05 October 2016
In this audit, the OIG found that the Secretariat has clearly identified the main risks that could affect program objectives in India. Financial risks are effectively managed; programmatic and data risk management are partially effective, although tuberculosis (TB) prevalence data is out of date. However, the auditors found that assurance mechanisms around procurement and supply chain require significant improvements. Furthermore, there is no transition plan to analyze the risks as the Global Fund progressively phases out funding from the country over the next ten years.
Implementing grants in India is critical to the Global Fund's mission to end the epidemics of AIDS, TB and malaria. India has the highest burden of TB in the world and the third largest HIV burden. Programs funded by the Global Fund in India made substantial progress between 2012 and 2015 with increases in the number of patients on TB treatment from 1.2 million to 1.5 million and those on antiretroviral treatment from 540,000 to 773,000. The Government of India invests significantly in the health sector, providing 80% of the annual budget for the HIV, TB and malaria programs.
The Global Fund recently notified the Government of India that it would phase out funding over the next three replenishment phases. However, both parties are yet to agree on a transition plan that includes an analysis of the risks. 80% of the Global Fund's funding in India is currently made up of health commodities, which will make the transition more complex. For example, the Global Fund currently finances 100% of the antiretroviral medicines for the national HIV program.
Regarding procurement and supply chain, in a 2013 audit, the OIG had noted delays of up to one year in health commodities. In the 2016 audit, delays in procurement processes increased, with an average of over 18 months for HIV commodities, 24 months for TB, and up to four years for malaria with the risk of stock-outs and treatment disruptions.
As for data quality, there has been no TB prevalence survey in India since 1958 to evaluate the extent of the disease burden and the required response. This means that, although updates have been made periodically, calculations for the TB control programme in India are now approximately 60 years old. Recent surveys in specific states show a two-fold increase over previous estimates. Given that the country accounts for 25% of the global TB burden, significant variation in the estimates and actual burden could affect global disease estimates.
The auditors also found that risks related to differing quality of drugs used in disease programs have not been adequately resolved. For example, the Global Fund finances only medicines that meet the World Health Organization's standards. Drugs procured using domestic funds are not subject to these requirements. The co-mingling of drugs at all levels in the TB program has meant that patients receive drugs from both sources. For the HIV program, given the planned transition to government funding of drugs in 2018, patients will be switching to drugs that do not comply with the same standards as before. No assessments to compare divergent quality assurance standards have been conducted to understand, for example, whether government-funded drugs are of a poorer quality, leading possibly to drug resistance.
Notwithstanding any quality differences, the Global Fund also pays more for its drug procurements. Based on a sample of four main TB drugs and a comparison of unit costs and quantities procured by the Global Fund and by the Indian government, the estimated cost differential is US$5 million out of US$13 million over the last three years.
Lastly, the auditors found that there are significant delays in the diagnosis and referral for treatment of new HIV patients. 80% of the patients sampled were found to have been put on treatment when their CD4 cell count was lower than 100, which is significantly less than national as well as international standards. Approximately half of TB patients are treated through the private sector, which is currently largely unregulated and does not report patients into national data systems. This leads to the risks of incorrect treatment regimens, weak follow-ups and treatment disruption, in turn leading to drug resistance.
The Global Fund Secretariat is putting in place corrective actions, notably supporting the Government of India in developing a funding transition plan and a new TB prevalence survey. The Global Fund is also ensuring the transfer of procurements of its health products to a new procurement agent to address the delays.
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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.
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