Cameroon is achieving good progress in terms of prevention, diagnosis and treatment coverage for the three diseases, according to an audit report from the Office of the Inspector General (OIG) issued on 3 December 2021.

The audit found that the COVID-19 pandemic has had limited impact on grant implementation, other than for HIV community-based interventions, thanks to timely Global Fund financial support to Principal Recipients (PRs).

Grant implementation arrangements for the 2020-2022 allocation period were found to adequately address most key challenges, particularly around grant governance and coordination at the Ministry of Health (MOH), mass distribution of long-lasting insecticidal nets (LLINs), and linkage of HIV testing to anti-retroviral treatment (ART) coverage. Nonetheless, pandemic mitigation measures would continue to need close monitoring.

However, the report also found that measures to ensure malaria care at community level remain insufficient because they fail to fully address the importance of ensuring regular drug supplies to Community Health Workers (CHWs). Similarly, the delayed appointment of a humanitarian Sub-Recipient (SR) is adversely affecting the delivery of malaria health care at community level in the two regions undergoing a humanitarian crisis. As a result, the OIG assessed mitigation measures to address key issues that affected grant implementation during 2017-2019 allocation period as only partially effective.

The Global Fund provided Cameroon with €15 million in additional financing to support the national response to COVID-19, initially for a period of 11 months to 30 June 2021. Most COVID-related activities, including the development of tools, communication and capacity building, were completed in a timely manner. However, the audit found that a major challenge concerned the timely procurement of commodities and equipment, which represented 86% of the C19RM grant amount. Some laboratory testing products were delivered only in the last three months of the grant, and 36% of planned procurements had still not been delivered by the end of the grant period. This was mainly due to delayed contracting with vendors. Processes for ensuring timely and effective implementation of COVID- 19 investments were deemed to need significant improvement.

This audit builds on initial audit work which started in early 2020 but which was suspended due to COVID-19. While that review was not completed, OIG observations were shared with the Secretariat at the time to ensure prompt actions were taken. Audit work performed in mid-2021 takes into consideration the mitigation measures to address key issues previously identified across the portfolio.

Key achievements

Since 2003, the Global Fund has disbursed approximately €608 million to Cameroon, of which €167 million and €54 million were for the 2018-2020 and 2021-2023 implementation periods respectively. Disbursements stand at $761 million (converted to € using an average rate of 0.8). Full details on the Cameroon grants can be found at the Global Fund’s Data Explorer website.

Significant progress against HIV and malaria

Cameroon’s performance against key HIV indicators remains consistently above average for the West and Central Africa (WCA) region. From 2010 to 2020, new HIV infections and HIV-related mortality declined by 57% and 47% respectively, compared to 37% and 43% in WCA. As of December 2020, 78% of people living with HIV knew their status and 74% of diagnosed patients were receiving ART. Estimated malaria deaths declined by 12% from 2010 to 2019.

Enhanced grant governance and oversight at the Ministry of Health

The MOH manages 88% of Global Fund-financed activities in Cameroon. In the previous allocation period (2017-2019), the Secretariat Technique du Bénéficiaire Principal (STBP), the MOH entity responsible for grant implementation, was constrained by various challenges including inadequate staffing, weak coordination, and limited MOH ownership from MOH. Accordingly, a new Programme Coordination Unit (UCS-FM) was set up to replace STBP in oversight and coordination. It is well designed and resourced but key performance indicators (KPIs) to monitor its performance are yet to be defined.

Key risks/issues

Risk of delayed LLIN distribution

In the previous allocation period (2017-2019), LLIN distribution was delayed by between six and 18 months in specific regions. Distribution campaigns planned for 2019 in the two regions assigned to a government counterpart are still pending. Regarding the next LLIN mass campaign in 2022-2023, while adequate mitigation measures exist to ensure timely distribution in the eight regions covered by the Global Fund grant, there is a high risk of delay in the two regions covered by government funding due to time-consuming national procurement processes.

Supply chain issues, including delayed delivery of COVID-19 commodities

Procurements of essential health products and equipment account for 86% of the COVID-19 funding (C19RM). Key commodities, including laboratory testing reagents and personal protective equipment (PPE) for medical staff, were ordered early and delivered during the grant implementation period. However, many urgently needed commodities, including PPE and medical equipment, could not be delivered before the end of the COVID-19 financing period due to delayed contracting with vendors.

In fact, persistent issues have dogged the supply chain in the country for many years: (i) recurring stock-outs of key health products; (ii) insufficient supply chain coordination; (iii) inadequate and insufficient storage capacity; and (iv) inadequate inventory management. After two years of inactivity, a transformation project aimed at addressing these challenges is now on track to provide sustainable solutions to these persistent challenges.

Delayed recruitment of a SR has affected malaria services at community level in two regions in crisis

Several challenges affected malaria case management during the previous allocation period (2017 – 2019). To response to humanitarian crises in the North-West and South-West regions, the MOH planned to recruit a SR to support community-based interventions. At the time of the audit, this had not been completed due to the selected SR’s programmatic and financial capacity gaps. This resulted in: (i) delayed payments to CHWs slowing down malaria service provision in crisis-hit regions; and (ii) untimely contracting and procurements leading to significantly delayed LLIN mass campaigns.

The number of CHW-notified malaria cases fell by 50% (North-West) and 39% (South-West) from February to May 2021. This decline contrasted with an increasing number of cases (up 56%) notified by health facilities in both regions in the same period and suggests that several community members suffering from malaria in communities might not be diagnosed and treated.

Insufficient mitigation measures to ensure the provision of health products to CHWs

For the ongoing implementation period (2021 – 2023), targets for CHWs were re-adjusted to take account of the proximity of health facilities. However, no measures were taken to ensure CHWs were supplied regularly with health products and these irregular supplies hindered malaria healthcare provision at community level.

Agreed Management Actions

1. The Global Fund Secretariat in coordination with the MOH and the Country Coordinating Mechanism will finalize the KPIs to measure the performance of the grant coordination unit and agree on the frequency of the performance assessments. The KPIs should cover the following core responsibilities of grant coordination unit: grants implementation oversight, fiduciary control, procurement and coordination.
2. The Global Fund Secretariat in conjunction with the relevant in-country stakeholders will support the MOH to establish a Steering Committee and technical committees focused on oversight, planning, coordination, and monitoring capacity to implement prioritized supply chain strategies.
3. The Global Fund Secretariat will engage with the relevant stakeholders – including the MOH, PRs and technical partners – to agree on mitigation measures to: (i) reinforce the regular supply of commodities to CHWs; (ii) strengthen the linkage to ART for KPs; and (iii) ensure the timely payment of CHWs operating in the two crisis regions. Mitigation measures will be monitored by the Global Fund Secretariat.

The report notes that, regarding the new C19RM grant for the period ending 2023, mitigation measures have been considered for the timely procurement of commodities. The country is required to complete purchase orders in Wambo for essential items within ten days of the allocation notification. In addition, the Secretariat has defined KPIs in relation to the timely procurement of commodities and absorption for the new C19RM grant. For that reason, no AMA is needed.

Commentary

On a first, quick read this report conveys a positive message of progress with identified shortcomings being addressed. However, a slower examination of the report raises some questions.

In the first finding, the report states: “Governance challenges at the civil society Principal Recipient are hindering grant implementation.” How then, in view of these challenges, did the OIG come to award a grant rating of A1 to this PR in the second half of 2020, whereas the MOH was only rated B1? The OIG’s response to this query is that the governance challenge started in February 2021 while the performance rating in the report refers to the period 2018 – 2020. At the time of drafting the audit report, the grant progress update report (which provides grant rating) was not completed for 2021.

In the Executive Summary it states that “Grant implementation arrangements for the 2020-2022 allocation period adequately address most key challenges, particularly ……..  mass distribution of long-lasting insecticidal nets, …” but, under key issues and risks, it says that “In the previous allocation period (2017-2019), the distribution of LLINs was delayed by between six and 18 months in specific regions.  Distribution campaigns planned for 2019 in the two regions assigned to a government counterpart are still pending.” This is confusing because it sounds somewhat contradictory. The OIG response is that the reported delays refer to the previous mass campaign which happened in 2019/2020. The mass campaign for the current funding cycle (2020 – 2022) is planned for 2022/2023. The objective of the audit was to ensure that adequate mitigation measures have been taken for the upcoming mass campaign to avoid the significant delays noted in the previous mass campaign (2019/2020). The conclusion is as follows: adequate mitigation measures are already in place to ensure timely completion of 2022/2023 mass campaign in the eight regions covered by Global Fund grant, but there is a high probability of delay in the two other regions assigned to Cameroon government financing.

There is no mention in the report of counterpart funding. Does mean that the disease programmes are fully funded by the Global Fund grants? The issue of counterpart funding is important because there have been many references to the secrecy of Government expenditure in Cameroon (some are mentioned below). The OIG agrees that domestic financing is a real concern in Cameroon; however, this area was scoped out because the OIG has been conducting an advisory review on this theme (report to be issued soon). To avoid repetition and/or duplication of effort, it was agreed not to review domestic financing in country audits in 2021.

The Executive Summary begins: “Cameroon is achieving good progress in terms of prevention, diagnosis and treatment coverage for the three diseases.” However, the reported HIV new infection rate for 2020 (quoted in the OIG report to have been 15,000) was certainly an improvement over 2010 (an improvement of 40% from 25,000) but, according to the World Bank, it was up 15% from 13,000 in 2019. Not a steady improvement. However, the OIG’s main source of information for HIV is UNAIDS. UNAIDS data show a continuous decline in HIV new infections and death since 2010. This is a classic example of the inconsistency between various data sources for the same period of time.

Perhaps more caution should have been applied given the possible – but as yet not assessed – impact of COVID-19. See for example an article at: https://gga.org/the-cracks-in-cameroons-health-system/. This agrees and shares these concerns. For this reason, one of the report’s AMA is to speed up the process for recruiting a humanitarian SR to assure continuity of service delivery by CHWs in these two Anglophone regions .The statement in the audit report is based on facts backed by data reported in the country’s health management information system (HMIS): data suggest a very limited impact of COVID on the three diseases as of December 2020 even if some issues were noted (refer to finding 4.3 on the slowdown of malaria care provision in the two regions in crisis).

Also, since 2018, Médecins Sans Frontières (MSF) has been running a 24/7 ambulance service, community-level care and support to health facilities in the two crisis regions. In 2020, almost 9,000 referrals were completed through the ambulance service. However, in December 2020, MSF medical services were suspended by Cameroon’s authorities in the Northwest region; this suspension had not been lifted when MSF reported on the situation in July 2021. This report shows a deteriorating situation in 2020 which looks likely to be reflected in many health indicators including those for HIV, TB and malaria.

With regard to Finding 4, in researching the effects of COVID-19 on the health system in Cameroon I came across a recent report that states: “The implementation of the response strategy was hampered by the highly centralized and heavily bureaucratic nature of the governance system of the country, especially at the level of purchasing arrangement where all decisions were taken from the central level and funds managed in total secrecy.” And another article by the Human Rights Watch openly discusses the Government’s secrecy in managing funds for the COVID-19 response. However, the OIG confirms that the procurement arrangements for Global Fund grants are not affected by the issue of Government bureaucracy as most COVID-19 related items are procured through systems (either Wambo or third party) outside Government control.