Auditors check data, so we tend to rely on their findings; but they do not always get it right. This report is such an example of inaccurate use of data. On 26 August 2022, the Office of the Inspector General (OIG) published its audit report on the Global Fund grants to the Republic of Congo. According to OIG, the burden of HIV, tuberculosis and malaria remains high in Congo and, in the past 10 years, little progress has been made in fighting the diseases, a result of both limited national government support and the limited scope of Global Fund grants in previous funding cycles. Can we be sure that this is in fact the case?

Progress or no progress?

The report does not state what 10-year period it is referring to but, for sake of comparison, let us use 2010 compared with 2019.  The reason for selecting 2019 is: (a) that is the most recent year for which health expenditure data are available; and (b) it avoids the distortions caused by the COVID-19 pandemic. In Table 1 are comparative disease data taken from the same source used by OIG (Oxford University: Our world in data):

Table 1: Comparison of Disease Data 2010-2019

	2010	2019	Change
Population (000s)	4,274	5,381	+25.9%
HIV prevalence	3.4%	3.3%	-3%
New HIV cases	8,100	13,000	+60%
% of deaths from HIV/AIDS	16.86%	12.05%	-26%
HIV deaths	5,966	4,274	-28%
TB deaths	2,121	1,961	-8%
Malaria deaths	1,904	2,102	+10%

This table suggests that some progress has been made in all diseases; and even malaria, because, although the number of deaths increased, the increase was much lower than the rise in population number. However, this data source may not be reliable. For example, most researchers use the Joint United Nations Programme on HIV/AIDS (UNAIDS) as the data source on HIV and AIDS. If we use UNAIDS data, we have the following comparison:

Table 2: UNAIDS HIV/AIDS Data on Congo

	2010	2019	Change
People living with HIV	90,000	120,000	+33%
New HIV cases	8,100	13,000	+60%
AIDS-related deaths	5,200	6,800	+31%

This is indeed bad news: not just ‘little progress’ but NO progress.

To confuse us further, the data presented later on the three diseases are drawn from different sources but they compare 2010 with 2020 data, an unfair comparison because of the impact of COVID-19. Also, no account is taken of the 29% population increase over that period. But the real issue is the impact of COVID-19 in 2020 – see Table 3 below – which is why using 2020 data for a ten-years comparison is inappropriate:

Table 3: The Impact of COVID-19 in Congo

	2019	2020	Change
Population (000s)	5,381	5.518	+2.5%
People living with HIV *	120,000	130,000	+7.7%
New HIV cases *	13,000	14,000	+7.7%
AIDS-related deaths *	6,800	7,100	+4.4%
TB deaths	2,781 **	5,200 ***	+87%
Malaria deaths	2,102	2,354	+12%
*     Source: UNAIDS . **   Source: World Health Rankings *** Source: Global Tuberculosis Report 2021.

OIG is not convinced by the above comparisons; but they happen to be the data available to this author. OIG has commented that they considered that COVID-19 had no material impact on the disease program in Congo; and hence the omission. That does not appear to be consistent with the Global Fund’s need to respond to the COVID-19 pandemic, including its C19RM allocation to Congo.

To confuse us yet further, the data used in the report’s section on country context are for varying periods. This looks to be intentional in order to paint the worst picture. Let us compare the data in the report with other data sourced from the World Bank online database:

OIG Report
	2012	2014	2019	2020	Change
GDP		*		*	-43%
Government expenditure on health per capita		US$76	US$48		-37%
Out-of-pocket health spending (% of total)	30%		46%		+53%

World Bank Data
	2010	2014	2018	2019	Change
GDP (constant 2015 US$)	2,422	2,602	1,840	1.609	-34%
Government expenditure on health (US$ million)	108.9	169.6	91.6	98.2	-10%
Government expenditure as % of total expenditure	3.6	1.9	3.5	3.5	-3%
Government expenditure on health per capita (US$)	25.5	35.8	17.5	18.3	-28%
Out-of-pocket health spending (% of total)	42.2	31.2	50.3	45.9	+9%

Lack of rationale for increasing Global Fund investment

The report notes that “The Global Fund has disbursed nearly US $137 million in the past 17 years to support the fight against HIV, TB and malaria. The results and impact, however, from these investments have deteriorated in the past 10 years.” It also notes: (a) the low government investment in the health sector (3.4% in 2017 and 3.5% in 2018 and 2019) and non-compliance with co-financing requirements (only 4%); and (b) the conditions for grant implementation under NFM3 are not optimal. Yet, in the summary it informs us that “The Global Fund has strengthened its controls and oversight since 2018 by enforcing its Additional Safeguard policy and has doubled grant allocation (from EUR 31 million to EUR 57 million).”  So, despite Global Fund support, results were deteriorating. The Global Fund responded by investing more when the government did not. Today, faced with the oncoming shortage of available funding (the 7^th Replenishment did not meet its target, was already insufficient for the gap outlined in the Investment Case, and the situation is being made worse by inflation), the rationale for doubling investment when the key conditions for grant implementation are not optimal is questionable. Note that the situation in Congo may have deteriorated but it is not classified as a Challenging Operating Environment country.

The reasons for poor performance

According to the first finding, the poor performance is the result of three contributory factors:

• Low government investment in health;
• The limited Global Fund allocation has narrowed the scope of interventions; and
• The limited number of partners investing in health.

The first has been consistent over time and is unlikely to change in the short-term.

The second, which echoes what is stated in the executive summary, is another way of stating that some priority interventions had to be omitted due to limited funding. For example, key interventions for HIV include prevention, testing and treatment. In NFM2, only treatment intervention, for patients already under antiretroviral therapy (ART), was funded by Global Fund. In this case, because of the funding constraint, the scope of the response to HIV was narrowed by excluding three key interventions (prevention, testing and expanding ART). In the absence of those three interventions, how will Congo progress towards eliminating HIV by 2030? The same limited allocation factor also implies that there is a minimum level of investment needed to achieve impact. Does the increased grant funding meet the minimum necessary to make some progress on prevention and detection; and is there any hope of achieving the 2030 disease elimination target on this basis?

As for the third factor, there is only one development partner in the health sector (the French Development Agency). Is that because Congo spends relatively more on health than many other countries in Africa (in 2019 Congo spent more per capita on health than 30 other African countries) and the government could spend more?

These factors are said to have resulted in: the human resource gaps at all levels; non-fulfilment of government commitments; weak governance over grant implementation (i.e. the Country Coordinating Mechanism (CCM) is not doing its job); unresolved Conditions Precedent; conflicts with national disease program priorities; and poor ART retention. These inadequate conditions for implementation are said to have contributed to significant delays in implementing workplan activities in 2021, particularly for the HIV/TB grant, such that, overall, only 51 of 198 (26%) planned activities were completed.

Are the Agreed Management Actions going to solve the problems?

To deal with this, the first Agreed Management Action (AMA) is for the Global Fund Secretariat to work with the Ministry of Health and relevant partners to review and revise its current approach to intervention design and implementation for HIV/TB high-volume priority sites. According to OIG, this revised approach should address issues including: health product availability and traceability, human resources, oversight, management and coordination.

This AMA is unconvincing to the outside reader because:

1. The inadequacy of human resources is mostly due to the lack of financial resources for health. This is not mentioned; nor is the need for government to: (a) comply with its co-financing commitments; and (b) consistently invest more in health;
2. It is to be applied only to HIV/TB high-volume priority sites (however they are defined) and not across the programs, so the weaknesses will remain in the programs;
3. It is unclear who the OIG and management consider to be the ‘relevant partners; and
4. It gives the disturbing impression that the Secretariat is going to become involved in program redesign and implementation. This could mean a lot more work for the Country Team. Good luck to them!

The second finding is that delays in preparing and executing distribution plans have led to severe stock-outs at health facility level. Inventory management in central warehouses has improved, but health facilities still experience challenges to account for received drugs due to weak inventory management systems. These problems are considered to be dealt with by the AMA for the first finding. Let us hope so.

The third finding provides some relief: malaria grant implementation arrangements provide good assurance over financial and fiduciary risks.

Conclusions

Four messages emerge from reading this OIG report:

1. OIG could be clearer and more consistent in its presentation of data.
2. The weaknesses and delays that resulted in disappointing progress may be overstated because of the effects of the COVID-19 pandemic (including, for example, the redeployment of human and financial resources), reflected in the deterioration in disease outcomes between 2019 and 2020.
3. The main action to be taken should surely be to hold detailed discussions with – and agree action plans with – the CCM.  It is the domestic stakeholders who must really take action.
4. The Global Fund should reconsider two policies: (i) what to do in the event that a government fails to meet its co-financing commitments; and (ii) should it not increase a country’s grant amounts until it is satisfied that current grants are being used efficiently and effectively?

Readers’ comments on the points raised in this article would be welcome.