Third OIG audit of Global Fund grants to Ghana highlights ongoing issues in supply chain and data management
Adèle SulcasArticle Type:
Article Number: 2
Progress against malaria and improvements in community-level services noted
ABSTRACT In a follow-up audit of Global Fund grants to Ghana, the Office of the Inspector General found that oversight and coordination, supply chain, data and financial management all need significant improvement, as do systems, processes and controls on quality of services for the three diseases. The OIG commended the country’s progress against malaria, on community-level services, and in the development of its National Health Insurance Scheme.
In the third audit of Global Fund grants to Ghana since 2012, the Office of the Inspector General has rated both implementation arrangements for oversight and coordination, and the systems, processes and controls on quality of services for the three diseases as needing significant improvement.
The OIG report, which was published on 2 April 2019, reviewed a 2-year period, from July 2016 to June 2018, and covered the two biggest of the country’s four Global Fund grants (see Table 1 below), namely the HIV/TB and malaria grants implemented by the Ministry of Health. The OIG considered the non-government HIV and malaria grants less risky.
The report concluded that a revised implementation structure by the Ministry of Health and Ghana Health Service has not yet improved oversight and accountability in Ghana’s Global Fund grants, with ambiguous reporting lines, lack of performance targets and duplicative roles contributing to weak performance and poor grant absorption.
The OIG acknowledged Ghana’s significant progress in malaria control, with reductions in prevalence, incidence, and mortality, but said that despite an overall decline in HIV prevalence, only 33% of the estimated 316,613 people living with HIV are on treatment, and that testing, treatment, and viral-load suppression challenges need to be tackled urgently if the country is going to reach its 2020 national targets. In addition, though the TB treatment success rate is a commendably high 85%, treatment coverage is only 32%.
Also receiving favorable mentions were Ghana’s geographical expansion of access to healthcare at the community level by increasing the number of Community-based Health Planning and Services (CHPS) points, and the National Health Insurance Scheme (NHIS), which currently covers 45% of the population and is required to cover antiretroviral therapy, first-line TB treatment, treatment for malaria, and for opportunistic infections.
During the audit, the OIG team travelled to four of Ghana’s ten regions (home to 56% of the country’s population), visiting 30 health facilities, four central and regional warehouses, and 30 storage facilities.
The Global Fund’s active grants in Ghana, from 2018 to 2020, amount to $193,980,639, with three Principal Recipients (PRs) implementing four grants across the three diseases. There is additional catalytic funding of $5.9 million to scale up interventions in key populations and human rights barriers to services.
Table 1: Ghana’s Global Fund grants included in the OIG audit
|HIV/AIDS & TB
|Ministry of Health
|Jan 2018 – Dec 2020
|Ministry of Health
|Jan 2018 – Dec 2020
|Jan 2018 – Dec 2020
|West African Program to Combat AIDS and STIs
|Jan 2018 – Dec 2020
Source: OIG audit 2019 (report number GF-OIG-19-009)
In 2002, Ghana became the first country to sign a Global Fund grant. To date, the Global Fund has signed grant agreements with Ghana for more than $965 million and disbursed $804 million. Ghana is considered a ‘high-impact’ country for the Fund (very large portfolio, mission-critical disease burden).
Ghana’s population is estimated to be 29.6 million people. With an economic growth rate of 8.5% in 2017, Ghana is classified as a lower-middle income country with one of the highest per capita incomes in the 27 West and Central African countries, and is ranked 81 out of 180 countries in Transparency International’s 2017 Corruption Perception Index.
Health expenditure in Ghana represented 3.6% of GDP in 2017, while the percentage of health expenditure coming from domestic resources actually decreased between 2010 and 2016, from 10.8% to 6.6%, before increasing to 7.8% in 2017. The World Health Organization includes Ghana as one of the 49 countries it deems to have a critical shortage in its health workforce (11 doctors, nurses and midwives per 10,000 people, against WHO’s benchmark of 23 for adequate coverage of essential health services).
The OIG’s main findings focused on five key issues and risks in Ghana’s Global Fund grants, summarized below:
- Stronger oversight arrangements and fulfilment of government commitments are needed
- Enhanced visibility and utilization of supply-chain information needed for decision-making and inventory management
- Improvements needed in HIV testing, treatment and viral load suppression to achieve national targets by 2020
- Improvement needed in TB case detection and management of MDR-TB
- Improvements needed to ensure quality data for decision-making.
Stronger oversight arrangements and fulfilment of government commitments for the three diseases are needed
Before the current grant implementation period, the Local Fund Agent (LFA) had recommended the creation of a Project Management Unit (RMU/MOH) to improve the oversight, visibility and coordination of the three disease programs and of donor funds. In response, the Ministry of Health tasked its resource mobilization unit to oversee Global Fund-supported programs, while the Ghana Health Service also established a ‘program secretariat unit’ (PSU/GHS) to oversee donor-funded programs.
This has resulted in overlapping roles between the two units, which have “as yet been unable to resolve structural complexities hampering the disease programs,” the OIG report said, and have not been able to address the underlying challenges contributing to a 32% absorption rate and below-average program performance of the current grants.
Though both units were established almost a year ago, they are not fully functional: there are outstanding staff contracts, unpaid salaries, incomplete standard operating procedures and unassigned roles and responsibilities. In addition, the integrated operational budget for supervision, training and human resources, and the grant performance indicators dashboard, are both outstanding.
Enhanced visibility and utilization of supply chain information is needed for decision-making and effective inventory management
Ghana has made some progress in addressing supply chain issues identified in the OIG’s 2015 audit, in part with support from the Global Fund and USAID. Since 2016, mechanisms have been in place to safeguard grant-funded commodities at the central level, with improvements in warehouse conditions and LMIS reporting.
However, the OIG says, at regional and facility levels inadequate inventory management persists, and there is limited use of logistics data for decision-making. This has contributed to $1-million worth of drug expiries in the 30 facilities the OIG visited, and stockouts of key commodities, lasting more than 30 days, at 70% of the facilities visited. The poor storage conditions can damage drugs’ effectiveness, exacerbating the risks of treatment failure and drug resistance; only 13% of the facilities visited had received technical pharmaceutical supervision. Inadequate supportive supervision and training contributed to the inventory management issues, the OIG said.
Improvements needed in HIV testing, treatment and viral load suppression to achieve national targets by 2020
In 2016, in line with UNAIDS’s 90-90-90 targets, Ghana adopted a universal “test and treat” policy, with the goal of testing 13 million people by 2020 and increasing antiretroviral treatment (ART) coverage from 35% to 90%. In this context, the OIG pointed out major testing and treatment gaps, notably low coverage and quality of HIV testing, low linkage to treatment and inadequate follow-up of ‘lost’ patients, and weak monitoring of patients on ART because of low rates of viral-load testing (33%, nationally). Inadequate training (from a ‘targeted’ to a ‘routine’ testing approach, introduced in 2018), inadequate laboratory staffing, and sample transportation problems seem to be the cause; viral load testing machines are available in nine of the country’s 10 regions.
Of those patients who have tested positive for HIV, only 37% have been initiated on treatment (60% for the facilities the OIG visited) and 22% of those initiated are lost to follow-up. The OIG identified a weak referral system linking patients to treatment as a major contributing factor.
Improvement is needed in TB case detection and management of MDR-TB
Though Ghana’s treatment success rate is estimated to be 85%, the country’s disease burden as defined in the 2015 TB prevalence survey is four times higher than previously reported, with a case detection of 33% (compared to the earlier estimated 80%), well below the average global case detection rate. The OIG said that the main reasons for this are: the under-utilization of GeneXperts for primary diagnosis (due to non-availability of guidelines or lack of training on the guidelines); the lack of a reliable mechanism to transport sputum samples from remote diagnostic sites to GeneXpert laboratories; and the “missed opportunity” of using Community-based Health and Planning services (CHPS) for TB services (only 17% of the country’s 5000 CHPS are expected to report on TB services).
Ghana does not have a dedicated MDR-TB treatment center, and delays in the roll-out of a shorter treatment regimen (adopted by Ghana in 2016) had only been initiated in half the country’s regions (five out of 10) by May 2018. Delays also in baseline test/culture results as well as stock-outs of MDR-TB drugs are other factors contributing to the 55% treatment success rate.
Progress made in data management but improvements needed to ensure quality data for decision-making
Ghana’s system for collecting and reporting health data – relied upon by the Global Fund and other partners for decision-making – is the District Health Information Management System (DHIMS2). The OIG said that the TB and HIV data reported into DHIMS2 is incomplete, with two of the four teaching hospitals and 45 out of 375 ART centers not reporting into it, among other missing data, including from CHPS and private facilities.
While the timeliness of data reporting for the three diseases has improved, the OIG said (from 46% in 2015 to 89% in 2017), data accuracy remains problematic, with significant inaccuracies reported for HIV and malaria in data quality audits performed in 2018.
The missing data and inaccuracies in the data that are reported undermine the reliability of data used for decision-making and performance measurement, the OIG said, identifying the main causes of these issues as inadequate or ineffective supervision and training of data officers. Other contributing factors were stock-outs of data tools, and the limited functionalities of the HIV e-tracker.
Agreed management actions
The Secretariat will work with the Ministry of Health on four Agreed Management Actions (AMAs):
- To develop a mapping of the Ministry’s and Ghana Health Services’ roles (regarding multiple areas of overlap and duplication), as well as accountabilities, deliverables and key performance measures
- To complete the installation of a logistics management information system (LMIS) throughout the supply chain, while clarifying processes and accountabilities, and ensuring adequate supervision and training
- To develop and deploy an off-line HIV e-tracker in ART sites to improve HIV monitoring, as well as a plan to improve differentiated HIV testing
- To develop, for TB, a plan to improve the utilization of the now-widespread but underutilized GeneXpert machines, as well as accelerate treatment enrolment.
The first three of the AMAs are due by 30 June 2020, the fourth (for TB) is due by 31 March 2020. All AMAs are ‘owned’ by Mark Edington, Head of Grant Management. (See page 22 of the audit report for the complete Table of Agreed Actions.)
- This audit report, Global Fund Grants in the Republic of Ghana, 2 April 2019 (GF-OIG-19-009)
- OIG Audit of Grants to the Republic of Ghana, 29 October 2012 (GF-OIG-10-018)
- OIG Audit of Grants to the Republic of Ghana, 27 October 2015