24 November 2022
Zambia is a key country in the global fight against HIV, tuberculosis (TB) and malaria. This is due in part to the significant disease burdens it has for malaria and HIV. The country has the world’s sixth highest malaria incidence, a growing number of multidrug-resistant tuberculosis (MDR-TB) cases and an estimated 1.5 million people living with HIV.
While there have been some improvements in the portfolio, including progress in the HIV treatment cascade for adults and robust programmatic performance for drug susceptible TB, since the last OIG audit in 2017, performance has also stagnated and declined in areas. This is most notable with malaria, as well as persistent issues with HIV prevention activities for key populations, issues with the Program Management Unit (PMU) of the Ministry of Health and challenges with procurement and supply chain.
The malaria program has seen downward trends in morbidity and mortality indicators since 2017, linked to issues in vector control, sub-optimal community case management, increasing lack of disease awareness and the government’s decreasing prioritization of the malaria response. While the HIV program has made significant progress overall, issues with assessing antiretroviral therapy (ART) attrition, significant delays, sub-optimal performance and limited scale-up of activities for adolescent and young people (AYP) and key populations threaten to stall and reverse programmatic gains made. MDR-TB is a growing problem in Zambia, with an increasing in estimated cases coupled with a decline in notifications. Thus, the design and implementation of grant programs needs significant improvement.
Good oversight of implementation and financial management has been noted for the Churches Health Association Zambia (CHAZ) Principal Recipient. However, there are significant issues with the Ministry of Health’s PMU, with key gaps in financial and sub-recipient management and oversight along with challenges in assurance and human resource management. This is despite significant investment in the PMU structure since 2012, with US$16.9 million budgeted between 2018-2023. Lapses in robust management and oversight in the Ministry of Health grant have resulted in material issues with financial management and program implementation for some activities. Thus, the adequacy and effectiveness of program and financial management and oversight needs significant improvement.
Zambia’s procurement and supply chain system has faced persistent challenges since 2017, notably with quantification and forecasting, as well as with the establishment of regional hubs and procurement and supply chain management (PSM) related data systems. Despite raising these issues in the previous OIG audit in 2017 and repeated management letters from the Global Fund Secretariat throughout NFM 2 and 3, there has been limited action to resolve them. A contributing factor has been the limited implementation of oversight controls and the lack of Ministry of Health senior management ownership over procurement and supply management activities. These factors have contributed to significant stock-outs of malaria commodities and high stock-out risks, as well as to actual stock-outs for HIV commodities. As such, the effectiveness of the procurement and supply chain needs significant improvement.