GLOBAL FUND: BUYING ON CREDIT IN MALAWI

UNCLAS SECTION 01 OF 03 LILONGWE 000933 SIPDIS DEPT FOR S/GAC, AF/S, AF/EPS, OES/IHA USAID FOR GH/AA (APETERSON) HHS/PHS/OFFICE OF GLOBAL HEALTH AFFAIRS (WSTEIGER) HHS ALSO FOR NIH (MDYBUL AND JLEVIN),HRSA (DPARHAM) GENEVA FOR DHOHMAN AND MCGREBE E.O. 12958: N/A TAGS: KHIV EAID SOCI TBIO ECON PGOV MI HIV AIDS SUBJECT: GLOBAL FUND: BUYING ON CREDIT IN MALAWI REF: A. STATE 202651 (NOTAL) ¶B. LILONGWE 497 (NOTAL) ¶1. Per reftel A request, post provides the following update on Global Fund activities in Malawi. SUMMARY -------------- ¶2. As the end of year two of Global Fund in Malawi approaches, the GOM will likely exceed anti-retroviral (ARV) treatment and voluntary counseling and testing (VCT) goals, but will fall short of meeting prevention of Mother-to-Child-Transmission (PMTCT) and care and support targets. At present, over 8,000 individuals are enrolled in anti-retroviral therapy (ART) programs, and 312 clinical staff have been trained and certified as ARV providers. By December 2004, ARVs are planned to be offered at 54 sites, 21 of which are currently operational. The Global Fund implementation process, which was stymied in bureaucracy six months ago, has been turned around by three principal factors: NGOs' willingness to begin ARV programs, with their own funding, in expectation of receiving Global Fund money; design of an explicit operational plan; and improved coordination within the Ministry of Health. Without the expectation of forthcoming Global Fund resources, the current expansion of HIV/AIDS treatment and care facilities in Malawi would be very unlikely. END SUMMARY. THE INITIAL LOAN: CURRENT STATUS OF PROGRAMS -------------- ¶3. With over 8,000 individuals enrolled in ARV programs, the GOM is on track to exceed its initial goal of providing ARVs to 10,000 individuals by the end of the Global Fund's second year in Malawi. 312 clinical staff have been trained and certified as ARV providers, and 21 ARV sites are operational. Through co-opting NGO clinics already providing health care services and rapid preparation of key GOM facilities, such as the three central hospitals, 54 sites are slated to offer ART by year's end. These recently published numbers suggest that the GOM will meet its original target of 25,000 individuals on ARVs after 5 years. ¶4. The GOM is also set to exceed its VCT goal of having 75,000 individuals tested by year's end. Of the 118 VCT sites in country, over 100 of them have opened in the last 18 months in anticipation of increased access to ARVs through Global Fund resources. Many of the VCTs are also positioning themselves to be ARV providers. The Ministry of Health (MOH) is currently assessing and certifying VCT sites. Given the requirement for all ARV sites to provide VCT services, rapid VCT expansion is clearly a result of the general expectation that Global Fund resources will bring greater access to ARV programs. ¶5. Less driven by the expectation of Global Fund resources, expansion of PMTCT and basic care and support services has been delayed, primarily due to the absence of a readily accessible network of providers. Reaction to recent technical recommendations about Niverapine mono-therapy has also slowed PMTCT expansion. THE CREDITORS: NGOs WILLING TO INVEST -------------- ¶6. The recent expansion of ARV programs, VCT services, and other HIV/AIDS-related initiatives is principally a result of the expectation of forthcoming Global Fund resources, not Global Fund resources themselves. NGOs (and to a lesser extent GOM agencies) have been willing to use their own funds to start ARV programs with the expectation that the programs will begin using Global Fund resources once available. This pre-establishment of Global Fund-driven programs, NGOs anticipate, will allow for more rapid expansion of services. (NOTE: Most of the NGOs operating such programs have already been approved by the National AIDS Commission as Global Fund grant recipients. END NOTE.) HELPING WRITE THE CHECK: WHAT'S DRIVING IMPLEMENTATION -------------- -------------- ¶7. In addition to NGOs' willingness to act before receiving funding, strong leadership in creating an explicit operational plan and in improving coordination within the Ministry of Health (MOH) has helped remove technical hurdles and concentrate on action. Two USAID/Malawi-funded technical advisors, one who works on ARV expansion planning and one who problem solves coordination efforts, have been key components to helping GOM agencies work with themselves and with the Global Fund bureaucracy. National AIDS Commission (NAC) and MOH's perception that they could lose Phase II Global Fund resources if they do not perform well against their original goals has also helped speed implementation along. If a Phase II grant is approved prematurely, the GOM's implementation momentum may lessen slightly. CHECKING THE BALANCE: GOOD INFORMATION SHARING -------------- - ¶8. The HIV/AIDS Unit of the Ministry of Health is the lead on information collection and progress tracking for clinical elements of the Global Fund program. The Unit has established its own data collection system, and, to date, has been able and willing to provide up-to-date data on progress against clinical service goals. NAC has also launched a national monitoring and evaluation system to track all HIV/AIDS activities in Malawi, regardless of funding source. Information that NAC collects, though sometimes limited by fragile data bases and voluntary reporting, is willingly and regularly shared. In addition, NAC quarterly publishes and distributes Global Fund expenditure data. Mechanisms for tracking other outputs attributable to Global Fund have been unclear. POTENTIAL DEBITS: CHALLENGES FOR YEAR THREE -------------- ¶9. Potential challenges as Malawi enters its third year of engagement with Global Fund are as follow: -- Delays in Drug Procurement: Global Fund and UNICEF (contracted by NAC to procure and distribute drugs and clinical supplies) have averaged ten weeks from order placement to supply arrival. If ARV sites have unanticipated increases in patients, adequate drug provision could be delayed for three to five months. -- Adequate Oversight: With rapid ARV program expansion planned as soon as Global Fund resources are available, there is question as to whether the MOH and NAC will be able to provide adequate supervision and quality control. -- Loss of Momentum: In the face of dramatic patient increases and greater demands on health care facilities, momentum to expand ARV services may wane before Global Fund goals are reached. -- Stigma and Loss of Focus on Prevention: Stigmatization of HIV/AIDS infected individuals and a loss of focus on prevention also remain concerns. COMMENT -------------- ¶10. Since the January 2004 release of the second tranche of funding, the GOM has made genuine and tangible efforts to facilitate rapid, effective utilization of funding and to avoid leaving resources idle. Moreover, there is no evidence that funds have been diverted for other purposes. While Global Fund resources in and of themselves have not resulted in many of the recent HIV/AIDS treatment initiatives in Malawi, it is clear that if the funding was not anticipated, those expansions would not be taking place. END COMMENT. RASPOLIC