At Dignitas, we innovate sustainable solutions to global health challenges, build resilient health systems, and advance the right to health for marginalized people and underserved communities. This is our mission and it is transforming how health care is delivered, both locally and globally.
We’ve been hard at work in 2017 living our mission to ensure that the right to health belongs to everyone. With the help of our supporters and partners, Dignitas is improving health care for people facing a high burden of disease and unequal access to health services in Malawi, in Indigenous communities in Canada, and beyond.
To achieve lasting results and uphold the dignity of every human being, we work on the frontlines with patients and health care workers to deliver medical care and treatment where it’s needed most. We conduct high-impact research and foster innovation to strengthen health systems and we advocate for equitable health policy using evidence generated from research and clinical practice.
Our mission is at the heart of all we do and in this report, we proudly share how we have furthered it in 2017.
Living our mission is the theme of our 2017 Annual Report – to innovate sustainable solutions to global health challenges, build resilient health systems, and advance the right to health for marginalized people and underserved communities.
At the heart of our work is Innovation, the search for better ways to deliver cost-effective healthcare in places where resources are limited and logistical challenges are real. You’ll read about the ground-breaking STAMP study - the perfect merger of innovation, practicality and good economics. While Tuberculosis (TB) is the leading cause of AIDS-related deaths worldwide, current TB testing methods using sputum samples are time-consuming, difficult for HIV+ patients, and expensive. The STAMP trial found positive health and cost outcomes for a new bedside urine-based test that can diagnose TB within 30 minutes. As a result of STAMP, urine-based TB screening in HIV+ in-patients may eventually become the global standard of care in high TB and HIV settings.
Building resilient health systems is equally critical to our mission. Dignitas’ learning partnership with the Sioux Lookout First Nations Health Authority (SLFNHA) in northern Ontario illustrates how our unique model of medical programs, research, and knowledge translation results in better health care delivery. The Community Health Worker (CHW) Diabetes Pilot Program succeeded in blending SLFNHA’s local mandate, knowledge, and capacity as a health services provider with DI’s evidence-driven research, evaluation, and experience in global health. Our 2017 CHW Program Evaluation showed results consistent with closing of gaps in community-based diabetes care.
Around the world Dignitas is having an impact in advancing the right to health for those who lack access. Mothers in developing countries give birth to babies free of the HIV virus. Prisoners in Malawi access comprehensive sexual health education and services. Female sex workers’ health care needs are met in safe, non-judgmental spaces. Indigenous peoples living with Type 2 diabetes in remote communities receive information and care at home in their own language.
We are proud of our successes in 2017, and are preparing for changes to come in 2018 as we move away from our role as a USAID implementing partner. This planned transition will involve a decrease in our USAID revenue from approximately $5.8m in 2018 to nil in 2019, resulting in reduced staffing and operations in Malawi. In addition, USAID may require repayment of unspent funds, and/or funds not spent in compliance with the grant agreement.
While this change in our funding model will bring challenges, it also provides us with an opportunity to focus on what we do best - innovative research, cost-effective medical programming, and knowledge translation activities that result in better health policy and practice. With the launch of the Dignitas Ideas to Impact Lab (i2i Lab) in 2018 we are forging new partnerships with some of Canada’s top universities to ignite innovation and empower the next generation of global health practitioners.
This is an exciting new era for Dignitas, and we thank you for being part of our work in 2017. We invite you to continue to live the Dignitas mission with us in 2018 and beyond!
Jennifer Keenan
Chair, Board of Directors
Heather Johnston
President and CEO
3.4 million
HIV tests administered
301,452
People started on treatment
12,492
Health care workers trained
A unique model that’s
changing lives.
Using an integrated approach, our research, medical programs and knowledge translation activities contribute to direct and positive impact on the health of individuals, communities and countries.
Many research questions emanate from our medical programs, and in return, our research helps us to determine if our medical programs are achieving the results we desire. We share our learnings with health care providers facing similar challenges around the world. These three pillars of our Mission work together, fueled by innovation, to strengthen human resources for health, to improve health care delivery and to drive equitable and evidence-based health policy in Malawi and with Indigenous communities in Canada.
At Dignitas, people are at the centre of everything we do. We work on the frontlines with patients and health care workers to address challenges and gaps in health care delivery. Our innovative programs aim to gain a deeper understanding of the barriers people face in accessing the services they need and to improve care for vulnerable populations in Malawi, Canada, and beyond.
Our international team of scientists unlocks the transformational power of research to generate evidence that directly improves local and global health care policy and practice. Our research is saving lives by improving how diseases like HIV, TB and meningitis are treated. Through operational and clinical research, Dignitas is generating scalable global health solutions that are transferable to resource-limited settings around the world.
Dignitas is committed to move research from the laboratory into the hands of people and organizations to advance the right to health for all. Local and international partnerships have the potential to ignite solutions for common health challenges faced by rural and remote communities around the world. We ensure that all parts of a health system are talking to and learning from each other to improve patient health, provide more effective health services and build strong, resilient communities.
An integrated health care,
research and knowledge
translation initiative.
Dignitas works in partnership with Indigenous communities in Canada to deliver innovative and culturally appropriate health solutions in some of Canada’s most remote and underserved communities.
Indigenous people in Canada experience significantly higher rates of chronic and infectious diseases than the general population in Canada. Rates of type 2 diabetes are up to 5 times higher and rates of new HIV infections are 3.5 times higher in First Nations populations.
To help strengthen health systems in rural and remote Indigenous communities, Dignitas partnered with the Sioux Lookout First Nations Health Authority (SLFNHA) to support First Nations-led health care solutions. Our three-year Community Health Worker (CHW) Diabetes Pilot Program in partnership with SLFNHA wrapped up in 2017 and expansion plans began to take shape. By training and empowering CHWs to play an active role in patient care, community members living with type 2 diabetes experience better continuity of care and targeted support to manage their condition and prevent traumatic diabetes complications. Our program evaluation measured improvement of the quality and overall satisfaction with the CHW Pilot Project by community stakeholders. Our results showed that the program was successful in establishing important foundational components.
Sharing best practices and joint learning is at the heart of our Indigenous Health Partners Program. This past year we also engaged in a variety of knowledge synthesis and translation activities with SLFNHA that will help to inform health systems globally. The Diabetes Environmental Scan for the Sioux Lookout Area and the Diabetes Management Task-Shifting Systematic Review are two examples of the knowledge generated. Program findings were shared at local, national and international forums including the 5th Annual Indigenous Health Symposium in Winnipeg, Manitoba and the World Health Organization’s 4th Global Forum on Human Resources for Health in Dublin, Ireland.
As we explore new ways to help support and strengthen Indigenous health in Canada, Dignitas launched a study to better understand HIV-related knowledge, attitudes, behaviours and services in Indigenous communities in Canada. A key component of the project involved consultations with approximately 30 AIDS Service Organizations, government representatives, service providers and experts across Canada to learn more about promising practices in Indigenous HIV prevention and care, as well as key challenges and gaps in service.
This project will build the foundation for future program and partnership opportunities, and help to expand our efforts in supporting the delivery of HIV prevention and care with Indigenous communities in Canada.
Igniting Innovations,
Empowering Leaders.
Powered by Dignitas International, the Ideas to Impact Lab (i2i Lab) was created in 2017 to ignite innovations and empower the next generation of leaders that will transform how health care is designed and delivered around the world.
The i2i Lab sparks programming, research and policy innovation to tackle current and evolving global health challenges - we do this by investing in people and promising ideas. Our i2i Fellows, comprised of scientists, health care providers, engineers, designers, international development practitioners, activists and entrepreneurs, whom are united for a single purpose: to make health care better for people who need it most. The Lab is a physical and virtual space that allows i2i Fellows to exchange knowledge, refine ideas and test global health innovations, while working in their local contexts.
In 2017, the i2i Lab developed a world-class network of clinical, entrepreneurial, public health, design, business and policy leaders to mentor our i2i Fellows through the i2i Lab’s innovation process. Once a fellowship engagement mechanism was designed, the Lab began recruitment of its first innovation cohort. Towards the end of the year, the i2i Lab launched KT-PEER: A partnership with the University of Alberta’s School of Public Health and a network of Indigenous Canadians and global counterparts driving equitable and inclusive non-communicable disease policy and programs. Also launched was a joint Canadian Indigenous and African Health Informatics Research and Innovation Platform in partnership with the Sioux Lookout First Nations Health Authority, University of Malawi and the University of Toronto’s Rotman School of Management.
Innovation fuels our ability to build dynamic and long-lasting pathways to change. It feeds into all aspects of our work through an iterative process in which the learning and discoveries of our work influence the direction and nature of our programming and research. This allows us to develop the next wave of original research and programs that respond to a changing landscape of global health challenges.
Here’s How:
Non-communicable diseases (NCDs) account for 70% of all deaths worldwide and are slated to become an even greater public health threat. In 2017, Dignitas started to build on its knowledge by leveraging existing HIV infrastructure in Malawi to integrate NCD treatment into a single model of care in four health facilities in its impact area – facilities that previously only provided either decentralized HIV, or limited NCD care. By efficiently providing on-site screening for chronic conditions, Dignitas is innovating to bring quality care closer to patients.
Studies indicate that roughly half of HIV+ adult patients who die in hospitals have tuberculosis (TB) which is the leading cause of AIDS-related illness in the world. The current test for TB detection in Malawi is a sputum sample, however this is a challenge for ill patients to produce it. The STAMP Study investigated whether screening HIV positive in-patients with urine-based test could increase TB detection in a cost-effective way, reducing mortality. Preliminary results indicate this innovative approach has potential to increase TB diagnoses and treatment initiations that will save lives, and is likely to influence national and international treatment guidelines.
In resource-limited settings, governments must find affordable and user-friendly solutions to optimize health care delivery. While medical reference materials are important to ensure protocol adherence across the country, updating, printing and distributing them is a challenge for Malawi’s Ministry of Health. This problem presented an opportunity for Dignitas to develop a mobile application for Malawi’s HIV Clinical Guidelines. Moving away from traditional printing and putting updated guidelines into the hands of health practitioners means that healthcare workers have real-time knowledge at their fingertips. They can search easily, receive automatic updates, and bookmark important content. This free app is revolutionizing how technology can improve health care delivery in low-income countries.
Getting tested and starting treatment turned my life around. I want all mothers to have this option.
- Patricia
Pioneered in Malawi, Option B+ is a globally adopted innovation that has dramatically increased the number of HIV+ women on treatment. Option B+ is making global gains in the prevention of mother to child transmission of HIV.
The National Evaluation of the Malawi Prevention of Mother to Child Transmission (PMTCT) Program (NEMAPP) study shows that the Option B+ program has lowered national mother to child transmission rates of HIV in Malawi to just 3.9%.
HIV mothers who start treatment prior to pregnancy now have just a 1.4% risk of transmitting the virus to their baby compared to a 19.9% chance for mothers who are not on treatment. Dignitas is protecting the health of mothers and babies by testing all pregnant and breastfeeding women for HIV and ensuring treatment is accessible for those who need it.
Following the deaths of her newborn twins, Patricia was devastated and afraid to get tested for HIV. However, when she found out she was pregnant again, she sought out testing and started treatment after her positive diagnosis. This helped to ensure that her son was born HIV negative.
Patricia is an inspiration to others to seek testing and treatment. She travels around her community as an Expert Mother providing support to her peers to help retain HIV+ women on treatment. Patricia, and other Expert Mothers like her, are restoring hope and health for families and communities.
According to the World Health Organization, a good health system delivers quality services to all people, when and where they need them. At Dignitas, we have been hard at work in 2017 working on the frontlines with patients and health care workers to deliver care for communities facing a high burden of disease and unequal access to services.
In Canada, Community Health Workers (CHWs) are on the frontline delivering community-based care in Indigenous communities. CHWs are highly valued because the services they provide are appropriate to the health and cultural needs of the community. This year marked the end of a three-year CHW Diabetes Pilot Program developed to support First Nations-led health care solutions among four communities in the Sioux Lookout Area, Northern Ontario. By training and empowering CHWs to play an active role in patient care, community members living with type 2 diabetes receive targeted support and better continuity of care to manage their condition and prevent traumatic diabetes complications.
HIV is still the leading cause of death teens in Africa. If we are to reach the UN’s ambitious goal of ending AIDS by 2030, it is imperative that we ensure adolescents have access to specialized youth-friendly care and support. Our 2017 Study published in the Journal of the International AIDS Society found that teens exposed to Teen Club were 3.7 times more likely to stay on treatment compared to teens who were not. This study is one of the first to look at the impact of a youth-targeted programmatic intervention on retention in care using retrospective program data, and lays the foundation for further exploration. It provides compelling evidence for cost-effective models of care for adolescents in resource-limited settings. As a result, Teen Club was introduced into the Ministry of Health’s standard package of care and will impact the treatment teens receive nationally.
Since 2012, Dignitas International has been working with the World Health Organization, the Ministry of Health and others to bridge gaps between researchers and policymakers through Malawi’s Knowledge Translation Platform (KTPMalawi). KTPMalawi translates lifesaving research into quality health policy and practical improvements in health care. In 2017, KTPMalawi engaged in several important policy deliberations, synthesizing and applying global and local research evidence to improve health policy in childhood malaria, the use of contraceptives among adolescents, and in prevention of mother-to-child HIV transmission programs. Through KTPMalawi, we are building researchers ability to convey complex research to busy policymakers and policymaker’s ability to find, assess and utilize research evidence.
Thank you Alice and Dignitas. Before I came to the clinic, I had lost hope. Now that I’m healthy, I’m optimistic for my future.
- Thandi
Health care workers themselves need access to good health care to save lives. When doctors and nurses are healthy, they can protect the health of communities.
Dignitas’ Health Care Worker (HCW) Clinics provide treatment and care to HIV+ health care workers confidentially and without discrimination. Nurse Alice is a part of a vital team of clinicians at the HCW Clinic.
Health care workers, like 33-year-old Thandi, are essential to our efforts to reach UNAIDS’ 90-90-90 goals in Malawi by 2020. However, fear and stigma kept Thandi from seeking treatment in her local health care facility. Her health deteriorated and she was beginning to lose hope.
A nurse convinced Thandi to visit our Tisungane HCW Clinic and meet Alice. With treatment, Thandi’s condition improved. Now she is able to continue her work on the frontlines to ensure that everyone in her community has access to the care they need.
Alice and Thandi’s stories are a testament to the power of Dignitas’ efforts to build a stronger health system in Malawi.
At Dignitas, we believe in the inherent dignity of every human being and that the right to health belongs to everyone. Our efforts to advance the right to health of marginalized people takes us to underserved communities where health care is limited and people experience a high burden of disease.
Our testing results in Malawi’s Lake Chirwa region and its coastal fishing villages point to a high HIV prevalence in the area. Close to 1 in 5 adults we tested were found to be HIV-positive – double the national average. Members of this remote community struggle to access essential health services because the closest public health facility is over 22 km away. Realizing this barrier, Dignitas provided remote screening and treatment for HIV, sexually transmitted infections and malnutrition to 4,399 people to this underserved area in 2017. With increased testing and treatment, Dignitas is helping to reduce new infections and reach UNAIDS ambitious 90-90-90 targets by 2020.
Severe overcrowding at Zomba Central Prison (ZCP) provides a harbouring ground for the rapid spread of HIV and TB. Nearly 30% of the prison’s population is HIV-positive and prisoners face challenges adhering to treatment. In collaboration with partners, Dignitas introduced a comprehensive package of interventions to prevent, screen and treat HIV, TB, Hepatitis B virus and Sexually Transmitted Infections. In 2017, Dignitas published a cross-sectional study in the Journal of the International AIDS Society. It investigated antiretroviral therapy (ART) outcomes at a Dignitas-run HIV Clinic at ZCP to assess if, even under difficult circumstances, viral suppression could be achieved among this key population. The study results were positive, proving that virological suppression can be achieved among Malawian prisoners on ART. This study will help to continue advancing the right to health for the prison population in Malawi and potentially beyond.
Sharing lessons learned through knowledge translation, partnership and collaboration was a key area of focus for our Indigenous Health Partners Program this year. Throughout 2017, Dignitas and the Sioux Lookout First Nations Health Authority (SLFNHA) supported knowledge translation and exchange between community participants, local stakeholders, project partners and on a local, national, and global level. Through community meetings and workshops, and the dissemination of research findings, we are translating lessons learned in Canada and beyond.
I had never been tested for HIV because the clinic was so far away. Now, I know my status and will encourage others to get tested too.
- Jacob
In our effort to advance the right to health for all, we must go where we are needed most. Marginalized people and underserved communities face barriers to quality health care that can seem unsurmountable. Often stigmatized and with limited rights, key populations, such as sex workers and men who have sex with men, face big challenges accessing prevention, treatment and care services in many countries around the world.
Seeing this critical gap, Dignitas set out to reach the most-at-risk whose access to health care is limited and who experience a high burden of disease.
We’ve conducted mobile clinics in hard to reach areas, we’ve carried out moonlight testing initiatives which brings care right to the door of communities at risk, and we’ve trained peer educators to mobilize community members. Together, these efforts are advancing the right to health for all.
Jacob, a fisherman in Lake Chirwa, was tested for HIV for the first time and screened for other illnesses at a mobile clinic. On the same day Jacob was tested, 416 additional community members were tested for HIV and the 75 people found to be positive were referred to treatment.
Dignitas’ greatest champions came together in October for our annual charity film screening. It was an evening of health and hope that raises essential funds for our medical and research programs. Inspired by the teens she met on her 2016 trip to Malawi, Canadian indie-pop superstar Leslie Feist, popularly known as Feist wanted to make a difference. Feist took a night off from her world tour following the release of her fifth studio album, ‘Pleasure’, to join the celebration. She generously donated a famous Kay 6 String Banjo to be live-auctioned at the event and even played a few chords for a captivated audience. Bids for this priceless banjo came from all directions and the winner was thrilled to slightly edge out the competition. The live auction helped the charity screening event raise more than $100,000 to support Dignitas’ mission.
In April, thirteen Board members and leadership donors travelled to Malawi to see the life-changing impact of their support. Through the lens of field staff and frontline health workers, travelers received a comprehensive, on-the-ground view of our programs, while also encountering the health challenges faced by many Malawians on a daily basis. Travelers toured our flagship HIV clinic, Tisungane, and made visits to rural health facilities supported by Dignitas, including Zomba Central Prison – accompanied by a performance by the Grammy-nominated Zomba Central Prison Band!
Give a Day is a grassroots response to the global HIV epidemic that challenges all Canadians to donate a day’s pay on World AIDS Day to stand with African families and communities affected by HIV. In 2017, more than $225,000 was raised for Dignitas International and the Stephen Lewis Foundation. Thank you to our incredible champions in the medical and legal communities including Osler, Hoskin & Harcourt LLP, Torys LLP, Borden Ladner Gervais, Filion Wakely Thorup Angeletti, Davies Ward Phillips & Vineberg LLP, Goldblatt Partners and the Ontario Medical Association.
Dignitas International gracefully acknowledges the many supporters who make our work possible. Thank you to all our generous donors.
Investing to Eradicate
HIV and Bring About an AIDS
Free Generation
We were so impressed on our trip to Malawi last year that we decided to step-up our support of Dignitas. The commitment and excellence of the staff on the ground at all levels has saved countless thousands of lives. Dignitas continues to be in the forefront of research and medical intervention in the battle to eradicate HIV/AIDS.
The Pace Family Foundation
Albert Pace and Kristin Morch established the Pace Family Foundation in 2007. The Foundation has contributed to improving health care in Ontario through support of the Toronto Rehabilitation Hospital Foundation, the Hospital for Sick Children, and the North Bay General Hospital, along with many other community causes and local charities. The Pace Family Foundation also supports health care and water projects throughout Rwanda, and in the Democratic Republic of Congo, Uganda, Niger, Kenya and Malawi. Since 2010 The Pace Family Foundation has generously supported Dignitas’ lifesaving medical and research programs helping to build resilient and healthy communities. Encouraged by the results Dignitas was achieving on the ground, Al and Kristin traveled to Zomba, Malawi in 2017 to see the impact of their support first-hand. They visited Dignitas-supported health facilities and met with a number of clients and health care workers. Inspired by the impact they saw in Zomba, Al and Kristin made their largest gift to Dignitas to date to strengthen Dignitas’ efforts to find sustainable solutions to global health challenges.
Through the power of the ripple effect, support from The Pace Family Foundation will not only help Dignitas to stay the course in the important fight against HIV in Malawi, but also to transform the quality of care available to marginalized people and underserved communities around the world.
Jennifer Keenan
Chair, Board of Directors
Lawyer/Philanthropist
Dr. Ross Upshur
Co-Chair, Scientific Advisory Committee
Head of the Division of Clinical Public Health, Dalla Lana School of Public Health
Dr. Michael Schull
Co-Chair, Scientific Advisory Committee
President & CEO, Institute for Clinical Evaluative Sciences Professor, Dpt. of Medicine, University of Toronto
Carol Devine **
Director, Dignitas International
Writer & Researcher, Global & Earth Health
Gospel Kazako
Director, Dignitas International
Broadcaster, Entrepreneur, Poet (Malawi)
Cheryl Hudson
Director, Dignitas International
Managing Director, Dove Management Inc.
Chikosa Banda *
Director, Dignitas International
Law Lecturer, University of Malawi, Chancellor College
Pam Hughes
Vice Chair, Board of Directors
Chair, Governance & Nominations Committee
Senior Counsel, Blake, Cassels & Graydon LLP
Phil Arthur
Chair, Finance & Audit Committee
Chartered Accountant
Dr. Rajiv K Singal
Director, Dignitas International
Urologic Surgeon, Michael Garron Hospital
Assistant Professor, Dpt. of Surgery, University of Toronto
Lynda Kuhn
Director, Dignitas International
Senior Vice President, Maple Leaf Foods
David Young
Director, Dignitas International
Playwright, Novelist, Screenwriter
Joanne O’Hea ***
Director, Dignitas International
Institutional Equity Trading, RBC Capital Markets
*Term began 2017
**Term ended 2017
***Term ended 2018
Michael Young
Chair, Dignitas USA Board of Directors
Founder, Quadrant Capital Partners, Inc.
Carol Devine **
Director, Dignitas USA
Writer & Researcher, Global & Earth Health
Dr. James Orbinski
Director, Dignitas USA
Director, Dahdaleh Institute for Global Health Research, York University
Professor, Faculty of Health, School of Health Policy & Management, York University
Professor (Adjunct), Dalla Lana School of Public Health, University of Toronto
Tom Stephenson
Director, Dignitas USA
CEO, Look Cinemas
Vanessa Weaver
Director, Dignitas USA
President, Primus Vantage Inc.
Pam Hughes
Director, Dignitas USA
Senior Counsel, Blake, Cassels & Graydon LLP
Marguerite Steed Hoffman
Director, Dignitas USA
Chair, Custom Food Group
Chikosa Banda *
Director, Dignitas USA
Law Lecturer, University of Malawi, Chancellor College
*Term began 2017
**Term ended 2017
***Term ended 2018
| Year ended December 31 | 2017 | 2016 |
|---|---|---|
| $ | $ | |
Revenue |
||
| Government and institutional grants | 11,410,185 | 9,677,142 |
| Donations and other income | 1,266,050 | 1,103,850 |
| Drugs in kind | 1,186,487 | 1,204,087 |
| 13,862,722 | 11,985,079 | |
Expenditures |
||
Program |
||
| International programs | 11,018,820 | 9,521,015 |
| Canadian programs | 252,601 | 493,529 |
| Program innovation | 144,720 | 28,920 |
| Drugs in kind | 1,186,487 | 1,204,087 |
| 12,602,628 | 11,247,551 | |
Supporting activities |
||
| Management and general | 414,261 | 384,384 |
| Fundraising, business development and marketing | 596,379 | 492,692 |
| 1,010,640 | 877,076 | |
| 13,613,268 | 12,124,627 | |
| Excess (deficiency) of revenue over expenditures | 249,454 | (139,548) |
| As at December 31 | 2017 | 2016 |
|---|---|---|
| $ | $ | |
Assets |
||
Current |
||
| Cash and cash equivalents | 2,174,264 | 1,175,214 |
| Accounts receivable | 1,157,623 | 1,458,413 |
| Prepaid expenses | 40,359 | 26,387 |
| 3,372,246 | 2,660,014 | |
| Capital assets | 564,091 | 462,329 |
| 3,936,337 | 3,122,343 | |
Liabilities |
||
Current |
||
| Accounts payable and accrued liabilities | 1,392,300 | 846,155 |
| Deferred contributions | 377,829 | 359,434 |
| 1,770,129 | 1,205,589 | |
Net assets |
||
| Invested in capital assets | 564,091 | 462,329 |
| Unrestricted | 1,602,117 | 1,454,425 |
| 2,166,208 | 1,916,754 | |
| 3,936,337 | 3,122,343 |
To view our full audited financial statements visit dignitasinternational.org/impact
The auditor’s opinion is qualified with respect to the uncertain collection of $613K of accounts receivable from the Malawian Revenue Authority.