UNCLAS SECTION 01 OF 02 LILONGWE 000402

SIPDIS

AIDAC

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: SUCCESS OF AN ARV PROGRAM: IT'S NOT JUST ABOUT
THE DRUGS

Ref: A) STATE 202651 B) LILONGWE 497 C) LILONGWE 933


1. Summary: Malawi has been making remarkable progress in
the roll-out of its Global Fund for AIDS, TB and Malaria
(GFATM) funded Anti-Retroviral (ARV) Program. It
appears that treatment goals will be met and testing goals
exceeded. Some government officials are now asking why
Malawi cannot reach even further, asking the U.S.
government for assistance particularly to increase the
amount of ARVs in the country. However, the ARV program
faces many challenges and will struggle to stay on pace
because of constraints unrelated to drugs, namely weak
infrastructure, human resource constraints, and open
questions regarding supervision. End summary.

Progress to-date on Malawi's HIV/AIDS ARV Program
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2. Per reftel C, Malawi's early progress in its GFATM
funded ARV program has exceeded all expectations. Over
750 clinical staff have been trained with 34 facilities
providing ARVs to 17,500 individuals as of March 2005 - a
50 percent increase since late 2004. A monitoring and
supervision system has been created which includes a
public reporting, on a quarterly basis, of progress and
clinical outcomes. The Clinton Foundation has recently
signed an agreement with the Government of Malawi and the
National AIDS Commission which will reduce the costs of
drugs procured under GFATM by 22 percent. Early reports
are that 300,000 people accessed testing and counseling in

2004. At its current pace Malawi is very likely to
achieve its 2005 goal of treating 44,000 and its 5-year
goal of treating 80,000.

The ARV pipeline: An impediment to continued scale-up?
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3. Drug procurement was an early and persistent impediment
to the rapid implementation of Malawi's HIV/AIDS ARV
program. The Govern

ment of Malawi felt that drug
procurement should be undertaken by the Government's
Central Medical Stores. A World Bank assessment
identified significant doubts as to CMS's financial and
procurement integrity. As a compromise, it was agreed
that UNICEF would provide drug procurement services as
well as capacity building to CMS.


4. Unfortunately, drug procurement under UNICEF brought
its own challenges. Early problems included delays in
funds transfers, unclear communication from NAC and the
MOH, as well as WHO's de-certification of a key
manufacturer. Further delays directly attributable to
UNICEF include a generally cumbersome procurement system,
no full-time dedicated staff on the ground, and a reactive
rather than proactive approach to procurement. It now
takes approximately 6 months from the time that funds are
requested to be transferred to UNICEF for drugs to arrive
in country.

Request from Government
--------------


5. Malawi Minister of Health Ntaba recently requested a
meeting with Charge Gilmour to discuss these matters.
During the meeting the Minister expressed deep concerns
regarding UNICEF's performance to date and their ability
to meet growing procurement demands as the number of
patients on ARVs increases. The Minister questioned why
only 80,000 will benefit from ARVs when the WHO estimates
that 170,000 are currently eligible for treatment. He
noted that while 59 health facilities are ready to provide
treatment there are only enough drugs for 34 of these
sites. The Minister highlighted the growing demand for
ARVs created by dramatic increases in the number of
Malawians getting tested. (Note: the South Region Central
Hospital, Queen Elizabeth, currently has a 5 month waiting
list for those wishing to access ARVs). He therefore
requested that the Mission advocate to Washington for the
release of PEPFAR funds for procurement of ARVs through
Malawi's Central Medical Stores.

Comment
--------------


6. The problems identified in the World Bank's initial
assessment of CMS persist, with no concrete action having
taken place to date to ameliorate them. Despite the
Minister's assurances that any such problems could be
quickly resolved, experience to date shows otherwise. In
addition, Mission consultations indicate that the quantity
of ARVs is of less importance, in the long run, to
reaching beyond the 80,000 target than issues of overall
capacity. Severely constrained human resources, limited
infrastructure, and fragile monitoring and supervision
systems are significant constraints to expansion in the
public sector. An example is a recently reported
conversation with staff at Queen Elizabeth Central
Hospital in which they unequivocally stated that, even if
they had more ARVs, they simply did not have the human
capacity to manage a greater influx of patients. A recent
back of the envelope estimation by the MOH indicated that
25 percent of the current health sector workforce will
need to be 100 percent dedicated to AIDS treatment if the
goal of 80,000 on treatment is to be reached.
Furthermore, critical questions of how to maintain current
levels of supervision and monitoring have yet to be
answered.


7. However, positive action can be taken. It is widely
recognized that UNICEF has performed below expectations
vis-a-vis procurement and, to date, has provided none of
the promised capacity building to CMS. Intervention by
UNICEF head office to reduce delivery time, to increase
proactive communication and attention to the Malawi
situation, and to deliver on the promise of capacity
building of CMS would be of great benefit. Immediate
improvements in current performance will keep the existing
program on track, building on success, as issues of
overall capacity are debated and addressed.

Note: USAID was recently selected, with the support of
CDC, to represent bilateral donors on Malawi's Country
Coordinating Mechanism-- the country's oversight body for
GFATM activities. This will facilitate greater
involvement on the part of the USG as well as real-time
monitoring of relevant policy decisions.

GILMOUR