KAZAKHSTAN: RECOMMENDATIONS ON GLOBAL FUND

UNCLAS ALMATY 002689 SIPDIS DEPARTMENT FOR S/GAC: CRConnelly, PPearson DEPARTMENT PLS PASS TO USAID/E&E: TAlexander; USAID/GH: MMiller E.O. 12958: N/A TAGS: EAID KZ SUBJECT: KAZAKHSTAN: RECOMMENDATIONS ON GLOBAL FUND PHASE 2 RENEWAL REF: STATE 129571 ¶1. (U) Summary: This cable responds to reftel request for post input into the decision of whether Grant Number KAZ-202-G01-H-00 from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) should receive funding beyond its initial two years. Progress in Kazakhstan has been on track for several components of the grant, while issues have arisen regarding the use of substitution therapy, delays in initiation of treatment, and changes have altered the Country Coordination Mechanism (CCM). Despite these implementation issues, given the measurable progress in grant implementation to date, the USG's substantial involvement in Kazakhstan's national HIV/AIDS program, and the opportunity to stem the epidemic, Post recommends that Kazakhstan receive the second tranche of its GFATM grant for HIV/AIDS. Summary Data on Kazakhstan's GFATM Grant ¶2. (U) The start date of the grant, for a total of $22,360,000, was December 1, 2003. Under Phase 1, $6,502,000 has been approved, with $6,201,999 disbursed to date. The Principal Recipient for the grant is the Republican AIDS Center (RAC). A total of $15,858,000 has been requested for Phase 2 of the grant. The Local Funding Agent is KPMG. The USG has been represented on the CCM by USAID and provided technical assistance in the preparation of both this and other grant applications from the Government of Kazakhstan (GOK) to the GFATM. Comments on Kazakhstan's GFATM Grant Performance ¶3. (U) In December, 2003, Kazakhstan was awarded a five- year, $22.4 million grant from the GFATM. Written in support of the national HIV/AIDS program, the main goals of the grant are to prevent HIV infections among vulnerable groups, and to expand care and support of those living with HIV, including the provision of treatment, primarily antiretrovirals (ARV). ¶4. (U) The GFATM grant supports Kazakhstan's national, multi- sectoral HIV/AIDS program. Originally developed in 2001 and slated to run through the end of 2005, it is currently being updated and renewed for the next five years. The program's three key strategies are: prevention of HIV and sexually transmitted infections among vulnerable groups, including injecting drug users (IDUs); HIV prevention among youth through education, information and communication; and treatment, care and support for people with HIV/AIDS. ¶5. (U) The GFATM's own indicators show that the grant in Kazakhstan is performing well in all but two areas, substitution therapy and ARV therapy. The GOK concluded that substitution therapy is unnecessary and therefore this approach to reducing injecting drug use (the major route of transmission of HIV in Kazakhstan) will not be implemented. The GFATM has decided to accept this GOK decision and, as a result, may reduce the grant by $1 million, although the request for the second tranche remains based on the full amount of the grant. ARV therapy was delayed because of procurement problems, while other progress to initiate this component remains slow. Given the status of the epidemic, and the relatively low numbers planned for ARV therapy, prevention efforts undertaken through the grant should be a priority. These other areas of performance have essentially met the expected targets to date. Post's Recommendation on Phase 2 Funding ¶6. (U) The still relatively low infection rate offers a unique opportunity for Kazakhstan to be successful in its efforts to prevent a generalized epidemic. USG assistance on HIV/AIDS prevention, provided primarily through USAID's Regional Mission for Central Asia, with technical support from the U.S. Centers for Disease Control and Prevention (CDC) and other implementing partners, averages $1 million per year in Kazakhstan and includes components for improved data gathering, prevention, treatment and care, and systems development. In light of the USG's substantial involvement in Kazakhstan's national HIV/AIDS program and the measurable progress in GFATM grant implementation to date, Post recommends that Kazakhstan receive the second tranche of its GFATM grant for HIV/AIDS. GFATM Grant Technically Sound ¶7. (U) The GFATM strategies are technically appropriate, and the RAC's role as Principal Recipient represents a sound decision, given its leadership role in almost all GOK HIV/AIDS initiatives. The GFATM grant targets prostitutes, IDUs, men who have sex with men (MSM),and vulnerable youth. These are all groups known to be at high risk for HIV due to their practice of risky behavior. (In fact, USAID targets the same groups.) Given the need to reach these high-risk groups with information and services, most experts in the country acknowledge that coverage is inadequate. Increasing coverage is one of USAID's priorities and an emphasis of its joint efforts with the RAC. Nonetheless, overly ambitious targets for coverage under the GFATM grant were revised in coordination with its Portfolio Manager. ¶8. (U) The RAC has a monitoring and evaluation (M&E) plan, and data for measuring progress against the target indicators is being collected. The United Nations and the CDC have conducted trainings on M&E as well. USAID plans to place an M&E specialist within the RAC to assist with improving the system for assessing GFATM grant activities as well as the overall national AIDS program. Country Coordination Mechanism (CCM) In Flux ¶9. (U) Kazakhstan formerly had a Country Coordination Mechanism (CCM) solely for the purpose of the GFATM HIV/AIDS grant. A new CCM created this past year, however, will also oversee a hoped-for grant on tuberculosis control. Some CCM members believe that the current model, which is much smaller, and linked closely to a new GOK National Coordination Council on Health Care, may turn out to be more efficient than that of the past. The new CCM is small but flexible and includes important representation: 40% are non-government members, including representatives of UNAIDS, the USG, the NGO sector and people living with HIV/AIDS. The new, overarching National Coordination Council should serve as a broad-based health coordination body, with responsibilities to include oversight of the national plan for health sector reform. USAID sees benefits to including the CCM under the Council; the last meeting of the Council focused on HIV/AIDS, elevating the issue to a national level and engaging GOK representatives outside the Ministry of Health. The link between the CCM and the Council may help to reduce the vertical nature of the country's HIV/AIDS efforts and promote further integration with other health sector reforms. ¶10. (U) The former CCM exhibited poor communication with and from local HIV/AIDS-related NGOs and a top-down decision-making process, in spite of a mandate for decisions by consensus. The RAC played the role of Secretariat for the CCM. The Secretariat's role SIPDIS included collecting information, developing meeting agendas, communicating the meetings' protocols, distributing information related to the CCM meetings, and collecting recommendations of partners on the issues related to analysis, programming, and implementation. The RAC continues to be represented on the new National Coordination Council, but the Secretariat function remains unclear. USAID and its partners will continue to work with these national bodies to improve overall coordination and national stewardship of the fight against HIV/AIDS. Collaboration Continues and To Be Further Encouraged ¶11. (U) The U.S. Mission has found the GFATM Principal Recipient (the Republican AIDS Center, RAC) to be willing and interested in collaboration. USAID is working with the RAC to establish it as the national steward for coordinating the implementation of the overall national GOK HIV/AIDS program, including and beyond the GFATM grant-funded activities. The RAC also serves as the lead partner for CDC's USAID-supported work in Kazakhstan on HIV sentinel surveillance, and RAC staff have served as consultants for CDC as other countries in the region embark on this USG-supported and important aspect of monitoring the epidemic. ¶12. (U) As Principal Recipient, the RAC should improve its collaboration with the HIV/AIDS-related NGO and civil society sector. (New GOK legislation on NGOs may also impact this aspect of its work.) Improving this coordination is another USAID priority. RAC and other GOK health officials are actively involved in the development of planned regional HIV/AIDS programs with other donors, such as the World Bank and the British Department for International Development (DFID),as well as with ongoing USG HIV/AIDS activities. Overall, the GOK HIV/AIDS response has been confined to the Ministry of Health (although this concern may be removed if GFATM approves Kazakhstan's new grant application for HIV/AIDS prevention in the military and prison system),and general reluctance throughout society to confront the disease continues. There has been limited private sector involvement in the GFATM and other HIV/AIDS initiatives. USAID also seeks to address this gap through pursuit of it Global Development Alliances between the public and private sectors. Points of Contact ¶13. (U) For further information, please contact Kerry Pelzman, Regional HIV/AIDS Advisor, USAID/Central Asia (kpelzman@usaid.gov); Andreas Tamberg, Public Health Advisor, USAID/Central Asia (atamberg@usaid.gov); or Almaz Sharman, Kazakhstan Country Office Coordinator for Kazakhstan, USAID/Central Asia (asharman@usaid.gov),the USG representative on the GOK CCM and National Coordination Council on Health Care. ¶14. (U) Minimize considered. 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