11 October 2016
An audit of Global Fund grants in Malawi confirmed that there has been significant progress in the fight against the three diseases, particularly HIV and tuberculosis (TB). However, the malaria program has significant weaknesses related to vector control and case management: for example, a delay in a mass distribution of mosquito nets may have contributed to more malaria cases. The OIG also concluded that the supply chain needs significant improvement especially at the facility level. Poor record-keeping, inadequate facility-level storage, and weak accountability lead to unreliable stock controls and drug theft.
With US$837 million disbursed over 12 years, important progress has been made to end the epidemics of AIDS, TB and malaria in Malawi. For example, the total number of people receiving antiretroviral therapy increased from 3000 in 2003 to 595,186 by December 2015; the TB treatment success rate reached 83% by the end of 2014; and there has been a steady decrease in reported malaria cases. An OIG anti-corruption campaign called "I Speak Out Now!" was launched recently in partnership with USAID, the Ministry of Health and the Malawi Anti-Corruption Bureau. The campaign encourages Malawians to speak out about drug theft or abuse, particularly regarding malaria drugs. The information received through the hotlines has led to the police action, raids and arrests.
Notwithstanding the progress, important activities have not been implemented, affecting the availability and quality of key services to beneficiaries. The delays in a mass distribution of insecticide-treated nets, delivered during and after the peak malaria transmission season, may have contributed to an increased number of malaria cases, requiring treatment and further contributing to stock-outs at the national level. Malaria is treated without confirmed diagnosis in health facilities and in communities. 60% of patients treated for malaria at health facilities are not tested and suspected malaria cases are reported without a confirmed diagnosis.
The HIV and TB programs also have room for improvement. For example, currently the number of HIV exposed infants and children tested within the recommended timeframes is low; and there is inadequate monitoring of CD4 counts and viral load testing for HIV patients. For the TB program, case notification targets are not met due to a lack of training and human resources capacity. This is critical when taken in the context of a 2014 TB prevalence survey which indicated that prevalence had doubled compared to previous estimates.
Effective procurement and supply chain controls are essential for the Malawi portfolio as drug procurement represented more than 80% of expenditures in the period from 2009 to 2015. The Secretariat and the Principal Recipients have put in place mechanisms to safeguard commodities at the central level, including pooled procurement and adequate storage. However, there are gaps in the supply chain system at the facility level which affect the country's ability to effectively store, account for and quality assure health commodities. Malaria medicines financed by international donors can be openly procured in public markets as a result of drug theft.
The Secretariat, working with in-country partners, is putting in place remedial actions including strengthening the quality of testing across HIV and TB programs and oversight of drug security and availability.
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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.
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