25 November 2022
Madagascar has a challenging environment due to its exposure to recurring natural disasters, successive waves of epidemics, hard to access environment and low human capital. The country continues to struggle to achieve expected impact to reduce mortality and incidence for HIV and malaria, although at least 70% of grant performance targets are met on average. For the past 10 years, tuberculosis incidence and related mortality has remained stable.
Despite a significant increase of patients on antiretroviral treatment in the past three years, coverage remains the lowest in Africa (15%). This is due to weaknesses in the design and implementation of HIV testing, recurring stock-out of HIV test kits and misalignment of grant indicators. As a result, HIV related mortality and new infections have continued to rise over the years in contrast with expected grant impact. Underperformance on HIV testing in the country was raised during the OIG audit in 2018.
Regarding malaria, both incidence and mortality have risen in 2021. The OIG noted limited planning and oversight of long-lasting insecticidal net (LLIN) mass campaign distribution as a contributing factor to increased incidence. Significant improvement is needed in HIV and malaria grant design and implementation to ensure grant objectives are achieved.
Key health commodities for the three diseases were continuously available during the implementation period with few exceptions. The OIG noted, however, limited assurance over the quality of health products due to sub-optimal storage conditions at peripheral levels and lack of in-country quality controls. There is also a risk of expiries of antiretroviral medicine and products, amounting to US$2 million procured through C19RM funds, due to low demand from health facilities. Significant improvement is needed in the adequacy and effectiveness of processes to ensure continuous availability of quality-assured commodities across the supply chain.
The Global Fund has instituted safeguard measures for government implementers, including the use of fiscal agent services and a zero cash policy to reduce exposure to fiduciary and financial risk. Although no material non-compliant expenditures were identified, the inadequate design of existing procurement procedures and recurring non-compliance indicates the need to strengthen oversight and internal control systems. Significant improvement is needed to ensure the adequacy and effectiveness of internal controls to mitigate financial and fiduciary risks.