25 August 2017
An audit of Global Fund grants in Guinea concluded that there has been significant progress in the fight against the three diseases despite the challenging operating environment. The supply chain is able to distribute medicines, although significant improvement is still needed to address inefficiencies identified in supply planning and related assurance mechanisms. The Global Fund country team has significantly enhanced financial controls to mitigate fiduciary risks and additional measures have also been instituted to address capacity constraints. These measures have reduced many of the risks, but some limited gaps still exist.
The Global Fund has signed over US$ 228 million and disbursed US$ 176 million in the fight against HIV/AIDS, tuberculosis and malaria in Guinea since 2003 and has currently four active grants in the country.
Guinea’s country context is important and relevant to the issues identified in the report. It is a low income country with a population of 12.6 million and about 55% live below the poverty line. The country is ranked 183 out of the 188 countries in the 2016 UNDP human development index report. The Fragile States index rates the country as high risk, with weak institutional structures and poor infrastructure which affect health service delivery. The country has one of the lowest health care workforce ratios, which also affects health service delivery. The health worker density is less than one health worker to 10,000 population. The challenging environment was compounded by the emergence of the Ebola virus epidemic in 2014, which had multiple economic and social consequences in Guinea and had profound impact on the health system.
As the fiduciary risks in this portfolio are considered high, starting in 2013 the Secretariat instituted various layers of financial assurance activities. The measures have reduced many of the risks, but some limited gaps still exist. The OIG therefore considers the mitigation measures instituted by the Secretariat as partially effective. The use of a fiscal agent and a zero-cash policy for sub-recipients is credited for reducing the extent of ineligible and unsupported transactions. Nevertheless, a capacity building plan is not yet in place for the National Committee for the Control of AIDS.
The audit highlighted inefficiencies in the supply chain that need to be addressed. There was an estimated US$3 million in potential expiry of anti-retroviral medicine for stock purchased in 2016. Simultaneously, stock out of HIV test kits were noted in health facilities, limiting potential for scale up of treatment activities. For HIV, morbidity data, which varies according to sources, is the basis for product needs quantification for example. A plan is being implemented to better understand the number of patients needing ARV treatment. For malaria, while treatment guidelines have changed, quantification under the old regimen drive quantification under the new treatment. Given both regimen have different treatment range, this, along with poor tracking of expiry across stock provided by different donors, leads to imbalance in the availability of treatment for different age groups. Challenges in Inventory and Logistics Management Information System remain as an LMIS systems is still needed for HIV pharmaceutical products and commodities.
Good coordination between stakeholders - Catholic Relief Services, the United States’ Presidential Malaria Initiative and the National Malaria Control - was noted in the malaria grant. This notably enabled a successful mass distribution campaign for bed nets, and good product availability in health facilities. In the HIV area, limited availability and capacity of in-country stakeholders have affected implementation of program activities and program performance. Low implementation of Prevention of mother-to-child transmission activities were noted, along with gaps in monitoring of patients on anti-retroviral therapy.
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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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