25 January 2019
Despite a challenging, hard-to-access environment, low levels of human development and frequent natural disasters, program results in Madagascar have improved over the last two years. Malaria mortality has dropped by 33%,1 and patients benefiting from MDR-TB and HIV treatment have increased. However, challenges remain: access to malaria services is low, particularly at the community level in hard-to-reach areas, HIV detection and treatment are significantly lower than prevalence estimates, and poor availability and inconsistencies in data-sets affect decision-making.
The supply chain in Madagascar is equipped to store and distribute health products. In particular, distributions from central stores to districts are timely. There are challenges in quantification, particularly for malaria, and related data management for decision making, despite strong support from partners. All three diseases experience issues with procurement planning. These challenges have resulted in stock outs at central levels and some stock outs and disruption of services to patients at the facilities. Improvements could be achieved through effective data supervision, timely procurement planning and strengthened staff capacity for the supply chain. This area is rated “partially effective”.
Despite high inherent financial risks in Madagascar, the audit did not identify material financial irregularities or ineligible expenditures, based on a review of over 60% of expenditures for 2016-17. This positive outcome for financial management is due to additional financial controls and assurances over Global Fund investments, such as the presence of both a fiscal agent and a Local Fund Agent, and channeling higher-value transactions through alternate mechanisms such as the pooled procurement mechanism, International Non-Government Organizations’ procurement systems or the Global Drugs Facility. Financial procedures have also been strengthened and applied, and financial software used by PRs has been upgraded. However, whilst these controls have effectively mitigated risks over use of funds, low financial management capacity within programs has delayed some procurement and other program activities. This, in turn, has contributed to low absorption of grant funds to fully achieve program impact.