[e-drug] The Global Fund granting system is failing

["Brook Baker" <B.Baker@neu.edu>]

E-DRUG: The Global Fund granting system is failing
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The Global Funds Laissez-Faire Granting System is Delivering Planned
Failure

As several other commentators have noted, the Global Funds granting and
grant management system is experiencing meltdown - millions of dollars sit
in bank accounts in Geneva and in nations capitols while thousands of
people die needlessly.  Moreover, initial proposals focusing on how to
improve "disbursements" miss most of the really important issues,
including:

      (1) lack of capacity in principal recipients to assess their own
      capacity to perform essential functions, to contract quickly with
      sub-recipients and suppliers, to get money out the door, and to
      manage/monitor/evaluate/report-on grant performance;

      (2) lack of coordination and communication between PRs and CCMs on
      grant disbursement, performance, and emerging needs;

      (3) a total lack of supervisory capacity by CCMs to monitor grant
      disbursements and performance by PRs and sub-recipients;

      (4) poor communication and management review between PRs and
      sub-recipients and documentation requests on sub-recipients that most
      are incapable of performing;

      (5) a laissez-faire approach to small-scale thinking and persistent
      pilot-project proposals from undemocratic and non-participatory CCMs
      instead of mandating more robust proposals for scale-up within
      existing capacity and for investment in health care capacity building
      for future delivery;

      (6) a local funding agent system that reduces fraud and audits the
      books, but does little else to ensure efficient programming;

      (7) the huge costs, in lives lost, of a GF management system that
      closely monitors fiscal accountability (avoidance of embezzlement)
      and that hopes without reason that performance will emerge from the
      end of the free-for-all sausage-making machine donors have
      constructed, but which provides no real regulatory control over the
      entire dysfunctional system.

The major solution under consideration is to tinker with the local funding
agent mechanism whereby it performs a better initial assessment of PR
capacity and whereby it contracts more expertise on procurement and supply.

What is needed is a technical partner that can help countries prioritize
treatment and health care capacity building and that can simultaneously
help them build capacity to manage the congruence of resources arriving
both from the Global Fund and bilateral donors, e.g., PEPFAR, as well as
new resources being committed by national governments.  The only trusted
partner competent to provide these services is the WHO (and even it is not
good enough yet).

The GF needs to put some teeth into the PR process - it has to demand and
fund a minimum amount of management/delivery capacity and pay the WHO
directly to provide services necessary to the creation of that capacity.
At this point, if the LFA assesses PR capacity and finds it lacking, what
happens?  Diddly squat!  The GF tell the PR to shape up (with no additional
resources to do so) or it scales back the programming to meet the limited
capacity of the PR which persists thereafter in under-performing.
Moreover, what happens if the PR and sub-recipients are not performing?
Diddly squat again (though I guess there will be a new early warning system
before the inevitable non-renewal decision is made).

The health management and health delivery system in most developing
countries is broken.  The GF thinks that by auditing a broken system, you
can make it work.  In the real world, fixing a broken system has to be
forced by policy and supported by financing.  Technical partners that can
help with the strengthening need to be paid.  If the LFAs are not going to
really make things happen and if CCMs and PRs, as presently constituted,
are incapable of doing so, activists need to argue that there has to a
mechanism that simultaneously ensures that programming occurs at the same
time that the health care system and its management/systems infrastructures
are being repaired and consolidated.

In this regard, issues of sustainability and local capacity building are
still crucial - for every WHO expert who is seconded to a MOH, there has to
be additional local resources that are being concurrently mentored and
trained.

I don't know if it is possible to shoe-horn these kinds of issues into the
Global Fund agenda.  Richard Stern has been trying to force them in with
data and stories from the front lines, but activists need to continue
arguing that the Global Fund management system, its fund portfolio
managers, its local funding agent, its principal recipients, and its CCMs,
is wearing no clothes.  The donors have saddled us with this ridiculous
system and Global Fund leadership corruptly acquiesces.  We are at risk of
losing the Global Fund and being stuck with ideological and highly
conditional bilateral programs unless we make the Global Fund be more than
a hands-off, what-you-want-is-good-enough-for-me granting agency.

Professor Brook K. Baker
Health GAP
Northeastern U. School of Law
Boston, MA 02115 USA
617-373-3217
b.baker@neu.edu