David McCoy is a public health physician based at Queen Mary University, London. He is also Chair of the Board of Medact.
On December 2nd, Panorama – one of the BBC’s flagship documentary programmes – screened a documentary (Where’s Our Aid Money Gone?) about the Global Fund for AIDS, TB and Malaria (Global Fund). The Global Fund is a global public-private partnership that channels more than US$3 billion a year to developing countries to support the expansion of HIV/AIDS, TB and Malaria programmes. Much of this money comes from official aid budgets.
Most people think the Global Fund is a good thing. Panorama’s documentary, however, accused the Global Fund of corruption and suggested that the British government was wasting taxpayers’ money by continuing to support the Global Fund. It was designed to achieve maximum embarrassment by being screened at the same time as the Global Fund’s replenishment meeting – a gathering at which governments and other donors make pledges to finance the Global Fund.
It is not clear why Panorama chose to attack the Global Fund. But I became an unwitting accomplice when they interviewed me for the programme. This resulted from their interest in an academic paper I had published with colleagues about the Global Fund’s claim to have saved 8.7 million lives through treatment for AIDS and TB and protection from malaria by bednets. The paper had argued that this claim was over-stated and that the measurement of ‘lives saved’ was problematic.
I was interviewed for a full hour – but this was boiled down to less than a minute in the broadcast which had me stating that the Global Fund alone may have saved ‘only’ between 4 and 5 million lives and that the discrepancy with the Global Fund’s 8.7 million figure represented a degree of ‘spin’ designed to maximise the Global Fund’s appeal to donors. In their editing of my interview, my accompanying caveats and explanations were ignored. This is ironic because in making its case against the Global Fund, Panorama stated that “the details matter”.
In this blog, I explain the discrepancy in figures and why this is relevant. I then discuss the Panorama programme more generally. International aid should be a topic of public discussion – but the Panorama documentary was a shoddy piece of journalism that deserves to be criticised.
How do you go from 8.7 million to 4 to 5 million?
The analysis of the Global Fund’s measure of ‘lives saved’ has been published in a peer-reviewed scientific journal which describes how the Global Fund translates data on the number of people on AIDS and TB treatment and the number of malaria bednets distributed into an estimate of ‘lives saved’. It does this by comparing the estimated mortality among beneficiaries of AIDS and TB treatment and malaria bednets with the anticipated mortality in a hypothetical scenario where no one received any treatment or bednets. The difference in the number of deaths between these two scenarios is taken as an estimate of the number of lives saved.
In analysing this model, it’s necessary to note that the Global Fund did not publish a breakdown of the 8.7 million figure by year or by each of the three separate interventions. This limited our ability to examine the accuracy and reliability of the overall figure.
So how might one get from 8.7 million to 4 – 5 million? There are three steps involved.
First, there are good reasons to conclude that the Global Fund’s model for estimating ‘lives saved’ contain some in-built biases that would result in an over-estimation of ‘lives saved’. This is primarily due to over-optimistic assumptions about the effectiveness of AIDS and TB treatment.
The second step concerns the use of the hypothetical ‘no-treatment’ scenario. While the worldwide scale-up of AIDS treatment and malaria bednets began at about the time the Global Fund was established in 2002, treatment for TB was already well established. Thus, a more appropriate estimate of ‘lives saved’ by Global Fund–supported TB programmes would be derived from comparing current levels of treatment effectiveness with a scenario of TB treatment in 2002 (rather than a ‘no treatment’ scenario). This would result in a 3- to 4-fold reduction in the estimated number of ‘lives saved’ by TB treatment.
The third step concerns the difference between ‘Global Fund supported programmes’ and the Global Fund alone. The Global Fund’s headline figure of 8.7 million lives saved is attributable to programmes that include a considerable (but unstated) amount of funding from other sources. An estimate of the Global Fund’s own and specific contribution would be considerably less (possibly by as much as 75% in the case of AIDS and TB treatment).
Thus, if one were to ask how many lives are saved by the Global Fund alone through its financing of HIV and TB treatment, and its distribution of malaria bednets, a generous estimate would be around 4 to 5 million. But it could be as little as 3 million.
But does this matter?
Many would say ‘no’. Many would say that what matters is that the Global Fund gets as much money as possible; and that maximising positive PR for the Global Fund is fine. But in my view, a clear and accurate measure of the Global Fund’s value and impact does matter if one wants an informed and intelligent public discussion about aid and its modalities. But why is it important?
In the published academic paper, a number of implications about the Global Fund’s narrow and selective approach to ‘impact measurement’ are raised and discussed in detail. This includes various potentially negative health systems and public health consequences. Some of this discussion is too technical for the general public and won’t be repeated here. However, a broader discussion about the evaluation of global health programmes, their value for money and their approach towards development assistance is an appropriate subject for a public documentary.
One important issue is the growing tendency towards ‘packaging’ international aid around a set of discrete disease-based programmes that are focused on clinical technologies. Such ‘packaging’, often for the consumption of the general public, over-simplifies the challenges inherent in improving health worldwide and reducing global health inequalities. This simplification and reductionism is amplified by the growing employment of ‘celebrities’ who act as uncritical and unquestioning PR agents for the aid industry. It also conceals the wider picture of an unruly international aid architecture in which different institutions, causes and diseases compete with each other for a shrinking pool of donor finance – encouraging a tendency to exaggerate and over-state claims of impact and value; as well as an over-prioritisation of clinical interventions at the expense of more fundamental social, economic and environmental change.
Two other issues important for public debate are: first, the framing of aid as an act of charity rather than an act of duty or economic justice; and second, the problematic way in which corporate actors are increasingly involved in and benefit from international aid.
These are ‘complex’ issues; but they are not beyond the remit of greater public understanding. The need for public education about international aid and how it fits into a globalised economy is necessary in the UK. Health activists and public interest actors in the South would want this. Panorama could have made a positive contribution. Instead, it did the opposite.
What was wrong with the Panorama programme?
An axe to grind?
The core message of the Panorama programme was that the Global Fund is inefficient, incompetent and unconcerned about corruption; and that it had sacked its Chief Auditor (John Parsons) because he was ‘too good’ at uncovering corruption. By interviewing a spokesperson from a ‘whistleblowing’ organisation, Panorama painted Parsons as victim whilst making Global Fund officials appear defensive and guilty of a cover-up. But this portrayal was wrong and misleading.
Some ‘balance’ was provided in the form of Bernard Rivers who was given a brief moment to explain that Parsons was sacked because he was not a good manager or leader. However, the many other reasons why it was right that Parsons had been fired were not explored by Panorama. So what was the motive behind Panorama’s support of Parsons? It’s hard to say. Perhaps a Freedom of Information request for all the minutes and correspondence that led up to the making of this programme would shed some light.
Corruption and the Global Fund
But the issue of Parsons (and his conduct) needs to be decoupled from the wider issue of corruption.
Has there been corruption associated with Global Fund grants?
Undoubtedly yes. How bad is the corruption? The investigations conducted by the Global Fund have uncovered significant corruption. But the scale of this corruption is not as bad as portrayed by Parsons and the mainstream media. Are Global Fund audits and investigations into financial mismanagement conducted speedily and efficiently? Probably not as well as they could – but it’s hard to say precisely without looking more deeply into the resources available for conducting audits and investigations, and considering the opportunity costs involved in greater speed and efficiency.
Are there problems with the oversight of Global Fund grants?
Yes – there are problems. But curiously, one of the major weaknesses was not mentioned at all by Panorama. Local Fund Agents (LFAs) are supposed to be the ‘eyes and ears’ of the Global Fund within recipient countries and mostly consist of accountancy firms such as PriceWaterhouseCoopers and KPMG. In the view of many people, LFAs are both expensive and of questionable quality and it is odd that no mention was made of their role in failing to prevent financial mismanagement or corruption.
Does the uncovering of corruption reflect badly on the Global Fund?
Not really – in many ways, it reflects well on the Global Fund because it shows a commitment to audit that is stronger and more effective than the case with other donors. There will be variability in the quality of oversight from country to country and there will always be room for improvement; but few people would argue with the fact that the Global Fund has a difficult challenge in managing the tension between rapidly scaling-up services to people with AIDS, TB and Malaria, whilst ensuring water-tight financial management. Policing corruption is expensive and time-consuming – and if over-done, it can also hinder and harm service provision.
Neo-colonial attitudes still rampant at the BBC?
Perhaps the most dismal aspect of Panorama’s programme was its tone of self-righteous indignation and its portrayal of Britain (with evocative shots of the Union Jack) as a generous donor; Cambodians as either corrupt or helpless and needy; and Global Fund as incompetent. While corruption and international aid is worthy of investigation, it needs to be handled sensitively and intelligently. At least three points should have been made by Panorama to place its story of Cambodian corruption in context and perspective.
The first is that corruption and the mis-use of public or charitable finance is not solely a developing country phenomenon. Embezzlement, scams and fraud exist in the UK, the United States and elsewhere. The second is that corruption in any country is a systemic issue and shaped by, among other things, social and cultural attitudes; the existence of financial management capacity and infrastructure; and the quality of local judicial systems. It is rarely isolated to a single actor or transaction. The third is that the biggest form of corruption affecting developing countries is not the embezzlement of aid, but the avoidance and evasion of tax by multinational corporations and the illicit outflows of private finance enabled by tax havens and banks. For every dollar of aid that goes into poor countries, approximately $10 flows out in the form of illicit financial flows. This is followed by large-scale corruption associated with arms deals and foreign direct investment agreements – involving both local and global actors.
While Panorama has every right to investigate corruption within the aid industry, it needs to do this responsibly. In the case of the Global Fund, evidence of corruption should also be placed in the context of the Global Fund’s contribution to the fight against corruption. Balance and perspective is required. In the same way, while I raised concerns about the Global Fund’s estimation of ‘lives saved’, I also told Panorama that the Global Fund is one of the better channels of development assistance for health.
Talking to the media
Talking to the media is always a risk. You have no control over how they may use your words. And there are always agendas and opinions dressed up as news and reporting. But I felt reassured by the BBC brand and believed that Panorama were interested in a real public discussion about aid and the problems associated with a fragmented and competitive global health complex. I was left disappointed. Hopefully, Panorama will regain my trust and respect in the future.