Investigation in Tanzania
28 January 2020
A follow-up investigation by the Office of the Inspector General (OIG) on concerns raised by a 2018 OIG audit in Tanzania [ download in English | Français ] could not quantify the extent to which anti-malaria drugs (ACTs) are being diverted, nor specific parties involved, due to persistent weaknesses of data management in supply chain operations.
The OIG only publishes investigation reports when conclusive findings of fraud and abuse have been made, in line with the applicable professional guidelines. The investigation has therefore been closed without a formal report.
In its 2018 audit, the OIG identified an unreconciled variance of 4.7 million Global Fund-funded ACT treatments or blisters. This was done by comparing the data of ACTs supplied by the Medical Store Department (MSD) to health facilities throughout the country over the period October 2016 to September 2017, with District Health Information System (DHIS2) data that reported consumption of ACTs by the facilities during the same period. MSD reported supplying 15.8 million ACT treatments, while the system recorded dispensing only 11.1 million. The OIG audit attributed the identified variances to under-reporting of malaria treatments in DHIS, unreported expiries by health facilities, or potential drugs leakages.
The OIG investigation, finalized in December 2019, confirmed that under-reporting of malaria treatments, expiries and drug leakages are responsible for the discrepancy of 4.7 million ACT treatments identified in the OIG audit. It also identified a series of weaknesses in Global Fund-financed ACTs supply and consumption data that continue to negatively impact the Global Fund’s malaria grant in Tanzania.
National Malaria Control Program (NMCP) erroneously inflates the quantities of ACTs dispensed
The vast majority of health facilities did not report data through DHIS2 during the audited period. NMCP’s ‘reporting rate’ measures the number of dispensing summary reports each District Medical Office (DMO) expects to receive from health facilities in its district, versus the number received. NMCP took low reporting rates by health facilities at the time into account when quantifying the number of ACT blisters dispensed, adjusting the reported number upwards from 5.9 million to 11.1 million. NMCP did not, however, take account of several important factors negatively affecting ACT consumption data:
- Significant delays in reflecting in DHIS2 changes related to newly opened and closed facilities;
- DMOs’ acceptance of ACTs reports with ACT sections left blank;
- Reports that use the wrong units of measurement, recording tablets instead of blisters (a blister pack typically contains 6-24 tablets), which results in health facilities placing orders using the wrong unit of measurement and receiving higher quantities than they can absorb;
- Failure to account for ACT blisters returned by health facilities to MSD, and ACT consumption data reported by private health facilities that do not receive Global Fund-funded ACTs.
Drug expiries are not properly reported
The OIG investigation could not estimate the total quantity of expired ACTs during the audited period throughout the entire supply chain, because the aggregated data on expired ACTs was not available. After the investigation was completed, MSD informed OIG that no ACTs expired during the audited period.
In contrast, in the six months period that followed the audited period, the LFA identified that 12% of ACTs expired at 18% of the health facilities reviewed by the LFA, representing a value of US$14,314. This discrepancy indicates that MSD is failing to accurately account for expired ACTs.
Possibility of leakages of ACTs from health facilities
The same LFA review observed that 32% of reviewed health facilities had dispensed fewer than 50% of the ACTs they had received from MSD. This amounted to 29,551 ACT blisters, valued at US$15,913, of potentially undispensed stock.
In September 2019, OIG investigators commissioned a market survey focused on the north-western part of Tanzania and covered Geita and Mwanza regions. The survey found Global Fund-financed ACTs on sale at 14% (8 out of 56) of the reviewed drug sale points.
The grant’s Lead Implementer could not fully account for 2,636,670 ACT blisters included in the total amount of 15.8 million ACT treatments supplied by MSD
MSD provided information to support how 2,636,670 blisters were issued to various facilities around the country through three programmatic accounts. MSD advised that these drugs had been requested either by the Ministry of Health, Community Development, Gender, Elderly and Children (the MoHCDEC), the Lead Implementer of the Global Fund grants in Tanzania, or by NMCP for special interventions such as campaigns and studies, in addition to ACTs which the same health facilities regularly requisition from MSD. However, MSD could only provide evidence of the MoH requesting 16,680 out of 2,636,670 blisters, and had no evidence of how consumption of any of the total volume of ACTs was accounted for.
To mitigate the risk of expiries and diversion into parallel markets, resulting from the oversupply of ACTs to health facilities, the Secretariat has agreed to trace the delivery of ACTs. If they are unable to trace them, the Global Fund will seek to recover the funds.
Conclusion
This OIG investigation identified a series of weaknesses in Global Fund-financed ACTs consumption data and evidence of drug diversion to parallel markets. There are significant discrepancies between data recorded in DHIS2 and data stored at health facilities. Drug expiries are not being properly reported and the NMCP erroneously inflates the quantities of ACTs dispensed. The investigation found that critical data flaws continue to negatively impact the Global Fund’s malaria grant in Tanzania. Based on the findings of this investigation, the Secretariat should continue working with the Ministry of Finance and Planning, the Principal Recipient, the MoHCDEC and the Tanzania National Coordinating Mechanism on implementation of the holistic supply chain review action plan, which resulted from a 2015 OIG audit of grants to Tanzania, to improve the accountability for these health commodities.