Audit by Global Fund to Fight Aids, Tuberculosis and Malaria finds millions of dollars unspent while health centres run low on life-saving drugs

The lives of hundreds of thousands of people are being put at risk by Uganda’s poor management of health spending, a report finds.

An audit by the Global Fund to Fight Aids, Tuberculosis and Malaria, published on Friday, said millions of dollars remained unspent even though drug shortages were common in health centres.

For a country often pleading limited resources for providing decent healthcare, the findings suggest that a big part of the problem could be paucity of smart governance.

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Since 2002, the fund has signed grants worth $1bn (£715m) to Uganda, of which $623m has been disbursed. About 90% of the money goes on buying drugs and other health commodities.

Last November, fund officials audited facilities to establish whether there was prompt delivery of quality drugs and supplies, accurate data to aid decision-making, and robust internal controls to minimise theft and waste.

Auditors found drugs had been stolen, health workers were using expired kits to test for HIV, condoms supposed to be distributed free of charge were being sold. They also found acute shortages of key drugs and suspicious discrepancies between inventory figures and actual stocks.

“Seventy per cent of the 50 health facilities visited during the audit reported stock-outs of at least one critical medicine, with HIV drugs being the most affected of the three diseases,” the audit says. “Furthermore, 54% of the health facilities visited had accumulated expired medicines.”

The ailing condition of the public healthcare system was one of the talking points during campaigning for last month’s general election, which were controversially won by President Yoweri Museveni. After opposition politicians were photographed in run down, understaffed, underfunded and underequipped health centres, the electoral commission banned politicians from the facilities. Police were often deployed to ensure no opposition visited hospitals to disturb patients.

Activists have routinely complained about the underfunding of Uganda’s health sector, to which just 5.3% of the budget is devoted – far below the 15% that the government committed to allocate to health under the Abuja declaration. Since late last year, there has been an acute shortage of antiretroviral drugs in government facilities. But while stories of drugs expiring in medical stores are not uncommon, news that the government has failed to use funding for Aids, malaria and TB will upset many.

“While the country lacks adequate funding to cover key activities, it has a low absorption of the limited grant funds that are sent to the country,” the report says. “The OIG [the Global Fund’s office of the inspector general] noted that only 46% of funds disbursed to the ministry of finance between January 2013 and June 2015 had been spent at the time of the audit.”

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One programme to procure food packs for patients with multi-drug-resistant TB, started in 2012, had neither bought nor distributed any packs as of last November.

A major indictment of the government relates to Global Fund grants. The grants come through the finance ministry to the ministry of health, which acts as the principal implementer. But auditors have accused health ministry managers of not prioritising grant management, implementing agreed upon steps, or regularly attending high-level meetings where lingering problems are discussed.

Uganda’s reputation as a country on the frontline of the fight against HIV and Aids took its first major battering in 2005, when the fund suspended all grants amid reports money was being stolen with impunity. Although grants were restored after governance reforms, each subsequent review has raised worrying queries. After the 2005 scandal, a judicial inquiry was set up and some people were jailed for stealing fund money. They included a former government spy who set up a bogus organisation to siphon off money – which led a judge to compare him to “a mass murderer”.

Among other recommendations, the audit proposed that the government presents a plan to improve administration of the grants, and convenes a review to establish the number of people who will need HIV and Aids treatment.

Facebook Twitter Pinterest A community reproductive health volunteer gives a condom demonstration to a young family in Kasese, Uganda, in 2012. Photograph: Jake Lyell/Alamy

However, civil society groups said in a statement released on Sunday that the recommendations made by the report were not far-reaching enough to trigger fundamental change.

“In some cases the problems that the OIG describes have been with the ministry of health for years,” said Joshua Wamboga, executive director of the Uganda National Aids Services Organisations. “Meanwhile, Ugandans with HIV are suffering entirely preventable stock-outs of medicines. The current situation is completely untenable – there is no leadership, no action, no accountability and no sign that government is taking these problems seriously.”

They recommended the ministry of health should be replaced as the main implementer of fund programmes, and that the government should double financing for HIV treatment to 200bn shillings (£42.7m) in the budget due in June.

Professor Vinand Nantulya, who recently resigned as chairman of the Global Fund country coordinating mechanism, would not comment because he had not yet read the report.

Jim Mugunga, a spokesman for the Ugandan finance ministry, clarified that the financial management of the grants was the responsibility of the health ministry, but gave a cool response to calls by activists to replace the health ministry as the implementer of programmes.

“There is never a perfect system,” said Mugunga. “The ministry of health is not static but must improve as the restructuring and human resource enhancements are implemented. This is an ongoing process.”

Rukia Nakamatte, a spokeswoman for the ministry of health, said: “If a mother is pregnant and this mother is put on option B drug, it takes nine months. We are not going to give all these drugs to a mother immediately she conceives. It’s a process.

“But we are very sure that by the time we come to June 2016, we shall have absorbed all the money.”