Global Fund's fight against diseases stumbles in Africa

WASHINGTON -- Five years ago, the Global Fund to Fight AIDS, Tuberculosis, and Malaria was just a concept. Today, the fund oversees $5.8 billion in projects to battle the infectious diseases, registering successes from Cuba to Mongolia as well as failures in a few key African countries.

As the fund's board prepares to elect a new executive director of the organization next week in Guatemala, a report issued yesterday said the Global Fund needs much better oversight of programs on the ground and must find ways to help countries make the initiatives work.

Three large African programs -- Nigeria, Uganda, and Kenya -- have had particularly rocky starts.

Kenya, until recently, hadn't spent much of its aid money, largely because of bad relations between the government and civil society groups; it has disbursed 38 percent of its $235 million in grants, and one malaria program is six months behind schedule. All of Uganda's five grants were suspended last year due to "serious mismanagement" by the Health Ministry. They later were reinstated, and now on average are six months behind.

Nigeria promised to use its grant to put 14,000 people on AIDS treatment in one year. The actual result was zero. In April, the fund terminated the AIDS grants, taking away $81 million from Nigeria.

The new director "must be really focusing on grants that are in trouble or could be in trouble," said Bernard Rivers , editor of the independent Global Fund Observer , a newsletter distributed to 10,000 people over the Internet. Rivers was one of 22 health specialists who produced a report by the Center for Global Development , a Washington think tank, on challenges and opportunities for the new fund director.

The five candidates are Hilde Johnson , Norway's former minister of international development; Michel Kazatchkine , France's HIV/AIDS ambassador; US Representative Jim Kolbe , an Arizona Republican not running for reelection; Bill Roedy , president of MTV Networks International ; and Michel Sidibe , a Mali citizen who is a top UNAIDS official.

While Kazatchkine has been the most aggressive in seeking the post, board members and outside health officials said no clear favorite has emerged. The new director will replace Richard Feachem , who took over at the organization's inception.

Designed to be primarily a financing mechanism, the organization now has 240 employees overseeing nearly $6 billion in grants in 128 countries.

The pace in the Geneva headquarters "feels chaotic, where they are constantly making a new rule for a new situation," said Celina Schocken , who has worked at the fund and later worked on the report. "The director needs to figure out how to make operations routine."

In many countries, the fund is by far the largest health donor. Several successes stand out, ranging from well-run programs for AIDS, tuberculosis, and malaria in Rwanda to feisty nongovernmental organizations challenging policy in China.

But trouble persists in many African countries, particularly those with histories of corruption or with little expertise in managing vast amounts of donor funds. In particular, countries that have grants from the fund and from the Bush administration's $15 billion, five-year AIDS program, health ministries often respond more quickly to demands from US AIDS workers who live in the country, Schocken said. "The Global Fund is not breathing down anyone's neck asking for a meeting to get things going, but others are," she said.

Still, Steve Radelet , the chair of the report on the fund, and US officials do not believe the organization should hire hundreds of technical experts in countries to monitor its grants. Instead, they said the fund should coordinate its programs more closely with the US and European donors and UN agencies to get more help.

German and British aid organizations have begun to help the fund's programs in a few countries, and the United States has designated $12.5 million in technical assistance.

"We need the fund and we need these grants to work," said William R. Steiger , special assistant for international affairs to the Health and Human Services Secretary and the US representative on the fund board.

John Donnelly can be reached at donnelly@globe.com