The Office of the Inspector General’s first audit of Global Fund grants to Lesotho concluded that quality of services overall was ‘partially effective’ but that program oversight and governance ‘need significant improvement’.
The audit report, published on 28 February, paints a picture of fragmented HIV and TB programs, implemented by two Principal Recipients (the Ministry of Health and Pact) whose delegation to sub-recipients has lacked strategy, coordination, and monitoring. Although grants in Lesotho are generally performing well against targets (in terms of the achievement rate of most of its coverage indicators) the performance for key TB and HIV prevention interventions is either not tracked or cannot be measured.
The OIG noted two categories of Lesotho’s ‘key achievements’: ongoing initiatives to address challenges in TB, and progress achieved against the 90-90-90 HIV/AIDS cascade. The audit report said Lesotho has already identified most of the weaknesses in its TB program that the OIG identified, and mitigating actions to address these were already in progress at the time of the audit. These included WHO-led technical assistance in the development of a revised case-finding strategy, and efforts by Lesotho to work with NGOs to conduct TB screening in communities using mobile X-ray machines.
Lesotho has achieved 86-71-93 against its 90-90-90 target – 86% of people living with HIV know their status, 71% are on treatment, and 93% of those are virally suppressed. The country’s ‘test and treat’ strategy is well integrated into the health system, the OIG report says, with 93% of patients who tested positive initiated on treatment at the same facilities.
‘Key issues and risks’ described by the audit are mirrored in the OIG’s main findings (see ‘Main findings’ section below).
Table 1: Global Fund grants in Lesotho covered by this audit
|Grant No.||Grant Component||Principal Recipient||Grant period||Signed amount (US$)|
|Funding cycle 2016-2018|
|LSO-C-MOF||HIV and TB||Ministry of Finance||Jul 2016 – Jun 2018||50,391,980|
|LSO-C-PACT||HIV and TB||Pact Lesotho||Jul 2016 – Jun 2018||8,261,040|
|Funding cycle 2018-2021|
|LSO-C-MOF||HIV and TB||Ministry of Finance||Jul 2018 – Jun 2021||55,499,451|
|LSO-C-PACT||HIV and TB||Pact Lesotho||Jul 2018 – Jun 2021||12,347,559|
Lesotho, which is a landlocked country of 2.3 million people in central-southeastern South Africa, is classified as lower-middle income by the World Bank, and is highly dependent on South Africa. It is a constitutional monarchy (the King is the Head of State). Lesotho is a ‘core’ country for the Global Fund (a larger portfolio, higher disease burden, and higher risk). It has very high HIV prevalence (23.6%) among 15 to 49-year-olds; 61% of its 340,000 people living with HIV are on treatment. Lesotho is classified by WHO as one of the 30 highest TB burden countries.
The Global Fund has granted more than $300 million ($256 million disbursed to Lesotho since 2003, funding 40% of the funding need for TB (43% is funded through domestic financing) and 9% for HIV (22% is funded through domestic financing).
Objectives, ratings, and scope of the audit
The OIG audit had two objectives, to assess the adequacy and effectiveness of
(1) Controls to ensure access to quality services including prevention programs – rated ‘partially effective’;
(2) Program governance and grant oversight including assurance mechanism to ensure efficient and sustainable achievement of grant objectives – rated ‘needs significant improvement’.
The OIG’s audit team visited 16 health facilities in five districts, covering nearly one fifth (19%) of people on antiretroviral treatment and more than one quarter (28%) of notified TB cases for the year ended June 2019. The audit team also visited warehouse and storage facilities in two districts.
Main findings and Agreed Management Actions
The OIG report discusses three main findings, with very detailed sub-findings for each. These are summarized below, each with their associated Agreed Management Actions (AMAs)
4.1 Bottlenecks in active case finding interventions and management of MDR-TB:
Lesotho’s TB incidence rate, at 611 per 100,000 population, is the highest in the world. It is one of the 30 high-burden countries for both TB and TB/HIV co-infection. While TB coverage increased by 7% from 2017 to 2018, it is still low, at 55% - this has driven the country’s National Strategic Plan to focus on case finding, preventive therapy for eligible HIV patients, and treatment of drug-susceptible TB patients.
TB case finding: Lesotho misses 45% of TB cases, compared to the global average of 31%, and is the country’s second-leading cause of death. Inadequate quality of TB screening and testing is a major factor in the gaps in TB case finding, the OIG report says. TB screening guidelines were inconsistently applied in 9 out of the 10 health facilities the audit team visited, and 38% of presumptive TB cases (showing signs or symptoms) were not tested for TB. All TB patients are systematically tested for HIV, but not all HIV-positive patients are tested for TB. Among many other issues identified, contact tracing for TB “remains in its infancy,” the report said, with more than 41% of contacts of confirmed TB patients not traced and screened for TB. Only 25% of estimated MDR-TB cases are diagnosed and enrolled into treatment.
MDR-TB case management: Only a quarter (25%) of Lesotho’s estimated MDR-TB cases are diagnosed and enrolled into treatment (achieving 64% and 63% of its MDR-TB case notification and treatment targets, respectively), a ‘sub-optimal’ performance which the OIG links to a centralized treatment model which lacks oversight and monitoring throughout the treatment cascade. Lesotho’s single MDR-TB treatment center has limited capacity to provide other services for MDR-TB patients, such as pain management, HIV care, or treatment of side effects. There is no formal mechanism and no documented guidelines to confirm that MDR-TB patients referred by districts and other health facilities are initiated on treatment promptly. Examples of this, the report said, were phone calls used for referral at some facilities but no records to support this, while TB patient transfer/referral forms were not used in 88% of facilities the OIG visited. Overall, the OIG said, the issues relating to both TB and MDR-TB “are influenced by the lack of governance, ownership and prioritization for the disease in the country”.
AMA 1: The Secretariat will work with (a) the Ministry of Health to finalize a plan to improve TB and MDR-TB case finding, and (b) the Principal Recipient to develop a coordinated, risk-based sub-recipient supervision plan including timelines, responsibilities, and feedback and follow-up mechanisms. (Due: 31 December 2020; owner: Head of Grant Management.)
4.2 Uncoordinated implementation arrangements for HIV prevention programs are impacting effectiveness of demand creation activities and service delivery
Lesotho’s second-highest HIV-prevalence (23.6%) and HIV-incidence (7.8 per 1000 population) rates in the world make prevention activities critical, and the Global Fund has invested “heavily” in HIV-prevention activities, the OIG says (more than $27 million across 2016-2018 and 2018-2021 funding). However, weak implementation undermines the effectiveness of demand-creation activities and linkages to service delivery, the report says.
The areas of concern include (1) the duplication of HIV demand-creation interventions by both PRs, who used sub-recipients (SRs) to execute the activities without plans to ensure no duplication; (2) lack of coordination and linkages between demand-creation activities and service delivery, notably the use by one PR (Pact) of many SRs to create demand for HIV prevention services without those SRs providing most HIV prevention services – testing, Voluntary Medical Male Circumcision (VMMC), and Pre-exposure prophylaxis (PrEP). Further, there are no supporting processes, the OIG said, to ensure linkages to services, nor a protocol between SRs working under Pact and the Ministry of Finance to coordinate and enable access to data, to confirm that patients who were referred for services in fact received those services.
In addition, PrEP implementation is “in its infancy,” with limited progress in scaling up PrEP following updates to the national guidelines recommending PrEP for HIV prevention among high-risk population groups, and no clarification of PrEP-implementation-related roles and responsibilities between health facilities, community- and civil-society organizations. This has been a major factor in low PrEP uptake, the report says, with the number of people on PrEP across all 16 facilities visited by the OIG amounting to 286 in total (with only a 34% retention rate) and an actual decline in PrEP uptake between 2018 and 2019 among the high-risk groups of female sex workers (23%), men who have sex with men (48%) and adolescents (100%).
AMA 2: The Secretariat will work with the Principal Recipients to assess the current sub-recipient implementation arrangements and programmatic gaps for HIV prevention activities, considering duplications, program implementation gaps and linkages between demand creation and service delivery. A coordinated implementation plan will be developed following the assessment. (Due: 30 June 2021; owner: Head of Grant Management.)
4.3 Inadequate governance and country ownership impacting continuation of services and sustainability of Lesotho’s HIV and TB programs
This finding contained extensive detail on three areas the OIG identified as major problematic areas in the category of ‘governance’ of Lesotho’s Global Fund grants – but the OIG’s overall comment relating to these challenges is that they “are influenced by the lack of stability in leadership and ownership for the HIV and TB response in the country”, including nine changes of Principal Secretary to Health since 2016, at the beginning of the New Funding Model 1 period. This has meant “no consistent leadership to drive the development of policies and ensure implementation from the central to the health facility level”.
The OIG commented on the specific problem areas of (1) procurement of HIV and TB medicines (stockouts of TB and TB-preventive medicines as a result of government’s falling short of its procurement commitments; (2) Human Resources for Health (HRH), notably that more than three quarters (77%) of key positions at the national level remain vacant, and no HR plan in place to guide the fulfilment of government’s commitment to the Global Fund to take over from donors support for key positions; (3) roles and responsibilities of key actors in the HIV/TB response, which has contributed to major delays in the development of critical strategies and policies, and therefore ineffective implementation.
AMA 3: The Secretariat will work with the Government of Lesotho and partners to assess (a) the budgeted commitments for financing commodities and human resources for health and health systems; and (b) current structures, roles and responsibilities of disease programs, including their governance, management and funding flow structures. This assessment will inform ‘mitigating actions’ for the short, medium and long term in Lesotho’s addressing current program challenges. (Due: 30 June 2021; owner: Head of Grant management.)
This audit report is ‘Global Fund Grants in the Kingdom of Lesotho’ (GF-OIG-20-005), 28 February 2020.