In this second audit of Global Fund grants to Côte d’Ivoire, the Office of the Inspector General (OIG) found that the newly created program management unit lacks a clearly defined vision and that health commodities at health facility level are not safe from shrinkage. Also, Côte d’Ivoire has made little progress against malaria targets, and HIV and tuberculosis (TB) interventions require better coordination and joint planning.
Côte d’Ivoire is a lower-middle-income country, according to the World Bank’s classification of 2020. Despite an expanding economy by an average of eight percent per year since 2011, about 46.3% of the people in Côte d’Ivoire are poor. Between 2012 and 2016, the country’s total health expenditure decreased from 6.1% to 4.4% of gross domestic product.
The Global Fund classifies Côte d’Ivoire as a ‘high impact’ country—a very large portfolio with a mission-critical disease burden. Since 2003, Côte d’Ivoire has received $644.6 million from the Global Fund to fight HIV, TB, malaria, and build Resilient and Sustainable Health Systems (RSSH). For the 2018-2020 implementation cycle, the Global Fund has allocated €191.5 million to Côte d’Ivoire. Malaria programs take the largest proportion (58%) of these funds, which amounts to €111.7 million, followed by HIV programs at 37%, and TB programs at five percent.
The audit covered the Global Fund grants to Côte d’Ivoire from January 2017 to June 2019. The audit assessed the effectiveness of new implementation arrangements at the Ministry of Health (MoH), the supply and tracking of malaria and TB health commodities, and community interventions. The OIG collected information from 17 district health offices, 31 health facilities, and the national drug store warehouse.
Audit findings and agreed management actions
The OIG report outlines four main audit findings and their agreed management actions (AMAs), as summarized below.
1. UCP lacks a clearly defined vision, which hinders its growth and development.
The OIG noted that the creation of a program management unit, Unité de Coordination des Projets (UCP), at the MoH in 2018, significantly changed grant implementation arrangements. At inception, UCP had about five roles: financial management, procurement, coordination, financial and program reporting, and monitoring and evaluation of programs. However, the audit revealed that UCP functions do not align with most of these roles. UCP does not have a role in the coordination of program activities, monitoring and evaluation, and program reporting, except for the cross-cutting RSSH activities. Consequently, it has little visibility of program activities and results. This negatively affects its ability to validate program outcomes.
The OIG found UCP’s financial management role to be effective. In September 2019, UCP started to verify payments made using the Global Fund grants. However, it does not monitor the budgets of the Global Fund grants allocated to the three national disease programs, thus limiting its financial reporting role. Moreover, UCP’s financial and accounting roles are undermined since its functions have been reduced to consolidating financial reports from the three national disease programs who have retained control of their own budgets.
The audit revealed that the procurement function at UCP needs to be more strongly centralized. UCP still shares some procurement processes with the three national disease programs. For instance, the national disease programs still retain the functions of signing and monitoring the execution of contracts, while UCP is responsible for the tendering process. Due to the sharing of procurement processes, UCP is not able to achieve the economy of scale that would result from a pooled procurement of common items.
2. Health commodities at health facility level are not safe from shrinkage
The OIG noted that Côte d’Ivoire’s national drugs store, Nouvelle Pharmacie de la Santé Publique (NPSP), had created a commodities order validation unit. The unit ensures that orders from health facilities align with actual needs based on patient data. Also, the OIG noted that UCP’s internal audit unit is effective in providing an oversight role in the distribution of health commodities: it was possible to track health commodities delivered from NPSP to district pharmacies and from districts pharmacies to health facilities.
However, the tracking of health commodities at health facilities was unsatisfactory. For some of the health facilities, drug consumption data could not match the number of tested cases reported. For instance, at eight of the 26 health facilities visited by the audit team, the number of malaria rapid diagnostic tests exceeded the number of tests reported by 75%. In addition, seven of the eight health facilities mentioned earlier had consumed almost twice the number of anti-malaria drugs as the reported tested cases. The consumption of TB drugs in two of the 26 health facilities was almost twice the number of notified TB cases. The lack of an electronic inventory management tool may have contributed to the inconsistent tallies.
The inability to sufficiently monitor/track drug stocks at health facilities may be due to leakage, driven by the existence of an informal market for health products in Abidjan. Supplying more drugs than what is required at health facilities may also have proliferated shrinkage. The failure of the district pharmacies to coordinate and supervise the inter-health facility drugs transfers leads to limited transparency and accountability.
3. Vector control and community-based malaria interventions require improvement
Since 2015, malaria key indicators have been on the rise in Côte d’Ivoire. The country had a 26% increase in new malaria cases, a 20% increase of deaths attributable to malaria, and the number of laboratory confirmed malaria tests increased by 10% from 68% to 78%. This is despite the mass distribution of 14.6 million and 15.9 million bed nets in 2014 and 2017, respectively.
The audit revealed that mosquito resistance to Long-Lasting Insecticidal Nets (LLIN) compromises the effectiveness of vector control in Côte d’Ivoire. The country was unable to address this issue in the previous mass distribution of LLINs. However, for the 2020 mass campaign, Côte d’Ivoire will distribute second-generation LLINs in areas earmarked as insecticide-resistant. Also, the absence of quality control inspection before shipment of 3.7 million LLINs failed to guarantee their effectiveness.
A survey conducted after the mass distribution of LLINs indicated that 35% of respondents did not use LLINs as they did not have any. This may be due possible under-coverage of the population owing to the use of inaccurate household registration data that was not validated beyond the district health management level. During the household registrations process, inconsistencies noted in 18 out of 83 districts were not investigated. Also, data from the survey indicated a 63.2% utilization rate of LLINs, which is low when compared to the national target of 80%.
The frequent stockouts of malaria commodities managed by Community Health Workers (CHWs) in Côte d’Ivoire compromise community-based malaria interventions. For instance, the proportion of CHWs reporting stockouts of malaria rapid diagnostic test kits for at least 15 days increased from 23% in January 2019 to 41% in October 2019. Similarly, the proportion of CHWs reporting stockouts of malaria drugs for at least 15 days increased from 36% in September to 52% in September and October 2019, respectively. In some areas, CHWs cover more households than stipulated in the national community-based intervention guidelines. This hamper their efforts to conduct active case finding in their communities as they have more people to attend to.
4. HIV and TB interventions require better coordination and joint planning
The audit found that HIV coordination among implementers is inadequate, and the size of the key population is unclear. The OIG noted duplication of HIV interventions that the Global Fund and the President’s Emergency Plan for AIDS Relief (PEPFAR) offer to key populations in four of the 17 districts covered by the audit. PEPFAR provides antiretroviral therapy (ART) to 81 out of 176 ART centers covered by the Global Fund grants. PEPFAR paid higher allowances (by 20%–39%) to CHWs and peer educators fighting HIV than those under the Global Fund-supported HIV programs.
The estimates used to determine the grant coverage targets for female sex workers (FSW) for the current funding cycle may have been underestimated. For instance, Alliance Côte d’Ivoire, a non-state principal recipient, reached out to 28 177 FSW in 2016, which is three times more than the National HIV/AIDS Program’s (PNLS) estimates of 8 719. A lack of a survey and a unique identifier for FSWs may have contributed to the use of underestimated targets for this key population.
The audit revealed a limited response to the increased death rate among TB/HIV co-infected patients and a low impact on the expanded TB services. About 68% of TB/HIV co-infected patients died in two referral hospitals while within their first two months of TB treatments. The spike in death rate is due to the lack of joint planning and supervision by both HIV and TB programs. A low screening of TB among HIV patients, which was at 67% in 2018, could also have contributed to the high death rate.
The Global Fund-supported initiatives in Côte d’Ivoire resulted in the expansion of TB care centers by 67%, from 184 to 307, between 2015 and 2018. However, the number of TB cases reported by these centers was low. For instance, the new TB care centers only reported 11% of TB cases in Côte d’Ivoire in 2018. The lack of awareness of the new TB care centers among the general populace and health care workers may have contributed to the low usage of these new centers.
To resolve the issues raised in the audit report, the Head of Grants Management Division will work with the MoH to achieve the following Agreed Management Actions:
- Develop a business plan for UCP by 31 December 2021.
- Assign the responsibility of tracking drug stocks and usage in health facilities to supervision teams by 30 June 2021.
- Conduct reviews to assess whether drugs have been effectively tracked and that measures to mitigate shrinkage are effective by 30 June 2021.
- Improve the effectiveness of the 2020 mass distribution of LLINs by updating the Operation Plan by 30 June 2021.
- Conduct a mapping review of the coverage of services provided by CHWs as well as the associated cost to improve this coverage by 30 June 2021.
- Improve and promote joint management of HIV/TB interventions by 30 June 2021.
- This 2020 audit report is ‘Global Fund grants in the Republic of Côte d’Ivoire’ (GF-OIG-20-007), 26 March 2020.
- The 2016 audit report, ‘Global Fund grants to the Republic of Côte d’Ivoire’ (GF-OIG-16-025), 14 December 2016.