31 May 2019
Shortly after my arrival at the Global Fund in 2018, I requested the Office of the Inspector General to conduct an advisory review on grant implementation in Western and Central Africa. The objective was to gain a better understanding of potential implementation barriers and to identify opportunities to enhance program performance. In this region the Global Fund has encountered a range of issues including low absorption, challenges in financial management, and lack of sufficient coordination among partners. I wanted an objective assessment of how well we were tackling these challenges and where there are opportunities for further improvement.
I want to thank the Office of the Inspector General (OIG) for the effort devoted to this in-depth review. Many of the challenges described in this report are well known to Secretariat staff, and the recommendations align well with our ongoing efforts to tackle implementation obstacles in this region. Based on extensive interviews with implementer partners and rigorous analysis of program data, the report provides an excellent analysis of the successes and challenges we face in the region. We also welcome the numerous recommendations put forward in the report, which provide us with ideas and options to work on and test for feasibility as we look to drive greater impact in these critical countries. In fact, the report builds on several initiatives we have been putting in place; the publication of this report reinforces the need to accelerate their progress.
The report’s depiction of the current state of the fight against three epidemics is mixed. In a region characterized (as the report describes) by high fragility and instability, weak health systems, limited fiscal space, low health financing and a significant funding gap, there has been significant progress in reducing mortality from malaria (-37 percent since 2010) and HIV (-23 percent), although disappointingly, deaths from TB have increased (+5 percent). In-country absorption is now better at 77 percent than the average of 74 percent for the rest of Africa (although this composite masks variation among countries, with some countries still falling short on this metric).
The Global Fund is making significant investments in the West and Central Africa region, with disbursements of US$6.9 billion since 2002. Of this total, over US$3.3 billion has been for malaria, representing 30 percent of the Global Fund’s malaria investment (against a 40 percent share of disease burden), over US$2.7 billion for HIV, representing 14 percent of total HIV investment versus 9 percent of the global disease burden, and over US$700 million for TB (including HIV/TB), with the share of expenditure and burden equal at 9 percent. Since 2014, US$1.1 billion has been invested in RSSH, 36 percent of total investment over this period. Indeed, recognizing the unique context of this region, including the overall fragility of the health systems in which the Global Fund invests, the report correctly notes that the Global Fund deploys 5 FTE per $100 million of grant funding in this region, versus 2 FTE per $100 million in the rest of Africa.
The report recognizes that some of the most critical impediments to greater impact, such as state fragility and instability or weaknesses in political leadership and overall governance, are beyond the control of the Global Fund. At the same time, the report offers a series of recommendations around potential changes to Global Fund processes, modifications to grant implementation arrangements, refinements to technical assistance and health systems investments and ways to expand access to health services. The recommendations provide fresh ideas and options as we work to enhance impact across the region. Some reflect initiatives already in progress (the thematic review on user fees), or a logical next step in the implementation of specific policies (unlocking the full use of the flexibilities in the Challenging Operating Environment policy). Others, such as the recommendations around relaxing some fiduciary control, will need to be carefully assessed on a country-by-country basis taking a risk-based approach. While countries in this region have received 18 percent of the Global Fund’s cumulative investments, they account for over 44 percent of non-compliant expenditures. There are also recommendations that will need to be considered from the perspective of the entire Global Fund portfolio, since they would have implications beyond this region. Finally, there are a set of recommendations on which we will need to engage our partners, such as the Ministries of Health in each country, and agencies, like Expertise France and WHO, who provide technical assistance.
To take this forward, fleshing out and testing the report’s recommendations and translating them into practical changes, we envisage three strands of activity. First, reviewing and modifying internal policies and the way they are implemented (such as those for fiduciary assurance), as identified by the report. Second, conducting country by country reviews, working with governments, in-country implementers, technical partners and other stakeholders, to devise specific and practical action plans for each country, with clear accountabilities for the different partners. And third, engaging with partners on those issues (such as the provision of long term technical assistance) that stretch beyond the mandate and resources of the Global Fund to resolve.
My decision to request the OIG to conduct this advisory review reflects the importance we attach to achieving impact across the Western and Central Africa region. Achieving success in this part of Africa is crucial to us attaining the Global Fund’s overall goals. We welcome the report and are committed to working with our partners to translate the insights and findings into actionable improvements that will enhance our collective performance in fighting the three epidemics in this region.