PERFORMANCE AUDIT REPORT of the AUDITOR GENERAL on …ANTI-RETROVIRAL DRUGS. I have the honour to...

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PERFORMANCE AUDIT REPORT of the

AUDITOR GENERAL

MANAGEMENT AND DISTRIBUTION OF ANTI-RETROVIRAL DRUGS

IN GHANA

This report has been prepared under Section 11

of the Audit Service Act 2000 for presentation

to Parliament in accordance with

Section 20 of the Act.

Richard Quartey

Auditor General

Ghana Audit Service

3 September 2012

This study team comprised:S. A. K. Quist, Minata Diabor, Dennis Agbleze, andSampson Osei Boadu

This report can be found on the Ghana Audit Service

website at www.ghaudit.org

For further information about the

Ghana Audit Service please contact:

The Director, Communication Unit

Ghana Audit Service

Headquarters

Post Office Box MB 96, Accra.

Tel: 0302 664928/29/20

Fax: 0302 662493/675496

E-mail: [email protected]

Location: Ministries Block 'O'

© Ghana Audit Service 2012

Performance audit report of the Auditor-General on management and distribution of Anti-retroviral drugs

TABLE OF CONTENTS

Page

Transmittal Letter i

Executive Summary iii

CHAPTER ONE………………………………………………………... 1

1.0 INTRODUCTION………………………………………............. 1

1.1 Reasons for the audit……………………………………………… 1

1.2 Purpose and scope………………………………………………… 2

1.3 Methods and implementation……………………………………… 3

CHAPTER TWO……………………………………………………… 5

2.0 DESCRIPTIVE CHAPTER ...…………………………………… 5

2.1 Historic background …………………………………………… 5

2.2 Statutory mandate……………………………………………… 5

2.3 Objective……………………………………………………….. 6

2.4 Funding………………………………………………………… 6

2.5 Current development…………………………………………... 6

2.6 Key players and their activities………………………………… 7

2.7 System description……………………………………………… 7

Performance audit report of the Auditor-General on management and distribution of Anti-retroviral drugs

CHAPTER THREE…………………………………………………… 8

3.0 FINDINGS AND RECOMMENDATIONS .…………………….. 8

3.1 Introduction……………………………………………………. 8

3.2 Inadequate supply of ARV drugs…………………………….. 8

3.3 Submission of inaccurate data……………………………….. 11

3.4 Delayed in submission of returns ……………………………… 12

3.5 Failure to supply drugs purchased...…………………………… 13

3.6 ARVs are partially delivered….……………………………… 14

3.7 Delays in clearing of ARVs from Airports…………..………… 16

3.8 Monies collected from PLHIV are not accounted for properly…… 18

Appendices

A Key stakeholders interviewed……………………………………… 20

B Documents reviewed…..…………………………………………… 21

C Key players and their activities……………………………………… 22

D NACP system description…………………………………………… 23

E Analysis of responses of treatment sites to questions asked……… 24

F Amount of money collected by sites visited as at the time of the audit… 25

G Treatment sites with buffer stock……………………………………… 26

H Air-conditioning at treatment sites…………………………………… 27

I Total amount of revenue collected from all the sites in the country… 28

J List of abbreviations…………...…………………………………… 29

Performance audit report of the Auditor-General on management and distribution of Anti-retroviral drugs i i

TRANSMITTAL LETTER

Ref. No. AG.01/102/Vol.2/57

Office of the Auditor-General

Ministries Block “O”

P. O. Box MB 96

Accra

Tel. (021) 662493

Fax (021) 662493

3 September 2012

Dear Madam,

PERFORMANCE AUDIT REPORT OF THE AUDITOR-GENERAL

ON MANAGEMENT AND DISTRIBUTION OF

ANTI-RETROVIRAL DRUGS

I have the honour to submit to you a performance audit report on Management

and Distribution of Anti-Retroviral Drugs in Ghana in accordance with my

mandate under Section 187(2) of the 1992 Constitution of Ghana and Section

13(e) of the Audit Service Act which requires me to carry out performance

audits.

2. The purpose of the audit was to determine whether PLHIV have access to

ARVs at all times at affordable prices and close to the location where they live

throughout the country. The audit covered the period 2005 to 2009 and was

carried out at 24 treatment sites in five regions.

3. The audit found that NACP has made huge progress in providing ARV

drugs to PLHIV and setting up and managing 117 treatment sites throughout the

country. There were however shortages in supply of ARV drugs as a result of

which drugs were rationed to patients.

Performance audit report of the Auditor-General on management and distribution of Anti-retroviral drugs ii

4. The shortages were caused by delays in receiving data from treatment

sites to inform forecasting of drug requirement to purchase the right quantity of

drugs and delays in clearing the ARV drugs from the Airport on their arrival.

5. This has defeated the goal of providing PLHIV with ARV drugs at all

times to improve their life expectancy. We however made appropriate

recommendations to address the challenges noted in the management and

distribution of anti-retroviral drugs to enable the project achieve the desired

goal.

6. The audit was undertaken by the Performance and Special Audit

Department under the supervision of Jacob Essilfie, Lawrence Ayagiba all

Assistant Auditors-General and Yaw Agyei Sifah, Deputy Auditor-General.

7. I would like to thank my staff for their assistance in preparing this report,

the management and staff of NACP, the Central and Regional Medical Stores

and the treatment sites visited for their assistance and cooperation during the

audit.

8. I trust that this report will meet the approval of Parliament.

Yours faithfully,

AUDITOR-GENERAL

THE RIGHT HON. SPEAKER

OFFICE OF PARLIAMENT

PARLIAMENT HOUSE

ACCRA

Performance audit report of the Auditor-General on management and distribution of Anti-retroviral drugs iii

PERFORMANCE AUDIT REPORT OF THE AUDITOR-GENERAL

ON MANAGEMENT OF ANTI-RETROVIRAL DRUGS IN GHANA

EXECUTIVE SUMMARY

The National AIDS/STI Control Programme (NACP) was set up in 2003 to

provide care and support to People Living with HIV (PLHIV) by ensuring that

they have access to anti-retroviral drugs (ARVs) all the time. Between 2005 and

2009, the NACP has with donor support procured ARVs worth US$22,156,890

and opened 117 treatment sites where PLHIV could receive ARV drugs.

2. The purpose of the audit was to determine whether PLHIV have access to

ARVs at all times at affordable prices and close to the location where they live

throughout the country. The audit covered the period 2005 to 2009 and was

carried out at 24 treatment sites in five regions. We used interviews, documentary

reviews, observations and administration of questionnaires to obtain our audit

evidence.

3. The audit found that high prevalence rate, high population density and the

farther away of treatment sites and Regional Medical Stores (RMSs) from Central

Medical Store (CMS) did not affect the accessibility of ARVs by PLHIV. Rather,

there was the problem of inadequate supply of ARVs which has led to rationing of

the drugs to the treatment sites.

4. CMS is required to distribute enough drugs to the RMSs and RMSs in turn

to treatment sites to enable the sites keep a buffer stock of three months.

Treatment sites were however given drugs that will last for one to two weeks, and

as a result the few available drugs were rationed to PLHIV.

Performance audit report of the Auditor-General on management and distribution of Anti-retroviral drugs iv

5. The shortages resulted from the following factors:

failure to supply all the ARVs purchased

partial delivery of drugs

delays in submitting returns

submission of inaccurate data

delays in clearing drugs from the airport, and

improper accounting for monies collected.

Failure to supply all ARV drugs purchased

6. Two contracts for the supply of ARV drugs costing US$222,764.00 which

were awarded in 2008 and 2009 respectively had not been delivered at the time of

the audit in November 2010.

Recommendation

NACP should ensure that they procure the required quantity of ARVs to

enable CMS, RMS and treatment sites maintain the required buffer stock.

Ensure the supply of the drugs by the defaulting firms or initiate steps to

recover the amount involved.

NACP through the Ministry of Health should impress on government to

buy ARVs from local manufacturers like DANADAMS now that Global

Fund will not finance the drug any longer.

Returns from treatment sites were delayed

7. Treatment sites are to report drug consumption returns to RMSs by 5th day

of each month while the RMSs should forward same to NACP by the 12th day.

Treatment sites delay in sending their consumption returns to RMSs and as a

result, RMSs also delay sending their returns to NACP.

Performance audit report of the Auditor-General on management and distribution of Anti-retroviral drugs v

Recommendation

NACP should ensure that treatment sites and RMSs submit their returns

by due date and that they submit the right data for the required ARVs to

be acquired.

NACP should provide needy sites with computers and accessories and

urgently repair or replace unserviceable computers.

Drugs arriving at the airport are not cleared on time

8. GSCL does not clear ARVs within eight days on arrival at the port as the

air waybills were written in the names of the Banks issuing the letters of credit

instead of MoH/PU. The name change takes between two and eight weeks to

complete.

Recommendation

Procurement Unit of MoH should provide all the necessary documents

to GSCL on time to facilitate the clearing of ARVs at the airport.

Monies collected were not properly accounted for

9. Total monies collected of GH¢594,091.30 by the treatment centres were not

lodged in the prescribed bank accounts.

Recommendation

NACP should retrieve monies collected by individual staff members and

those invested in private accounts with the accrued interest and sanction

staff members who have violated directives from the Director General

of GHS to lodge funds collected in the hospital account.

Performance audit report of the Auditor-General on management and distribution of Anti-retroviral drugs vi

NACP should inform the treatment sites to bank the revenue collected in

the certified bank account and educate patients on the need to pay

GH¢5 fee per visit.

NACP through MoH should liaise with National Health Insurance

Scheme (NHIS) to include the treatment of AIDS patients in the

scheme.

Performance audit report of the Auditor-General on management and distribution ofAnti-retroviral drugs 1

CHAPTER ONE

1.0 INTRODUCTION

1.1 Reasons for the audit

National AIDS/STI Control Programme (NACP) is responsible for

coordinating and managing HIV and AIDS issues of the Ghana Health Sector

Strategic Framework. According to the NACP annual reports for 2005 and

2006 respectively and the 2009 HIV Sentinel report, the number of reported

AIDS cases, AIDS related deaths and children orphaned by AIDS has kept

rising.

2. According to the Sentinel report, the number of People Living with HIV

(PLHIV) increased from 104,995 in 2005 to 267,069 in 2009, an increase of

162,074 (154%). The disease has also affected the most productive citizens

constituting the work force of the country and falling in the age group of 20 to

49 years. In 2005 and 2006 respectively, this age group constituted 81% of

PLHIV.

3. In 2003, NACP was mandated to provide care and support including

anti retroviral drugs (ARVs) to keep PLHIV healthy and productive. NACP

procured ARVs for 2,000 patients in 2003 and has so far opened 117 treatment

sites where PLHIV could receive ARVs. NACP procures and stores ARVs to

ensure that PLHIV have constant supply of the drug at affordable prices and

close to the location where they live.

4. Despite these interventions, statistics available indicate that not all

PLHIV have access to ARVs and there are problems with the provision of the

drugs. In an interview on myjoyonline.com of 15 December 2009, the Acting

Director General of Ghana AIDS Commission stated that Ghana is about 70%

deficient in the supply of anti retroviral drugs to over 230,000 PLHIV and that,


at the time, treatment covered about 37% of PLHIV. This means that 85,100

PLHIV are on treatment. Out of this figure, 40,000 are on ARVs while 45,100

are on adherence counselling and drugs to take care of opportunistic diseases

like TB and skin diseases. In January 2010, PLHIV went on a demonstration

because there was shortage of anti retroviral drugs in Ghana.

5. The Auditor-General in line with Section 13(e) of Act 584 of 2000

commissioned performance audit into the management of ARV to determine

whether the procurement, revenue, storage and distribution of ARV are

managed in a way that enable PLHIV have access to the drugs at all times.

1.2 Purpose and scope

6. The purpose of the audit was to determine whether the funding,

procurement, storage and distribution of ARVs are managed in a way that

PLHIV have access to the drugs at all times. The team examined the following

in carrying out the audit:

funding of ARVs

procurement of anti- retroviral drugs

use of Electronic Logistic Management Information System (E-

LMIS) in gathering data for quantification and forecasting of ARV,

and

management of revenue collected from PLHIV.

7. The audit covered the period 2005 to 2009 and was carried out from

April 2010 to October 2010. The team visited the Central Medical Store

(CMS), five Regional Medical Stores (RMS) and 29 treatment sites in five

regions (Greater Accra, Eastern, Ashanti, Northern and Upper East). The

choice of the regions was based on HIV prevalence rate (areas with high rate of

PLHIV), population density (high populated area) and distance from CMS.


8. The team went to Eastern Region because of its high prevalence rate of

4.2% to ascertain whether quantity of ARV drugs matched the prevalence rate.

In Ashanti, the team ascertained whether the population density of 3,187,607

out of the total population of 18,412,247 (17.3%) had any bearing on

accessibility of ARVs by patients while in the Northern and Upper East the

team assessed whether the distance (Tema to Northern Region: 458 Km; Tema

to Upper East: 606 Km) from CMS which is the main depot for ARVs had any

bearing on the availability of the drugs in the regions.

1.3 Methods and implementation

9. We used interviews, document review questionnaire administration and

inspection of facilities to obtain audit evidence to inform our finding and

conclusions.

Interviews

10. The audit team interviewed key stakeholders of the programme, as

listed in Appendix A. The interviews were to enable the audit team obtain data

on funding, procurement, storage and distribution of anti-retroviral drugs to

conclude on our findings.

Documents review

11. We reviewed annual reports, laws, rules and regulations governing the

operations of NACP. Details of documents reviewed and information gathered

from them are listed as Appendix B. We reviewed the documents to ascertain

and confirm information gathered during interviews on the management of

ARVs.

Questionnaires

12. We administered questionnaires to management of NACP, HIV

Coordinators, pharmacists and accounts officers of the various sites visited.

The questionnaires captured information on the Electronic Logistic


Management Information System (E-LMIS) which is used to gather

returns/data from the treatment sites for quantification and forecasting, monies

paid by PLHIV per visit, procurement and storage facilities.

13. We analysed the information obtained from the sites visited to enable us

ascertain whether NACP is managing anti- retroviral drugs effectively.

Inspection

14. We inspected treatment sites, storage facilities (size of stores, cabinet,

shelves, etc.) and computers and printers for generating returns. The purpose

was to find how drugs were stored to ensure their efficacy at all times and

whether sites and RMSs were able to generate timely returns.


CHAPTER TWO

2.0 DESCRIPTIVE CHAPTER

2.1 Historical background

15. NACP started as the National Technical Committee on AIDS and later

became National Advisory Council on HIV and AIDS in 1985. The first case of

HIV was reported in Ghana in 1986 and there after, there has been a rapid rise

in HIV cases in Ghana. To ensure a systematic approach and response to the

spread of HIV and AIDS, the Government in1987 tasked NACP under the

Disease Control and Prevention Department of the Public Health Directorate of

the Ghana Health Service (GHS), to coordinate and manage all HIV related

activities: funding, procuring, distributing and storage of ARVs and managing

treatment sites and RMSs.

16. The treatment of PLHIV and the management of ARVs started as a pilot

programme in Ghana beginning in Manya Krobo and Yilo Krobo districts

between 2003 and 2004 with 2000 patients. The lessons learnt led to the

expansion of anti-retroviral therapy at Korle-Bu Teaching Hospital and Komfo

Anokye Teaching Hospital by February 2004 to serve the southern and

northern sectors of Ghana respectively. NACP has since opened 117 treatment

sites where PLHIV could receive ARV drugs and adherence counseling

throughout the country.

2.2 Statutory Mandate

17. NACP draws it authority from the mandate of GHS, which is a “Public

Service body established under Act 525 of 1996 as required by the 1992

constitution. It is an autonomous Executive Agency responsible for

implementing national policies under the control of the Minister for Health

through its governing Council - the Ghana Health Service Council.”


2.3 Objective

18. The objective of the programme is to provide care and support services

for PLHIV.

2.4 Funding

19. The ARVs are mainly paid for by Global Fund (90%) and Government

of Ghana (10%). Government of Ghana’s contribution is in the form of

training and capacity building. Management of NACP was not able to provide

the details of government’s contribution which according to them, comes in

various forms from different sources. Table 1 shows the amount of money

NACP spent on procuring ARVs per year, totalling US$22,156,890 for the

audit period.

Table 1: Sources of funding for ARVs from 2005 to 2009

Year/source

2005

US$

2006

US$

2007

US$

2008

US$

2009

US$

Total

US$

Global Fund 3,053,989 2,813,167 6,418,658 1,161,095 4,534,828 17,981,737

TAP 1,300,000 1,618,674 - 1,201,391 - 4,120,065

GoG - - - -

DFID - 55,088 - - - 55,088

Total 4,353,989 4,486,929 6,418,658 2,362,486 4,534,828 22,156,890

Source: NACP

2.5 Current Development

20. NACP failed to win Global Fund’s bid (Round 10) for financial support

to procure ARVs for PLHIV for the period between 2012 to 2015. According

to the Programme Manager, they were seeking an amount of $1billion between

the period of 2012 to 2015 to fund the programme. This means that the

government of Ghana will have to finance the procurement of ARVs from its

own budget.


2.6 Key players and their activities

21. The key players of NACP and their activities are shown in Appendix C.

2.7 System Description

22. A chart showing the main activities undertaken by NACP and its key

players in assessing the needs of the treatment sites, initiating procurement

process, storing, supplying and distributing anti retroviral drugs can be found

at Appendix D.

23. Treatment sites gather data on the consumption of ARVs by PLHIV

which is sent to NACP through RMSs for planning (quantification) and

forecasting to procure ARVs to last for a period of two years. NACP

subsequently sends the processed data to Procurement Unit where World

Health Organisation (WHO) pre-qualified suppliers are invited to bid and

supply ARVs. When the drugs have been supplied, they are sent to Central

Medical Stores (CMS) from where ARVs are distributed to various RMSs or

treatment sites according to the quantity requisitioned for dispensing to PLHIV.


CHAPTER THREE

3.0 FINDINGS

3.1 Introduction

24. NACP was set up to provide care and support to PLHIV by ensuring

that they have access to ARV drugs at all times. Between 2005 and 2009,

NACP in collaboration with donor partners have procured ARV drugs worth

GH¢32,127,491 ($22,156,8901) and opened 117 treatment sites where PLHIV

could receive a constant supply of ARV drugs at affordable prices and close to

location to where they live throughout the country.

25. Despite the achievements made in ensuring the provision of ARVs at the

treatment sites throughout the country, NACP is saddled with the following

challenges which have resulted in rationing ARV drugs to PLHIV:

inadeqate supply of ARV drugs

failure to supply all drugs purchased

partial delivery of ARVs

delays in submission of returns

delays in clearing of ARVs from airports, and

improper accounting for monies collected.

3.2 Inadequate supply of ARV drugs

26. The National policy for the treatment of PLHIV is to provide patients

with ARVs to last for three months at a time before the next supply. This is to

ensure that there is enough time to procure and re-stock by the MoH so as to

maintain a sustained supply of the drug to patients. The policy is also designed

to reduce the burden of patients having to travel frequently for treatment.

Therefore, to ensure that ARVs are in constant supply and patients are provided

with the needed drugs at all times, NACP is required to collate information on

1 Exchange rate of $1.45.


ARVs and to ensure that the quantities required are procured and supplied by

MoH to the CMS.

27. In addition, NACP is to ensure that CMS distributes to all RMS and

treatment sites enough ARVs to enable them keep the following buffer stocks:

CMS - a buffer stock of nine months

RMSs - a buffer stock of six months, and

Treatment Sites- a buffer stock of three months.

28. PLHIV were reluctant to speak to the audit team, and as a result, only 48

of them availed themselves to be interviewed at the 24 treatment sites visited.

We found through the interviews that drugs given to patients to last for three

months actually lasted for not more than two weeks. Interviews with

pharmacists at the 24 sites revealed that there were shortages of ARVs at the

treatment sites, so they have no alternative but to ration the drugs or give

substitutes in order to make sure that all patients were supplied the drugs.

29. The team reviewed requisition forms and inspected the stores and found

that, the stores did not have enough ARVs in stock. The reason given by the

pharmacists was that they do not get all ARVs they request from CMS or

RMSs.

30. Further review of requisition forms of treatment sites showed that

between 2005 and 2007, the sites received ARVs they requested. The issue of

sites not receiving the required quantity of ARVs started in 2008 and became

pronounced in 2009. The Programme Manager of NACP confirmed this

through interview that there was a break in procurement process due to change

of government in 2008. He further explained that the new minister who came in

2009 needed time to study the procurement process and that resulted in the

delay of procurement of ARVs.


31. Table 2 shows requisitions of ARVs made by some sites and the

quantities supplied. While some ARVs supplied were less than the quantity

requested, others were not supplied at all.

Table 2: Quantity of ARVs requisitioned, supplied and shortage

Date Treatment site ARV Quantity

requisitioned

Quantity

supplied

Shortage

4/06/08 Mampong

District

Hospital

Tb. Dauvir 300/50mg

Nevirapine 200mg

Efaveraz 600mg

Stavudine 300mg

6,000

6,000

3,000

6.000

2,940

1,560

1,050

420

3,060

4,440

1,950

5,580

28/07/0

9

15/5/09

Bekwai

Municipal

Hospital

‘’

Tb. Nevirapine

Syr. Zidovudine

Tb. Combivur

Syr. Nevirapin

5,280

1,800

6.780

3,000

3,000

Nil

600

Nil

2,280

Nil

6,180

Nil

14/4/09 Kdua. Reg.

Hospital

Syr. Nevir.

Efavir.600mg

Zidovu.syr.

Lamido. Oral

Stavudine syr.

15

47,520

21

90

216

Nil

5,400

8

32

15

15

42, 120

13

58

201

16/6/09 RMS Bolga Tb. Fluconazole

Syr. Nevir.

6,270

150

Nil

90

6, 270

60

28/09/09 War Memorial

Hospital

Tb. Combiviv

Nevirapine 200mg

Efavirenz 600mg

Lamivudine sp

12,000

9,000

3,000

9,000

1,200

6,450

900

6,000

10,800

2,550

2,100

3,000

28/09/09 Walewale

Municipal

Hospital

Efavirenz

Zidovudine

9,000

3,000

6,480

900

2,520

2,100

1/10/09 Tamale Central

Hospital

Tb.Combivur

Tb. Nivirapine 200mg

Tb. Multivate

6,000

14,460

20,000

4,320

6,000

Nil

1,680

8.460

Nil

16/11/09 St. Patrick

Hospital, A/R

Tb. Lamivudine

Tb. Aluvia

Tb. Nevirapine 200mg

16,200

1,800

20,000

Nil

Nil

18,000

16,200

Nil

2,000

Source: GAS compilation

32. Further analysis of annual reports of NACP revealed that the shortage of

ARVs at treatment sites, leading to their being rationed was caused by the

submission of inaccurate and delayed data from the treatment sites to estimate

the right quantities of ARVs to be bought. Additionally, there were other


causes like the failure to fully supply all ARVs bought, piecemeal delivery of

ARVs and delays in clearing ARVs from the airport.

3.3 Submission of inaccurate data

33. For NACP to procure the right quantity of ARVs, it requires data on

PLHIV who need the drug from the treatment sites. This is collated using a

customised software called an Electronic Management Information System (E-

LMIS) introduced by NACP. This upgraded version of the manual system or

Excel application package is expected to be used by all treatment sites. The E-

LMIS has been programmed to capture the required combination and dosage of

ARVs both for children and adults. It also records consumption levels and

automatically updates inventory.

34. With the E-LMIS, officers at the sites are able to check the minimum

stock levels and make requisition for the right combination or quantity of

ARVs to replenish stock. By entering the right data, the system will

automatically generate the required quantities of the ARVs needed to be

procured by NACP.

35. The audit team’s analysis of data collected from the sites shows that 20

out of the 24 sites visited were still using either the manual or the excel

application package. The use of manual leads to delay in sending returns to

NACP thereby delaying the procurement process.

36. Interviews with Programme Manager of NACP revealed that the

shortages of ARVs occur because some treatment sites send inaccurate data of

the number of patients who actually need ARVs. For example, the pharmacist

at Zebilla stated through questionnaire that he found it difficult to generate

accurate ARVs and Opportunistic Infection reports.


37. The effect is that NACP is not able to procure the right quantity of

ARVs to cater for all existing PLHIV and new patients. According to

pharmacists at the various treatment sites visited, patients who travel long

distances to sites to avoid stigma find it difficult to be regular on clinic days

because of the cost of transportation and as a result develop resistance to the

drugs.

Recommendation

38. NACP should ensure that sites and RMSs submit the right data for the

required quantities of ARVs to be purchased. In addition, NACP should

provide needy sites with computer and accessories, and repair or replace the

unserviceable computers, and train site managers in the use of the E-LMIS

software.

Management responses

39. Management of NACP disclosed that they give ARVs to PLHIV for a

period of three months, however, it is only the newly initiated clients and those

with adverse drugs reactions who are given drugs for two weeks. The

programme manager also stated that ARVs would continue to be rationed

because of the shortages of some drugs. According to the programme manager,

shortages of ARVs is a serious issue, especially now that Ghana has lost the bid

for support of Global Fund to sponsor the programme for the next round ( 2012

and 2015).

3.4 Delays in submission of returns

40. Treatment sites are required to report drug consumption returns by the

fifth day of each month to the RMSs who in turn should forward them to

NACP by the 12th day. This is to enable NACP forecast and quantify the

required ARVs to avoid any shortages.


41. We noted during the audit that the treatment sites delay in sending their

consumption returns to the RMSs and consequently, RMSs delayed in sending

their returns to NACP. The audit found that the consumption of 15 out of the

24 treatment sites visited were sent between the sixth and 15th day of each

month. A review of consumption returns at Bongo District Hospital showed

that, returns were sent after three months. While five out of the 24 (21%)

treatment sites sent their consumption returns by the fifth day of each month,

three had not sent their request at the time of the audit in October 2010.

42. The audit also revealed that all the RMSs visited sent their returns to

NACP between the 15th and 20th of the month. According to the programme

manager of NACP, submission of returns after the 12th affects the procurement

process by a month because the date for submission to NACP is the 12th of

each month and any submission after the 12th will have to be deferred to the

following month.

43. According to the officials of the treatment sites visited, the reasons for

delay in sending data to RMSs are that the personnel see the task as an

additional responsibility and some sites also have to wait for preparation of

other reports to RMSs. Delay in sending returns to NACP leads to late

submission of the data to Procurement Unit of the MoH for procurement of

ARVs.

Recommendation

44. NACP must ensure that sites and RMs submit their returns on due dates

to facilitate planning and forecasting ARVs requirements.

3.5 Failure to supply drugs purchased

45. We also found that not all drugs procured were delivered by suppliers.

According to the Programme Manager of NACP and officials of the

Procurement Unit of MoH, contracts are awarded for drugs and are supposed to


be honoured within 90 days. A list of contracts and expected date of delivery is

sent by the MoH/ Procurement Unit to the CMS to confirm that a contract has

been entered into. Any supplier who fails to supply within the 90 days is given

a grace period of 30 days. If after the grace period the supplier fails to supply

the ARVs, then the contract is abrogated.

46. All supplies of ARV drugs procured by the Procurement Unit of MoH

must first be received at the Central Medical Stores. On the contrary, our

review of data on ARVs at Central Medical Stores revealed that between 2008

and 2009, two contracts (MoH/2008/RT/B.2.1/06/CO4 and

MoH/2009/SHP/B.2.1/01/C20) amounting to GH¢323,009.00 (equivalent to

$222,764.00) were not delivered by the suppliers as at the time of audit in

November 2010.

47. The effect is that there will be shortages of ARVs forcing pharmacists to

ration drugs to patients.

Recommendation

48. The Procurement Unit of MoH should provide all the necessary

documents to GSCL on time to facilitate the clearing of AVRs at the airport.

Additionally, NACP should prevail on suppliers to use Airlines that would

carry the consignments en bloc.

Management response

49. The Programme Manager of NACP confirmed that the two contracts

have not been delivered but did not give reasons why they were not delivered.

3.6 ARVs are partially delivered

50. Our interviews with the officials of GSCL revealed that another cause of

delay is short landing of ARVs, that is, when ARVs arrive at the airport in bits

or small consignments or quantities. This occurs because certain airlines do not


ship all the consignment at the same time. They explained that when the first

consignment of ARVs is shipped, it comes with the original documents

covering the whole consignment. This document is used to clear the first

consignment at the airport. When the earlier consignment has been cleared, the

documents are removed from the computer system of Custom Excise and

Preventive Service (CEPS).

51. Thus when the remaining consignment arrives, it becomes difficult to

trace the original documents covering the entire consignment, thereby

contributing to delays in clearing the subsequent consignment. As shown in

Table 4, a consignment of 7,331 kgs of ARVs was to arrive on the 20 August

2010, but as at 4 September 2010, 6,385kgs had been received in six

consignments. Officials of GSCL confirmed that this was not an isolated case

and that it was a matter of concern.

Table 4: Partial delivery of ARVs in 2010

Master air

waybill

Expected

date of

arrival

Confirmed

date of

arrival

Days

delayed

Landed

weight/kg

Total

weight/kg

Expected

7,331

70622145410 20/8/10 20/8/10 - 177

“ 24/8/10 4 1963

“ 25/8/10 5 1478

“ 26/8/10 6 2436

“ 27/8/10 7 47

“ 4/9/10 15 284

Total weight/kg

collected

6,385

Difference yet

to arrive

946

Source: Audit Service compilation

52. Thus, three months after the confirmed date of arrival of the total

consignment of 7,331kgs, 946 kgs was yet to arrive at the time of the audit in

December 2010. The effect is that NACP does not receive the full complement


of the required quantity of ARVs to be supplied to the treatment sites for use

by PLHIV at the right time, thereby creating shortages.

Recommendation

53. The Procurement Unit of MoH should provide all the necessary

documents to GSCL on time to facilitate the clearing of ARVs at the airport;

and ensure that the suppliers of ARVs use more reliable Airlines to carry the

drugs at once.

Management response

54. The Progamme Manager stated that this is a normal practice with the

shipping of ARVs and that it is an arrangement between the supplier and the

airlines as to how much quantity can be shipped at a point in time. However, he

gave assurance that they would insist on full delivery instead of short landing.

3.7 Delays in clearing of ARV drugs from Airports

55. Ghana Supply Company Ltd. (GSCL), the main clearing agent for MoH,

is required to clear the ARVs within eight days on arrival at the Kotoka

International Airport. Failure to clear ARVs within the eight days leads to the

payment of demurrage of GH¢ 0.10 per kilo per day. The Procurement Unit

(PU) of MoH should notify GSCL through correspondence or telephone of the

arrival of drugs at the airport and provide the necessary documents to enable

the company clear the goods.

56. Our interviews with the manager of GSCL at the airport disclosed that

the Procurement Unit does not notify GSCL when ARVs arrive at the airport.

The manager also complained that, the air-waybills are written in the name of

the Banks that issued the letters of credit to the suppliers instead of MoH/PU.

Therefore the name must be changed from ‘Bank’ to ‘Procurement Unit’ which

takes between two and eight weeks. This situation makes it difficult for GSCL


to clear the ARVs from the Airport on time. Table 3 shows how long it took to

clear ARVs in November/December 2009.

Table 3: Delay in the clearing of ARVs

Air-

waybill

No.

Flight

no.

Arrival

date

Date

ARVS

were

collected

or leared

at the

airport

No. of

days

taken

to

clear

ARVs

Time

to

clear

goods

from

air

port

Days

delay

ed

Weig

ht/kg

Cha

rge

kg/

day

Total

Amount

charge to

NACP

GH¢

1 125

80724033

BA081 20/11/09 11/12/09 21 8 13 3,199 0.10 4,158.70

2 125

80724136

“ 21/11/09 15/12/09 24 8 16 2,773 0.10 4,436.80

3 125

80724136

“ 22/11/09 15/12/09 23 8 15 2,591 0.10 3,886.50

4 125

80724136A

BA081 23/11/09 15/12/09 22 8 14 8,621 0.10 12,069.40

Total 24,551.40

Source: Audit Service compilation

57. It could be seen in Table 3 that four consignments of ARVs which

arrived between 20 and 23 November 2009 were eventually cleared from the

airport on 11 and 15 December, 2009. The team interviewed clearing agents at

the airport and collaborated by Custom Officers, that goods of this nature that

have clearance from the MoH should take one day to clear. As Table 3 shows,

for the four consignments of November/December 2009, NACP paid

demurrage of GH¢24,551.40 because it took an average of 22 days (instead of

8 days) to clear the ARVs which could have been used to purchase more drugs.

Recommendation

58. The Procurement Unit must ensure that the airway bills are written in

the name of MoH. Additionally, it should provide all the necessary documents

to GSCL on time to facilitate the clearing of ARVs at the airport.

Management response

59. The Programme Manager of NACP said that adequate notice in the form

of airway bill is always given to GSCL to facilitate clearing of ARVs at the


airport. But, the manager of GSCL at airport insisted that they do not receive

adequate information in terms of correspondence to enable them clear ARVs

on time.

3.8 Monies collected from PLHIV are not accounted for properly

60. PLHIV are required to pay a fee of GH¢5 per month. This is for

comprehensive care comprising consultation, a month’s supply of ARVs and

medicines for opportunistic infections, half yearly CD4 assays2, laboratory

investigations and viral load monitoring. NACP policy is that monies collected

are to be banked in the facility drug account and patients who do not have the

money are not turned away. They are treated, given the drugs and asked to pay

on their next visit. Although this amount does not cover the total cost of

treatment which is between $250 - $300 per visit, the intention is to have funds

available for drugs in case of emergency.

61. Accounting practice requires that such funds are entered in a cash book

and put into specified bank accounts to keep track and control of the usage of

the monies. Financial Administration Regulation (FAR) also requires that such

fund must be banked in whole within 24 hours according to Regulation 15(1)

of the FAR, 2004.

62. We observed on the contrary that three out of the 24 treatment sites

visited did not pay the monies into any bank account. For example, at Sandema

and KNUST hospitals, an amount of ¢2,075.00 collected were being kept at the

offices, while at Yendi the revenue officer kept the money collected in his

personal account. The revenue officer was however not available at the time

the audit team visited the treatment site.

63. The account officer at Holy Family Hospital at Nkawkaw had invested

the monies in a fixed deposit in a bank for the hospital. Review of the cash

2 CD4 assay is a measure of the number of helper CD4 cells per cubic millimeter of blood used to analyse the prognosis of

patients


book and bank statement showed that the principal and the accrued interest

amounted to ¢40, 829.48 as at October 2009. The rest of the treatment sites

kept the monies in their drugs account and gave the assurance that although the

monies are used, they can be refunded when the need arises. As at the time of

the team’s visit in November 2010 the 24 treatment sites had between them

collected a total of GH¢594,091.30 as detailed in Appendix D.

64. The team found through interviews that NACP is aware of the issues

with managing moneys collected at the sites but have not taken any steps to

address them. In the absence of a clear directive from NACP, the risk exists

for abuse and embezzlement of the money thereby, defeating and undermining

the effort to build up capital in case Global Fund withdraws its support

Recommendation

65. NACP should retrieve monies collected by individual staff members and

those invested in private accounts with the accrued interest and sanction staff

members who are found to have violated directives from the Director General

of GHS to lodge funds collected in the hospital account. Additionally, NACP

should direct the treatment sites to bank the revenue collected in a certified

bank account and educate patients on the need to pay GH¢5 fee per visit.

66. NACP through MoH should liaise with National Health Insurance

Scheme (NHIS) to include the treatment of AIDS patients in the scheme.

Management response

67. The Programme Manager of NACP disclosed that a letter from the

Director-General of GHS was sent to all treatment sites to lodge funds

collected in the hospital account and generate ledgers to track collections. He

further indicated that they would enforce this directive.


Appendix A

Key Stakeholders interviewed

1 Programme Manager of NACP

2 Monitoring and Evaluation Officer of NACP

3 HIV Coordinators in the Five regions visited

4 Pharmacists at the Central Medical Stores (RMSs)

5 Manager, Procurement Unit (MoH)

6 Officer in charge of ARVs at the Ghana Supply Company Ltd.

7 The five pharmacists at the five Regional Medical Stores visited

8 Twenty pharmacist, senior nurses and account officers at the

treatment sites visited

9 48 PLHIV


Appendix B

Documents Reviewed

Source: GAS Compilation

1 NACP Annual Report 2005, 2006, 2007 2008 & 2009

2 NACP Logistic Management Information System (LMIS) Manual

3 Public Procurement ACT ( 663) 2003

4 NACP Transitional Guide 2008,

5 Audit of USAID/GHANA’S HIV/AIDS PROGRAM, 2010

6 HIV Sentinel Survey Report 2008

7 Contract Documents of ARVs

8 Air -waybills of ARVs

9 Guidelines for Antiretroviral Therapy in Ghana September 2008

10 Bank statements of treatment sites


Appendix C

Key Players and their activities

No. Key Players/Stakeholders Activities

1 NACP Tasked with the responsibility to provide support to PLHIV by

ensuring that ARVs are available at all times for their use. Collates

data on PLHIV and submits information on quantities of ARV

required to the Procurement Unit of MoH for procurement.

2 Ministry of Health (MoH) Formulates policy for the health sector including HIV –AIDS

3 Ghana Health Service (GHS) Implements policy decisions taken by MoH relating to HIV-AIDS

4 Ghana AIDS Commission

(GAC)

Implement policy of the HIV-AIDS related aspects of the Ghana

Health sector strategic framework

5 Procurement unit (MoH) Procures ARVs for NACP.

6 Central Medical Stores (MoH) Implement and monitor ARVs supply plans. Store ARV buffer stock

and supply ARVs to RMSs.

7 Regional Medical Stores Manage ARVs and supply to the treatment sites in the regions.

Collate ARV usage from treatment sites and supply information to

CMS for planning and procurement.

8 DFID/World Bank Provides technical support

9 Global Fund/World Bank(TAP) Provides funding and budgetary support.

10 UNDP (UNAIDS)-Ghana Collaborates with AIDS agencies like NACP to fight HIV prevalence

in Ghana.

11 USAID (Deliver JSI) Provides technical support and advice on HIV-AIDS.

12 WHO Provides technical support to NACP.

13 Treatment Sites Treatment of HIV infection & AIDS using ARVs. Stores and

provides data on usage of ARVs to NACP

14 Ghana Supply Company Ltd. Clearing of ARVs at the airport

15 PLHIV Beneficiaries of the ARVs.

Source: Ghana Audit Service compilation


Appendix D

NACP system description


Arrows going upwards signify submission of data/ information from treatment sites to

NACP, through RMSs for quantification and forecasting of ARVs

Arrows pointing downwards signify how RMSs and sites receive ARVs CMS

Procurement Unit – for procurement of ARVs

receives quantification and forecasting data /drug estimates

from the NACP

advertises for WHO pre-qualified Pharmaceutical

companies to bid.

receives ARVs from receives quantification and forecasting

data /drug estimates from the NACP

advertises for WHO pre-qualified Pharmaceutical

companies to bid.

evaluate and award contract

1.0 award contracts to WHO pre-qualified suppliers

2.0 CP

1.0 ies of RMSs and treatment sites

3.0 y Ltd who clears the drugs

4.0 supplies or distributes drugs to the various regional Medical

Stores and some sites designated as regions

5.0 receives ARVs from receives quantification and forecasting data

/drug estimates from the NACP

6.0 advertises for WHO pre-qualified Pharmaceutical companies to

bid.

7.0 evaluate and award contract

8.0 award contracts to WHO pre-qualified suppliers

9.0 CP

2.0 ies of RMSs and treatment sites

10.0 y Ltd who clears the drugs

11.0 supplies or distributes drugs to the various regional Medical

Stores and some sites designated as regions

and award contract

award contracts to WHO pre-qualified suppliers

Regional Medical Stores

receive ARV’s from CMS

supplies treatment sites with ARVs

receives monthly reports on ARVs from sites

sends quarterly reports from treatment sites to NACP

NACP – quantification and forecasting for ARVs

estimate the needed ARVs –using morbidity and

consumption data methods

forward estimates to the procurement unit

NACP establishes letters of credit for purchase of ARVs

monitors activities of RMSs and treatment sites

Central Medical Stores receives ARVs from airport through Ghana

Supply Company Ltd who clears the drugs

supplies or distributes drugs to the various

regional Medical Stores and some sites

designated as regions

Treatment sites

send monthly returns/ data to NACP RMS for quantification

and forecasting

receive ARVs from RMSs and CMS

supply ARVs to PLHIV

provide adherence counseling to PLHIV

Supplier /Manufacturer of ARVS

bids for contracts to supply ARVs

supplies ARVs to NACP/CMS


Appendix E

Analysis of responses of treatment sites to questions asked

No. Hospital Which

software

do you use

Has staff

been

trained?

Do you have

the necessary

equipment?

By which date of the

month are returns

sent to RMS?

1 Regional Hospital, Koforidua E-LMIS Y Y 10th

2 Suhum Gov’t Hospital E-LMIS N Received in

Sept 2010

3 St Joseph Hosp, Koforidua Manually Y N

4 Holy Family Hospital Manually Y Y 5th

5 Akuse Gov’t Hospital Excel N N From the 8th

6 Atua Gov’t Hospital Excel Y N 10th

7 Komfo Anokye Teach Hosp Excel N N After 15th

8 Suntreso Gov’t Hospital Excel Y Y 4th

9 Obuasi Gov’t Hospital Excel Y Y 7th

10 KNUST Excel Y N 15th

11 Bekwai Excel Y Y 5th

12 St Patrick’s Hospital, Offinso E-LMIS Y Y

13 Juaben Gov’t Hospital Excel N Y First Wed

14 Mampong Municipal Hosp Excel Y Y 10th

15 Bawku Hospital Manually Y Y

16 Zebilla District Hosp Excel Y Y After 5th

17 Sandema Hospital Excel Y Y Do not know when to

send returns

18 Bongo District Hospital Manually N Y After three months

19 War Memorial Hospital E-LMIS Y Y Defaults sometimes

20 Bolgatanga Reg. Hospital Excel Y Y 5th

21 Tamale Teaching Hospital Excel N Y

22 Central Hosp Tamale Manually Y Y (not in use

because of

lack of space)

23 Yendi Municipal Hosp Excel N Y

24 Walewale District Hosp Manually Y N-not

functional

Do not send returns

because the computer

has crashed Source: GAS Compilation

Y=sites which responded yes to questionnaire

N= sites which responded no to questionnaire


Appendix F

Amount of money collected by sites visited as at the time of the audit

No. Hospital Amount of revenue

GH¢

1 Regional Hospital, Koforidua 21,728.00

2 Suhum Gov’t Hospital

3 St Joseph Hosp, Koforidua 3,725.00

4 Holy Family Hospital 40,829.00

5 Akuse Gov’t Hospital 411.00

6 Atua Gov’t Hospital 116,775.00

7 Komfo Anokye Teach Hosp 317,458.00

8 Suntreso Govt Hospital 21, 021.50

9 Obuasi Govt Hospital 8,349.00

10 KNUST 550.00

11 Bekwai 4,271.00

12 St Patrick’s Hospital, Offinso 6,817.00

13 Juaben Gov’t Hospital 1,930.00

14 Mampong Municipal Hosp 12,444.00

15 Bawku Hospital 4,479.00

16 Zebilla District Hosp 1,081.00

17 Sandema Hospital 1,525.00

18 Bongo District Hospital 710.00

19 War Memorial Hospital 2,388.00

20 Bolgatanga Reg. Hospital 17,660.90

21 Tamale Teaching Hospital 3,969.90

22 Central Hosp Tamale 1,840.00

23 Yendi Municipal Hosp 3,609.00

24 Walewale District Hosp 520.00

Total 594,091.30


***** = Newly created site and yet to start operation


Appendix G

Treatment sites with buffer stock

No. Hospital Buffer stock

1 Regional Hospital, Koforidua N

2 Suhum Govt Hospital Y

3 St Joseph Hosp, Koforidua N

4 Holy Family Hospital Y

5 Akuse Govt Hospital Y

6 Atua Govt Hospital Y

7 Komfo Anokye Teach Hosp Sometimes

8 Suntreso Govt Hospital N

9 Obuasi Govt Hospital Sometimes

10 KNUST N

11 Bekwai Y

12 St Patrick’s Hospital, Offinso Y

13 Juaben Gov’t Hospital Y

14 Mampong Municipal Hosp N

15 Bawku Hospital N

16 Zebilla District Hosp N

17 Sandema Hospital Y

18 Bongo District Hospital Y

19 War Memorial Hospital Sometimes

20 Bolgatanga Reg Hospital N

21 Tamale Teaching Hospital N

22 Central Hosp Tamale N

23 Yendi Municipal Hosp N

24 Walewale District Hosp N


Y = those who responded yes to questionnaires

N = those who responded no to questionnaires


Appendix H

Air-conditioning at treatment sites

No. Hospital Air-conditioners Generator

1 Regional Hospital, Koforidua Y Y

2 Suhum Govt Hospital Y Y /not strong to

power air-con

3 St Joseph Hosp, Koforidua Y Y

4 Holy Family Hospital Y Y

5 Akuse Govt Hospital Y Y

6 Atua Govt Hospital Y Y

7 Komfo Anokye Teach Hosp Y N

8 Suntreso Govt Hospital Y Y

9 Obuasi Govt Hospital Y Y

10 KNUST Y Y

11 Bekwai Y Y

12 St Patrick’s Hospital, Offinso Y Y

13 Juaben Govt Hospital Y Y

14 Mampong Municipal Hosp Y Y

15 Bawku Hospital N N

16 Zebilla District Hosp Y N

17 Sandema Hospital Y N

18 Bongo District Hospital Y /not functioning N

19 War Memorial Hospital Y N

20 Bolgatanga Reg Hospital Y N

21 Tamale Teaching Hospital Y N

22 Central Hosp Tamale Y N

23 Yendi Municipal Hosp Yes Y

24 Walewale District Hosp Yes/breaks down often N

Source: GAS

Y = those who responded yes to questionnaires

N = those who responded no to questionnaires


Appendix I

Total amount of revenue collected from all the sites in the country as at June

2009

Region Amount collected

(GH¢)

Military Hospital 10,620.00

KATH 122,281.00

Ashanti 21,496.40

Upper East 27,474.40

Brong Ahafo 21,974.00

Eastern 270,632.50

Greater Accra 66,232.00

KBTH( 2008, Half year 2009) PAED 120,659.91

Northern Region 35,702.00

Upper West Region 16,227.00

Western Region 8,113.00

Police Hospital 5,040.00

Volta Region 28,901.50

Total 755,353.71

Source: NACP


Appendix J

List of abbreviations

ARVs ----------------------- Anti retroviral

CMS ----------------------- Central Medical Stores

GH¢ ------------------------ Ghana Cedis

GOG ----------------------- Government of Ghana

GHS ------------------------ Ghana Health Service

LMIS ------------------------ Logistic Management Information System

MOH ----------------------- Ministry of Health

NACP ---------------------- National AIDS Control Programme

PLHIV----------------------- People Living with HIV

RMS ----------------------- Regional Medical Stores

GSCL ----------------------- Ghana Supply Company Limited

PU ------------------------ Procurement Unit

Mission

Statement

The Ghana Audit Service exists

To promote

good governance in the areas of transparency,

accountability and probity in the public financial

management system of Ghana

By auditing

to recognized international auditing standards the

management of public resources

And

reporting to Parliament

PERFORMANCE AUDIT REPORT of the AUDITOR GENERAL on …ANTI-RETROVIRAL DRUGS. I have the honour to...

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