Fraudulent and abusive practices in the Guinea malaria nets mass campaign

Author:

Oliver Campbell White

Article Type:

Article Number: 6

Global attention should be paid to this report

Abstract: This Office of the Inspector General investigation report on the 2019 LLIN mass distribution campaign in Guinea concludes that two critical data sets from the campaign were fraudulently manipulated. The OIG also found that insufficient controls and a lack of clear accountability for data accuracy contributed to the fraudulent data being used in the campaign; and that widespread data manipulation contributes to an environment in which commodity diversion becomes possible and may go undetected. Of major significance to the Global Fund and partners in the fight against malaria: the findings – and the agreed management actions – apply not only to Guinea but are relevant to mass distribution campaigns in other countries.

Background

Catholic Relief Services (CRS) is a Global Fund Principal Recipient (PR), implementing Global Fund grants in Guinea to strengthen malaria control services. Some 27% ($15 million) of CRS’s $56 million grant (signed amounts) for the implementation period 2018-2020 was allocated to the long-lasting insecticidal nets (LLIN) mass distribution campaign.

Under a sub-agreement signed between CRS and the Ministry of Public Health, the National Malaria Control Program (NMCP) was allocated $7.6 million from the Global Fund grant during the implementation period and led the 2019 LLIN mass distribution campaign organization. $4 million was dedicated to campaign organization activities, including micro-planning and household counting.
Though not mentioned in the report, Guinea is classified by the Global Fund as having a challenging operating environment and is subject to its Additional Safeguard Policy.

On 22 February 2023, the Office of the Inspector General (OIG) published its investigation report on fraudulent and abusive practices in the LLINs mass campaign in Guinea. The investigation was initiated after 117,500 LLINs from the 2019 mass campaign were found to have been diverted to neighbouring Mali. OIG confirmed that these included over 10,000 nets financed by the Global Fund; the remainder were LLINs supplied by the Against Malaria Foundation (AMF). Although the value of these diverted Global Fund nets is not considered material by OIG, the report notes that the widespread data manipulation suggests a risk that the true number could be higher.

The investigation covered the 2019 LLIN mass campaign – specifically the activities that occurred in the CRS zone of operations. CRS was responsible for campaign distribution activities in 20 prefectures (the sub-regional administrative districts in Guinea), and managed three regional warehouses (Kankan, Mamou and N’zerekore). Another international donor, the US President’s Malaria Initiative (PMI), managed campaign activities in the rest of Guinea. Guinean health authorities, including the NMCP, had a coordination function, while prefectural and sub- prefectural health authorities led field operations and data management.

Prior to distribution, key activities, including microplanning (an estimation of the local populations and campaign needs) and household counting (a full physical survey of every household), were used to determine the exact number of beneficiaries and LLINs required. After each distribution wave, remaining LLINs were returned from distribution points to regional warehouses, a process called ‘reverse logistics,’ to be used in subsequent distribution waves.

Findings

The main findings of this report are that:

1. 1. Some campaign LLINs were diverted to Bamako, Mali, including over 10,000 nets financed by the Global Fund. The diverted LLINs were resold to the Malian government in a procurement that contained ‘red flags’ for fraud and collusion.
   2. Two separate campaign data sets were fraudulently manipulated, creating an environment in which LLIN diversions went undetected. The first involved fraudulent data in household counting which undermined its accuracy. The second was the distribution data that contained irregularities and indicated potential over-allocation and diversion risk. These issues created a risk of over-allocation of LLINs, as well as an environment in which LLIN diversions occurred and went undetected.
   3. The design and implementation of controls over the data reported by health centres were inadequate, creating a lack of accountability for the accuracy of campaign data. This is reflected in: (i) the lack of review of field data and effect of data consolidation; and (ii) the lack of authoritative denominator data and the risk of over-estimated population numbers leading to the inefficient use of resources.

 

An important assurance provided by the report is that “Despite the LLIN diversion detailed above, the Global Fund did not receive reporting that beneficiaries had not received LLINs during the campaign”.

Impact of the Investigation

This investigation has highlighted how accurate data are essential not only to ensure the identification of all eligible beneficiaries, but also to ensure an efficient campaign and accountability for the significant investments made in LLIN mass campaigns globally. This case showed that theft and waste may go undetected if the underlying data are unreliable. Fraudulent or inaccurate data also risk impacting future campaigns because the counted population from a previous campaign often forms the basis of projections in the following campaign.

The challenges of mass campaign data collection and the impact of inaccurate or manipulated data are not isolated to Guinea. The OIG has therefore recommended that the Global Fund consider the potential repercussions of manipulated data on mass campaigns more broadly and examine similar risks across portfolios.

LLIN mass campaigns are complex activities that are vulnerable to commodity diversion. While individual diversion schemes that come to the Global Fund’s attention may seem to have a limited or localized impact – given the sheer scale of mass campaigns across the Global Fund – small schemes have the potential to add up to a significant amount of misuse or waste. This is particularly important today (as of March 2023) because the current average price for an LLIN is close to $2 – see the AMF website. Improving traceability of LLINs is therefore an important step in deterring and detecting such thefts, and an agreed management action will leverage advances in traceability to improve the Global Fund Secretariat’s ability to mitigate this type of wrongdoing.

As a result of this case, OIG has recommended the recovery of $54,824 in grant funds for the Guinea 2019 mass campaign not used for the purposes for which they were intended.

Agreed Management Actions

In response to this investigation report, the Global Fund Secretariat has agreed the following three management actions (AMAs):

1. The Global Fund will, by 30 September 2023, finalize and pursue, from all entities responsible, an appropriate recoverable amount. This amount will be determined by the Secretariat, in accordance with its evaluation of applicable legal rights and obligations and associated determination of recoverability.
2. The Global Fund will, by 31 December 2023, leverage current advances in traceability offered through GS1 standards by encouraging portfolios to procure LLINs from manufacturers implementing GS1 principles. The Global Fund will explore the development of a traceability strategy to capture the unique identifiers from commodities implementing GS1 principles, and of standards to be adhered to by implementers, to be rolled out incrementally.
3. The Global Fund, in collaboration with technical partners, will, by 31 December 2023, review the guidance on population size estimates to inform LLIN campaigns. This will: (i) strengthen the tools on pre-campaign household enumeration and the quality of the exercise through supervision, monitoring, data analytics, and (ii) clarify expectations on roles, responsibilities and accountabilities, to collect and verify data across various levels of health care delivery systems. This work will complement the holistic campaign guidance produced and continually updated by the Alliance for Malaria Prevention. This will also ensure Local Fund Agent assurance over campaign operations includes guidance concerning verification of data during census and distribution as appropriate.

 

Commentary

This is a worthy report which, as stated earlier, could well have wider applicability, However, to an observer reading this report, it does raise three questions.

First, and most importantly: due to the reliance on extensive manual recording and reporting, it is surprising that AMAs 2 and 3 do not mention placing greater emphasis on introducing/extending a standard information and communication technology (ICT)-based system(s) for malaria programs. Through user-centred interface design, built-in data quality control, and workflow automation, such a system would improve the management and oversight of data recording, control and reporting processes.

Second, there is a surprising absence of summary data on planned and distributed numbers of LLINs across the country; and it is unclear if LLIN distribution in the prefectures not handled by CRS were affected by the same fraudulent practices.

At an online Alliance for Malaria Prevention conference held on 27 March 2019, Guinea reported that it would need 8,825,000 LLINs for its 2019 mass distribution campaign and had secured the following support:
– Against Malaria Foundation 4,500,000 (to be distributed through CRS)
– Global Fund 1,884,500 (to be distributed through CRS)
– PMI 881,218 (to be distributed through RTI-Stop Palu)
– Senegal River Basin Dev. Org. (SDBDO) 600,000
– Government (for Conakry) 837,000 (through the NMCP)
Total: 8,692,718

There is no subsequent information available online as to the actual number of LLINs made available by the listed parties. According to the PMI Malaria Operational Plan for Guinea for 2020, the mass distribution campaign in 2019 resulted in the distribution of 8,309,233 LLINs supplied by AMF, GFATM, PMI,  and the SRBDO. Note that the government is not included as a supplier; and nor is the number of LLINs supplied by each donor stated. According to that same Plan, at that time PMI supported malaria prevention and control activities in 14 out of the 33 prefectures in Guinea as well as the five communes of Conakry while GFATM supported those activities in the remaining 19 prefectures.

Finally, an odd feature in this report are the several references to the ‘other donor partner’, whose name is not disclosed. This is odd because anyone familiar with the malaria program in Guinea will already know; and, for the uninformed, it only takes two minutes to look up the topic on the internet to see that the other partner is PMI; hence its mention in this article. The reluctance to refer by name to PMI in the report was explained by OIG as follows:
“This is because the OIG refrains from naming entities in its investigation reports that are not directly connected to, or implicated in, the findings. Our reports focus on facts and findings as they apply to Global Fund programs and we do not comment on, or refer to, other donors’ programs unless they are material to the case.”

Well, I believe that mentioning PMI is important for two reasons. First, the prefectures where malaria interventions are supported by the Global Fund were in part determined by the PMI selection of where it chose to operate. Second, PMI is a major donor to malaria programs and an important Global Fund partner; and they should be sharing data on the supply of LLINs and other malaria commodities.