Audit of Grants in Sierra Leone
18 January 2019
The Global Fund is a key partner in Sierra Leone, accounting for approximately 19% of the health sector budget and 27% of international health funding for the period 2015 to 2017: the current grants provide funding for 90% of the HIV program, 70% of the TB program and 74% of the malaria program. The 2014 Ebola outbreak stalled progress made on HIV and reduced TB services; the country, and in particular the health sector, remains engaged in recovery from the outbreak’s adverse effects.
Delays in executing key activities have meant that grant implementation has been adversely impacted, particularly on cross cutting health system strengthening key deliverables, such as warehouse construction. In terms of mitigating the high financial risks in Sierra Leone, the Global Fund has implemented various layers of financial controls, assurance activities and governance improvements. However these processes are not operating effectively to mitigate key financial and procurement risks. The implementation and oversight arrangements therefore need significant improvement.
Global Fund support for malaria, constituting 34% of total Global Fund investments in the existing grant cycle, has led directly to significant reductions in malaria incidence and mortality, mainly through improvements in prevention and treatment activities. For the other diseases, ongoing programmatic challenges include low TB case detection, difficulties in targeting key populations for HIV testing, low retention of patients on HIV treatment, and data weaknesses. Results have started improving as the impact of Ebola declines, and new and catch-up initiatives have been budgeted in both the current and the next grant cycle. Overall, the program management and monitoring processes are partially effective in providing quality services to patients and data for decision-making.
Sierra Leone’s supply chain is able to distribute medicines to districts and health facilities, however, there are limitations in the underlying systems and inefficiencies in procurement and supply chain management processes. These have led to stock outs and disruptions in treatment, emergency orders, expiries, and material gaps in stock records and reconciliations. The supply chain mechanisms therefore need significant improvement in ensuring timely provision of good-quality medicines to patients.