Guinea, a West African country of about 12 million people, faces several serious challenges in implementing its Global Fund grants. Some challenges have been related to the country’s political and epidemiological contexts. Others are related to the implementation of some Global Fund policies in the country. Guinea is a ‘core’ country in the Global Fund classification, characterized by a large portfolio, a high disease burden for at least one disease, and is considered ‘high risk’ for grant management.
The HIV epidemic in Guinea is generalized but still at relatively low prevalence (HIV prevalence in the general population of 15 to 49 years old is 1.5%), in keeping with its neighboring countries where the prevalence ranges from 0.4% in Senegal to 3.4% in Guinea Bissau. Although the country does not figure in any list of high-burden countries for tuberculosis, TB incidence remains a major public health threat, and malaria is endemic.
Predictably, HIV prevalence is higher among the key populations of sex workers (10.7%), men who have sex with men (11.4%), and people who inject drugs (5.5%). TB incidence was 22,000 cases according to the 2018 Global TB report published by World Health Organization database. Malaria is widespread in Guinea: a recent household survey estimated that 30% of children under five had malaria parasites in their blood. This finding means that the children are infected though they might be asymptomatic. In clinical practice, those children should receive treatment otherwise they might progress to full clinical presentation of malaria disease. Thus, it is not surprising that among children under five, malaria accounts for 31% of outpatient visits, 25% of inpatient admissions, and 14% of hospital deaths in public facilities.
Estimates for malaria among the general population are close to those of children; malaria is the primary cause of 34% of outpatient visits, 31% of inpatient admissions and 14% of hospital deaths in public facilities, according to the President’s Malaria Initiative, citing the National statistics in Guinea.
These estimates exclude malaria cases treated in private facilities or in the community. It is in that epidemiological context that Guinea has applied for Global Fund grants for the three diseases for the period 2017-2020.
This article aims to analyze challenges in grant implementation in Guinea, and identify lessons learned - or issues missed – by stakeholders. Information for this article comes from publicly available documents (see list at the end of this article), including the grant funding requests and grant performance, the Office of Inspector General (OIG) August 2017 audit report on Guinea, as well as interviews with officials in Guinea and with the Global Fund Portfolio Manager.
Global Fund and other partners’ investments in Guinea
Guinea receives support from the Global Fund as well as other external partners to fight the three diseases. To date, the Global Fund has disbursed $114,711,999 for malaria, $87,157,784 for HIV, $16,289,030 for TB and $2,552,108 for HIV/TB according the Global Fund’s country website page on Guinea. Disbursements to Guinea amount to a total of $220,868,633.
In the 2015-2017 implementation period, the Global Fund committed $113,563,396 to Guinea, out of which $93,179,148 was disbursed (Table 1). Catholic Relief Services, as Principal Recipient for the malaria grant, managed $45,612,251; Two PRs managed the HIV grants totaling $38,169,376; Population Services International (PSI), in charge of prevention, managed $6,438,817 while the Comité National de Lutte contre le Sida managed $31,730,559.
Table 1: Characteristics of grants to Guinea for the current and previous implementation periods
|Implementation Period||Component||Principal Recipient||
|Current 2018-2020||HIV / TB||Plan International, Inc.||14,550,605||6,302,624||2,552,108|
|Current 2018-2020||HIV/ AIDS||The Ministry of Public Health||33,573,749||12,235,253||5,318,835|
|1er Oct 2015 to 31 Dec 2017||HIV/ AIDS||Population Services International||14,071,558||11,286,991||6,438,817|
|1er Oct 2015 to 31 Dec 2017||HIV/ AIDS||Comité National de Lutte contre le Sida||46,774,989||40,595,710||31,730,559|
|1 Jan 2014 to 31 Dec 2016||TB||Population Services International||7,066,900||6,686,932||6,675,684|
|1er Jan 2017 to 31 Dec 2017||TB||Plan international||3,894,373||3,504,935||2,721,837|
|1er Oct 2015 to 31 Dec 2017||Malaria||Catholic Relief Services||62,200,441||51,488,828||45,612,251|
Source: Global Fund website, Guinea country page
To protect the Global Fund investment in Guinea, the country is under the ‘additional safeguard policy’, which means that the Secretariat takes a series of extra procedures to strengthen fiscal and oversight controls in especially high-risk environments (see more on the policy here).
In Guinea, this policy takes the form of engaging international entities as PRs for some grants, a restricted cash policy in grant operations, and the use of a fiscal agent who co-signs expenditures for grants managed by national PRs.
Guinea is also designated by the Global Fund as a Challenging Operating Environment (COE), which describes “countries or regions that experience disease outbreaks, natural disasters, armed conflicts and/or weak governance”. The COE policy, adopted by the Global Fund in 2016, is designed to improve the effectiveness of Global Fund investments by reaching key populations, and through more flexibility, support to innovations and stronger partnerships.
The Global Fund is the principal external donor for HIV and TB in Guinea, but for malaria, Guinea’s second largest donor (after the Global Fund) is the US President’s Malaria Initiative (PMI), which has been active in Guinea since 2011. This support makes a huge difference in the management and performance of the Global Fund grant for malaria as the PMI contributes $15 million towards purchasing health commodities, supporting vector control, mass distribution of insecticide-treated nets as well as a Logistics Management Information System for malaria, according to the OIG’s 2017 Audit Report.
Guinea’s weak health system
Guinea’s health system, health information, surveillance, supply chain, as well as infrastructure and logistics systems were weak, as evidenced by the outbreak and spread of Ebola in 2014 to early 2016, according to the World Health Organization. This Ebola outbreak occurred in the three neighbouring countries of Guinea, Sierra Leone, and Liberia with a total of 28,616 cases of Ebola Virus Disease and 11,310 deaths. In Guinea, 3,814 people died during this epidemic, according to estimates by the US Centers for Disease Control and Prevention.
The country’s weak health system is due in part to the small government investment in health in Guinea. According to a World Bank report on strengthening post-Ebola health systems, the government budget’s share to health was only 1.9% in 2012, 4% in 2015, and 4.6% in 2016. For subsequent years, the country has planned to increase this percentage to at least 6% of the budget. These increases in government funding for health are a sign of the re-prioritization of the health sector in Guinea. While these percentages represent an improvement relative to 2012, they still fall short of the 15% share to health that the country committed to in the Abuja declaration. (In context, this finding is not surprising as only six countries — Rwanda, Botswana, Niger, Zambia, Malawi and Burkina Faso — actually meet that commitment.)
After the Ebola outbreak, the Guinea government established a telephony-related tax dedicated to sectors affected by Ebola (in addition to health, the sectors are agriculture, livestock farming, and fisheries, trade and industry, mining, tourism and air transport, infrastructure), which could raise nearly $67 million per year – an amount slightly larger than total government health spending in 2015.
The health component of the recovery plan developed by the Guinea Ministry of Health with its partners, the “plan de relance 2015-2017,” took stock of the situation, and planned a way forward with an estimate of resources needed.
HIV grant run as project
The Global Fund 2015-2017 HIV treatment grant managed by the Government Principal Recipient (PR) was plagued with issues relating to poor coordination and inadequate quantification that led to expiries and understocking, according to the 2017 OIG audit report on Guinea’s grants.
Over the course of the grant, its performance was mostly rated B2 (“Inadequate but potential demonstrated”) by the Secretariat. The government PR was the Comité National de Lutte contre le Sida (CNLS, or National Committee for AIDS Control) which is a state agency independent of the Ministry of Health (MoH). (The non-State PR, Population Services International, was in charge of HIV prevention).
According to one source, the grant was managed “like a project and not as part of the tasks of the Ministry of Health”, which deprived it of existing expertise, and which led to dysfunction. For instance, the CNLS used “fanciful” numbers (“fantaisiste” in the French, original quote) for anti-retroviral (ARV) procurement contributing to stockouts in health facility (see article in this issue of the GFO on the OIG’s investigation into data falsification in Guinea) although the MoH employs pharmacists competent in health commodities quantification who could have helped obtain more reliable estimates of the need. Similarly, the MoH’s department of health-care delivery, which oversees health facilities and employs experts in coordination of provision of care in public facilities, was not involved with managing the grants either, contributing to stock-outs of health commodities in public facilities.
For the current grant allocation period of 2017-2020, the MoH is the Principal Recipient (PR) (Population Services International closed its operations in Guinea in 2018, according to the Global Fund; PLAN has now replaced PSI in supporting interventions aimed at key populations). This change in government PR, along with the creation of a coordination unit for the Global Fund grants inside the MoH for the three diseases, is expected to improve coordination of different activities, and lead to improved grant performance.
While Guinea’s Ministry of Health was PR, up to 2012, grant results were unsatisfactory. But the Global Fund is optimistic about improvements in implementation now that the ministry has new leadership and the government has committed to better funding of the health sector after the Ebola epidemics. Despite the new leadership and goodwill, the fact that antiretroviral medicines for HIV were out of stock between May and July 2018 (as documented by Medecins Sans Frontières), is an enduring signal of the depth of some of Guinea’s implementation problems.
Co-financing used for ARVs
The Global Fund implements a co-financing policy that requires low-income countries such as Guinea to demonstrate increased domestic contributions to their respective health sectors and to the three disease programs, with every new funding cycle. Disbursement of 15% of the allocation is conditional on that contribution.
The specific form of the co-financing depends on negotiations between the country officials and the Secretariat’s country team. (The GFO will publish a separate article on co-financing in Guinea and other countries, in January 2019). In the 2015-2017 allocation cycle, Guinea committed $19,857,143 to the New Funding Model (NFM) account to buy ARVs. Guinea honoured its commitments, in part: the country spent $10,844,930, i.e. 54.6% of what it had committed, to buy ARVs in the last year of the grant. However, this procurement was late, causing ARV stock outs during the course of the 2015-2017 grant, and disrupting patients’ treatment. (Efficient health systems place an emphasis on avoiding stock outs of important medications.)
Again, during this current allocation period (2017-2019), ARVs have been out of stock from May to July 2018 in Guinea for similar reasons: the country’s co-financing was intended for the purchase of ARVs but the funds did not materialize in a timely manner. As a temporary solution, the HIV program was able to rely only on the health commodities procured by Global Fund.
Guinea’s in-country supply chain management is inadequate, with the most problematic issue for the HIV grant being the recurrence of periods of ARV overstock succeeding periods of stock out.
The OIG audit in 2017 estimated that about $3-million worth of antiretroviral medicines financed by the Global Fund in 2016 was likely to expire due to inadequate in-country management of inventory, supply-chain and logistics. Subsequently, stakeholders decided to estimate the amount of remaining ARVs and move them to other countries that might need them, before their expiry – but the warehouse where the ARVs were kept burnt down before this action was taken. (The cause of the fire is not publicly known.)
Since the OIG’s 2017 country audit, the Secretariat has worked with the PR to implement the Agreed Management Actions that the OIG recommended. Among them are actions to strengthen some aspects of the state supply-chain mechanism.
The malaria grant, which is larger than the HIV grant, has fewer problems due to its being supported by PMI, and is effectively coordinated by the MoH’s disease program.
Lessons learned and missed opportunities
Guinea is a challenging environment considering the overall weakness of the health system and the country’s recent Ebola epidemics. More recent evidence of this weakness is highlighted in the latest OIG investigation in Guinea where a contracted NGO provided fraudulent data for an Integrated Biological and Behavioral Survey (IBBS), and misleading indicators (see GFO article).
More than ever, there is a need in Guinea for a stronger sense of country ownership. Such a change should be supported by the Global Fund, with a flexible application of the co-financing policy, and by other partners. In that context, the change of PR and leadership of Guinea’s Global Fund grant management appears to be a step in the right direction. The country needs to invest in its health system choosing an entry point that makes sense in their context: an investment in health information systems that would cover data collection and quality assurance as well as forecasting, quantifying and warehousing of health commodities, are all good candidates for such investments.
Further reading on Guinea:
- The OIG’s 2017 country audit of Global Fund grants to Guinea
- The OIG’s just-published 2018 investigation into data falsification in Guinea
- The article in this GFO on the OIG investigation into data falsification
- Information on grants in Guinea on the Global Fund Website
- Plan de relance du système de sante
- The Abuja declaration ten years on
- The Abuja declaration on HIV/AIDS, Tuberculosis and other related infectious diseases