26 February 2016
In an audit of Global Fund grants in Uganda, the Office of the Inspector General (OIG) found the following problems: pervasive stock-outs of key medicines, unexplained stock differences, funds that could not be accounted for, lapses in services provided to patients and poor grant oversight by the Ministry of Health. The case has been referred to the OIG’s Investigations Unit for further review and the Global Fund is putting in place a number of corrective measures.
The Global Fund has disbursed US$623 million to the Republic of Uganda since 2002. The country has made significant headway in the treatment of the three diseases, for example: new HIV infections have decreased from 140,000 in 2010 to less than 100,000 in 2014, the number of people receiving anti-retroviral treatment for HIV has gone up from 21% in 2010 to 50% in 2014; and malaria prevalence in young children has decreased from 42% in 2009 to 19% in 2015.
The OIG auditors identified stock-outs of key medicines, particularly those to treat HIV, in 70% of 50 health facilities visited which could result in treatment disruption for patients. Furthermore, 54% of the health facilities visited had accumulated expired medicines. 68% of facilities reported stock-outs of anti-malaria medicines and test kits and 64% of the facilities reported stock-outs of tuberculosis medicines of between one week and three months.
The OIG concluded that the supply chain system does not effectively distribute and account for medicines financed by the Global Fund. There were reported cases of theft, including 40 cartons of artemisinin-based combination therapies; an unexplained difference of US$21.4 million between recorded and actual stocks at the central warehouse; and a difference of US$1.9 million between commodities received and actually dispensed to patients from January 2014 to June 2015 in eight high-volume facilities visited by the auditors.
The OIG also noted problems around the data which are essential to ensure quality of services and to inform decisions to fight the three diseases. For example, 30% of facilities visited had either under or over-reported results related to malaria; 43% of patients were treated for malaria without a confirmed diagnosis and/or with negative results. Twelve per cent out of the 50 facilities visited were testing for HIV using expired test kits and, contrary to national guidelines, 14% of facilities visited did not perform confirmatory tests on clients diagnosed as HIV positive. This increases the risk of patients getting false HIV results.
Uganda has aligned its anti-retroviral therapy policies to the latest guidelines from the World Health Organization and UNAIDS. This has not only increased the number of people qualifying for HIV treatment (estimated to be 260,000 in 2016) but has also resulted in a funding gap of US$92 million for HIV and 9 million for tuberculosis. If unaddressed, this funding gap will result in treatment disruption in the future.
Despite this under-funding, the authorities also have difficulties in using the money that they receive. The OIG noted that only 46% of funds disbursed to the Ministry of Finance between January 2013 and June 2015 had been spent at the time of the audit. This low absorption rate is attributed to protracted procurement and recruitment processes.
The Ministry of Finance is a pass-through Principal Recipient and has delegated most of its role to the Ministry of Health. The OIG noted lapses in Principal Recipient oversight and inadequate financial management by the Ministry of Health. Financial transactions are recorded using basic software which is prone to human error and not secure. The current financial management system has also been unable to effectively support processes such as budget monitoring, advance management and tracking of value-added taxes paid with grant funds.
The Global Fund is working with the Ministry of Health to address the implementation problems identified by the OIG as well as seeking to recover any lost assets.
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The Office of the Inspector General safeguards the assets, investments, reputation and sustainability of the Global Fund by ensuring that it takes the right action to defeat AIDS, tuberculosis and malaria. Through audits, investigations and consultancy work, it promotes good practice, reduces risk and reports fully and transparently on abuse.
Established in 2005, the Office of the Inspector General is an independent yet integral part of the Global Fund. It is accountable to the Board through its Audit and Ethics Committee and serves the interests of all Global Fund stakeholders. Its work conforms to the International Standards for the Professional Practice of Internal Auditing and the Uniform Guidelines for Investigations of the Conference of International Investigators.
The Global Fund believes that every dollar counts and has zero tolerance for fraud, corruption and waste. Through its whistle-blowing channels, the Office of the Inspector General encourages all to speak out to report fraud, abuse and human rights violations that prevent Global Fund resources from reaching those who need them.