from the fund to the government, which I obtained in Lagos recently, the fund has ”serious concerns” about the way its money has been spent over the last two years. It is threatening to end the programme unless remedies are found fast. No other recipient of Aids grants from the Global Fund has ever had such a warning.
The fund’s move is doubly embarrassing since Nigeria hosts the latest biennial conference on Aids and sexually transmitted infections in Africa next week. Scientists, researchers, community activists, United Nations officials, government ministers and people living with Aids will converge on Abuja for discussion. But not until the conference is over will the Nigerian government hear from the fund whether its response to the charges and its list of reforms will have saved the grants due for the next three years.
Nigeria is notorious for corruption, although there is no suggestion in the fund’s letter that this is the problem with the handling of its grants. It complains that the government has failed to give clear evidence of the number of Nigerians on antiretroviral drugs (ARVs). The ministry of health has only said how many ARVs were distributed. It failed to set up a computerised accounting system to ”allow for traceability of funds”. There was ”an absence of an adequate monitoring and evaluation system”.
The toughness of the Global Fund’s letter is a tribute to the high standards it has set in its short life. Conceived by the G8 nations in 2001, the fund has already become a model for the way large international donor agencies ought to work.
Six decades since the creation of the World Bank and International Monetary Fund, their lack of transparency, elitist approach, ideological biases and the unfair voting procedures of their boards, in which the richest countries have excessive power, are major problems.
The Global Fund, by contrast, works on a basis of transparency and inclusivity, which also has lessons for the big UN funding agencies such as Unesco and Unicef, where reforms are needed too. The fund’s board of 20 voting members contains an equal number from the world’s north and south. Private pharmaceutical interests have seats as well as donor governments, but so do non-governmental organisations from the south and north. There is also a place for groups representing people with the diseases the fund is fighting.
At board meetings the NGO member is accompanied by up to four experts from groups such as Oxfam, Save the Children and Médecins Sans Frontières, who may not vote or speak but can give advice. Many decisions are taken by e-mail votes, which are also preceded by intense consultation among NGOs.
At the country level similar inclusivity applies. While there must be a ”principal recipient” for the fund’s grants so as to establish a clear legal responsibility — in Nigeria’s case it is the federal ministry of health — there is a ”country coordinating mechanism”, which consists of NGOs and other stakeholders.
They help to draw up the grant proposals and review their implementation, thereby ensuring that proposals are relevant to people’s needs and making space to debate contested issues.
Where the Global Fund is weak is in its rule that, as it is not an implementing body, it cannot prescribe policies to recipients. This would clash with the principle of local ownership. But it is probably right that at this early stage the fund should avoid the ideological interventionism of the World Bank and the IMF. They use ”conditionality” to push their own prescriptions — demanding privatisation, insisting on certain types of infrastructure projects or forcing local capital markets to open.
The Global Fund goes to the opposite extreme, which is one reason why the US, while giving money to the fund, has also set up bilateral programmes with Aids-ridden countries. Washington uses these to promote its agenda that abstinence is the best method to prevent HIV.
Three huge issues affect the fight against Aids, tuberculosis and malaria in the poor south. They include the shortage of health workers (compounded by the brain drain to better-paid jobs in the north) and the price of imported medicines.
The third issue has had relatively little attention. It is the matter of ”user fees”, which people have to pay for healthcare in most developing countries, regardless of their income. Pressed on states under World Bank and IMF conditionality in the 1980s, these ”cost recovery” programmes are a clear deterrent to people who need medical help.
Uganda is one of the few African states to have abolished them. Others, including oil-rich Nigeria, still have them. What is the point of the Global Fund giving grants to countries to buy ARVs and blood-testing equipment if people cannot afford to be checked or get the drugs they need? Nigeria does not charge people the full cost, but even its subsidised medicine is too expensive for most.
In a message to the continent’s activists as they converge on Abuja, Femi Soyinka, the president of next week’s Aids conference, promised to highlight ”the issue of affordability and increasing access to those who need it” and called it ”fundamental”.
If it gets over the threat of having its Global Fund grants cut off, Nigeria’s government ought to listen to Soyinka. Up to four million people with HIV live in Nigeria. They deserve to get their medication free. – Guardian Unlimited Â