MALARIA: Sierra Leone: Quarter of Vital Donated Drugs Missing or Stolen

14 Jun 2011 : IPS News
Sierra Leone - Three-year-old David bolts up from his feverish stooper as a needle pricks his thumb, producing a tiny bead of blood. He looks down horrified but is too exhausted to cry and falls back into his mother's lap as the blood is wiped away. Juane K. Nabieu, a community health officer in the district's main Peripheral Health Unit (PHU) drops the specimen of blood onto a strip. Within seconds two fine lines appear and David's mother Naomi Sam is told that her son has malaria.
Malaria is endemic in the country - it is one of the biggest killers of children. David is lucky. He is treated with the last batch of Artemisinin-based Combination Therapies (ACT) that Nabieu has just collected from the neighbouring district government drug storeroom. But poor record keeping, wastage and theft may be responsible for the loss of a quarter of vital aids drugs that have gone missing from the central government warehouse in Freetown, denying other children like three-year-old David the chance of survival.
The regular UNICEF stocktake found a preliminary figure of 25 percent of the aid was unaccounted for, UNICEF said in a statement on Jun. 14. The drugs are thought to include vital life-saving drugs like ACT. "An internal stock take report revealed the possible loss of drugs destined for government health clinics and that we asked the authorities to review... At present we are still looking into how much of the losses can be attributed to poor record keeping at health centres and district warehouses or to wastage due to improper storage or theft."
A UNICEF representative said that the internal stock take began at the end of 2010, and has just been completed. It reviewed stocks from the rural health posts across the country in a bottom-up check of drugs. It also follows reports from district hospitals across the country and PHUs about an ongoing shortage of ACT, vital in the treatment of malaria. At the Khailahun PHU there are only two more packets of ACT left - serving 156 PHUs. When the remaining doses run out, Nabieu, will refer his patients to the government district hospital.
"Most of the people who come here will not be able to afford the ACT sold privately - they rely on the free drugs," he says sitting behind a desk with an array of medicine bottles all lined up in front of him. "You can see we have many drugs, but the supply of fast moving essential ones like ACT always arrives in spurts - every month there is a shortage, and every month there will be people who suffer because of it." Sierra Leone's government took a massive step when it announced last April that health care for children under five and pregnant women would be free. The Free Health Care Initiative is 90 percent funded by international donors like UNICEF, the African Development Bank, UNFPA and the government of Sierra Leone.
In Khailahun district, drugs that were given as aid by the Global Fund and UNICEF are reported to be found in private drugs shops and sold by street market traders. "We have patients who come from neighbouring Liberia, which puts a strain on our resources, but the drugs in the local market may also be drugs that have come from Liberia or Guinea - the aid that comes into West Africa is generic and that makes it easy to sell anywhere," Nabieu explains. On the other side of Khailahun town, at the district hospital, things are no better. In the paediatric ward, tightly packed with mothers and babies all eerily quiet, nurse Alice Mansaray has a stack of paperwork and a new baby with complications from malaria to admit.
"Most children come to us with severe anaemia or convulsions - sometimes their mothers suppress their child's fever with paracetamol, when there are no free stocks of ACT in their PHUs, and they can't afford the private drugs. "When I run out of ACTs I send them to a private drug store. They have to go because they can't see their children die. We have seen more cases of malaria and more children with complications," she says as she holds up a strip of ACT. Though the government's hospital monitors say malaria cases have decreased compared to last year in Khailahun, there is no record kept of how many patients come back with complications. There is also no record of those who were entitled to free drugs, or who had to purchase them from the private sector because of the shortage of aid.
The Civil Society organisation, Health for All Coalition (HFAC), implemented a monitoring system, parallel to the government's. Alhassan Kamara at HFAC estimates that 45 to 50 percent of the aid that comes in disappears finding its way to the market - though no survey has been conducted to substantiate this. "Our monitors travel in drug delivery trucks. We insist community and district hospital representatives receive the consignment." This has reduced the "leakages" Kamara calls the thefts. "Transportation from district to the PHU needs to be strengthened. There is less transparency, and scope to sell on route."
This is not the first time such irregularities have been discovered in Sierra Leone. In 2008 a BBC report discovered UNICEF's malaria drugs in Kono (Eastern Province) were being re-sold in private pharmacies. "If there was such mass pilfering, the system would collapse," says Dr Amara Jambai, director of Disease Prevention and Control at the ministry of health and sanitation. "The community are very active and watch supplies very closely." Jambai admits that the capacity of the government is too weak to deliver the drugs to each PHU. "The cause of the shortage is not because there are thefts, but because demand is great, and the system is new."
The district hospitals in Khailahun, Pujehan in the South, and Bo in Central Sierra Leone, say that when they have approached Freetown for ACT, they still have supply issues. Pujehan hospital said they had not received a delivery since February - though they had a small supply remaining of ACT, other essentials like antibiotics and paracetamol had long been unavailable. Mahimbo Mdoe, UNICEF country representative says that UNICEF is due to take over the operation to run the logistics themselves. "We are hiring an international company to manage the central warehouse, and they will be responsible for doing a "milk-round" to all 1,200 PHU's across the country. "A year ago 80 percent of people didn't go to the doctors because of the cost. Sierra Leone is a fragile state. The numbers of people accessing the aid for the first time is an important step forward."
Meanwhile, Naomi Sam says that she could not have gone to the private drug store to buy the ACT that has just saved David's life if it were unavailable, because "I have no money," she says simply. She knows that coming to the PHU means that David will get free treatment. But, the 20 or so women with sick babies waiting outside may not be so lucky today.
http://www.ipsnews.net/news.asp?idnews=56071

MALARIA: National Theft of Global Fund Medicines

Millions of dollars of donated antimalarial drugs have been stolen, most often by staff of recipient government medical stores; this strengthens criminal gangs and undermines donor intent. The main culprit donor is the Global Fund to Fight AIDS, TB and Malaria, which worryingly is pushing ahead with further schemes that have the same inherent weaknesses, which may worsen the theft problem. Sweden and Germany have already suspended funding to the Global Fund due to financial irregularities, but it is time for a thorough investigation of drug theft - to ensure that drugs are being used by those intended, rather than encouraging illegal parallel distribution systems, in both recipient nations and nations where products are diverted.
It is likely that the entire incentive system needs to change, so that donors only receive future taxpayer funds when they can show that the drugs they buy actually reach intended patients in developing nations, not just reach their governments’ medical stores.
http://www.fightingmalaria.org/pdfs/AFMBrief_NationalTheftofGFMedspdf

MALARIA: Global Fund denies reports of huge malaria drug thefts

20 April 2011

The donated drugs have been found for sale in shops and on the black market

A global health organisation has denied reports that hundreds of millions of dollars-worth of donated malaria drugs may have been stolen in recent years.
In the paper, leaked to the Associated Press, the Global Fund to Fight Aids, TB and Malaria said about $2.5m ($1.5m) in drugs had been stolen since 2009.
But spokesman Jon Liden told the BBC the scale of the problem was "nowhere near" as high as other figures alleged.
Mr Liden said the fund treated all thefts extremely seriously.
AP said it had obtained the documents from an official at another health agency, who had in turn received them from an employee at the Global Fund.
In the papers, the Global Fund confirmed the theft of nearly $2.3m-worth (£1.4m) of drugs from Togo, Tanzania, Sierra Leone, Swaziland and Cambodia between 2009 and 2011 and in some incidents before. Nine other African countries, including Nigeria and Kenya, were also named.
Once stolen, the drugs - which are widely and cheaply available through legitimate sources - are then either sold in shops or through the black market, or are shipped out of the country, sometimes within hours, to be sold on.
In about 70% of cases, the drugs were stolen from government-run warehouses by members of staff.
"The cases show that drug misappropriations are well-organised and predominantly planned by insiders using falsified documents," AP quotes the documents as saying.
“We pursue every single theft - we do consider it a troubling fact but the scale is nowhere near what has been reported” Jon Liden, Global Fund
The papers say such theft "appears to be on the rise and becoming increasingly sophisticated".
Mr Liden confirmed the quotes and said the figure of $2.4m was not "the final word" in evaulating the group's losses. But he told the BBC that the figure was a "fraction of our overall delivery" of drugs and that the vast majority of malaria medicines "do actually do reach people they way they're intended to". He said the level of theft was within that expected by all development agencies.
"We are concerned about every drug theft we find, but we do not believe that in general this is an overall threat to the procurement and delivery of drugs in Africa," said Mr Liden.
"We pursue every single theft - we do consider it a troubling fact but the scale is nowhere near what has been reported."

'Cost lives'

Malaria kills one million people every year, mostly in sub-Saharan Africa Global Fund's investigation comes after accusations in January of large-scale corruption and drugs theft from its programmes.
In February, the fund announced it was introducing measures to "reinforce its financial safeguards and increase its capacity to prevent and detect fraud and misuse in its grants"
In a statement, executive director Michel Kazatchkine said the organisation had "zero tolerance for fraud and corruption".
The fund suspended or amended grants to several countries in light of the allegations.
The Global Fund is the biggest single source of money to tackle the world's three big killer diseases.
It was set up in 2002 and says that since then, it has committed $21.7bn in 150 countries to support programmes preventing and tackling the diseases.
Campaigners say a drastic overhaul of how drugs are distributed and stored is needed to undermine the illicit trade in medicines.
Roger Bate of African Fighting Malaria told AP it was likely that the entire system of incentives for tackling malaria needed to change so that taxpayers fund were only given once drugs reached the patients and not the government medicine stores.
But Nathan Ford of Doctors Without Borders said it was "an unfortunate reality" that poorly paid staff working in an under-resourced system would be tempted to make money from selling on medicines.
http://www.bbc.co.uk/news/world-africa-13145554

MALARIA: Anti-malaria drugs worth millions of dollars stolen from global health charity

20 April 2011


Anti-malaria drugs worth millions of dollars stolen from global health charity Thirteen countries identified, mostly in Africa, where drugs have been sold on the black market
A global health fund believes millions of dollars' worth of its donated malaria drugs have been stolen in recent years. In internal documents leaked to the Associated Press, officials from the Global Fund to Fight Aids, Tuberculosis and Malaria – backed by big names including the singer Bono and Bill Gates, chairman of Microsoft, and hailed as an alternative to UN bureaucracy – identified 13 countries, mostly in Africa, where drugs have gone missing. Spokesman Jon Liden confirmed the fund suspects malaria drugs worth $2.5m were stolen, mainly from 2009 to 2011. He said investigations were under way to determine how much was stolen elsewhere. "We take this very seriously and we will do what it takes to protect our investment," he said.
An AP report in January exposed high rates of misappropriated money in some Global Fund grants and bruised the reputation of the multibillion-dollar fund.
But the fact that these revelations have come to light at all may be due to stricter self-policing and greater transparency at the Global Fund, compared with other aid organisations.
Malaria infects more than 250 million people every year, killing about a million, the vast majority of whom are children in Africa. Because there is a huge demand for malaria drugs, which are widely available at pharmacies and on private markets, they are easier to sell than drugs for other diseases such as Aids, which are mainly handed out at health clinics.
After discovering the scope of the malaria drug thefts, the new Global Fund documents indicate the fund took prompt action, suspending grants for medicines to be stored at government warehouses in Swaziland and Malawi.
Other than the drugs confirmed stolen in Togo, Tanzania, Sierra Leone, Swaziland and Cambodia, specific dollar figures were not available for the other nine countries, all in Africa and including Nigeria and Kenya, where the Global Fund has large programmes.
The fund singled out a $200m contract for malaria drugs in Tanzania in which it suspects theft took place. It listed the theft at more than $1m but said: "The potential cost of the misappropriation is not yet quantified." In Togo, the fund reported $850,000 worth of drugs disappeared in 2008 in a case of "insider stealing".
The audits that the AP wrote about in January suggested that tens of thousands of dollars worth of malaria drugs are stolen every year.
The Global Fund's inspector general said in a report to its board of directors late last year that it was beginning to investigate allegations of "organised theft of anti-malarial drugs" in African countries, after discovering that drugs were ending up on store shelves in African countries instead of going to the intended recipients for free.
The new documents obtained by the AP – which are the results of that investigation – show that in about 70% of cases, the drugs were stolen at government-operated warehouses by security personnel, warehouse managers and doctors.
"The cases show that drug misappropriations are well organised and predominantly planned by insiders using falsified documents," one of the reports said. The documents also state that pilfered drugs were being shipped to other countries for resale, often within hours of their arrival.
Officials wrote that there was a "parallel market for the sale of Global Fund-procured drugs" and that many other investigations on alleged thefts in other countries were under way.
http://www.guardian.co.uk/society/2011/apr/20/malaria-drugs-stolen-africa

MALARIA: The Global Fund's response to drug theft

GLOBAL FUND OBSERVER (GFO), an independent newsletter about the Global Fund provided by Aidspan: Issue 138: 24 January 2011


Kazatchkine and Parsons said that the Global Fund has zero tolerance for theft or fraud, and that, "contrary to Mr Bate's claims, the Fund is acknowledged (by the U.S. and other governments) to have one of the most rigorous mechanisms to uncover and tackle fraud and to recover stolen funds." Kazatchkine and Parsons said that the Global Fund's Office of the Inspector General (OIG) "is at the forefront of the international community" in addressing drug theft, diversion and counterfeiting.
Concerning Togo, Kazatchkine and Parsons said that the Deputy Director of CAMEG "and his accomplices" were involved in the misappropriation of malaria drugs worth $849,832 and that when alerted to suspicions of this theft, the Togolese Country Coordinating Mechanism (CCM) took swift action. In addition, the government of Togo promised to compensate the Global Fund for the missing drugs, and has already repaid most of the amounts involved. "It is ultimately the Togolese tax payer who will pay for this theft, not international donors," said Kazatchkine and Parsons. "While the theft is despicable, it is not a reason to withdraw continued support for the country's efforts to fight malaria, since the entire population should not be punished for the actions of a handful of bad people."
Just as important, Kazatchkine and Parsons said, the thefts have spurred the Togolese government to analyse weaknesses in its drug distribution system and to strengthen the system, such that the risk of theft in future has been greatly diminished.
Kazatchkine and Parsons said that the solution to drug theft in developing countries is to work with countries and their partners to ensure that existing systems include appropriate safeguards. "To imply, as Mr Bate does, that only foreign oversight can secure drug distribution is an affront to the vast majority of honest, hardworking pharmacists, doctors and nurses who are successfully and conscientiously delivering drugs to patients in many countries around the world."
In its latest progress report to the Global Fund Board, reported on in GFO 137, the OIG said that it had also received reports of organised thefts of anti-malarial drugs in Malawi, Tanzania, Kenya, Nigeria, Uganda and Côte d'Ivoire.
Several months ago, Bate wrote an article on this topic in the journal Research and Reports in Tropical Medicines, in which he said that the problem also affects aid programmes at the United States Agency for International Development (USAID). See "Report Renews Concerns About Stolen Malaria Medicines" in GFO 131.

Editor's note: The Global Fund is planning to convene a meeting in the near future bringing together major international funders of drug supplies to developing countries, technical and law enforcement agencies and implementers of health programmes to intensify joint efforts to prevent theft of medicines.

MALARIA: Africa's Epidemic of Disappearing Medicine

ROGER BATE: JANUARY 11, 2011




The arrival of nearly $10 million worth of donated antimalarial drugs in the small West African country of Togo starting in 2005 should have been fantastic news for the hundreds of thousands of impoverished people who fall sick with malaria there each year. The several million doses of treatments were meant to be handed out free in government clinics, helping those who couldn't afford the drugs. But that's not what happened. Instead, a third of the drugs were stolen, "diverted" away from free government clinics to be sold in street markets and for-profit pharmacies. Suddenly, they were priced way out of reach of most Togolese. And the international donors that provided the funds to buy the drugs didn't even know they'd gone missing until months after the fact. Worse, they didn't do a thing once they found out.
Sadly, Togo is not alone. Every year, perhaps as many as 30 million donated malaria treatments are stolen, similarly diverted from their intended, needy recipients into the hands of profit-driven distributors. What's most incredible about this, however, is that most of those treatments come from one of the world's most respected public-health donors, the Global Fund to Fight AIDS, Tuberculosis and Malaria. Next week, the body will finally hold a meeting devoted to drawing up a plan to stop the theft. "Theft of medicines is a problem that affects all institutions investing in health services, and we must clamp down on it," said Michel Kazatchkine, the Global Fund's executive director. In the same December 2010 news release, he asked for help: "[N]o single institution can act on its own. We can only solve this challenge if we all work together." But that plea amounts to too little, too late. The Global Fund has always had the power to oversee the distribution of its funds, but it has chronically failed to act on that responsibility
When the international health community, backed by the G-8 leaders and the United Nations established the Global Fund in 2002, it was widely heralded as a new leader in solving some of the world's most pressing public-health problems. The model was simple: Rather than individual wealthy countries buying commodities like drugs or bed nets on an ad hoc basis, the Global Fund would serve as a clearinghouse, ensuring that funds were distributed according to need and preventing overlap and inefficiencies. It was an approach that gained the endorsement and support of the U.S. government. To date, the Global Fund has dispersed an incredible $21.7 billion in grants since its creation, $7 billion of it donated by Washington.
Yet however commendable the Global Fund's aim, its accountability standards don't nearly measure up to its hefty budget and vast influence. Recipient governments are responsible for managing the funds they receive, and often their local institutions are simply not up to the task. The Global Fund gets a third of its donations from the United States, but more than U.S. dollars, it needs American oversight. Currently, the administrative work done by the international health specialists working for the Global Fund Secretariat is overseen a 20-member board, in which the United States has only one seat. The Global Fund board's consensus-based decision-making is politically expedient, but it lacks the executive, investigative power to ensure real accountability. The Global Fund simply doesn't have the resources to both administer and audit medicinal grants.
Togo is only the most recent case in which the Global Fund's shortcomings have been on display. But it's a case in point. The small West African country is an ideal candidate for the Global Fund's attention and a microcosm of its failures. With a population of about 6.5 million, Togo suffered nearly 900,000 incidents of malaria in 2008, with 2,663 reported deaths. It's a country that neatly symbolizes the scourge of malaria and the difficulties of fighting it in straitened economic circumstances -- half of the population survives on $1.25 a day, and the government only provides about $70 per person per year in health spending. (Most mid-income countries spend 10 times as much, while Western countries' spending is usually a hundred times more than that.) So it was appropriate that in 2005 the Global Fund approved a grant to Togo of more than $10 million to purchase and distribute top-of-the-line malaria treatments and to train health workers.
The Global Fund does not distribute funds directly; in Togo's case, the United Nations Development Program (UNDP) acted as the principal recipient in country. The UNDP then handed over the funds to UNICEF, which helped a Togolese agency, the Essential and Generic Medicine Procurement Agency (known by its French acronym CAMEG), to procure the relevant drugs. From that point forward, as per the Global Fund's standard practices, CAMEG was solely responsible for storing and distributing them for free through government clinics. At the outset, everything seemed to be going well. The Global Fund reported in 2010 that more than 3 million people in Togo had been treated with antimalarial drugs.
But in July, Mamessile Assih, CAMEG's chief executive, reported to the Togolese government that some of the drugs had been stolen. An internal government audit later revealed that 544,161 malaria treatments, well over a quarter of those donated, had been stolen from government stores. When my West African research colleagues went to Togo and dug a bit further, however, they found that the donated drugs -- still in their distinctive packaging -- were widely available in street markets across the country. The donated products were being sold rather than being given away at the state clinics. Togo's poor, who were supposed to be the beneficiaries, were now entirely excluded. Worse, these drugs were not stored in ideal conditions and hence were degraded, reducing their efficacy -- and potentially even helping to incubate drug-resistant strains of malaria.
On Oct. 29, Togo's health minister, Komlan Mally, reported that the government audit had revealed that roughly a third of the antimalarial medicines provided by the Global Fund, worth well over $1 million, had been stolen. What is worse, CAMEG's own chief financial officer is alleged to be involved. He, along with four other CAMEG officials, including another senior manager, an operations manager, a warehouse manager, and a storekeeper, are under investigation for theft and trading in stolen products. Several remain in Togolese custody, considered potential flight risks. The investigation is ongoing. But the losses are considerable. The Togolese government managed to recover some of the stolen drugs from the markets, but much has simply disappeared, possibly to other African markets.
Corruption can occur anywhere, and it is to the credit of the Togolese government, and to Assih of CAMEG in particular, that it has been relatively transparent about these problems. But the Global Fund never should have allowed malfeasance to reach this level. The organization took too long before sending investigators to Togo -- they arrived in autumn, months after the first credible reports of widespread corruption -- which meant the trail had gone cold well before they arrived. A more cynical interpretation, though, is that by acting slowly, much of the evidence of a problem had disappeared by their arrival.
Unfortunately, Togo is not an isolated instance of abuse. The Global Fund has a long history of problems with stolen funds and failing projects. In 2005, it suspended grants to Uganda for mismanagement, and in 2010 it stopped giving funds to Zambia's Health Ministry, preferring instead to work with the more transparent UNDP.
My research into criminal drug distribution has revealed a steady increase in stolen drugs over the past three years. As many as 30 million donated malaria treatments are "diverted" every year, leaving malaria sufferers to pay in private markets for poorly stored products they should have received for free. Unsurprisingly, criminal gangs are now gaining greater control over medicinal distribution systems in many emerging markets across the globe. Rich international donors, by exponentially increasing the formerly limited drug supply, have also unwittingly expanded the opportunities available to criminal drug traders, from Pavel Garg's team in India to the Bryntsalov family in Moscow. In short, this is a huge and growing problem. Yet the Global Fund grant system continues unchanged and unaffected by the evident corruption in the states that receive funding. Currently, the organization only temporarily cuts the flow of funds from Geneva before again turning the funding tap back on.
Theoretically, that could change in the near future. At next week's meeting, the Global Fund will convene law enforcement and health officials to draw up a plan to combat the problem. Their efforts, however, are likely to amount to mere talk. This is a problem that requires not bureaucratic hand-wringing, but the attention of an international criminal-justice organization like Interpol.
One model for the Global Fund may be the U.S. medicinal aid system, which controls its own drug purchases for the developing world far more tightly. First, unlike the Global Fund, the U.S. government doesn't simply provide funds to recipient countries. Rather, it comes to an individual agreement with each country regarding which drugs the country wants; then it buys the drugs and has U.S. contractors deliver the products to the government distributors. When it encounters a problem with public-sector drug distributors, as it has in Angola, it completely bypasses the troublesome actor -- in this case the Angolan government -- and looks for other private distribution networks, including direct handoffs from U.S. contractors to in-country clinics. The global health community doesn't approve of this approach, however, suggesting that it wastes funds that could in principle be used to treat more people. Perhaps, but it's indisputable that the drugs at least get to where they're supposed to go.
The new U.S. Congress is lead by a Republican Party that has promised to take a hard look at wasteful spending decisions. The Global Fund, and its broken distribution systems, would be a good place for them to test their mettle.
http://www.foreignpolicy.com/articles/2011/01/11/africas_epidemic_of_disappearing_medicine?print=yes&hidecomments=yes&page=full

Global Fund - timely oversight or trigger happy

Bill Brieger : 26 Dec 2010

In the past year the Global Fund to fight AIDS, TB and Malaria (GFATM) has suspended grants in Mauritania, The Philippines, Zambia, and Mali. In fact one grant to Mali was terminated. Efforts to identify high risk grants are underway.
Some are saying that the Office of the Inspector General (OIG) of GFATM is finally showing some teeth, while others worry that actions to suspend and terminate will harm the very persons that the Global Fund was set up to help. At the recent 22nd GFATM Board Meeting the Executive Director provided the following comments based on OIG work:
Based on recent OIG findings in a number of countries, activities involving cash transfers for training events and associated costs, including per diems, travel, meal and expense payments, are in many cases posing a high risk of misuse
The OIG has identified five countries where measures to protect Global Fund-financed drug shipments from theft need to be implemented
The Secretariat and OIG agree that LFAs have not been sufficiently focused on the identification of fraud risks and actual fraud in Global Fund-financed programs, and may not currently have the capacity to address these risks
Prior to the recent Board meeting, one wonders whether the communication between the Secretariat, the Executive Director and the Office of the Inspector General were clear and efficient. A 6th December 2010 memo entitled “Joint communication on Inspector General matters” mentioned that, “The Inspector General and the Executive Director of the Global Fund have initiated sincere effort towards collaboration to follow up on recent findings by the Inspector General as well as to take steps to permanently strengthen grant oversight.”
The memo concluded that, “The Global Fund, by nature of its mandate, sometimes has to work with entities with weak programmatic and financial capacity, and to operate in environments where there may be a paucity of financial controls and lack of oversight systems. The Global Fund’s risk management systems are constantly improving. Recently discovered fraud has made the Secretariat determined to redouble its efforts to improve these systems.”
In some cases of suspended grants the Global Fund is looking for alternative Principal Recipients to manage the funds or find alternatives to ensure services to those in need do not cease to be served. The concern about the Local Fund Agents is valid since the Global Fund, unlike other international agencies, does not have country offices or provide technical assistance.
Several years ago I worked with a team in Nigeria to design and deliver adolescent and youth peer education on reproductive health through community based organizations (CBOs). The initial effort focused on how to organize and train peer educators and the technical aspects of reproductive health. Eventually it became obvious when one CBO leader was using her personal bank account to keep project funds that the local CBOs needed as much technical assistance in establishing and maintaining proper financial and accounting procedures as they did in organizing peer based reproductive health education.
The Global Fund operates in a scale thousands of times larger that our small peer education projects, but the basic principle remains. Don’t condemn local organizations for poor financial performance if you did not try to help them develop better financial and accountability procedures in the first place.
Currently 22% of grants are considered to be poor performers. Too much is at stake in reaching 2015 and beyond to simply say to poor performers, “sorry, your funds are suspended.”
http://www.malariafreefuture.org/blog/?p=1135

MALARIA: The Global Fund Proposes Joint Action to Prevent Theft of Medicines

10 December 2010


GENEVA – The Global Fund to Fight AIDS, Tuberculosis and Malaria will invite major international funders of drug supplies to developing countries, technical and law enforcement agencies and implementers of health programs to intensify joint efforts to prevent theft of medical drugs.
The Global Fund will invite the agencies to take concerted action to stem drug thefts, ranging from information-sharing and joint strengthening of procurement and distribution capacity in developing countries to applying stringent security measures around drug storage and transport. A preliminary meeting will be held in January to draw up a joint action plan.
Theft of drugs is an old and persistent problem in developed and developing countries alike, especially for drugs that may be cheap or free in the public sector but fetch high prices on the open market or in neighboring countries with different pricing policies. Problems are exacerbated by limited resources and imperfect distribution systems in many of the world’s poorest countries.
In past years, reports and allegations of large-scale theft of new, effective malaria drugs have received particular attention. The medicines, known as Artemisinin-based Combination Therapies (ACTs), are given out for free or very cheaply in public health centers and hospitals in a large number of countries but are sold over the counter in pharmacies and street stalls for US$8 or more per treatment. Typically, more than half of malaria drugs in African countries are not given out by doctors or nurses but are sold over the counter.
“Theft of medicines is a problem that affects all institutions investing in health services, and we must clamp down on it,” said Michel Kazatchkine, the Global Fund’s Executive Director. “However, no single institution can act on its own. We can only solve this challenge if we all work together.”
The Global Fund has demanded stricter control with drug warehousing and distribution in five African countries already based on reports of possible drug thefts. Lessons from these countries and from other organizations’ similar efforts will be shared and developed further over the coming months.
“The Global Fund tolerates no fraud and will do whatever it can to ensure that donor money reaches those it is intended for,” said John Parsons, the Global Fund’s Inspector General. “By convening the major parties involved in global drug procurement, we hope to achieve results each one of us would not be able to do on our own.”
In an initiative that complements the work to secure drug storage and distribution, the Global Fund is leading a US$216 million global innovation to finance improved access to ACTs by subsidizing the costs to buyers and patients in the private, non-governmental and public sectors.
The main purpose of this Affordable Medicines Facility-malaria (AMFm) is to ensure that older, ineffective malaria drugs are driven off the market by cheap, universally available ACTs. Retail prices of ACTs are expected to dramatically decline as a result of the combined effect of several factors, including: the reduced prices at which importers now buy ACTs under the AMFm; an increase of ACT quantities in each country; increased competition among sellers; and an increase in public information and marketing campaigns to increase awareness among buyers and patients of recommended prices in each country.
A potential additional benefit of driving down prices of drugs in the private sector is to reduce the incentive to steal drugs from public health services to sell them expensively in private stalls and shops. If successful and rolled out continent-wide, this innovation could curb a principal cause of theft of malaria drugs.
*****
The Global Fund is a unique global public/private partnership dedicated to attracting and disbursing additional resources to prevent and treat HIV/AIDS, tuberculosis and malaria. This partnership between governments, civil society, the private sector and affected communities represents a new approach to international health financing. The Global Fund works in close collaboration with other bilateral and multilateral organizations to supplement existing efforts dealing with the three diseases.

Since its creation in 2002, the Global Fund has become the dominant financier of programs to fight AIDS, tuberculosis and malaria, with approved funding of US$ 19.8 billion for more than 600 programs in 145 countries. To date, programs supported by the Global Fund have saved 6.5 million lives through providing AIDS treatment for 3 million people, anti-tuberculosis treatment for 7.7 million people and the distribution of 160 million insecticide-treated bed nets for the prevention of malaria.

MALARIA: Global Fund to fight medicine theft

2010-12-10
Johannesburg - The Global Fund to fight Aids will be inviting other international funders to intensify efforts to fight medicine theft, the organisation said on Friday.
Spokesperson Andrew Hurst said: "We will invite the agencies to take concerted action to stem drug thefts, ranging from information-sharing and joint strengthening of procurement and distribution capacity in developing countries to applying stringent security measures around drug storage and transport."
The Global Fund is a public/private partnership dedicated to providing resources to prevent and treat HIV/Aids, tuberculosis and malaria.
Hurst said the theft of drugs was an old and persistent problem which was exacerbated by limited resources.
There have been reports of large-scale theft of new malaria drugs.
"The medicines, known as Artemisinin-based Combination Therapies (ACTs), are given out for free or very cheaply in public health centres and hospitals in a large number of countries, but they are sold over the counter in pharmacies and street stalls for $8 or more per treatment.
"Typically, more than half of malaria drugs in African countries are not given out by doctors or nurses but are sold over the counter".
Michel Kazatchkine, the Global Fund's executive director said the problem could only be solved if all health institutions worked together.
The Fund has demanded stricter control with drug warehousing and distribution in five African countries already based on reports of possible drug thefts.
"Lessons from these countries and from other organisations' similar efforts will be shared and developed further over the coming months."
http://www.news24.com/SouthAfrica/News/Fund-to-fight-medicine-theft-20101210

MALARIA: Do Aid Agencies Want to Know When Their Medicines Go Missing?

 By Roger Bate: AEI Online: No. 5, December 2010
Roger Bate (rbate@aei.org) is the Legatum Fellow in Global Prosperity at AEI.
Kimberly Hess and Lorraine Mooney assisted with this Outlook.


Lifesaving drugs donated by taxpayers to developing countries are being stolen, strengthening criminal gangs and undermining donor intent. More worryingly, some donors are not investigating this problem sufficiently; rather, they are moving ahead with programs that have the same inherent weaknesses, which may worsen the theft problem. The U.S. government should conduct an independent review of practices at donor agencies such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) to ensure that drugs are used by those intended, rather than facilitating illegal parallel drug-distribution systems in recipient countries. The incentive structure should change so donors receive taxpayer funds only when they show that the drugs they buy actually reach intended patients in developing countries, not just government medical stores.

Key points in this Outlook:
Drugs donated to developing countries are being stolen by criminal groups, which harms patients, encourages criminal networks, and probably leads to dangerous counterfeiting.
Aid agencies do a poor job of assessing whether donated drugs reach those in need.
The U.S. government should launch an independent investigation of the aid agencies U.S. taxpayers fund to estimate the size of the problem.
Taxpayer funds should go only to agencies that demonstrate that donated medicines reach the intended recipients.
Aid agencies aim to do good; those providing medicines for fatal diseases literally save lives. But there is a constant tension between the desire to provide immediate help and the long-run dependence that develops. Recipient governments and the donors of the medicines become addicted to aid, since for many it is their livelihood. This means that agencies perpetuate aid even when they know it is not particularly effective.
Many aid agencies purchase medicines, some of them in significant amounts. Take malaria: in 2009, the U.S. government's President's Malaria Initiative (PMI) bought 29 million treatments. The Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) had acquired 90 million treatment courses for sub-Saharan Africa alone over the same period.[1] In other words, the two largest agencies annually procure about 120 million treatments of the best antimalarial medicines, primarily for use in Africa.[2]
Many drug-distribution systems are plagued by waste, delay, and theft.
This is certainly true with lifesaving malaria medicines in the world's poorest countries.Donors intend that these 120 million treatments will reach people with malaria, especially the poorest, who are unable to buy the best treatments. Inevitably, however, many drug-distribution systems are plagued by waste, delay, and theft. This is certainly true with lifesaving malaria medicines in the world's poorest countries. These problems are so severe that any short-term benefit from well-meaning donors could be outweighed in the long run by unintended, perverse outcomes.

Assessing the Diversion Problem
Anecdotal evidence of diversion is rife. Free media, where they exist, report numerous examples of drugs not reaching their intended targets. Uganda, for example, found that in one district only 20 percent of antimalarials dispensed from clinics actually went to those with malaria. The other "patients" were speculators who hoarded the top-quality free handouts for future use or sold them to dealers.[3] Since most clinics do not have diagnostic tests for malaria, patients with fevers, especially children, are presumptively treated for malaria. Although there are numerous other causes of fever, malaria is usually the most lethal disease a doctor will see, and immediate treatment is considered the cautious approach. Patients know this, so some fraudulently claim malarial fever, demand treatment, and then sell the medicines in the private market.
The theft of medicines is also widespread in Uganda. According to Stephen Malinga, the Ugandan health minister, some drugs stolen from Ugandan government stores have been diverted to private pharmacies in Sudan.[4]
Numerous colleagues and I have been sampling drugs from pharmacies in Africa since October 2007. Based on these samples, we assessed the diversion problem in private pharmacies in eleven African cities. The decision to focus on pharmacies was based on practicality and budgetary constraints--pharmacies are visible, permanent, and accessible, which makes them easy and relatively cheap to survey. (It also makes them highly vulnerable to surprise raids, as an increasing number of purveyors of fake products are finding out.)
Our recently published study found that 6.5 percent of the antimalarial drugs in the private sector had been stolen from the public sector.[5] These medicines had been donated to stores and clinics and should have been available free of charge. Of the clinically superior, most expensive, and widely donated products, closer to 30 percent had been diverted from free clinics and government stores. The percentage of stolen drugs diverted from the public sector accelerated over the three years of study. During that time, some efforts were made to crack down on diversion.
GFATM. After our study was published, GFATM announced that it was conducting an investigation into medicine theft.[6] GFATM's regular audit reports highlighted product theft as a problem in 2008 and 2009, and the Secretariat received information in mid-2010 from pharmaceutical companies, government officials, and customs officers indicating that the problem warranted an investigation.[7] But as a funding agency, GFATM likely lacks the competence for a thorough investigation. GFATM requires help from the police and other security agents within each country, and if that is not forthcoming, its investigations are severely hampered.
Interpol.
It is rumored that Interpol--the only international organization with a track record of coordinating action against pharmaceutical crime--will assist in the investigation. Even Interpol, however, relies on local security-agency support, since it is primarily a coordinating and data-gathering and data-dissemination organization. Sources familiar with GFATM say that Interpol's involvement might be disconcerting to the GFATM staff, since Interpol will undoubtedly find that GFATM's lack of oversight is at least partly to blame.
NAFDAC. NAFDAC, Nigeria's drug authority, is making good progress against pharmacists selling counterfeit or substandard medicines, and collaborative efforts among drug regulators, police, courts, and Interpol in the East African Community countries--where diversion of donated medicines is a major problem--have paid off. Operation Mamba III, conducted simultaneously in five countries during summer 2010, seized ten tons of counterfeit and illegally diverted medical products and led to more than eighty arrests of individuals suspected of involvement in the illegal manufacture, trafficking, or sale of such products.[8]
These successes have been highly publicized to deter other offenders. But those trading and selling diverted products respond to incentives, and they alter their behavior to minimize the risk of detection, product confiscation, and arrest. In an October 2010 review of the pharmacies originally sampled in eleven cities, colleagues found diverted drugs in only one city (Nairobi), whereas eight months earlier nine cities were found to have diverted drugs. But diverted products are still readily available outside city pharmacies. Investigators addressing the problem now will find that the game has changed; much trade has been driven away from the previously lucrative and substantial market of urban pharmacies into informal or rural markets. My colleagues and I found diverted and counterfeit products at every street market in all six towns surveyed on both sides of the Benin-Nigeria border.

Out of the 100 million high-quality antimalarial dosages donated to Africa, approximately 30 million are diverted.If my study, other research findings, and anecdotal reports of hundreds of different batch numbers of stolen products accurately represent the scale of diversion, out of the 100 million high-quality antimalarial dosages donated to Africa, approximately 30 million are diverted. About 20 percent of these drugs are diverted by those individuals who seek free treatments from clinics and then sell the drugs via private channels. More disturbing to taxpayers and humanitarians alike, the vast majority of diversion (80 percent, or 24 million treatments) takes place directly from government-run storage and distribution facilities--with the support of local government officials, or at least without their interference. Some of these stolen products find their way to the police, army, and other branches of government. With malaria poorly treated among the lower ranks and their families, diversion ensures ample high-quality supplies for military personnel. Some may be complicit in the trade; more accept drugs as payoffs for not preventing smuggling.

Donor Responses
The rhetoric of donors and recipients suggests that efforts would be made to curtail this illegal trade, but donors do not like to discuss bad news. While some individuals care enough to risk their jobs by talking, most lack the incentive to call attention to the problem.
Financial incentives in drug companies, and career advancement in aid groups, are based on how much product is delivered, not how many lives are saved.It is easy to see why: no one suffers in the short run, other than patients (and taxpayers). Even though the drugs are stolen, the decision makers (donors, drug companies, recipient finance and health departments, and even some clinicians) all benefit from the current system. Financial incentives in drug companies, and career advancement in aid groups, are based on how much product is delivered, not how many lives are saved. Of course, product delivery and saving lives are linked, but international health aid programs have rarely monitored health outcomes--that is, whether their aid reduces disease. In fact, certain parties actually benefit more when orders have to be duplicated due to theft.
Given the lack of incentives to expose the problem, donor responses have generally been limited. Most do not publish any information about product theft. Some donors, notably PMI, publish audit reports and insist that the most egregiously corrupt recipients are removed or bypassed. When repeated thefts occurred from government stores in Angola, for example, PMI began using only bonded private warehouses.[9] Similar problems have occurred in Malawi, and PMI has indicated that it is initiating the same action there.
GFATM has pressured recipients to punish those involved in theft. In October 2010, the Ugandan government upheld a hefty criminal conviction of a high-level official for embezzling Global Fund money, but as local media note, only low- and mid-level operators were sanctioned.[10]
GFATM also publishes audit reports; although more reticent than PMI, it is dealing more proactively with these problems than most other bilateral and multilateral donors. Unfortunately, public access to audits of such donors--the World Bank, for example--is rare and almost never makes a difference. Yet concerns over the misuse of grant money in several countries have led at least one donor (Sweden) to withhold funding from GFATM.[11]
Zambia is one example of the limitations of audits. A 2009 audit conducted by GFATM's Office of the Inspector General found that all the principal recipients of grant monies in Zambia (including two government ministries) have "shown evidence of significant financial management and control weaknesses, episodes of misappropriation and fraud."[12] It is a positive step that GFATM publishes this information, but it continues to work extensively in Zambia. Furthermore, it has not revealed the quantity of drugs diverted (unlike PMI) and gives the impression that the problem is minimal.[13] If 30 million treatments are going missing, the vast majority are likely from GFATM donations, due to both the organization's quantity of donations and its lack of efficacy in combating diversion.
One reason GFATM has been less aggressive than PMI is that it was established to help poor countries manage their own drug-procurement and delivery processes. GFATM's approach follows the predominant international health policy goal of at least the past forty years: to assist poor countries in building the competence to deliver health care to their own people. Not only is this aim noble, it is also essential since no level of foreign assistance can, on its own, improve another country's health for an extended period. If the local health systems do not evolve, aid has little effect in the long run.
While this is a sensible long-term strategy, in the short run drugs are being stolen, almost certainly with high-level political support--and consequently, not a great deal is being done about it. Some wish to return to the older, arguably more paternalistic, model of separate distribution systems to bypass the greatest corruption problem: African government officials. To a certain extent, this is what the U.S. government and PMI are doing in places like Angola.
The crux of the problem is that too many poor countries, and their identified drug recipients, are simply not capable of supervising drug delivery to patients. If GFATM's approach helps these countries move toward better health care delivery, one could make the case that the aid is worthwhile, even if only 20 percent of malaria drugs reach patients. But the aid system's culture of dependence hinders progress on that front, which makes even successful programs perform poorly over time.
Evidence from countries in the Middle East indicates that what starts out as a smuggling operation can quickly become one devoted to the higher profits of counterfeiting.A second problem is the rise of counterfeiting operations. Criminal groups will continue to gain a foothold as large-scale networks develop to distribute stolen and fake drugs. Kenya has already been named a "safe haven" for such cartels by the World Health Organization.[14] Evidence from countries in the Middle East indicates that what starts out as a smuggling operation can quickly become one devoted to the higher profits of counterfeiting.[15] With more counterfeit medicines comes the danger of increased drug resistance. Currently, the concern about drug resistance to the newest antimalarial products is confined to Southeast Asia (primarily Burma, Cambodia, and Thailand), but counterfeit antimalarials could easily bring the problem to Africa, with disastrous results. If that happens, patients will be without recourse to any effective drugs.
A third problem is not as self-evident--boredom and frustration among those within GFATM and other agencies. The entrepreneurs who started the organization established channels and raised funds to buy medicines for poor countries, and they garnered a lot of positive publicity as a result. It was exciting, and they loved the attention and the prospect of success. Sadly, the fun was short-lived. They or their successors subsequently encountered the difficult slog of maintaining funding every year, which requires that they report their programs' efficacy--often resulting in significant exaggerations. Reports, and especially projections about expected future performance, require a masterful sleight of hand because the organizations do not systematically gather performance data. Their arcane modeling exercises do not actually measure lives saved, just how many drugs are distributed. The systematic investigations that are undertaken find that many recipient countries are simply incapable of delivering drugs to the patients who need them.
The result is blind advocacy, which is surprisingly effective at raising funds, regardless of a lack of evidence of success in combating disease. The majority of those in Congress who recently supported increases in funding for GFATM have never pushed for a proper investigation of the efficacy of these disbursements. Most of the supporters--101 Democrats in the House of Representatives signed a letter of support--like the idea of supporting multilateral efforts like GFATM;[16] it is the mantra of the Obama administration to do more with multilateral partners. But it appears that neither the White House nor Congress actually wants to know that their chosen method--multilateral distribution of funds--does not work.
A secondary result is the increase in the appearance of performance. Two efforts adopted by GFATM spring to mind: health system strengthening and the Affordable Medicines Facility for malaria (AMFm).
Health System Strengthening. Although GFATM was established to fund commodities like pharmaceuticals, it also funds health system strengthening in poor countries, partly because it belatedly realized that national systems are too weak to deliver the drugs they are providing. However, GFATM is not equipped to develop health systems; it has allowed its own mission to creep without the requisite competence to complete it. (Recall that it does not even attempt to properly measure whether its core mission is working.)[17]
AMFm. GFATM backed and now runs AMFm, a financing mechanism for subsidizing high-quality malaria treatments in the private sector. AMFm is arguably a smart intervention in some locations, but GFATM does not have the competence to manage this either. It does not understand local markets (no one does, since they have not been properly investigated), and it relies on self-serving reports that show the system will work.[18] AMFm does not even address the question of product theft, and it barely considers the possibility of counterfeit AMFm products. It claims that special packaging will be used to identify its discounted products, failing to realize that counterfeiters copy packaging for a living and that AMFm packaging will be no exception.
GFATM and AMFm have publicly declared that they have no intention of showing whether the program's "pilot phase," costing hundreds of millions of dollars, has achieved its aim. In a recent article, the director of AMFm and the director of the strategy, performance, and evaluation cluster at GFATM wrote: "Expectations of attributable and rapid increases in measures of service delivery at the household level, which are neither new nor unique to AMFm, are inappropriate and unrealistic within the duration of the pilot studies."[19] In other words, taxpayers could subsidize another program that strengthens criminal networks, and no one will even measure whether it has a positive effect.
This position is in direct contradiction of the demands of the Global Fund Board. As one board member, who asked not to be identified, told me recently: "failure to provide evidence on whether there has been an increase in the use of good quality ACTs [the key antimalarial artemisinin combination therapy], including by the poorest two quintiles, will be a red line for many Board delegations."

Conclusion
Many lifesaving drugs are being stolen before they reach their intended recipients. Most donors, including GFATM, are reluctant to admit that this is a problem. The threat continues to grow, and if donors allow these practices to go unchecked, criminal groups will continue to gain a foothold as large-scale networks develop to distribute stolen and fake drugs. The long-run impact on the distribution systems and available medicines could be severe, especially if drug resistance spreads. It is hard to see how the GFATM aid model can work satisfactorily, given the lack of competence in many recipient countries.
The U.S. government should push for an independent review of practices at GFATM to ensure that drugs are used by those intended, rather than facilitating illegal parallel drug-distribution systems in recipient countries. We know that patients are benefiting from GFATM drug distributions, but criminals are also making money; we know taxpayer funds are being wasted, but we have no idea which of these forces is dominant. Do criminal networks, building over time, negate any short-run progress? We do not know whether major changes to the entire system or just minor tweaks are required, although given available evidence it is likely the former. The lack of measurement means we are largely relying on guesswork, and although that is fine for most aid-industry insiders, it perpetuates the dysfunctional status quo.

1. Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), "World Malaria Day: 2010 Is Critical Year for Global Efforts to Defeat Malaria," news release, April 25, 2010, available at www.theglobalfund.org/en/pressreleases/?pr=pr_100414 (accessed October 22, 2010).
2. In this Outlook, I primarily deal with antimalarials, but it is clear that diversion and counterfeiting is a significant problem ranging across many types of therapeutic medicines.
3. Hamis Kaheru, "Shortage of Malaria Drugs Is Largely Artificial," allAfrica.com, September 21, 2010, available at http://allafrica.com/stories/201009210515.html (accessed October 22, 2010).
4. Mark Honigsbaum, "The Killing Season," Al Jazeera, May 30, 2010, available at http://english.aljazeera.net/focus/2010/05/20105261374999817.html (accessed October 22, 2010).
5. Roger Bate, Kimberly Hess, and Lorraine Mooney, "Antimalarial Medicine Diversion: Stock-Outs and Other Public Health Problems," Research and Reports in Tropical Medicine, September 2, 2010, available at www.aei.org/paper/100136.
6. Talea Miller, "Global Fund Investigates Possible Theft, Sale of Malaria Medication," PBS NewsHour, September 4, 2010, available at www.pbs.org/newshour/rundown/2010/09/global-fund-investigating-possible-theft-of-malaria-medication.html (accessed October 22, 2010).
7. GFATM, Office of the Inspector General, Audit Report on Global Fund Grants to Tanzania (Geneva, Switzerland, June 10, 2009), available at www.theglobalfund.org/documents/oig/Tanzania_Country_Audit_Final_Report.pdf (accessed October 22, 2010).
8. Interpol, "East Africa's Operation Mamba III Bolsters Fight against Counterfeit Medicines with INTERPOL-IMPACT Support," news release, August 26, 2010, available at www.interpol.int/Public/ICPO/PressReleases/PR2010/PR065.asp (accessed October 22, 2010).
9. President's Malaria Initiative, "Malaria Operational Plan--Year Five (FY2010), Angola," available at www.fightingmalaria.gov/countries/mops/fy10/angola_mop-fy10.pdf (accessed October 22, 2010).
10. Josephine Maseruka, "Corruption Watchdog Hails Cheeye Conviction," New Vision, October 21, 2010, available at www.newvision.co.ug/D/8/13/735743 (accessed October 23, 2010).
11. Ann Danaiya Usher, "Defrauding of the Global Fund Gives Sweden Cold Feet," The Lancet 376, no. 9753 (November 13, 2010): 1631.
12. David Garmaise, "OIG Finds Serious Deficiencies in Performance of All Four PRs in Zambia," Global Fund Observer, no. 132 (November 2, 2010), available at www.aidspan.org/index.php?issue=132&article=1 (accessed November 2, 2010).
13. In the case of Zambia, we found stolen drugs from some of the same Zambian principal recipients in our peer-reviewed study.
14. George Omondi and Mwangi Muiruri, "WHO Names Kenya as Safe Haven for Fake Drug Cartels," Business Daily (Africa), November 10, 2010, available at www.businessdailyafrica.com/Corporate%20News/WHO%20names%20Kenya%20as%20safe%20haven%20for%20fake%20drug%20cartels/-/539550/1050938/-/jud3flz/-/index.html (accessed November 12, 2010).
15. Roger Bate, "Lessons from a Syrian Drug Bust," Wall Street Journal, April 28, 2010.
16. Letter to President Barack Obama from 101 Democrat members of the House of Representatives, July 27, 2010, available at www.results.org/uploads/files/global_fund_3_year_pledge_letter_to_president_7-29-10_final_with_list_of_co-signers.pdf (accessed October 28, 2010).
17. For a review of the problem of mission creep at the Global Fund, see Alex Shakow, "Global Fund--World Bank HIV/AIDS Programs: Comparative Advantage Study," prepared for GFATM and the World Bank HIV/AIDS Program, available at http://siteresources.worldbank.org/INTHIVAIDS/Resources/375798-1103037153392/GFWBReportFinalVersion.pdf (accessed November 30, 2010).
18. See, for example, GFATM, "Affordable Medicines Facility--Malaria," available at www.theglobalfund.org/documents/amfm/AMFmFAQs_en.pdf (accessed October 29, 2010).
19. Olusoji Adeyi and Rifat Atun, "Universal Access to Malaria Medicines: Innovation in Financing and Delivery," The Lancet 376, no. 9755 (November 27, 2010): 1869-71.
http://www.aei.org/press

MALARIA: Theft and corruption take malaria drugs away from Africa's poorest

Oliver Steeds 01 Oct 2010 The Independent
Widespread government corruption and theft of anti-malarial drugs is preventing the poorest people in Uganda from receiving treatment for a preventable disease that kills 300 people in the country every day, an investigation has revealed.
The Deputy Prime Minister, Nick Clegg, said at the United Nations last week that Britain would treble the amount it spends on tackling malaria in Africa to £500m a year. But an investigation by Channel 4's Unreported World has revealed that Ugandan health officials have sold the pills on the black market, and organised crime gangs are behind a thriving cross-border smuggling operation with Kenya. There are few figures to indicate the scale of the problem, but the office of President Yoweri Museveni was sufficiently concerned to set up a small unit to investigate the theft of government drugs that are passed to fake clinics for sale.
In the last nine months, the unit has made more than 100 arrests and seized anti-malarial drugs worth more than £1.5m. Convictions include government health workers and three senior Health Ministry officials who manage the national malaria control programme.
A raid in Lira, northern Uganda, uncovered drugs embossed with "Government of Uganda - Not for Sale", a box of 600 doses of anti-malarials donated by China, and antimalarial nets from the US.
Reducing malaria deaths remains one of the eight key Millennium Development Goals agreed by world leaders, but despite billions spent, nearly a million people die from the disease each year, most of them in Africa. The international community, including Britain, donated £20m of anti-malaria drugs this year to Uganda which are supposed to be distributed free.
Richard Okoth, a government security official in northern Uganda, said: "The problem is within the health workers. There has been the diversion of drugs, illegally and these drugs will end up in the private clinics and drug shops".
Uganda is among the 10 worst-affected countries, and yet malaria is preventable. Impregnated bednets and insecticide spraying combined with malaria treatment is effective. In Africa, notably in Eritrea, São Tomé and Principe, Rwanda, Zambia and Zanzibar, malaria death rates have almost halved in recent years.
Problems remain in Uganda. The district hospital in Apac Town, northern Uganda, said it struggled with drug shortages. Families were told to go to private clinics to buy them. The hospital pharmacist said: "Here, if you don't have the money, you die."
http://www.independent.co.uk/news/world/africa/theft-and-corruption-take-malaria-drugs-away-from-africas-poorest-2094525.html

MALARIA: Antimalarial medicine diversion

Roger Bate, Kimberly Hess, Lorraine Mooney
September 2010
Antimalarial medicine diversion: stock-outs and other public health problems

Background:
Antimalarial medicine diversion has been seen across numerous African markets and can lead to serious stock-outs in the public sector, which can be dangerous to countries with high burdens of disease. This study discusses the numbers of diverted antimalarial medicines from several samplings in Africa.
Methods:
A total of 894 samples of antimalarial medicines were covertly purchased from private pharmacies in 11 African cities from late 2007 to early 2010. All medicine packages were visually inspected for correctness, in line with the protocol established by the Global Pharma Health Fund e.V. Minilab®, as well as for signs of diversion.
Results:
Overall, 6.5% (58 out of 894) of collected antimalarial medicines were found to be diverted, comprising 2.4% (5/210) of medicines collected in 2007 from six African cities, all of which were artemisinin-based combination therapies (ACTs); 2.3% (3/129) of medicines collected in 2008 in Lagos, Nigeria, two of which were ACTs; and 9% (50/555) of medicines collected in 2010 in 10 African cities, 35 of which were ACTs. ACT was by far the most diverted treatment in this study: 15.6% (5/32) of ACTs collected in 2007, and 30.7% (35/114) of ACTs collected in 2010.Conclusion: The number of diverted ACTs over the 33 months covered by this study is probably related to the laudable provision of vast amounts of donated or low-priced ACTs across African nations and the actual increase in diversion of these medicines into the private sector. The small sample sizes in this study might exaggerate any problem, but a potentially serious problem may well exist. To the extent that diversion of medicines exacerbates stock-outs, this is a public health problem, and a perversion of donor intent, but there are other possible harms of diversion, such as increased trade in counterfeit, and expired and otherwise substandard medicines.
http://www.dovepress.com/antimalarial-medicine-diversion-stock-outs-and-other-public-health-pro-peer-reviewed-article-RRTM

MALARIA: Some donated malaria drugs being stolen in Africa

Maria Cheng

01 Sep 2010

Millions of free malaria drugs are sent to Africa every year by international donors. New research is now providing evidence for what health workers have long suspected: some of the donated medication is being stolen and resold on commercial markets.During three periods from 2007 to 2010, American and British experts bought malaria medicines randomly from private pharmacies in 11 African cities. Of the 894 samples, they found 58, or 6.5 percent, were supposed to have been donated to government hospitals and clinics.The study will be published Thursday in the journal Research and Reports in Tropical Medicine and was paid for by the Legatum Institute, a U.S. philanthropic group with no ties to drug makers.The finding was particularly strong in artemesinin combination drugs, the best available malaria drugs, and those often purchased by international donors. In 2007, they found about 15 percent of such donated drugs had been stolen for resale. This year, it was nearly 30 percent.The authors acknowledge the sample sizes were small and could exaggerate the problem. Outside experts said donated drugs regularly disappear across corruption-plagued Africa and that the research was credible. There have been no large-scale published studies analyzing the problem."The study is important because it clearly documents something that we need to study (the issue) more closely," said Tido von Schoen-Angerer, a director at Medecins Sans Frontieres, which works across Africa.Von Schoen-Angerer said it is extremely difficult to determine the scale of the problem since drugs are not often followed from their origin to their ultimate destination in Africa.According to an audit last year by the U.S. President's Malaria Initiative, about $640,000 worth of medicines sent to Angola vanished from airports and the government's medicines warehouse."Critical malaria commodities are not reaching their intended beneficiaries and more Angolans may be unnecessary victims," the report said."We've heard about this kind of corruption anecdotally for years," said Julian Harris, a health expert at International Policy Network, a London-based think tank. He was not linked to the study. "But the response from funders has been to keep throwing millions of dollars' worth of these medicines into countries, even when there is evidence the drugs aren't reaching the needy."In the study, Roger Bate, a fellow at American Enterprise Institute in Washington DC, and colleagues focused on the most popular artemesinin combination malaria drug, Coartem, made by Novartis AG. They bought it in private markets in Ghana, Kenya, Tanzania, Uganda, Rwanda and Nigeria. Other drugs from Sanofi Aventis, Cipla and dozens of other companies were also included.Novartis makes two versions of the drug for Africa: the one to be donated comes in a flat white packet with a blister sheet of pills while the one for commercial markets is sold in an orange and white box.Bate, an economist who studies health policy, found donated drugs originally meant for Nigeria on sale in Kenya, drugs with "Not for Sale" stamped on them, and drugs packaged in the wrong local language, which suggests they were stolen from aid deliveries.Novartis declined to comment on the issue.The donated medicines were first bought by the Global Fund to fight AIDS, Tuberculosis and Malaria and the U.S. President's Malaria Initiative, a joint program led by the U.S. Agency for International Development and the U.S. Centers for Disease Control and Prevention. Both the Global Fund and the President's Malaria Initiative receive funds from international donors, including U.S. taxpayers.The Global Fund did not respond directly to questions about their drugs were being stolen. But in a recent review, the Fund discovered loopholes in its distribution system and admitted medicines could end up in commercial markets. It has previously suspended grants to Mauritania, Uganda and Zambia when it couldn't track where its money was going.Some experts dismissed the theft of donated drugs as a major health concern.Dr. David Sullivan, an associate professor in the Malaria Research Institute at Johns Hopkins Bloomberg School of Public Health, said he did not condone the theft of drugs, but thought the supply of high-quality drugs — like those bought by international donors — to private markets was actually a good thing.He said about half of Africans go to private health clinics, often flooded with cheap drugs that don't work. "The methods of getting better drugs is not ideal, but from a public health perspective, it's better that effective drugs are available in private clinics."But Henry Emboho Wanyama, a researcher in Uganda's malaria control department, said stolen drugs can have deadly consequences. "Drugs sent to health units are stolen by medical workers and the malaria patients who go there for treatment are told there are no drugs," he said."The patients who cannot afford (to buy) drugs ... end up dying."

http://www.google.com/hostednews/ap/article/ALeqM5jA8O8aJGbzRyY4x8UjWvfFtz7KSAD9HV3PB80

MALARIA: Some donated malaria drugs being stolen in Africa

MARIA CHENG (AP)
Millions of free malaria drugs are sent to Africa every year by international donors. New research is now providing evidence for what health workers have long suspected: some of the donated medication is being stolen and resold on commercial markets.
During three periods from 2007 to 2010, American and British experts bought malaria medicines randomly from private pharmacies in 11 African cities. Of the 894 samples, they found 58, or 6.5 percent, were supposed to have been donated to government hospitals and clinics.
http://www.google.com/hostednews/ap/article/ALeqM5jA8O8aJGbzRyY4x8UjWvfFtz7KSAD9HV3PB80