In this second audit of Global Fund grants in Togo, the Global Fund’s Office of the Inspector General found that the country has made significant strides in the fight against HIV, TB and malaria. The Togolese results are remarkable compared to the West and Central Africa regional average, according to the audit report.
The OIG audit opinion was that the Togolese systems, processes, and controls on data quality require significant improvement. However, the processes and controls to account for medicines paid for by the Global Fund across the in-country supply chain, as well as the grant implementation arrangements, were partially effective.
The OIG used a four-tier rating ranging from the lowest to the highest: Ineffective, needs significant improvement, partially effective and effective.
This article summarizes the OIG audit report published on 12 November 2019. The OIG had previously audited the Global Fund grants in Togo in 2011.
Togo is a low-income West African country with 7.9 million inhabitants. In the Global Fund categorization, Togo is a ‘core’ country, with relatively large grant portfolios, higher disease burdens, and higher-risk grants.
According to the OIG audit, Togo’s HIV epidemic is generalized, with a population prevalence of 2.3%. Predictably, HIV prevalence rates are higher among key populations: 22% among men who have sex with men (MSM) and 13.2% among female sex workers (FSW). An estimated 110,000 people in Togo are living with HIV, of whom 73% know their status. Among those who know their status, 82% were on treatment in 2018. The OIG report is silent on the proportion with suppressed viral loads. The three percentages are important in view of the plan ‘90-90-90 by 2020’ promoted by UNAIDS. This ambitious plan aims to have 90% of people knowing their HIV status, 90% of those who tested HIV-positive on treatment, and 90% of those on treatment with viral loads suppressed (HIV virus level is undetectable so they cannot transmit the disease). The OIG review of the grants in West and Central Africa highlighted the fact that the region is significantly behind the rest of Africa in this 90-90-90 plan. Aidspan described that report earlier.
The annual number of new infections was 4,950 in 2018, down by 31% since 2010.
In 2017, Togo was among the ten countries with the highest incidence of malaria worldwide, with 371 per 1,000 population at risk, according to the OIG audit report. In other words, more than a third of the population was considered at risk of contracting malaria every year. Malaria-related annual deaths decreased by 27% in the last four years for which data were available, from 1,361 in 2013 to 995 in 2017.
Tuberculosis incidence was 41 per 100,000 population in 2017, down from 51 per 100,000 population in 2014. The rate is much lower than the average of sub-Saharan Africa (237 per 100 000), according to the World Bank.
The country has one Principal Recipient, the Project Management Unit (Unité de Gestion de Projet - UGP), which is under the Office of the Prime Minister. The three disease programs in the Ministry of Health are the sub-recipients. For the current implementation cycle running from January 2018 to December 2020, the Global Fund and Togo signed $73.2 million in grants. As of June 2019, halfway through the grant cycle, $22.1 million, representing 30% of the signed amount, had been disbursed, as shown in Table 1.
Source: OIG audit report Global Fund grants in Togo
According to the OIG report, the PR met at least 80% of the targets that had been agreed upon in the grant performance agreement, except for the routine distribution of bed nets. The PR explained that most people targeted for routine distribution of bed nets (e.g., pregnant women, children under the age of 5 years) declined to receive them because they still had some which they had received during the mass distribution campaign held in 2017.
Audit objectives and risk areas
The OIG audit aimed to assess the adequacy and effectiveness of:
- Grant implementation arrangements;
- Controls and processes in place for the storage, distribution, and traceability of medicines, health commodities, and program assets;
- Controls and processes in place to ensure the reliability of data for decision making.
The OIG report described three important findings.
- Poor data quality
In March 2018, the country rolled out the District Health Information Software 2 (DHIS 2), an electronic tool to collect data from health centers and consolidate them into a Health Management Information System (HMIS). The DHIS 2 is deemed superior to the traditional paper-based system because health workers can more easily fill in the forms; more health facilities can report quality data; the data can be more easily analyzed. DHIS uses a basic mobile phone system and does not require an internet connection. It is currently used in 67 low- and middle-income countries, according to its website.
In Togo, the introduction of DHIS increased the timely completion of HMIS from 14% to 56% between January and December 2018, according to the report. Unfortunately, data in the Togo DHIS 2 was not accurate. The OIG found cases of double-counting patients, improper record-keeping in facilities, and patients in the DHIS 2 that could not be traced in the facility. Among the causes of this poor data, the report said, were the scarcity of health personnel, and the lack of mechanisms to check and assure quality data both at the Secretariat and country level.
- Poor traceability of drugs at district and service delivery level
Global Fund grants in Togo are highly commoditized (68%). In other words, about two-thirds of the grants is used to pay for health and non-health commodities like medicines, mosquito nets, and adequate warehousing for medicines. This means that procurement and the supply chain are areas at high risk of mismanagement given that they absorb a significant proportion of the grant funds. The country uses the Global Fund Pooled Procurement Mechanism (PPM), which reduces the risks associated with purchasing those commodities. The government medical store (called CAMEG) receives those health commodities and delivers them to the districts, which in turn deliver them to health facilities. So, no single government entity is responsible for the whole supply chain. The CAMEG responsibilities end at the point of delivery in each district. This absence of a single authority over the whole supply chain is one of the issues that the OIG report highlights as an obstacle to the traceability of medicines (see below).
During the audit, the OIG traced health commodities at the CAMEG and noted no material expiries or wastage. However, the OIG noted a lack of inventory management tools at the district level, which resulted in poor traceability of medicines. At the lower level, health facilities could not account for significant proportions of drugs received from the district. CAMEG delivered antiretroviral (ARV) medicines for HIV treatment directly to health facilities, however, so ARVs were fully traceable.
- Assurance and implementation arrangements need improvement
The audit found that the UGP, which is the PR, was well-structured and coordinated the activities of the different partners and sub-recipients effectively. However, some UGP personnel roles duplicated existing ones on the government payroll at the district level. According to the OIG, this is a concern in terms of sustainability, as the grants paid for the staff employed by the UGP. The OIG also found that the CCM played an important oversight role and helped solve issues that arose, such as a projected stock out of ARVs in 2018.
However, the OIG noted that the PR did not properly oversee its procurement agent, which was in charge of supplying non-health commodities worth $5.3 million. The poor oversight resulted in delayed renovation of the central warehouse, which in turn resulted in commodities being warehoused in sub-optimal conditions at the time of the audit.
Another important issue was the lack of government guidance to health workers, on which patients should buy anti-malarial medicines or should receive them free of charge in health facilities. In Togo, health facilities could sell anti-malaria medicines purchased from private distributors/manufacturers or give free medicines supplied by the Global Fund. In the absence of guidelines on who should buy the anti-malarial medicines and who should get them free of charge, health care workers decide on an ad-hoc basis. Such a situation could discourage poor patients from accessing the care they need as they cannot predict whether they will have to pay for the medicines or get them for free.
Agreed Management Actions
The agreed management actions were all directed to (“owned” by) the Head of Grant Management in the Secretariat.
The Secretariat would support the UGP (the Principal Recipient) as well as the Ministry of Health, and other partners, when relevant, to:
- Update and implement the manual of procedures of the Health information system (MOP-SNIS) to improve data quality. This action is due by 31 December 2020.
- Develop a supply-chain strengthening road map. This action is due by the 31 July 2020.
- Develop and disseminate clear guidance for public health facility prescribers on when to prescribe free versus paid antimalarial medicines to patients to ensure vulnerable populations are not disadvantaged; the guidance should be shared widely with the public. This action is due by the 31 December 2020.
- Evaluate the UGP structure and incorporate changes for the next funding cycle. This action is due by June 2020.
The full table of AMAs can be found on page 19 of the report.
- This audit report, Global Fund Grants in Togo (GF-OIG-19-022, 12 November 2019)
- Audit report: Audit of the Global Fund Grants to Population Services International Togo (GF-OIG-10-021, 31 October 2011).