Audit of Grants in South Africa
19 July 2017
The OIG found that Global Fund programs are well aligned to South Africa’s needs and target the right areas. At the same time, the audit also identified a need for significant improvement in implementation of the programs. It is important to evaluate the issues identified in the audit in the following context:
- Given the significance of the country’s innovative approach, the country was audited relatively early in the grant cycle so as to identify key implementation challenges, to draw some initial lessons and, where necessary, consider potential course corrections in a timely manner.
- The Global Fund’s financial contribution is limited in relation to the overall national health budget. Whilst this contribution focuses on critical areas of intervention, especially in relation to certain key populations, it represents only 5% of the overall contribution to HIV and tuberculosis (TB) funding in South Africa.
- The interventions funded by the Global Fund are well-aligned to the country’s national strategic plans as well as the national HIV and TB investment case.
- Conceptually, most of the Global Fund interventions are comprehensive, technically sound, strategically focused on relevant key populations and informed by use of available epidemiological and programmatic data.
- Some of the interventions, such as the Social Impact Bond program, are innovative approaches. If successful, these innovative approaches could help leverage and provide the country with additional resource mobilization and programmatic options to address the dual heavy HIV and TB epidemics in South Africa. As with any significant innovations, there is a learning curve that is inherently involved and early identification of issues and challenges should allow the Global Fund and the implementers to make the necessary course corrections and achieve the intended objectives.
- Both the Global Fund Secretariat, the Country Coordinating Mechanism and the implementers have been responsive to the audit findings and corrective actions are already underway to address several of the issues. If these corrective actions are effectively implemented, the programs should be on track to achieve their intended objectives.
South Africa accounts for 19% and 7% of the global HIV and TB burdens respectively, making it the country with the highest number of people living with HIV and sixth highest for TB in the world. South Africa has made great progress against HIV, and has dramatically improved the nation’s overall life expectancy in recent years. The South African government has demonstrated a strong sense of ownership in the response to the three diseases and it funds approximately 80% of the HIV/AIDS and 90% of the TB response. The Global Fund concentrates mainly on prevention activities through innovative programs implemented by eight Principal Recipients. The programs focus on key populations such as sex workers, men who have sex with men, as well as adolescent girls and young women.
With the above context as an important background, the OIG found challenges particularly in the TB programs. Eighteen percent of Global Fund investments in the current cycle are earmarked to fight TB. Although TB program activities began in July 2016, some grant indicators were still at a 0% achievement rate as of 31 December 2016. This was mainly due to the ineffective management which hampered the planning and delivery of key program activities.
The auditors also identified several changes in coverage, scope and content to programs that were not reviewed by the Country Coordinating Mechanism or the Secretariat to evaluate the impact on overall program objectives. These changes include a reduction in geographic coverage of interventions addressing treatment adherence from 31 to 21 districts, and HIV and TB-related stigma from 18 to 6 districts.
Without mechanisms in place to ensure consistency and quality across similar activities, it is difficult to coordinate programs across the eight Principal Recipients. This is particularly an issue in activities targeting adolescents and youth that are implemented by six different implementers, all of which operate to different standards and quality. Program interventions have been allocated to Principal Recipients without taking sufficiently into account core technical competencies and geographic presence in the areas of program delivery. As a result, many of the implementers have spent most of the first year of grant implementation setting up operations, learning about the new interventions, and trying to obtain from various provinces the necessary approvals to begin grant activities.
The OIG also found a multiplicity of uncoordinated data systems and tools across the various implementers. Good quality data is important for the accountability and effective monitoring of grant interventions. At a national level, which is beyond the control of the Global Fund program, there was no national monitoring and evaluation plan during the period covered by the audit. At the program level, the indicator definitions for key program activities are yet to be clarified in the current performance framework.
The Global Fund Secretariat, as part of its program oversight mandate, had already identified some of the risks such as the need to revisit its monitoring mechanisms to ensure that they remain effective with regard to new program interventions and innovative approaches. The Secretariat has also developed plans to address the issues identified, including the following actions: developing revised budgets and implementation arrangements for the remaining duration of the grants to improve the availability and quality of TB and drug resistant TB services; by supporting the Principal Recipients in the development of quality standards for adolescent girls and young women and revisiting the work plans; strengthening Country Coordinating Mechanism oversight, rolling out a revised consolidated performance framework for interventions related to adolescents and young people in and out of school.
- Audit of Global Fund Grants to the Republic of South Africa (GF-OIG-17-014 - 19 July 2017)
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Thomas Fitzsimons
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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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