Recent audits of grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria in Kenya and Mozambique have identified gaps in the procurement and supply chain processes in both countries, contributing to essential drugs and commodities going out of stock.
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Dismayed by the results, civil society groups are demanding accountability from the Global Fund.
Though the audits acknowledge that the problems in both countries originate in weak local structures and inadequate political accountability, activists say that those issues have been well documented. Given its outsize role in supporting programs for patients with HIV, tuberculosis, and malaria in both Kenya and Mozambique, activists say the Global Fund has an obligation to demand immediate improvements or fund alternative delivery systems to prevent future shortages.
The Global Fund currently administers $444 million worth of active grants in Kenya and $927 million worth in Mozambique, according to the organization’s Office of the Inspector General, which conducted the audits. Particularly in Mozambique, where nearly 80% of that funding goes toward procuring medicines and health products, any shortcomings can have a significant impact on programs across the country.
The Global Fund has committed to action plans to address the issues raised in the audits, but civil society groups are unconvinced.
“This is a problem that has been there for a long time,” said Maureen Milanga, the director of international policy and advocacy for Health Global Access Project, speaking to Devex from Nairobi, Kenya. “The Global Fund should be held accountable because they keep funding a broken system.”
In Kenya, stockouts of essential drugs and commodities have persisted for several years, fueling frustration with the Kenya Medical Supplies Authority, or KEMSA. The state corporation is responsible for the procurement and storage of medicines and health products, as well as for delivering those products to county governments or directly to health facilities.
The OIG audit found a system dogged by procurement delays. The Malaria, TB, and HIV commodities that were tracked saw an average gap of 345 days between procurement and delivery. The system also lacked adequate processes for monitoring, tracking, and reporting those items as they entered the health system.
This raised concerns about corruption, seemingly confirmed by the OIG’s discovery of Global Fund-financed commodities on sale in pharmacies in four counties — even though KEMSA had reported them as not having been distributed.
The organization is no stranger to allegations of corruption. In 2020, KEMSA was accused of mishandling a tender of 7.7 billion Kenyan shillings (worth about $71 million at the time) for procuring COVID-19 personal protective equipment — leading President Uhuru Kenyatta to disband the entire board in April of last year.
Overall, the Global Fund’s OIG deemed the procurement and supply chain controls and assurances ineffective at delivering and accounting for drugs and other health products.
“There is no assurance that the medication that comes into the country actually reaches the person living with HIV,” Milanga said. “They need to be responsible for the lives of the people they claim to want to support.”
Jack Ndegwa, the head of health systems and policy at Kenya AIDS NGOs Consortium, said some HIV patients have even taken to registering with several facilities to access antiretroviral medication, knowing they will likely have to visit multiple clinics before finding the drugs they need in stock.
A reform of KEMSA is underway, and the Global Fund’s secretariat has committed to working with the organization to outline the procurement process, clearly assigning responsibility for each step, and to develop an action plan “to provide enhanced assurance oversight of in-country distribution of Global Fund commodities.”
“The Global Fund should be held accountable because they keep funding a broken system.”
— Maureen Milanga, director of international policy and advocacy, Health GAPGlobal Fund representatives met with their counterparts in the Kenyan government and other officials in March, with a Global Fund spokesperson telling Devex that “the government is committed to the necessary steps to significantly improve KEMSA’s performance.”
But Ndegwa cautioned that “KEMSA still has a long way to be reformed to be an effective public health institution to serve all of the demands and needs of 47 county governments.” This is why activists are outraged that the Global Fund is continuing to utilize KEMSA, rather than pursuing an alternative route.
“They owe it to the people living with HIV to move all of that supply chain that they have through KEMSA to another, more credible supply chain system, at least up until KEMSA is able to fix house,” Milanga said.
The Global Fund spokesperson told Devex that it was “premature to look at other alternatives, but if the required actions are not done, that remains an option.”
In Mozambique, gaps in the procurement and supply system are different, though the outcome is the same: stockouts and low stock levels across the supply chain. Patients are forced to travel long distances to access medicines, according to Ezequias Simango, the director of Associação Moçambicana de Activistas Voluntários e Agentes Polivalentes de Saúde, a Mozambican health activist organization. And there are concerns that many are falling off treatment.
The OIG audit in Mozambique specifically cited a host of problems, including a lack of warehouse space, a fragmented supply chain, and data quality challenges that are contributing to drugs expiring on shelves.
And while the report acknowledges an absence of political will to address these persistent problems — including the sluggish implementation of a national plan for pharmaceutical logistics, introduced in 2013 — it also faults the Global Fund team.
“Despite this [procurement and supply chain] issue being well-known to the Global Fund, the mitigation measures to address it have had limited effectiveness,” according to the audit.
The secretariat has committed to help improve inventory management at Central de Medicamentos e Artigos Médicos — a legal entity that handles procurement, storage, and distribution of health products in the country — and develop a plan to reduce common delays in procurement.
Activists called for the Global Fund to act urgently, saying that supply gaps can have especially significant implications in a place like Mozambique, where the donor plays a pivotal role in supporting the procurement of drugs and other commodities. Delays and stockouts are hugely disruptive to the work of partners — particularly for the U.S. President’s Emergency Plan for AIDS Relief, the other major donor to Mozambique’s HIV response.
PEPFAR’s 2021 country operational plan for Mozambique indicates just how closely the two programs are intertwined, with several services — including an advanced HIV disease service package in each province — fully dependent on receiving adequate commodities through Global Fund grants. Neither PEPFAR’s team in Mozambique nor its Washington headquarters responded to requests for comment.
In a response to the audit, Global Fund Executive Director Peter Sands wrote that the donor “is committed to working with Mozambique and partners to address all the key issues and risks identified under the audit.”
Simango said the only choice is to wait to see how urgently the Global Fund addresses the challenges raised by the OIG.
“The problem is the government doesn’t help itself,” he said. “It depends on PEPFAR and the Global Fund.”