Uganda may miss out on the 2016 Global Fund grants, due to its failure to spend past funds and deliver the programmes for which the money was intended.
The Uganda Country Coordinating Mechanism (CCM), the country's Global Fund Board, has criticised key agencies for their poor performance. The CCM board has called for these issues to be addressed before it applies for further Global Fund grants.
Professor Vinand Nantulya, who has led the CCM for four years, has tendered in his resignation. In a letter dated 21 December 2015, addressed to the finance ministry permanent secretary Keith Muhakanizi, Nantulya expressed dismay over the poor use of funds.
The revelations come at a time when about 1.6 million Ugandans, including 180,000 children, are living with HIV. Around 800,000 clients are currently enrolled on antiretroviral treatment, according to Ministry of Health statistics.
Poor management of funds
Nantulya's letter notes that although CCM has continuously secured financial resources for health, none of the grants between December 2014 and June 2015 had used more than 75 per cent of the money approved by Global Fund. It adds that this stems from slow procurement processes, weak coordination of grant implementation and poor planning.
"All the grants that were approved by the Global Fund have not absorbed more than 75 per cent and this has affected the implementation of HIV programmes," he said.
However the CCM successfully secured a total of US$375,209,259 for the fight against HIV, tuberculosis and malaria in the period of 2015 to 2017. The money was also meant to strengthen the health system, including the expansion of National Medical Stores.
The money was given to the finance ministry as the public sector principal recipient, then channelled to the health ministry to implement the programmes. The AIDS Support Organisation (TASO) also received funds.
Health ministry failures
The CCM board blames the health ministry leadership for not being in control of implementing the Global Fund grant and programme activities.
"The procurement of food enablers for tuberculosis patients has taken four years but no results; the recruitment of human resources which are vital for health service delivery has taken more than a year; failure to have a Global Fund Assets register - a condition from the Global Fund, has been standing for over four years," Nantulya said, in the letter.
It also says there is no functioning system to account for and track the money, contrary to expectations from the Global Fund. The letter also reveals that recurrent audit findings and recommendations by the Office of the Auditor General have never been addressed.
"The CCM resolved not to apply for any additional Global Fund grants in 2016 as needed to address malaria, and HIV-TB disease burdens unless these issues have been resolved," Nantulya wrote.
When contacted, Nantulya confirmed his recommendations. He revealed that the Global Fund inspector general had visited Uganda to see how it was fairing, but declined to give any more details.
Muhakanizi acknowledged that he had received the letter. "Nantulya is right. I have chaired meetings with relevant entities to ensure that government programmes are implemented, otherwise we will lose funding. Those who do not want to work will face disciplinary action," he said.
Dr Bernard Michael Etukoit, executive director of TASO, said he was confident the issues would be sorted out.
He warned that the repercussions of under-performance were enormous. "They include inadequacy in addressing the targeted diseases, reversal of gains in the control, especially the malaria grant that ends this year, and icy relations with the Global Fund, that could affect even future grants," he said.
HIV activists speak out
Civil society organisations, HIV activists and people living with HIV are dismayed that the Global Fund monies are being taken lightly.
Stella Kentutsi, executive director of the National Forum of People Living with HIV/AIDS Networks in Uganda, said lives would be at stake if there is interrupted funding.
"This is likely to affect the flow of services given limited domestic financing of the HIV response," she said. "We request the Ministry of Health and other parties responsible to address the gaps in the shortest time possible to enable the flow of funds from the Global Fund."
Lillian Mworeko, coordinator of The International Community of Women Living with HIV Eastern Africa, said: "This will have a negative impact on the country's response against the three diseases. It will also have a negative impact on the lives of Ugandans."
Margaret Happy, a person who has lived with HIV for a decade, said it would be suicidal if funding is lost due to complacency. "If people have to adhere to treatment, antiretrovirals must be readily available," she said. "With this kind of development, you would expect more and more people not to adhere because we would expect more shortages."