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Audit Report: Global Fund Grants in the Republic of Côte d’Ivoire

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1. Executive Summary

1.1 Opinion

With €191 million of signed grants in the current funding cycle, the Global Fund is Côte d’Ivoire’s major financing partner in the fight against malaria and tuberculosis, providing approximately 40% of total funding.

Grant implementation arrangements at the Ministry of Health (MOH) changed significantly in early 2018 with the setup of a program management unit, Unité de Coordination des Projets (UCP). The ministerial decision to create UCP outlined its remits but did not define the type of implementing entity it should be, either in the short or long term. This makes it difficult to design a structure supporting UCP’s evolution. UCP’s limited accountability for centralized functions, notably procurement, does not help address bottlenecks and challenges in the procurement process. The effectiveness and efficiency of the new implementation arrangements at MOH are rated as partially effective.

Drug traceability is satisfactory at the central level. Likewise, items delivered by the National Medical Store (Nouvelle Pharmacie de la Santé Publique - NPSP) to districts and hospitals are traceable in most cases. A unit for validating orders from health facilities/districts has been put in place at the NPSP. Challenges with issued stock remain mainly at health facilities level. At several health centers and TB care centers, the consumption of anti-malaria and anti-tuberculosis drugs was nearly double the number of reported cases, with no explanation for the discrepancies. Drug transfers between health facilities are not supervised or adequately documented, leading to limited transparency and accountability. Both UCP internal audit and the supply chain department of the National Malaria Programme (PNLP) uncovered similar findings in health facilities out of those visited by OIG. Main contributing factors include the limited scope of supervision as well as the existence of a large informal health products market. The adequacy and effectiveness of controls and processes for distribution and traceability of malaria and TB health commodities mainly at health facilities need significant improvement.

According to routine data from the MOH’s health management information system (HMIS) and estimates from the World Health Organization (WHO), there has been little improvement in reducing malaria impact indicators such as malaria incidence, mortality and malaria test positivity rates, compared to 2015 results and the national targets. Vector control challenges (low bed nets utilization rate, increasing resistance to insecticide) and malaria case management at community level (recurring stock-outs of commodities, low coverage), among other factors, could have contributed to the slow progress. Concerning TB, community-based interventions have helped stabilize case notification and reduce the rate of cases lost to follow-up, from 7% in 2016 to 3% in 2017. However, the mortality rate of TB/HIV co-infected (21%) has been high for 5 years, due to insufficient joint management of co-infection as well as a high proportion of HIV patients who are lost to follow-up. Community-based HIV interventions have improved the linkage of new HIV cases to care, but insufficient coordination among implementers results in overlapping interventions at the community level and sub-optimal coverage of targeted populations. The adequacy and effectiveness of community interventions to achieve intended grant objectives are rated as partially effective.