Audit of Global Fund Grants in Bangladesh
22 December 2017
Bangladesh has made significant progress in ending the three epidemics despite political unrest and severe flooding in recent years. The country is edging closer towards malaria elimination with 51 out of its 64 districts now considered to be non-endemic. However, many cases of tuberculosis go undetected which could compromise gains made to date. The OIG audit also called for more operational efficiency and value for money from current grant arrangements as well as a longer term plan to transition programs to national implementers.
Bangladesh has seven active Global Fund grants totalling US$117 million. Four of the grants are implemented by non-governmental organizations (NGOs), mainly due to the weak capacity of national programs. This has ensured that Global Fund program objectives have been consistently met, at least in the short term. The country has reduced child mortality under five; implemented innovative measures such as short courses for multi-drug resistant tuberculosis; and met targets for HIV prevention activities for key populations.
However, preliminary findings from a recent country-wide tuberculosis survey estimated rates of 62% for incidence and 53% for prevalence. A large proportion of cases are only detected at advanced stages of the disease. The undetected cases may increase morbidity and contribute towards mortality if not addressed. Limited planning and use of GeneXpert diagnostic machines, as well as little private sector engagement in screening, contribute to low case detection. Only 11% of reported tuberculosis cases in 2015 and 2016 were diagnosed using the machines.
The OIG found that implementation arrangements for Global Fund grants have been effective so far in achieving program targets. However, the arrangements need to be rationalized as there are cost variations between the two NGOs responsible for the HIV grants. For example, staff costs are 24% higher at the NGO that receives the smaller grant and has a lower number of staff compared with the other implementer. This affects the unit cost of some interventions. The government and Global Fund recipients need to improve coordination to reduce duplications and overlaps in the location of drop-in centers which provide services to key populations vulnerable to HIV. Some districts had more drop-in centers than required while other high priority districts had none.
Global Fund grants have been mostly implemented by the NGOs for the past 12 years due to resources and leadership constraints in the national programs. The government said that it would take over HIV care, support and treatment services in September 2017 but at the time of the audit there were few transition arrangements in place. The government has not assessed whether its public health facilities will be able to provide the services. Nor had it recruited the necessary staff as of August 2017. People living with HIV may be at risk of not receiving adequate services if the transition is not properly managed.
Gaps in supply chain systems continue to affect the delivery of medicines and health products with delays in port clearance, suboptimal storage conditions for tuberculosis drugs and limited quality monitoring. The Secretariat has put in place several measures, including a temporary warehouse, to ensure that Global Fund-procured medicines are effectively distributed. Although the measures have mitigated stock-outs at health facilities, underlying systemic weaknesses continue to impact supply chain arrangements.
The Global Fund Secretariat is taking corrective actions to address the issues identified by the OIG audit. Actions include plans to better use the GeneXpert machines, map drop-in-centers to population needs, and move medicines away from the temporary warehouse to other storage facilities.
- Global Fund Grants in the People’s Republic of Bangladesh
(GF-OIG-17-027 - 22 December 2017)
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For more information:
Thomas Fitzsimons
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Mobile: + 41 (0)79 412 1461
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