Concerns on Global HIV/AIDS, TB and Malaria Fund conflicts of interest

Summary of letter¹ and responses^2,3

A typical example of a shebeen in an informal settlement, Namibia

This article raises a number of issues about corporate sponsorship in the public health sector and as such is of interest to those working in the nutrition sector where ‘corporate capture’ is a much discussed issue (Ed).

Recent letters in the ‘Round Table’ section of the World Health Bulletin debate the issues around funding by the Global Health Fund of an education intervention by alcohol giant SABMiller. A first letter sets the scene in stating that SABMiller is a major beer supplier to approximately 34,000 licensed outlets in South Africa and through them to an estimated 200,000 illegal outlets called ‘shebeens’ that act as de facto distribution arms. The company has established an education intervention that aims to minimise alcoholrelated harm in men and reduce male violence against women and children, as well as reduce the spread of HIV/AIDS. The Global Fund to Fight AIDS, Tuberculosis and Malaria has included SABMiller as a sub-recipient of its Round 9 funding in support of the brewery’s Tavern Intervention Programme for Men.

The authors argue that Global Fund support for this initiative is cause for concern because it reflects the successful attempt of a highly profitable industry to position itself as committed to public health objectives. In reality, they argue, the liquor industry’s aggressive marketing of its products is irrevocably linked with major health harms throughout the world, in South Africa in particular. Furthermore, as the impetus by government and non-governmental organisations (NGOs) to address alcoholrelated harm in South Africa has increased, there has been an upsurge in efforts by the liquor industry to partner with government and public health agencies. Such partnerships lend legitimacy and provide a platform for the liquor industry to lobby against proposals to reduce the availability of alcohol, increase the price of alcohol, through raising excise taxes and place restrictions on the marketing of alcohol, despite the global evidence that these measures are the most cost-effective way to decrease alcohol-related harm.

The authors argue that although a programme that aims to reduce HIV infection as well as violence against women and children is welcome, it is debatable whether men who attend shebeens are the best target group for the intervention, whether a drinking establishment is the best location and whether the educational intervention itself is effective. Their experience is that the liquor industry is inclined to support alcohol interventions that have limited impact on drinking at a population level. Also, eliciting funds earmarked for the global public good not only provides the liquor industry with free advertising and mechanisms to achieve its goals, but also reduces available funding for less well-resourced organisations.

The authors state that calls for accountability and good governance relating to the Global Fund and similar agencies have been increasing recently and that such bodies should not fund organisations with conflicted interests. They also state that despite submission of a request for the Global Fund to reconsider the award to SABMiller, the funding is going ahead. They fear that the problem of ‘corporate capture’ described in the field of nutritional research, has now spread to one of the largest health funders in the world.

The Global Fund were invited to respond to this letter in the same issue and in so doing made a number of points. The Global Fund, as a public-private partnership, encourages the private sector to engage in all aspects of its work, ranging from mobilisation of resources, implementation of grants and governance of funds. The Global Fund does not endorse the actions, practices or policies of any corporation or industry beyond the field of the fight against these three diseases (HIV/AIDS, TB and Malaria). The model of the Global Fund is based on the concept of country ownership. Countries determine their own programmatic priorities and implementation strategies and submit requests for funding based on identified funding gaps. One of the central channels of country ownership is the Country Coordinating Mechanism, which is made up of representatives from both the public and private sectors including governments, multilateral or bilateral agencies, NGOs, academic institutions, private businesses and people living with the diseases. In its mandate as the Country Coordinating Mechanism, the Resource Mobilisation Committee of South Africa submitted a Round 9 HIV proposal focusing on HIV prevention and care and support activities. The proposal was reviewed by the Global Fund’s Technical Review Panel, an independent panel of international experts on health and development.

A portion of the Round 9 funding is directed towards a cost-sharing programme that is implemented jointly by SABMiller, the South African Business Coalition on HIV/AIDS (SABCOH) and the Government of South Africa. This programme focuses on the provision of HIV counselling and testing, training and peer education in taverns and shebeens and psychosocial support for caregivers. The Global Fund regards this cost-sharing programme as an important endeavour to mobilise greater resources for the fight against HIV and recognises the contribution that SABMiller and SABCOHA can make in reaching at-risk populations with prevention and care and support activities.

Researchers estimate that more than 85% of locations where individuals meet new sexual partners in South Africa are shebeens and other alcohol-serving establishments. Studies have shown that even brief interventions in bars and taverns can result in reduced risky sexual behaviours. The Global Fund considers men attending alcohol-serving establishments to be a key target population and sees these establishments as viable and dynamic locations for intervention. The Global Fund therefore supports South Africa’s implementation strategy to collaborate with SABMiller and SABCOH as an innovative approach to address the HIV/AIDS epidemic. As is the case with other programmes it supports, the Global Fund will monitor the performance of the grant and expects an evaluation of the programme in line with its system of performance-based funding.

A final letter in the round-table discussion re-emphasises the conflict of interest element stating that at the heart of the problem is the apparent failure by both the Global Fund and the Government of South Africa to recognise and adequately address the potential conflict between corporate interests and public health goals. The authors suggest that the initial failure to recognise this conflict of interest lies with the South African Government, which entered into a partnership with SABMiller before the Global Fund funded this public-private partnership. It is further argued that industries whose products are harmful to health are increasingly attempting to enter into such partnerships as part of their corporate social responsibility strategies. Furthermore, evidence suggests that these corporate social responsibility strategies are intended to facilitate access to government, co-opt NGOs to corporate agendas, build trust among the public and political elite and promote untested, voluntary solutions over binding regulation.

The authors conclude that the Global Fund is being naive in simply exempting tobacco and arms producers from its remit. The products sold by these corporations may be unique but their conduct is unlikely to be and these two issues should not be confused. Whether a company sells cigarettes or alcohol, its main goal is to maximise shareholder returns. Policies that could reduce such returns are therefore contrary to its interests.

¹Matzopoulos. R et al (2012). Global Fund collusion with liquor giant is a clear conflict of interest. Bulletin World Health Organisation 2012; 90:67 69|doi:10.2471/BLT.11.091413

²Bampoe.V et al (2012). Response from the Global Fund. Bulletin World Health Organisation 2012;90:70|doi:10.2471/BLT.11.096990

³Gilmore. A and Fooks.G (2012): Global Fund needs to address conflict of interest. Bulletin World Health Organisation 2012. 90:71-72|doi:10.2471/BLT.11.098442