- Executive Summary
South Sudan is one of the most challenging operating environments in the Global Fund portfolio.
The Global Fund is a key development partner, providing 31% of HIV, 64% of TB and 39% of malaria funding across the 2018-2020 NFM2 period. Despite significant challenges in terms of political stability, economic dependence on oil and inadequate capacity of human resource for health, progress has been made across the three diseases since the 2015 OIG audit. Global Fund grants are materially meeting their performance targets; in particular, over 2 million insecticide treated bed nets were distributed in 2017 and 2018, and steps have been taken to align the grants to the recently devolved state expansion (from 10 to 321 states).
While key risks across the portfolio are adequately identified and mitigation activities are generally appropriate, implementers’ actions to mitigate risks have been materially delayed or incomplete.
Issues exist in the timeliness and accuracy of data that is available for the three diseases, with delays in national health management information system (HMIS) reporting in 2017 and 2018. Despite the challenges, the roll out of DHIS2, which was originally planned to be finalized by December 2017, has been postponed to December 2020. The national monitoring and evaluation framework has not been completed and no data quality audits were conducted in 2017 and 2018 by the Ministry of Health (MoH). Significant delays have also been noted in the completion of key studies and surveys.
These have affected the availability of reliable data for strategic decision making and performance measurement.
There was inadequate planning and monitoring for the mass bed net distribution. Malaria behavioral and change communication activities were not undertaken during or prior to mass distribution campaigns in 2017 and 2018. No post-distribution assessments to review the effectiveness of mass campaigns were conducted. The program has taken full advantage of flexibilities2 under the Challenging Environments (COE) Policy in bed net distribution as well as the opportunity to use service providers and humanitarian aid delivery to support distribution, but an incomplete framework to implement flexibilities on bed net distribution has resulted in multiple interpretations by different parties on their use. This contributed to implementers not exploring other flexibilities in the Global Fund COE policy (such as on grant revisions, the performance framework or monitoring and evaluation activities) due to lack of clearly defined risk appetite for these flexibilities. The mitigation of significant portfolio risks therefore needs significant improvement.
With the Government of South Sudan’s contributions to health declining from 7% in 2012 to 1% of GDP in 2016, effective partnerships and coordination play a vital role in the fight against the diseases.
The audit found gaps in partner coordination, which contributed to parallel commodity distribution and delays in executing key program activities, including the roll-out of the Boma Health Initiative, a critical intervention for community health engagement in the country. Donor coordination with key donors such as PEPFAR for HIV and the Health Pooled Fund for malaria (through strengthening primary health care at the facility level) is critical in addressing systemic challenges such as parallel commodity delivery, and patient and logistics reporting systems. Implementers also contribute to financing CCM oversight activities, which contravenes Article 3 of the Global Fund CCM Funding policy. Grant implementation arrangements, including governance, oversight and partner coordination to achieve grant objectives are therefore partially effective.
Global Fund grants in the country are managed under the Global Fund’s Additional Safeguards Policy due to the country’s need to rebuild systems, infrastructure and capacity following years of conflict. The audit found non-compliance with Global Fund policies and guidelines, including unsupported payments (US$211k) and non-competitive procurements (48% of sampled cases).
Processes and controls around fixed asset management, an issue previously identified during the OIG’s 2015 audit of South Sudan, have materially improved, however gaps were noted in the utilization and recording of assets. Given the context of South Sudan as a COE country and the magnitude of the financial management issues identified, financial management and assurance over grant funds are therefore partially effective.