A NEW source of money to fight the HIV/AIDS epidemic may expand funding by tens of
millions of dollars if promises are fulfilled, government officials say. The government
and donors expect to spend about $22 million in 2003.
The Global Fund (GF), a $1.5 billion initiative to combat malaria, tuberculosis and
AIDS, has pledged at least $11.2 million over the next two years to control the epidemic,
said Peter Godwin, an advisor at the National Centre for HIV/AIDS, Dermatology and
STD (NCHADS) under the Ministry of Health (MoH).
"The Global Fund is establishing a completely new funding mechanism with new
procedures," said Godwin. "It is a new way of doing business."
He said available funding could increase by as much as 20 percent next year. Even
more is promised in the future.
A second round of funding has been approved promising $14 million in coming years,
most of which is reportedly for the purchase of anti-retroviral drugs to treat AIDS
patients. Another government proposal submitted for the third round of funding is
still under negotiation. It asks for $42 million over five years.
The first disbursement of funding has recently arrived, although it is not yet being
used. All of the money from the Global Fund will be administered directly by MoH,
though about 70 percent of its recipients are in civil society. This controversial
strategy entrusts governments to distribute international aid.
For some NGOs, citing the need for scrupulous oversight on all spending, this seems
to fly in the face of what has been proven to work.
"I anticipate a lot of problems on the horizon," said one HIV/AIDS worker
in Cambodia, who asked not to be named. "The Global Fund does not have in place
the kind of oversight they need to watch a developing country cover this kind of
money."
But GF defenders are quick to point out that the money comes with a caveat: any signs
of financial impropriety will end future grants.
In the case of Cambodia, quarterly progress reports written by local auditing firm
KPMG will keep Global Fund administrators apprised of whether procedures are being
followed and if further grant money should be disbursed. Cambodia will probably undergo
its first audit within three months of accessing the funds, which it is expected
to do in October, officials said.
In its application, Cambodia has committed to an ambitious and unequivocal list of
"anticipated results" it must fulfill in order to receive the full allotment
of aid money.
Among other things, the government said it would hold the number of sex workers infected
with HIV at or below levels detected in 2000. Health workers must also increase the
number of centers providing HIV/AIDS care and counseling and train 4,000 police and
military officials in HIV/AIDS prevention.
But NGO and government officials openly admit the possibility that the funding will
outstrip the capacity of the government and NGOs to administer it. Already, NGOs
report they must be careful not to hire too many people away from the government
among the limited pool of those qualified to administer HIV/AIDS programs.
The major influx of money promises to "significantly" affect Cambodia's
struggle against the AIDS epidemic, considered to be the worst in Asia, said Godwin.
But simply raising the stakes of aid may not be enough. The major increase in funding
could be too much for Cambodia's limited infrastructure and human resources to absorb
effectively.
"In the real world, you can only put so much water into a glass," said
Godwin. "It remains to be seen how that will work."
The government currently spends only a fraction of its health care budget on HIV/AIDS
programs. According to a report compiled by NCHADS, that equals about 45 cents per
person, or just 15 percent of the $3 it expends per capita annually on health care.
The total budget is about $6 million.
But with the AIDS virus a primary cause of mortality among those aged 15 to 49, many
health officials say the budget is too low.
And health sector workers say how the money is handled is as important as the amount.
For that reason, some said the GF idea was doomed from the start.
"It can only be as transparent as the people handling the money," the aid
worker said. "[The GF] has already lost on that one as well."
The worker said those controlling the Fund at the MoH were among the most corrupt
in the Ministry. She predicted that the Fund would "just attract sharks".
Still, many health care workers expressed confidence that Cambodia, touted by the
UN as one of the world's few "success stories", would continue to keep
the AIDS epidemic under control.
The most recent figures released by the Ministry of Health (MoH) estimate that 2.6
percent of the population, or at least 160,000 people, are infected with the virus.
At least 20,000 people are predicted to die from the disease, and its complications,
this year.
Since 1998, however, the UN Population Division estimates the rate of new infections
and the number of AIDS cases have fallen. Public health officials credit a massive
campaign to prevent and contain the spread of the disease through behavior-change
interventions and education.
That is one reason why the river of aid money continues to flow into Cambodia.
"You can make a very strong case that acting swiftly and effectively with large
amounts of money on a very large scale is the best way to deal with an AIDS epidemic,"
said Godwin. "In many ways, that has been Cambodia's experience. The Cambodians
have been able to use the money very effectively to very good effect."
Government officials still say that more funds will benefit the country.
Dr Mean Chhi Vun, director of NCHADS, said that expanding existing programs to provide
long-term care and teach HIV/AIDS prevention would be paid for by the Global Fund
money.
"If we want to scale up nation-wide, we need more support," he said.
But national donors have also maintained a significant financial commitment to battling
the disease.
The US, which takes an opposite tack from the Global Fund strategy by directly funding
NGOs, said it wants to seize on existing gains to further rein in the epidemic.
"This is when you want to have aggressive measures to keep the prevalence low
and push it lower," said a spokesman from the Embassy. "You don't want
it to escalate."
US funding will channel about $30 million directly to NGOs during 2004 and 2005,
primarily to scale up behavior-change prevention programs, support programs looking
at treating AIDS patients with anti-retroviral drugs and supporting vulnerable children.
The funding measure is the sector's largest aid package provided by a single donor.
DFID, the British aid agency, plans to provide $22 million in aid over the next five
years beginning in 2003, Elizabeth Smith, an official at DFID said. Another $5 million
grant is being provided by the BBC World Service Trust.
The World Bank and Asian Development Bank injected more than $1 million into the
sector this year and plans continued funding. Médecins Sans Frontières
also contributed about $1 million this year.
The intra-ministerial National AIDS Authority (NAA) and the MoH's NCHADS have assumed
responsibility for coordinating much of the response to the epidemic.
Smith said the challenge for donors would be to focus on caring for victims of HIV/AIDS,
including their families, while staying vigilant against the spread of the virus.
The effort must be directed at a broad spectrum of issues.
"The interesting issue about HIV/AIDS is it's not something you could put support
in one ministry," said Smith. "It's a cross-sectoral response. It's quite
a challenge for any government."
Who administers funding for HIV/AIDS
programs
2003
USAID-funded NGOs
$9,022,362
42%
Govermment
$5,859,565
26%
Other NGOs
$4,877,955
22%
DFID-funded NGOs
$1,166,600
5%
UN System
$1,111,286
5%
Total:
$22,037,768
100%
Data supplied voluntarily. Figures are approximate.
Source: MoH; NCHADS
