By Prince AGWU, Peter EVANS, & Obinna ONWUJEKWE

THE Global fund has agreed to a US$993 million grant to Nigeria to help eliminate HIV, Tuberculosis and Malaria. This is great news. It is the first part of new planned grants totalling USD 1 billion over the next two years out of a US$15 billion planned health investments in the long term.

Grant means a gift, not a loan. This is a tremendous opportunity and confirms Nigeria as the Global Fund’s biggest recipient of funding on the African continent. The standard Global Fund deal is that there must also be counterpart funding – so there will be added in-country investments, notably Federal and State health budgets, and special health allocations like the Basic Health Care Provision Fund (BHCPF).

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With more money, comes more corruption

Some Global Fund investments in Nigeria have previously been upset by a series of corruption cases, with infractions committed by both the public and private sectors, leading to the Global Fund actually stopping funding in 2016. There were also corruption problems with GAVI funds, and Nigeria had to refund some funds to GAVI in order to keep benefiting.

So, what is now different in the Nigerian context that will assure accountable and transparent use of Global Fund’s disbursements in order to significantly improve population health? How can citizens track the use of the funds and verify the outputs and outcomes? What accountability mechanisms are openly available?

Like ‘sweet crude’ like ‘sweet Global Fund money’?

To irk the average Nigerian, remind him or her of the large crude oil deposits in the country. It is a classic case of poverty amidst plenty. While we wonder how came about the description ‘sweet crude’, we are reminded that it was not just about the easiness in refining the oil, but that those with power made and continue to make quick and easy generational wealth out of the pains of people, communities and their environments. Perhaps, if those without power had chosen the label, it would have been ‘bitter crude’.

So, like ‘sweet crude’, how do we ensure that the Global Fund grant does not become ‘sweet money’ but is instead smart money – an investment, not a spree?

Global Fund money – so what?

Each year Global Fund invests more than US$5 billion globally to ensure healthier populations. But it is not just about the cash – the Global Fund champions the ‘means’ as well as intended ‘ends’. It is a worldwide partnership instigated to fight diseases, challenge the injustice that fuels them, and strengthen health systems resilience, including responses to health emergencies. It proudly unites world leaders, communities, civil society, health workers and the private sector to find solutions that have the most impact and take these to scale. This is laudable, but easier to say than do, especially in contexts that may be at variance with the guiding principles of the Global Fund, and have been historically so, just like ‘sweet crude’.

It will be a disservice to global health if Global Fund’s money is reduced to ‘sweet money’ and further facilitates a ‘tragedy of commons’ experience. So, in the spirit of the Global Fund’s ideal mission of sustained health security for all, and because we are passionate about squeezing every last drop of value for Nigerians out of these grants, we offer some thoughts drawing from our experience in health systems and accountability across the globe.

First, learn from experience – they say it is the best teacher

Everyone sees how unhappy Nigerians have been with the management of COVID-19 funds, especially with very tiring news around corruption and disregard for accountability by authorities. The Financial Times captured it clearly when it published an article with the title – ‘theft doesn’t even stop during a pandemic’.

A recent shocking revelation from Nigeria was the diversion of N3 billion, about US$2 million of COVID-19 funds to verify a social register whose veracity has been in much contention. Here is a country whose health sector is in the world’s bottom 12, spending funds from a pandemic ‘lavishly’ – ‘sweet money’, right?

Again, we should be frank to ask – what happened to Nigeria’s COVID-19 Fund tracker? We recall some articles between 2021 and 2022, about one year after the pandemic struck, complaining about the early disappearance of Nigeria’s COVID-19 fund tracker from the internet. In contrast, the COVID-19 fund tracker of the United States of America is still up and running. Transparency and accountability are endurance events, not sprints!

This pretence of accountability must be noted by the Global Fund. If trackers are set up, evidence of paying for web hosting and domain for more than 10 years should be presented, as well as evidence of data maintenance and a dedicated technical team. Optimism can only come from being open about the very real risks that lurk in this space and showing confidence that we have the measures in place to address them, not blind faith.

In fact, with Nigeria’s poor score on the Corruption Perception Index at 25/100, applying deep sense of caution whenever money flows in the system must be a priced asset.

Second, be bold! And refuse to fold!

A typical Nigerian will ask – ‘but how come these big organisations and developed countries see how corrupt our leaders are, yet they give us a lot of money?’ An explanation that drives this home is the fact that Nigerian legislators, in the heat of a pandemic took delivery of 2020 Toyota Camry model cars. Yet, the country continued to receive several millions of donations. Not one of the donors could be bold enough to call out such irresponsibility. And this passes on the feeling of complicity on the streets. So, funders have a huge responsibility to change this thinking!

The Global Fund’s commitment to ‘Challenging power dynamics’ is a brilliant aim and is the key to unlocking the maximum effectiveness of its investment.  But (again) it is easier to say than do. It is hard to achieve without cool-headed analysis and open debate about exactly which ‘power dynamics’ are at play (which real people, interest groups), and what can be done to ensure that they do not disrupt or divert funds or implementation.

Of course, researching and talking about the politics of implementation is tricky, but whether the P is for ‘Power’ or ‘Politics’ we need to have courage and be frank. Moreover, there is high-quality research on ‘political constraints’ (we know as we deliver this under the world-renowned Anti-Corruption Evidence (ACE) Consortium). The Global Fund and its Nigerian partners should reach out to expert researchers – and can also fund research to fill any gaps in knowledge and practice around accountability and anticorruption, ensuring that its money is not ‘sweet money’.

Third, think quality as well as quantity: numbers don’t always tell the entire story

We can all revisit the comments made by Bill Gates during his 2018 visit. Gates in that meeting with the then Minister of Finance, spoke about how not to expect efficient health service delivery from a health system that is weak. He said, as of then, USD 1 billion he has spent on health in Nigeria has not returned commensurate value.

The Global Fund is certainly a major step forward in the quantity of investment. But quality cannot be assumed. When Nigerians are informed of the numbers, there should be public approval of the value. Over the next two years, Nigerians anticipate USD 1 billion worth of health from Global Health alone. There should be value for money! We expect the books to be open for independent value-for-money assessments.

Fourth, build on the successes that we already have

What are our measures and tools for ensuring quality? Well, we can track the funds. Nigeria has impressive (globally renowned!) independent accountability organisations such as International Centre for Investigative Reporting (ICIR), The Budgit Foundation and Connected Development (Follow the Money), and that can track the funds allocated to and disbursed by politicians. The alternative is to be miserly with data and make any interested parties work hard – and cause friction – through mechanisms such as Freedom of Information (FoI).

A bold step towards ‘challenging power dynamics’ is an early, unequivocal commitment to proactive disclosure. This could be through the benefiting organisations signing a compact that will include publicly available expenditure tracking systems and scorecards on the outputs and outcome of the funds. These do not cost too much but will need budget and altruistic champions if we truly want ‘communities to have an equal voice in the fight and an equal chance at a healthy future’.

Also, our national procurement guidelines are excellent but need to be enforced. Global Fund could catalyse a burst of openness and use public interactive technology to supercharge progress in best procurement practices.

Fifth, build trust, and don’t let it die

Accountability is built on trust, and so the Global Fund recipients need to be consistent in how they share data and engage external partners. Nigeria’s online tracker for COVID-19 funds holds a lot of lessons. Do we set up public accountability systems only for them to be of no use and eventually die? We see how countries such as the US and UK still have their public accountability systems for COVID up and running, even as they continue to entertain debates and litigations.

Sixth, the value of the investment is a reflection of the system’s politics

Why not have a proactive discussion (including all the themes above) about how to truly ‘strengthen health systems resilience’. An article mentioned, ‘we need to talk about bad resilience’, pointing to systems basking in illusions of growth when its foundations are in deep rot. Global Fund cannot put money in a political system and shy away from speaking about political-economic elements that could undermine its investments.

We repeat for those at the back

Going forward, health investments in Nigeria should be on the increase despite sub-optimal national and sub-national allocations. Influxes of money from diverse sources including the Global Fund have raised expectations for an improved health sector in terms of improved health outcomes and improved ratings of the country’s health system.

Of course, there are fears of the invested funds not yielding commensurate value, as that has been the track record of Nigeria for a long time. No thanks to COVID, as public accountability during the pandemic consolidated this obnoxious track record. In fact, regaining public confidence and trust in the health sector is among the goals of the current health sector leadership. But we fear that trust may be further plundered with Global Fund’s injection of ‘scarce’ dollars into the health sector.

This article tries to helpfully but strongly raise this alarm, asking for caution, begging for reflection through past experiences, instructing that books must stay open to the public, advising the importance of engaging evidence experts in accountability and anticorruption to elicit checks and ensure optimal use of funds, and demanding that organizations like Global Fund be bold and engage on the power and political constraints to galvanise an efficient system and squeeze every drop of value out of the Global Fund grant.

Global Fund must resist the labelling of its money, ‘sweet money!’, and we have offered thoughts on what can be done.

Authors’ bios

Prince Agwu is an academic on research positions at University of Dundee, Scotland, and University of Nigeria. He holds a PhD in Social Policy, with his research niche covering governance and policy issues in health systems and migration. He is the African Section Editor for Social Work and Social Sciences Review, an Academic Editor for PLoS ONE, and Associate Editor, Health Research Policy and Systems. He has published remarkably in refereed journals and ranks among top-500 scholars in Nigeria by Sci-Val.

Peter J Evans is a freelance consultant. He was a DFID social development and governance adviser for two decades, and led DFID’s commissioning team for governance, conflict, inclusion and humanitarian research before becoming Director of the U4 Anti-Corruption Resource Centre. He is ‘Not that Peter Evans’ (the more famous American political sociologist).

Obinna Onwujekwe is Professor of Health Economics and Policy, with base at the University of Nigeria, where he is currently the Director of Research. He is the Coordinator of the Health Policy Research Group and the Nigerian Center Director of the African Health Observatory Platform (AHOP) on health systems. He is a member of the Nigerian National Health Research Committee and the African Advisory Committee on Health Research and Development.

For correspondence: [email protected]