Africa's Epidemic of Disappearing Medicine

The global system for public health donations has a crippling accountability problem.

BY 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.

 SUBJECTS: PUBLIC HEALTH, AFRICA
 

Roger Bate, the Legatum fellow at the American Enterprise Institute, is writing a book on illegal drug markets.

JLIDEN

1:46 AM ET

January 20, 2011

A Half Truth on drug theft

Roger Bate has told half a story about drug theft. Let us complete the picture.

Theft of medicines is indeed a serious problem in both the developed and developing worlds. It is a challenge for all donors and aid programs for health. While the Global Fund to Fight AIDS, Tuberculosis and Malaria is aggressive about addressing the issue and speaks openly about the problem, it is not the only organization facing such challenges.

The Global Fund has zero tolerance for theft or fraud. 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. Its Office of the Inspector General aggressively audits and investigates these issues and is at the forefront in the international community when it comes to addressing drug theft, diversion and counterfeiting. The Fund is continuously working with law enforcement and other agencies as well as with drug manufacturers to investigate claims of theft. The grant management side of The Global Fund works closely with the Inspector General to safeguard donor money once any form of misappropriation is discovered.

Mr Bate uses Togo to illustrate how donor money gets lost and suggests that the Global Fund has turned a blind eye in this country. Let’s get the facts straight. In Togo, the Deputy Director of CAMEG - a Togolese national procurement agency - and his accomplices were involved in the misappropriation of malaria drugs worth $849,832 from a program financed by the Global Fund. When alerted to suspicions of this theft, the Togolese national oversight body responsible for Global Fund grants took swift action. The government of Togo pledged to compensate for missing drugs and has since repaid the Global Fund most of the value of the stolen drugs. It is ultimately the Togolese tax payer who will pay for this theft , not international donors. 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. Equally important, this scandal has spurred the Togolese government - with the support of international organizations and foreign missions in the country - to analyse weaknesses in its drug distribution system and strengthen it so that the risk of theft in future has been greatly diminished.

Different remedies are required in different settings. In a few cases, temporary systems parallel to national ones are necessary to prevent ongoing losses. However, the solution to drug theft in developing countries is not to depend upon parallel systems but to work with countries and their partners to ensure that existing systems include appropriate safeguards. Long-term solutions lie in working with honest people to build secure and sustainable supply chains so that products reach the intended end users. 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.

Perhaps Mr Bate focuses upon the Global Fund because it is so transparent and because we talk publicly about these problems when they arise. For example, the Fund has recently demanded that five countries take action to prevent theft based on indications of irregularities. These measures were announced publicly to ensure that the other 140 countries we support understand that the Fund is ready to take tough measures. In the coming weeks we will hold a meeting that brings together the main U.S. and international organizations to encourage them to work collaboratively with the Global Fund to better prevent such theft.

Mr Bate has never contacted The Global Fund to discuss his campaign against drug theft, to verify his information or to learn about our policies, but had he done so, he would have discovered that he has a strong ally in The Global Fund.

Professor Michel Kazatchkine, Executive Director, The Global Fund

John Parsons, Inspector General, The Global Fund

 

ELIZABETH DICKINSON

11:50 AM ET

January 27, 2011

Posted on behalf of Roger Bate, author

Sir,

My article was relatively short and couldn’t address all of the nuance of my concerns about the Global Fund.

More detail on the research I've done can be found at http://www.dovepress.com/antimalarial-medicine-diversion-stock-outs-and-other-public-health-pro-peer-reviewed-article-RRTM

and also here http://www.aei.org/outlook/101009

As to contact with the Global Fund, which the authors appear to be unaware of, I spent about an hour on a call with a Global Fund investigator in early December discussing the theft of medicines. And my colleagues and research assistants have contacted the Fund on several occasions over the past year to gather information.

The fact that most of the actors that the Fund works with are competent and honest, does not mean they can be complacent about the remainder – a few rotten apples can destroy entire systems, or rather develop alternative dangerous networks.

But the Fund's IG and ED are correct in other regards, they are more transparent than any other multialteral agency, and I commend them for it - and in the above documents and most of the articles I write, I point this out. It is a travesty that UNDP hides its data from the Fund.

But the fact that other agencies are worse than the Global Fund doesn't mean we can be complacent when drugs go missing, and I fear that the Fund cannot oversee drug delivery particularly well.

-Roger Bate