Thursday, 14 November

International Health Donor Expresses Concerns

Global Fund Calls for Reforms to TB Program in Armenia

Hetq speaks to Ms. Sandra Irbe, the Global Fund’s Program Officer for Eastern Europe and Central Asia. The Global Fund to Fight AIDS, Tuberculosis and Malaria is an international financing institution that invests the world’s money to save lives. To date, it has committed US$ 21.7 billion in 150 countries to support large-scale prevention, treatment and care programs against the three diseases.

Recently, the Global Fund sent a letter to various Armenian government agencies citing its displeasure regarding the manner in which preventative HIV/AIDS and tuberculosis programs it has financed are being conducted in Armenia. You have traveled to Armenia and met with the prime minister. What issues have arisen and why are you concerned?

There are various factors at play. Let’s start with why we have met with the prime minister. There are numerous administrative hurdles linked to the procedures of humanitarian committee, Ministry of Finance and Ministry of Health. In general, these hurdles complicate the work of the Global Fund in terms of allocating grants. We had expected that the programs would be quickly launched so that we could obtain results every three months. But if it takes three months for the Finance Ministry just to set an annual budget, you can imagine the results occurring at the end of that quarter.

For example, purchases also pass through the State Purchasing Agency. Its methods do not exactly correspond to those methods employed by the Global Fund in terms of transparency, competitiveness, etc. In addition, there is the factor of the personal control of the programs, which is reflected in the governance of the program. In the RA Ministry of Health there are managers with varying degrees of competence. I can only speak positively about Health Minister Kushkyan, who was personally in charge of administering our programs. This is a fairly rare occurrence, when a country’s minister took personal charge of our program and strategically supported the completion of our program, as was the case with the tuberculosis program. He was able to prove that the ministry could actually work according to international standards. It was a truly wonderful collaboration.

A new deputy minister was appointed, Sergei Khachatryan and a new chief of Staff, Vahan Poghosyan. Naturally, the minister cannot be expected to administer the program personally in the long-term. He handed over those functions to Sergei Khachatryan. It is also natural that problems arise when a person first steps foot into new surroundings and is faced with a new work load. There are delays in the process. Also, it was the time when programs and contracts were being signed. Suddenly, someone appears that doesn’t sign a contract for a full ten months because the person has certain questions. But all those questions had been addressed a long time ago. This is the reason for writing the letter. We realized that things couldn’t continue in this fashion. It would have an effect on the program’s end results.

According to the rating results posted on your website, in addition to the first program, all five had garnered poor ratings of B1 or B2. If the performance of these people was good – then why the poor ratings?

Here too, there are various reasons. One of the reasons for the B2 rating at the Ministry is due to non-optimal administration. Mr. Poghosyan was formerly Head of Administration for Organization of Medical Assistance of the Staff of MH RA and Head of the National TB Program. In addition, he administered other programs conducted by fewer staff whose numbers didn’t correspond to the work load involved. Do you think that this same person could conduct such an extensive amount of work and all successfully? We had often told them to bring more people on board and they would answer – 2 or 3 is enough. No, it isn’t enough.

For example, an important issue is that everything be purchased on time, that the agencies are supplied, that they spend the money, that the program advances. If, say in Georgia, five staffers are working on purchases, in Armenia there is only one; and a young, inexperienced staffer to boot. Or an inexperienced financial worker can’t even record 3-4 large grant amounts. The staffer just can’t do it all. This is the reason why Mr. Poghosyan was dismissed from the two posts – the Global Fund grant program and the National TB Program early this year. The dismissal of just one person will not lead to an immediate improvement in an already back-logged process of programs that must be completed.

Is Global Fund satisfied with the way in which grants have been allocated in Armenia?

Yes, because we have very specific monitoring procedures. We have local agents who review the expenses, who conduct audits and other inspections. In this regard, I have no concerns. What actually concerns us is the administration of the program.

Has everything been ironed out or are there still problematic points?

The successful outcome of the negotiations also led to finding someone who possessed knowledge of international standards and could perform accordingly. The B2 rating essentially applied to the tuberculosis program that also had weak spots. In May, a new manager was appointed for that program, Margarita Balasanyan. She has a good character reference and took over for Mr. V. Poghosyan, who had been running the program ineffectively.

How would you rate the tuberculosis situation in Armenia?

Tuberculosis is a major problem in Armenia; especially chronic TB. Again, poor administration of the program and especially the institution is the culprit. Naturally, we understand that doctors aren’t paid much, that they leave Armenia, and that a normal infrastructure is lacking, etc. However, what is being done in the republican dispensary is unacceptable. Let me make the argument that tuberculosis is actually being financed in Armenia. I say this because hospitals have a vested interest in keeping their beds occupied. The longer the patient remains in a bed, the more money the hospital gets. This is unacceptable.

Thus, you have a situation where a person who has contracted TB is in the same ward with someone merely in the early stages of the infection developing. The longer these two remain in neighboring beds, the greater the risk of the infection spreading between them. The Abovyan dispensary’s administration doesn’t really pay much heed to the advice of the World Health Organization. They are mainly interested in getting more money for the dispensary. This is an unacceptable approach in terms of preventing the spread of the infection. The financial system, especially in institutions dealing with TB, must be altered. This is even more vital since the international track record shows that an individual can be easily treated at home.

To what extent have the Global Fund programs improved the situation?

We conduct various activities – retraining of medical staff, allocation of drugs and investment in the testing system. We also work to strengthen the health system. But our grants can’t cover all the bases. The recipient nation must decide its priorities and come to us with specific programs for funding.

In comparison with neighboring countries, Armenia has received less in grants. Is this due to fulfillment results or other factors?

I wouldn’t say that the overall amount of grants in Azerbaijan is greater. I mean, the country is a bit larger and there are more incidents of tuberculosis. It depends on the country. For instance, Georgia submits a grant proposal every year. They are very actively engaged in the process. The last proposal tendered by Armenia was accepted. It was a major achievement.

But I repeat, all the work cannot be effectively administered by just one person. My view is that they didn’t get around to clearly analyzing the situation and submitting a bid, or else they couldn’t join forces.

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