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.

Ordway


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