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Challenges in Global Fund-supported health programs in Africa:  Financial constraints, policy and legal hurdles, and capacity building deficiencies
GFO issue 445

Challenges in Global Fund-supported health programs in Africa: Financial constraints, policy and legal hurdles, and capacity building deficiencies


Samuel Muniu

Article Type:

Article Number: 7

In this article, we delve into the common challenges faced by health programs in Côte d'Ivoire, Ethiopia, Ghana, and Uganda, as uncovered in the Office of the Inspector General audit reports released in December 2023. The discussion centers on three primary areas: financial limitations, policy and legal obstacles, and deficiencies in capacity building. These challenges collectively hinder the efforts to combat prevalent diseases such as malaria, AIDS, tuberculosis, and other public health threats in these countries.

The Global Fund’s Office of the Inspector General (OIG) published audit reports in December 2023, highlighting common challenges in health programs across Côte d’Ivoire, Ethiopia, Ghana, and Uganda. These challenges include low utilization of health interventions, data quality and management issues, and procurement and supply chain obstacles. Our article titled “Common challenges in African health programs: Utilization, data management, and supply chain issues” delved into the first three challenges. Here, we focus on financial limitations, policy and legal obstacles, and deficiencies in capacity building. These obstacles collectively impede endeavors to fight malaria, AIDS, and tuberculosis (TB). Overcoming them necessitates collaborative efforts among governments, donors, and stakeholders to bolster healthcare systems and enhance health results.


Financial and resource mobilization limitations

Limited government funding, delays in fund disbursement, and heavy reliance on external donors, present significant financial challenges to health programs in many African countries. These obstacles hinder the expansion of interventions, procurement of essential commodities, and implementation of health policies and programs, ultimately impacting the provision of healthcare services to the population.

In Côte d’Ivoire, the insufficient and delayed release of government funds for acquiring healthcare products results in frequent shortages of crucial drugs and health supplies. Despite commitments to purchase primary TB medications and cover HIV-related health needs, actual funding falls short, leading to gaps in essential healthcare provision.


Similarly, Uganda faces hurdles in grant execution due to inadequate management of sub-recipients. Delays in awarding contracts, releasing funds, and late submission of accountability reports impede financial administration and program oversight, particularly in malaria control efforts.


Ghana encounters setbacks in funding requests for domestically financed goods, exacerbated by prolonged procurement processes and economic pressures. Despite commitments to co-finance, only a fraction of the required goods is procured, leading to shortages at healthcare facilities and compromising service delivery.


Ethiopia’s challenges stem from delayed designation of conflict zones as difficult operating environments, leading to disruptions in healthcare services for HIV, TB, and malaria patients in affected areas. Despite operational policies for managing such scenarios, resource constraints and bureaucratic delays hinder timely intervention and exacerbate health challenges in these regions.


Obstacles in policies and legal frameworks

Policy constraints, legal frameworks, and socio-cultural factors often act as significant barriers hindering marginalized populations’ access to healthcare services, exacerbating health disparities and undermining public health efforts. In several African countries, including Côte d’Ivoire, Uganda, Ghana, and Ethiopia, discriminatory laws, stigma, and human rights violations impede essential health service delivery and program implementation for key populations such as men who have sex with men (MSM), female sex workers (FSWs), and people living with HIV/AIDS (PLHIV).



In Côte d’Ivoire, inefficiencies in malaria prevention efforts, particularly the Long-Lasting Insecticidal Nets (LLIN) mass distribution campaign, have led to an increase in malaria cases despite attempts to reduce them. The country fell short of its goal to increase LLIN usage from 50% to 80% between 2016 and 2020 due to neglected critical communication activities promoting LLIN use and low coverage of Intermittent Preventive Treatment (IPT) for pregnant women, highlighting systemic issues in program implementation and access to preventive services.


Uganda faces challenges in implementing HIV prevention interventions for key populations, such as MSM, due to the passage of the Anti-Homosexuality Bill and delays in program implementation. Legal and political contexts contribute to human rights barriers, hindering progress in reducing HIV among vulnerable groups and perpetuating stigma and discrimination, further marginalizing these populations and impeding their access to essential healthcare services.


Similarly, Ghana struggles with gaps in its HIV key population response, limited government funding, and reliance on outdated studies and proposals for legislation, leading to the marginalization and criminalization of key populations and adversely impacting their access to healthcare services.


In Ethiopia, not all key population sub-groups are targeted in HIV programs, and recommendations to include MSM and transgender people have yet to be implemented. Stigma and discrimination based on religion, social, and cultural factors further impede key population programs, highlighting the urgent need for policy reform, legal protection of marginalized groups, and the promotion of inclusive healthcare services that respect human rights and dignity.


Capacity building and coordination

Limited institutional capacity, insufficient training, and coordination gaps among implementing partners and sub-recipients pose significant challenges to the effectiveness of health programs in various African countries. These challenges hinder healthcare delivery and impede the achievement of public health goals. To address these issues, enhancing capacity building initiatives, coordination mechanisms, and stakeholder collaboration is crucial.



In Côte d’Ivoire, challenges such as limited staffing capacity and procurement delays have resulted in low absorption of grant funds for health programs, particularly in areas such as Resilient and Sustainable Systems for Health (RSSH) and COVID-19 Response Mechanism (C19RM). These challenges highlight the importance of strengthening institutional capacity and improving procurement processes to ensure efficient utilization of resources and effective program implementation.


Similarly, Uganda faces challenges with delayed mass distribution campaigns and gaps in prevention and treatment programs, exacerbating efforts to control diseases such as malaria. Insufficient training and coordination among implementing partners contribute to these challenges, underscoring the need for improved capacity building and collaboration among stakeholders to enhance program effectiveness.


Ghana encounters data management lapses at the sub-national level, including errors in data validation checks and deficiencies in data management and supervision. These issues hamper effective program monitoring and evaluation, hindering the ability to assess the impact of health interventions accurately. Strengthening data management systems and providing training for personnel involved in data collection and analysis are essential to address these challenges and improve program monitoring and evaluation.


In Ethiopia, deficiencies in the financial management system pose risks of loss of grant financial information and unreliable reporting. The use of unlicensed accounting software and lack of policies for IT infrastructure procurement and maintenance further exacerbate these challenges. Investing in financial management capacity building and establishing robust policies and procedures for IT infrastructure procurement and maintenance are essential to address these deficiencies and ensure the accuracy and reliability of financial reporting.


Way forward

Addressing the healthcare challenges in African countries requires a comprehensive strategy. One critical aspect is prioritizing domestic resource mobilization and allocating sufficient funds for healthcare. This involves not only increasing overall healthcare spending but also ensuring efficient and transparent utilization of funds. Enhancing financial management and oversight mechanisms is crucial for accountability and efficient resource allocation. Additionally, diversifying funding sources through collaboration with the private sector and leveraging innovative financing mechanisms can contribute to sustainable healthcare financing. By reducing reliance on external aid, countries can exert greater control over their healthcare systems and enhance resilience to fluctuations in international funding.


Moreover, addressing obstacles in policies and legal frameworks necessitates a multi-faceted approach. This includes advocating for policy reform to eliminate discriminatory laws, providing legal protection to marginalized groups, and promoting inclusive healthcare services sensitive to socio-cultural factors. Efforts to reduce stigma and discrimination, improve access to healthcare services, and empower marginalized populations are essential for achieving equitable health outcomes and advancing public health goals in African countries.


Furthermore, overcoming challenges related to limited institutional capacity and coordination gaps requires investment in workforce development, clarifying roles, and promoting multi-sectoral collaboration. Implementing these strategies can enhance program efficiency and sustainability, ultimately improving access to quality healthcare for all citizens.

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