14 December 2016
An audit of grants in Côte d'Ivoire found that current implementation arrangements have led to good program results overall. However, the three disease programs that manage grants under the aegis of the Ministry of Public Health and Hygiene have difficulties in implementing cross-cutting activities. As a result, not all funds can be absorbed. The auditors also noted that supply chain controls and assurance mechanisms need significant improvement with the disease programs only playing a limited role in supply chain monitoring. The Global Fund, with its country partners, is putting in place corrective measures including the establishment of a cross-cutting Project Management Unit at the Ministry to ensure better coordination between all actors.
Côte d'Ivoire is one of the Global Fund's high impact countries, with a US$260 million funding allocation for 2014-2017. The country has the fifth largest malaria burden in the world and the highest HIV prevalence among adults in West Africa. Overall, the country is performing well on most of the key performance indicators: as of 30 June 2016, 170,000 people living with HIV were on antiretroviral treatment, 93% of confirmed malaria patients had received antimalarial treatment, and 79% of tuberculosis (TB) cases had been successfully treated.
The OIG identified that, as of 30 June 2016, a significant proportion of planned grant activities had not started yet: 42 out of 113 activities (37%) for the National Malaria Control Program, 30 out of 189 (16%) for the AIDS Control Program, and 13 out of 43 (30%) for the TB Control Program. Consequently, absorption rates for grant budgets (excluding health product procurements) to date are relatively low at 45%, 38% and 33% per disease program, respectively. However, grant activity delays have not had a significant short-term impact on programmatic results due to generally stable health product deliveries.
Regarding supply chain and distribution, the OIG found a number of problems. The disease programs do not review or validate product orders submitted by the districts and the largest health facilities to the central medical store. As a result, they do not monitor whether district and health facility stock levels, as well as consumption, are in line with the programmatic data available.
The OIG auditors found significant gaps in inventory controls and reporting at la Nouvelle Pharmacie de la Santé Publique, the country's central medical store, responsible for most distributions. Semi-annual stock counts do not report stock quantity variances to the disease programs, leading to the risk of potential product theft or loss going unnoticed. The "first-expired-first-out" method has not been applied for all distributions, resulting in a high likelihood of earlier product expiry in 2017.
Limited ownership of the health product management and monitoring processes by the disease programs, combined with inconsistencies in reports from the central medical store, led to significant stock-outs of some health products in mid-2016. For example, seven out of ten principal malaria drugs, malaria tests, as well as microscopy slides were not available for more than two months, and HIV tests for more than one month. Fortunately, the consequences for patients were not too serious owing to stock reserves and flexible arrangements at the health facility level.
The Global Fund Secretariat is already addressing some of these issues including providing technical assistance to support product quantification by the disease programs and the central medical store's stock management system. In the next few months, it will continue to work with country partners to improve controls and oversight over stocks and distribution to ensure the best grant impact in Côte d'Ivoire.
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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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