06 June 2017
An audit of Global Fund grants in Haiti concluded that there has been significant progress in the fight against the three diseases despite a challenging country context, limited infrastructure and an unstable political landscape. The Global Fund Secretariat and the Principal Recipient, Population Services International (PSI), have designed financial assurance and implementation arrangements to ensure efficient and effective use of grant funds. There is, however, room for improvement in the way programs are assessed, in the assurance framework and in building capacity to ensure optimum grant impact.
According to the World Bank, Haiti is the poorest country in the Western hemisphere. The country has a shortage of health care professionals, low retention rates and gaps in services at all levels of the health care system. In January 2010, an earthquake of a 7.0 magnitude struck the island with devastating consequences. More than 220,000 people lost their lives, over 100,000 homes were destroyed and around 1.2 million people were displaced.
Total Global Fund investment of over US$376 million in Haiti since 2003 has contributed to the country significantly increasing the number of HIV patients on antiretroviral treatment. Currently, over 82,500 people receive antiretroviral treatment, representing 64% of the total estimated number of people living with HIV. The country is on the path towards malaria elimination. Malaria incidence decreased by approximately 50% between 2010 and 2015. Successful malaria interventions have made it possible for the country to adopt a national strategic plan with the aim of eliminating local malaria transmission by 2020.
However, the auditors also noted a number of key risks and challenges. PSI does not assess whether its grant sub-recipients have the necessary capacity (resources, equipment, strategies and systems) in place to reach programmatic grant objectives. This, together with other factors such as delayed signing of sub-recipient contracts and starting up of grant activities, may have contributed to low programmatic performance in the first year of grant implementation. The Global Fund addresses capacity building through, for example, financing grant activities related to recruitment and training of health workers. There is a risk, however, that these grant activities will not be sustainable if the government cannot assume the responsibility of the health workers beyond the lifetime of the Global Fund grant.
In 2016, the programmatic assurance framework was not prioritized although the country is categorized as a ‘Challenging Operating Environment’ by the Global Fund. This should have been a priority in line with Global Fund Board expectations that progress for these countries is regularly evaluated. Moreover, there are weaknesses in the Principal Recipient’s controls over programmatic and health product data quality at source level and limited mechanisms to ensure that the data it receives is accurate and complete throughout all reporting levels.
The auditors also found weaknesses in financial control arrangements. The local PSI affiliate does not have a functioning mechanism in place for fraud prevention, detection or reporting. There is a need to strengthen the link between financial controls and programmatic activities. The auditors found some expenditure does not relate to the intended grant activities. Sub-recipients, especially the governmental entities lack basic financial controls. The accounting systems are not reliable, policies and procedures are not updated, and there is no internal audit function.
The Global Fund Secretariat has plans to address the weaknesses identified by the OIG including updating the assurance framework; developing tools to assess the programmatic capacity of sub-recipients and ensuring that future grants include a component of capacity development.
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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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