When it recommended a Mali malaria grant for approval recently, the Global Fund’s Grant Approvals Committee (GAC) acknowledged that there are implementation challenges associated with this grant and said that it welcomed the Secretariat’s plans “to identify bottlenecks, and holistically review and harmonize the controls in place with the aim of balancing risk mitigation and effective grant implementation.”

The Mali malaria grant was part of a batch of grants approved by the Global Fund Board on 21 December 2018 (see article in GFO 348). The Board was acting on recommendations from the GAC and the Technical Review Panel.

The concern about balancing risk mitigation and effective grant implementation has been raised before in other grants. To use the Global Fund terminology, there is a “risk” that too heavy an emphasis on risk mitigation could impede implementation of the grant.

Mali is designated by the Global Fund as a “challenging operating environment (COE).” Armed militias in the north of the country have been fighting against the Government of Mali since 2012, seeking greater autonomy for their region. Mali’s extreme malaria burden has led the Secretariat to designate Mali’s grant portfolio as “high impact.”

Countries are categorized as focus, core or high impact. Focus countries have smaller portfolios, lower disease burdens and lower mission risk. Core countries have larger portfolios, larger disease burdens and larger mission risks. High-impact countries have very large portfolios (usually greater than $400 million) and larger disease burdens and are considered “mission critical.” Other high impact countries in West Africa include Côte d’Ivoire, Nigeria, Ghana and Burkina Faso. (Burkina Faso was recently designated “high impact” because of its extreme malaria burden.)

Mali is one of the top 10 countries worldwide with respect to its malaria burden. The grant is aligned with Mali’s 2018–2020 national strategic plan for malaria. The grant aims to contribute to (a) reducing malaria-related mortality and malaria incidence by at least 50% compared to 2015; and (b) strengthening the malaria program’s coordination and management capacities at all levels of the health system.

The GAC said that Mali has a strong culture of net ownership (82% of pregnant women sleep under a net), “but [that] the country is far from reaching LLIN universal coverage with only 39% of households having one LLIN for two people.”

The principal recipient (PR) for the grant is Population Services International (PSI). Catholic Relief Services (CRS) and the National Malaria Control Program (NMCP) are sub-recipients (SRs). The grant aims to enable a progressive transfer of responsibility for implementation to the Ministry of Health and the NMCP. The plan is for CRS to be phased out as SR, leaving NMCP as the main SR. The Secretariat and in-country stakeholders are finalizing a technical assistance/capacity building plan to strengthen the NMCP’s capacity.

The GAC said that because the security situation in Mali continues to be volatile, the country coordinating mechanism (CCM) has developed a contingency plan to ensure continuation of program implementation under several potential scenarios.

During the last grant, the GAC noted, PSI experienced some communication and coordination challenges between its headquarters in Washington and its country office in Mali. PSI Headquarters and the Global Fund Secretariat are actively addressing these issues (in Mali as well as in other countries where PSI is serving as a PR).

According to the GAC, the Office of the Inspector General (OIG) is finalizing an investigation into a grant managed by PSI in another country. The GAC said that the findings of this investigation are relevant to other grants managed by PSI.

Editor’s Note: The OIG shared with the Board some of the findings from its investigation. In its report, the GAC said that the OIG’s report was still in draft form and that it had not yet been shared with the CCM, the Audit and Finance Committee or the full Board. (Aidspan has learned that a draft report was subsequently shared with the CCM on 21 December 2018.) Aidspan will report on the findings of this investigation only once the OIG has published its final report.

The GAC recommended that the Mali malaria grant be approved with PSI as the PR, and the Board concurred.

The GAC noted that Mali conducts a rolling LLIN campaign due to the perennial problem of funding limitations. It said that there are currently significant gaps in 2019 and 2021 relating to mass campaigns in three of Mali’s seven regions (Bamako, Koulikoro and Sikasso). These gaps are addressed in proposed above-allocation initiatives which the TRP has approved for inclusion in the Registry of Unfunded Quality Demand. The TRP said that if these initiatives were prioritized for funding through portfolio optimization, this could generate significant cost savings and improvements in efficiency and coverage of Mali’s campaign against malaria.

The fund portfolio manager for Mali, Sonia Florisse, informed Aidspan that in December 2018, the Secretariat recommended that additional funds be made available from portfolio optimization for mass LLIN campaigns in Mali. If the Board approves this recommendation, the funds will be added to the malaria grant.

The Government of Mali has made sufficient commitments to meet the co-financing requirement. However, the GAC said that given the political environment, there is a risk that the country may not be able to realize its commitments. The GAC emphasized the importance of Mali realizing these commitments in view of the trajectory of the malaria burden in Mali and the trend of decreasing external funding for health.

Most of the information for this article was taken from Board Document GF-B40-ER2 (“Electronic Report to the Board: Report of the Secretariat’s Grant Approvals Committee”), undated. This document is not available on the Global Fund website.