22 December 2017
Zambia has successfully scaled up its response to the three diseases and made significant progress towards ending the epidemics. However, as the programs have scaled up, the country’s infrastructure has had difficulties in keeping up, particularly in terms of human resources, diagnostics, monitoring and evaluation capacities. The auditors also noted stock-outs and expiries in the supply chain that the OIG is currently investigating in a separate engagement.
The Global Fund has invested close to US$1 billion in Zambia since 2003. Based on a recent population survey, 89% of people living with HIV aged 15-59 years old have suppressed viral loads; malaria deaths decreased by 70% between 2010 and 2015; and progress has also been made on tuberculosis with incidence falling by 40% since 2003.
Despite the good progress, the country does not have enough health workers, with capacity only at 30% of what WHO recommends for effective and quality service delivery. This makes it more difficult to diagnose, monitor and retain patients on treatment. For example, late diagnosis for infants who have been exposed to HIV delays the start of treatment. A two-year delay in realizing a donor commitment significantly affected the delivery of multidrug-resistant tuberculosis care. As a result, only 8.5% of estimated multidrug-resistant tuberculosis cases in the country are reported as receiving treatment.
Delays in the implementation of key interventions have also impacted the availability of services. For example, indoor residual spraying took place late in the 2016 rainy season which made it less effective as a preventive measure against malaria. Delays in tuberculosis care have affected the number of cases identified with an estimated 40% of cases remaining undiagnosed across all age groups.
Approximately 60% of grant funds are spent on procuring, storing and distributing health commodities. Due to the rapid expansion of people on treatment, the supply chain is stretched to deliver health products and to account for those received. The audit identified stock-outs and expiries of health products of varying magnitudes at different levels of the supply chain including expiries of antiretroviral medicines valued at almost US$4 million.
The Global Fund and other partners rely on a health management information system for routine data on the three diseases. The country also carries out national surveys to inform decisions. However, routine disease data reporting is not always accurate nor complete. This is due to the absence of up-to-date monitoring and evaluation plans to guide the relevant activities; fragmented patient information systems; and gaps in capturing data at facility level.
The OIG audit also noted gaps in governance, leadership and program oversight which compromise program effectiveness. The country needs to develop a consolidated map of the donor landscape to better coordinate interventions to avoid gaps and potential duplications.
The Global Fund Secretariat has plans to address the risks identified by the OIG including strengthening diagnostic capacity, referral mechanisms and patient monitoring in new grant activities and improving stock management and last mile distribution of health products.
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