Monrovia — The Ministry of Health has officially responded to the latest report released by acclaimed international health body Global Fund, partially distancing itself from some of the allegations and instituting measures to address ones that are established in a bid to avoid future risks of misapplying donors’ funds provided to boost Liberia’s health sector.
On April 8, The Global Fund released a damaging report on the Ministry of Health, unearthing alleged acts of corruption amounting to more than US$1M.
The Global Fund is a partnership designed to accelerate the end of AIDS, tuberculosis, and malaria as epidemics. As an international organization, the group mobilizes and invests more than US$4 billion a year to support programs run by local experts in more than 100 countries.
In a report released by the Office of its Inspector General on April 8, 2022, the group pointed out the alleged conflict of interest, procurement fraud, overcharging for services rendered, concealing improper payment of fuel taxes, systemic fraud, and misappropriation, among others, amounting to nearly US$1M.
But in a statement issued under the signature of its Communication Director Felecia Gbesioh, the MOH justified that it is “impossible” for Global Fund to report that about US$990,000 from grants provided to the ministry has not been accounted for.
“We believe the vigorous system of check and balance the Global Fund Grant management system has in place at the Ministry of Health along with our robust Financial Management System and many years of managing grants we can safely say it’s impossible to engage in massive corruptions without being detected over a long period of time as it has been portrayed by the OIG report. OIG findings declared an aggregate expenditure summing up to US$990,000 (Nine Hundred and Ninety Thousand United States dollars) non-compliant and recommended restitution”.
“Though we do not agree with everything in the report, the Ministry wishes to assure the public that it is giving significant attention to the allegations of fraud and misappropriation. As the report implies, significant measures have already been taken to mitigate some of the risks identified”.
Analyzing the report
The Ministry pointed out that consistent with a desire to discharge its duties in line with established guiding principles, it is analyzing the Global Fund report to inform action (s) to be instituted.
It recalled that the OIG’s investigation was triggered by the Ministry when it discovered irregularities at one of its programs, the National AIDS Control Program (NACP) by the internal audit unit of the Ministry in 2020 after which the Ministry’s alerted the Global Fund in keeping with the Grant Agreement.
The MOH further justified that during the period under review in keeping with the Global Fund grant management and procedure, the fiduciary responsibilities such as procurement, Financial Management (including co-signing of checks, Local Purchase Orders and Vouchers), Internal Audit and External Audit functions were all being jointly executed by many international firms with multiple responsibilities.
The firms
The Ministry disclosed that Cardno International Development, an American -based financial management firm was contracted by Global fund as its Fiscal Agent (FA) and was stationed at the MOH with the fiduciary responsibility of reviewing all procurement and financial transactions as well as providing pre-audit and post- audit functions on global fund transactions.
“If the Local Fund Agent (LFA) dissatisfied with a particular transaction or transactions, it doesn’t get processed until its corrected and signed on by the FA. The FA has the right to also declare a transaction as illegible even after it has occurred. Cardno served the Ministry in this capacity from 2015-2021 and has now been replaced by GFA Consulting Group another Internal Financial and Procurement management firm as of January 2022”.
It emphasized that the Swiss Centre for International Health has also been under contract by the Global Fund as the Local Fund Agent (LFA).
The MOH disclosed that the LFA oversees quarterly reviewing and certification of all quarterly transactions submitted to the Global Fund along with their supporting documents, adding that, “they also provide assurances of all quarterly report submitted to the Global Fund on a periodic basis”.
“The LFA performed post audit of all transactions on a quarterly basis and report to the Global any irregularities. The LFA has the right to also declare expenditures stated in the quarterly report as illegible after it has reviewed the transactions. In which case, the MOH will have to reimburse the Global Fund for such expenditure deemed illegible. Since 2015 the Swiss Center for International Health has played the roles Local Fund Agent”.
The Ministry also named Moore Stevens International Auditing Firm based in the UK as another institution that was hired by the Global Fund.
“For the period of the OIG report, as is expected, the International Auditors provided assurances of all transactions carried out by the Ministry during the period 2015-2020. These very transactions which were reviewed by the FA, and LFA were also authenticated by the external auditors through the provision of an unqualified Opinion (Clean Opinion)”.
It noted that The Moore Stevens five years contract has ended and has been replaced by Ernst & Young, another international Auditing firm that is currently conducting Audit of the Global Fund transactions for the fiscal year which ended December 31, 2021.
Appreciating Global Fund
Meanwhile, the Ministry has appreciated the efforts of the Global Fund and its desire to safeguard and ensure transparent implementation of all Global Fund grants generally.
It emphasized that it is in possession of the investigation report issued by the Global Fund’s Office of Inspector General (OIG) pertaining to the examination of the TB/HIV and Malaria/Health System Strengthening Grants implemented by the MoH as Principal Recipient (PR).
“We are advised that proper management of the grant fund is very important for the attainment of the overall goal of the Global Fund–which is “to invest the world’s money to end HIV/AIDS, Tuberculosis and Malaria.” Akin to that of the Global Fund, the goal of the Ministry of Health is “to improve the health status of the population of Liberia on an equitable basis.” Amongst other things, the Ministry is guided by principles such as efficiency, accountability, and transparency in the discharge of its duties- like the Global Fund”.
Progress made
The MOH pointed out that despite the report, significant progress has been made toward the fight against HIV, TB, and Malaria in Liberia.
It added that it has reduced morbidity and mortality occasioned by malaria by over 50% (Malaria Mid-Term Review Evaluation report 2018); distributed close to ten million mosquito nets, protecting the entire population with sustained vector control interventions; treated over fifteen million cases of uncomplicated malaria; tested over 25M of suspected malaria cases over the period under consideration and beyond.
The ministry maintained that significant progress has also been made toward HIV interventions over the years.
It noted that HIV prevalence among the sexually active population (age 15-49) has been declining yearly–from the peak of 2.8 in 1996 to 1.2 in 2018 and 1.1 in 2020 (Prevalence of HIV, total (% of population ages 15-49) – Liberia Data (worldbank.org)).
“Among other things Liberia has accelerated HIV test coverage to reach 68% of persons living with HIV knowing their status; the number of persons living with HIV receiving treatment increased from 5,916 in June 2015 to 19,328 by June 2021 (an increase by 13, 412 in 6 yrs.); in September 2019, Liberia introduced Tenofovir/Lamivudine/Dolutegravir (TLD) and accelerated the transition from TLE to TLD with about 92% of all clients on the more potent regimen; viral load testing coverage went up from 20% in 2018 to 32.5% among those on treatment in 2020 whilst HIV suppression rate also rose from 52.5% to 73.9%; progress towards the 95-95-95 global target is on an upward trajectory and currently stands at 68-89-65. Despite the challenges with Early Infant Diagnosis (EID), testing coverage among infants born to HIV-positive mothers increased by over 50%, from 163 in 2018 to 256 and 367 in 2019 and 2020 respectively”.
To achieve these feats, the MOH added, that a National Program has been swift in adapting new guidelines and partnering with the local communities and civil society organizations to implement diversified service delivery to simplify HIV services to efficiently address the expectations and needs of people living with HIV, or vulnerable to HIV as well as reducing unnecessary burdens on the already challenged health system.
The Ministry indicated that despite the momentous progress, no assurance that services were delivered as outlined in the OIG’s Report, cast general aspersion on those achievements.
The Ministry bragged that it has so many dedicated employees who are committed to providing required HIV/AIDS, TB, and Malaria services and without some of those staff, Liberia could not achieve the feats mentioned above.
“However, like in all society, few bad actors tend to derail the effort of the many good ones. This seems to be the case here where a few unacceptable behaviors are casting doubt on the progress of our dedicated staff, some of whom have committed most of their productive lives to the fight against HIV, TB, and Malaria”.
Investigation ongoing
According to the ministry, personnel accused of fraud and misappropriation relative to the GF report are being investigated further, and plans are underway to ensure the termination of employment in some cases, restitution of funds in others, and the involvement of the Liberia Anti-Corruption Commission (LACC) when needed.
“The Ministry will keep the public informed of the progress towards administrative actions taken to reduce the recurrence of prohibited practices identified and remains committed to full transparency adherence to our Public Financial Management and Procurement Laws”.
As a Principal Recipient of the Global Fund grants, the Ministry of Health says it remains committed to the fight against AIDS, TB, and Malaria and shall not compromise the health and security of those within and without the borders of Liberia, for the contrary will not only violate the Grant Agreements with the Global Fund, but it will also be a dereliction of the statutory duties of the Ministry of Health.
The findings released by Global Fund appear to discourage efforts towards ensuring a resilient healthcare delivery system in Liberia.
In its findings, GF pointed out that US$0.52 million in grant funds were wasted or misused for the Mother-to-Mother Peer Program and travel-related costs.
The report disclosed that the program was a component of the prevention of mother-to-child transmission of HIV module under the HIV/TB grant.
It quoted the MoH as saying that the program was an essential component for early infant diagnosis, which had been identified as a key program activity in Liberia.
As a result, Global Fund invested US$0.25 million towards incentive payments to mother peers, who were required to provide MoH with reports on mothers they had enrolled into the program, and the infants that had been tested.
The report unearthed that between January 2020 and April 2020, MoH spent US$27,032 in Daily Subsistence Allowances (DSA) and fuel to deliver incentive payments to mother peers, or to have them sign contracts.
“The OIG found that there was no reasonable assurance that these activities took place. Depending on the period, our review highlighted that between 92-100% of the dates allegedly provided by the mother peers for the receipts of their incentive payments fell outside of the dates of travel reported by MoH staff. In 50% of cases, MoH attendance records showed that staffs were at headquarters during dates of the alleged travel”.
It noted that separate travel cost claims for the same activity to the same counties, were made by both NACP and PCU staff, while vouchers for fuel either did not contain vehicle logs confirming the travel or showed that the fuel coupons were delivered during or after the alleged travel.
“MoH incentive distribution lists showed that between 2018 and 2020, 232 mother peers were enrolled. MoH could not however provide the OIG with contracts for all mother peers. We found that some mother peers who did have a contract were not included in the incentive distribution lists, and vice-versa. We compared the signatures of 122 mother peers on identification documents, contracts and DSA distribution lists, and found inconsistencies between signatures in 92% of cases”.
It indicated that though Mother peer reports were a contractual condition for incentive payments, the NACP could only provide the OIG with a very small number of reports, which were inadequate.
“They included data inconsistencies, as well as reports from mother peers who were not part of the Global Fund-financed program. Some mother peers listed each other as clients, and the reports showed that only a small number of infants had actually been tested for HIV. The OIG was unable to determine whether the reports were fraudulent or whether they contained data errors that should have been identified by MoH. MoH could not provide evidence that it reviewed or used any of the reports. NACP’s Program Manager misrepresented the authenticity of program documentation, claiming it was used by NACP in 2018 and 2019 despite it only being created in 2021”.
Other travel-related costs
The report further pointed out that GF reviewed 47 payment vouchers for DSA totaling US$0.35 million and found that MoH overcharged the Global Fund by approximately 44%, or US$0.15 million, by applying incorrect US$ exchange rates which inflated the amounts.
Given the number of payments for travel-related costs, the report maintained that the total amount of overcharge was likely even higher.
“The Global Fund requires that when meals are provided, the DSA amount should be reduced accordingly. MoH however told OIG that its practice was to provide both catering and full DSA. We reviewed payment vouchers for 12 activities and found that MoH overcharged the Global Fund US$90,638 by providing meals and full DSA”.
Non-compliance with policies, insufficient controls
It disclosed that there was also a non-compliance with policies, insufficient controls and a lack of oversight which led to no assurance over program delivery in 75% of cases reviewed, totaling US$0.4 million.
According to the report, the OIG reviewed payment vouchers, supplier invoices, per-diem distribution lists, attendance records, activity reports and vehicle logs for program activities carried out by the National AIDS Control Program (NACP) and the National Malaria Control Program (NMCP), totaling US$0.54 million.
It emphasized that in 75% of expenditures for field activities, the OIG found fraud and in 90% of these expenditures there was no reasonable assurance that the activities took place as reported or even at all. “The majority of the remaining 25% of expenditures did not comply with MoH or Global Fund policies and/or there was no reasonable assurance that the program activity took place”.
The report named some of the prohibited practices and unsupported expenditures as the Roll-out of 2019/2020 National Operational Plan.
It recalled that in June 2019, a cheque for US$23,535 was made payable to a Program Coordination Unit (PCU) accountant to cover Daily Subsistence Allowances (DSA), transportation reimbursement, catering, and hall rental for five meetings in five counties to roll out the 2019/2020 National Operational Plan.
The report disclosed that the OIG review of the payment and supporting documents found multiple red flags, including identical phone numbers and taxpayer-identification numbers for supplier bidders, and the same names listed in attendance registers for the same day in different areas, adding that, “all attendance registers contained entries apparently written by the same hand”.
Quality Control review of Health Facilities
The report pointed out that in October 2020, the Global Fund approved MoH’s request for US$14,650 for three teams to conduct a Diagnostic Quality Assurance and Quality Control review of health facilities.
According to GPS trackers installed on the vehicles, one of the three teams travelled for only 6 of the 15 days claimed, and to 2 of the 4 counties they reported visiting.
In the counties to which the team did travel, the report added that, the team did not travel to at least five health facilities which they reported visiting.
“The second team only traveled for 8 of the 21 days they reported and did not travel to at least 3 health facilities they reported visiting. A review of the third team’s travel revealed its members were eligible for 2.5 days of DSA, as opposed to the 17 days they claimed”.
Maintenance and training for GeneXpert machines and chemistry analyzers
The report uncovered that in March 2020, the NACP spent US$11,420 for DSA and fuel to conduct maintenance and training for GeneXpert machines and chemistry analyzers.
According to the report, the same NACP staff members were recorded as attending different events on the same dates.
“NACP attendance logs showed that staff members allegedly participating in the activities were actually present at the NACP office. Vehicle logs and activity reports were fabricated: for example, one activity report included photocopied sections of another. NACP acknowledged that the activities did not take place, and MoH financial records stated that the expenditures had been voided and the funds reimbursed. However, MoH bank account records revealed no such reimbursement”.
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Roll-out of 2018/2019 National Operational Plan
The report further recalled that in June 2018, a cheque for US$14,740 was issued to a PCU accountant for a meeting to “consolidate, validate and print” the 2018/2019 national operational plan.
It noted that the quotation for event venue and catering and the receipt for payment were both dated for the first day of the meeting.
“DSA was provided to 45 people, 24 of whom signed attendance registers for less than the number of meeting days. Attendance registers appeared to have been falsified and included 11 people who did not receive DSA. Three people signed the register twice on the same day, and one director was listed on 8 April 2022 Geneva Switzerland Page 8 of 18 the attendance register as a driver. There was no budget for fuel, and no vehicle logs supporting travel. There was also no activity report to justify the expenditure”.
Financial Management System training
The report stated that in September 2018, US$35,320 was paid to a PCU accountant to also conduct a refresher, in-person training event on its financial management system, but there was no evidence that three quotations were received for catering and hall rental, and venue invoices were identical to the amount budgeted.
It claimed that 34% of DSA recipients did not attend the training for the number of days they received DSA and the attendance registers appeared fabricated, including signatures of individuals who had not received DSA as well as signatures of individuals twice on the same day.
It noted that some NACP staff requested and received DSA from NACP for the training, despite also having received DSA from the PCU accountant.
“In January 2019, US$47,800 was paid to a PCU accountant for an additional in-person financial management system training event. The activity report indicated that the activity was held over 10 days, but there were attendance registers for 11 days. 68% of DSA recipients did not attend the training for the number of days they received DSA. Attendance registers included signatures of people who did not receive DSA, and individuals who signed the register twice on the same day. There was no evidence that three quotations were sought or received for the supplier of the training”.
The report maintained that the budget referenced a 12-day activity, and the amount invoiced by the supplier for 11 days was identical to the amount budgeted.
“Despite representing to the OIG that all supporting documents had been reviewed, validated and retained, no records could be produced for the OIG to review.
It added that the Ministry of Health allegedly concealed improper payments of fuel taxes of at least US$0.16 million.
According to the group, the MOH controls, policies and oversight were either insufficient or overridden, while Fiscal Agent oversight was ineffective, and its personnel engaged in conflicts of interest and misappropriation of grant funds.
The group pointed out that there was systemic fraud and misappropriation by staff of the Ministry of Health (MoH), a Principal Recipient for Global Fund grants in Liberia.
“Our investigation found non-compliant expenditures and/or various types of wrongdoing in 91% of the expenditures reviewed. Non-compliant expenditures totaled US$1.1 million, of which we recommend recovery of US$0.99 million. Staff of the National AIDS Control Program conducted fraudulent procurements of both vehicle repairs and advertising services, for which there is no reasonable assurance of delivery”.
“No assurance could be provided over program delivery in 75% of MoH field activities that we reviewed. The MoH also overcharged the Global Fund for daily subsistence allowances and misused grant funds by providing incorrect allowances and catering expenses”.
The report emphasized that Global Fund’s US$0.25 million investment into the mother peer program for early infant diagnosis produced a small number of inadequate reports that were not used.
Contrary to Grant Regulations, the report divulged that, the MoH used grant funds to pay taxes on fuel, and knowingly misrepresented the grants’ tax-exempt status to the Global Fund.
“MoH controls, policies, and oversight to mitigate fraud and misappropriation were either insufficient or did not exist. Where they existed, they were overridden. The Global Fund has implemented several internal controls to address this issue, and further controls will be implemented as a result of this investigation”.
