GLOBAL FUND GRANTS IN TOGO: ACHIEVEMENTS GOING UNNOTICED
Djesika Amendah and Djinta Litaaba-AkilaArticle Type:
Article Number: 9
This article looks at the various grants received and managed by Togo in the context of its response to the three major diseases (HIV, tuberculosis and malaria). Togo is performing well in terms of grant management. The Principal Recipient changed in 2009 from the Ministry of Health to the Prime Minister's Office, which is now the sole Principal Recipient. However, despite successes in grant management, Togo’s Project Management Unit in Togo has faced various challenges at both strategic and operational levels.
In terms of its management of Global Fund grants Togo performs better than average compared to other countries in the West and Central African region.
The achievements are noticeable, particularly with regard to declining malaria mortality and declining HIV prevalence/a reduction in the number of new HIV infections. There are also achievements regarding programmatic and financial grant performance with absorption rates above 75%, the threshold set by the Global Fund Board. Finally, there have been no ineligible expenses in the grants’ financial management over the past decade, which is also testament to Togo’s achievements.
This success is due, among other things, to national ownership at the highest level of government (the offices of the President and Prime Minister), to competent and motivated staff, to good management practices and learning from experience, and to the establishment of a Project Management Unit (PMU) with increased scope over time.
This article provides an overview of the successes of Global Fund grants in Togo and also highlights ongoing challenges. Information used in this article comes primarily from documents available on the Global Fund website and other publicly available data from the presentation by the Global Fund PMU Coordinator and from discussions with the Executive Secretary of Togo’s Country Coordinating Mechanism (CCM).
Achievements in the response to the three diseases in Togo
Since 2003, the Global Fund has invested $391,842,613 in Togo. This investment has been of paramount importance to the national response to the three diseases. Indeed, recent trends indicate that HIV prevalence has decreased from 2.9% in 2009 to 2% in 2020, according to UNAIDS. Antiretroviral treatment coverage has nearly doubled, rising from 31% in 2013 to 60% in 2018, which surpasses the regional coverage rate of 51% in West and Central Africa, but remains below the 90% rate recommended by UNAIDS. The number of new HIV infections decreased by 21% between 2013 and 2018, while HIV-related deaths reduced by 16% over the same period.
The percentage of tuberculosis (TB) notifications, for which the norm is 100% for TB cases, reached 80% in 2017, compared to an average of 48% in the rest of the West and Central Africa region.
Malaria incidence decreased by more than 25% between 2015 and 2018, while mortality decreased by 8% during the same period, according to the World Malaria Report 2019. Between 2013 and 2017, the malaria mortality rate decreased by 27%. Annual deaths decreased from 1,361 to 995. Malaria testing has also increased considerably. The number of tests increased from 808,000 in 2015 to one million in 2017. Togo accounted for 0.8% of malaria cases worldwide and 0.6% of deaths in 2020. These data show significant progress in the quality of care.
Effective management of Global Fund grants
These results were achieved through sound financial management and an adequate and efficient use of Global Fund resources. Grant absorption rates at the end of the NFM2 cycle were 98% for TB, 93% for HIV and 81% for malaria.
For the current implementation cycle (January 2021 to December 2023), Togo’s allocation is $122,915,459. By June 2022, halfway through the grant cycle, $84,273,378 had been disbursed, representing 68.56% of the approved amount.
Global Fund grants have improved the availability of health data. The country successfully deployed DHIS2 (the District Health Information System) in March 2018. Most health facilities have access to digital tablets, enabling them to send data directly to DHIS2. In this way, the timeliness of data reporting by health facilities has improved, from a level of 14% at the beginning of 2018 to 56% in December 2018. However, weak data quality was noted by the Office of the Inspector General in its 2019 audit.
Programmatic and financial performance
The Global Fund provides funding based on programmatic and financial performance. Performance ratings range from C (unacceptable) to A1 (overachievement of objectives). For the current grant, in 2022 Togo had a score of B1 for HIV and TB, and a score of A2 for malaria.
Table 1 below presents Togo’s absorption rate and grants ratings for grants under the new funding model.
Table 1: Grant rating and absorption rate for Togo Global Fund grants since 2014
END OF NFM2 (2017-2019)
S1 2022 NFM3
High level of country ownership: President and Prime Minister’s offices
The CCM is chaired by the President of the Republic
The President of the Togolese Republic is the statutory chair of the Global Fund CCM in Togo. In reality, the President delegates this role to a member of the government. Currently, the Minister of Public Works chairs the Togo CCM.
The Prime Minister’s office is the sole Principal Recipient
Togo has one Principal Recipient (PR): the Prime Minister’s office. The PMU has gradually expanded its scope from focusing on the medical HIV component in 2009 to its present range of all Global Fund grants. Currently, in addition to Global Fund grants, GAVI grants (administered by Deutsche Gesellschaft für Internationale Zusammenarbeit – GIZ – which acts as the fiscal host) complement funding dedicated to strengthening management of the health system and of malaria cases.
When the Global Fund PMU was created in 2009, it was supervised by the Ministry of Health (MOH) General Directorate of Health (DGS) and was called the PMU-MOH (UGP-MS in French). At that time, it received support from experts from the German cooperation agency (GIZ), who also served as fiscal host between 2009 and 2012. PMU-MOH was initially responsible for managing the medical component of the HIV grant relating to testing, care and treatment in Round 8. The community-based HIV prevention component was managed by Population Services International (PSI). The MOH was the first grant recipient in 2009.
Building on their initial successful management experience, the PMU-MOH took on the management of the bio-medical component of the Round 9 malaria grant from 2011 and the TB grant from 2012. The community component of the R9 malaria grant was managed by Plan Togo.
In 2014, in anticipation of the Global Fund’s new funding model, the PMU-MOH was placed under the responsibility of the Prime Minister’s office and became the ‘PMU’. Since 1 October 2015, the PMU has managed all Global Fund grants (medical and community components). The national disease control programs, the MOH’s health regions and the Central Purchasing Agency for Essential Generic Drugs (CAMEG) are the Sub-Recipients (SR) for the medical component. Three civil society non-government organizations (NGOs) are the SRs for the community component. The SRs are truly the cornerstone of these grants.
The PMU has operational autonomy. It coordinates administrative, programmatic, financial and monitoring and evaluation activities. Strengthening institutional and technical capacity of partner entities is also part of its mission.
Financial management system
The PMU’s financial management involves dividing tasks between the various grants (HIV, Malaria and TB). The PMU periodically organizes accounting checks and financial transaction validation assignments with each SR. SRs are supported by the account managers to carry out their activities. Nonetheless, in order to facilitate accounting management, accounting software were purchased and installed by each SR. However, online data are centralized at the PR level. Account managers have been trained to use them well and efficiently. The procedures manual is periodically updated and used by all accounting staff.
The risk management system: the importance of internal audits
One of the objectives of the Global Fund is to integrate risk management into its organizational culture, strategic planning, decision-making and resource allocation. Effective risk management is in this way a key component of good governance. It should be noted, however, that this approach can only provide a reasonable, but not a comprehensive, guarantee.
The PMU strives to use the best global managerial practices. The PMU’s internal audit team is linked to the Prime Minister’s office and reports to the Government’s General Secretariat. The team operates around an internal audit charter validated by the Global Fund and approved by the Government’s Secretary-General. The charter sets out the mission, role and responsibilities of the internal audit team.
At grant start up, the internal audit team identifies and assesses the risks that all implementing bodies are subject to, based on a risk mapping which it itself has conducted. The risk mapping is updated annually and presented to all stakeholders during activity planning workshops (generally before the final three months before year end).
For each body, the mapping includes:
- Risks identified by modules/interventions/implementation activities.
- Risk/due diligence management measures that can mitigate the risk.
- Persons responsible.
- Procedures to be implemented by management.
Once the risk management plan has been shared, the internal audit team prepares an annual audit plan, which is approved by the Government’s Secretary-General for the current year. This audit plan includes internal audit commitments and related timeframes. The purpose of the various audit assignments is to assess the internal control frameworks in place within each body to ensure governance and administrative, programmatic and financial coordination.
Procurement and supply management
Togo mainly uses Global Fund platforms for procurement, namely wambo.org. Around 70-80% of Global Fund’s investments in Togo relate to procurement and supply management of medical and non-medical supplies. As a SR, CAMEG initiates the procurement process on behalf of the PR, receives the products, stores them and then distributes them. CAMEG is also in charge of quality control.
Despite the achievements outlined above, the PMU is experiencing some operational difficulties.
Strategically, the country is dependent on Global Fund procurement structures that have limited interventions, as they target symptoms and not root causes. Challenges in relation to this include:
- Inadequate and/or ineffective leadership and governance structures to facilitate prioritization, coordination and accountability within supply chain activities.
- Lack of accurate and reliable data for informed decision making.
- Lack of human resources in relation to service provision and supply chain management
- Lack of financial resources for supply chain transformation.
Operationally, the PMU is a victim of its own success: experienced staff often leave the organization for other expert positions abroad. In addition, various different external assignments, including visits by Local Fund Agents (LFAs), visits by Global Fund country teams, as well as various unplanned requests for information by the Global Fund, all encroach on working time and create an additional burden for PMU staff.
Managing grants awarded by public donors requires a high level of transparency and good management. Although clearly justified, this requirement sometimes represents a challenge for certain communities or civil society organizations. Yet Togo manages to demonstrate the potential to combine proximity with communities with management excellence.
Graph: Overview of Togo statistics
Source: World Bank