MALAWI: POST RECOMMENDATIONS ON GLOBAL FUND PHASE 2

UNCLAS SECTION 01 OF 02 LILONGWE 000509

SIPDIS

SENSITIVE

STATE FOR AF/S GALANEK
STATE PASS TO USAID/GH MILLER
HHS FOR WSTEIGER
STATE FOR S/GAC PEARSON

E.O. 12958: N/A
TAGS: EAID KHIV SOCI TBIO MI HIV AIDS
SUBJECT: MALAWI: POST RECOMMENDATIONS ON GLOBAL FUND PHASE 2
RENEWALS

REF: SECSTATE 103678


1. (U) Malawi


2. (U) Grant No: MLW-102-G01-H-00
Phase 1 amount: $41,751,500.00
Phase 2 amount requested in proposal: $155 million


3. (SBU) Overall Comments/Recommendations: Post recommends
funding Malawi's Phase II, HIV/AIDS proposal at the levels
requested. However, approval of Phase II should be
accompanied by more attentive and probing monitoring on the
part of GFATM staff. Field visits should extend beyond a
day or two and include solicitation of feedback from a wider
representation of stakeholders. PR must be held accountable
for performance against all aspects of the grant, not just
treatment.


4. (SBU) Grant Performance: The performance of the grant has
been mixed. While achievements in ARV treatment are
exceeding expectations and HIV testing proceeding apace,
performance in the areas of Prevention of Mother to Child
Transmission (PMTCT) and Home Based Care (HBC) are
foundering. There are no measurable service achievements in
these last two categories. The ARV achievements are due to
national political support and pressure, MOH and NAC
management attention, and the provision of critical
technical assistance particularly from the USG. The Public
sector funding is hindered by weak proposal and budget
development capacity and lack of urgency outside of
expansion of access to ARVs.


5. (U) Technical Considerations: The proposal is technically
sound. However, the monitoring plan includes critical, some
would say doubtful, assumptions related to management
commitment to release staff to tend to monitoring duties
and/or contracting out this function.


6. (SBU) Degree of Coordination: To date the Country
Coordinating Mechanism (CCM) has been reactive to issues
brought to its attention rather than providing proactive
oversight and attending to accountability. Its irregular
meetings are typically scheduled to facilitate GFATM
deliverables. CCM members are not active, as CCM members,
outside of these meetings. Other than pressure to meet
treatment goals and ensure provision of funds to the public
sector, CCM has not held PR accountable to performance.


7. (SBU) CCM processes lack transparency and accountability
to stakeholders who are not members. Stakeholders external
to the CCM have been told that meetings are minuted but that
minutes are not publicly available. Therefore,
documentation of process or outcome cannot be verified.
Those that wish to observe CCM proceedings are instructed to
formally request to do so. Invitations would then be issued
at the pleasure of the Chair. Verbal requests on the part
of USAID, on two occasions, did not result in an invitation.
General interest is not considered a sufficient reason for
participation. It should be noted, however, that this
policy does not seem to have been universally applied
particularly to the UN and government.


8. (SBU) The President selected representatives to the CCM.
Although these individuals represented a perspective (e.g. a
person living with AIDS) they were not held accountable to a
constituency body either to raise particular issues/concerns
or to debrief after CCM meetings. The Government holds the
largest number of seats. Seats vacated due to death or
resignations have not been filled. Meetings were not
publicly announced making requesting an invitation
difficult. In addition, meetings were frequently called at
the last minute creating a crisis in decision making,
basically extracting desired outcomes because time
constraints prohibited the exploration of alternative
measures. Materials were frequently provided to CCM members
on very short notice, making thorough review extremely
doubtful.


9. (SBU) The CCM self-assessment was seen by many as
generous and not a good faith effort at elucidating
challenges and gaps in performance. It has, and continues,
to be, chaired by the Principal Secretary of Health. At
times this has resulted in muted responses on the part of
the CCM regarding performance of the MOH as a sub-recipient.
In general, the role of the CCM versus the National AIDS
Commission (NAC) is somewhat murky, leading to disagreements
over authority. A Trust Deed has been drafted which
clarifies these matters. It is to be presented to
Parliament during the current sitting.

10. (U) Recent events, however, raise the possibility of
significant improvements in CCM performance. In response to
GFATM guidance, the NAC has convened several constituency
groups who have selected their own representative to the
CCM. These representatives are called on to solicit and
raise concerns as well as convene their constituencies for
consultation and briefing. NAC is providing funding for
this process. USAID fills a new seat that was created for
discrete donors. Although the Principal Secretary of Health
is still the chair, it is recognized that a conflict-of-
interest process must be developed. It should also be noted
that there is a new PS for Health who seems more
constructive in his management of the CCM. We understand
that CCM minutes will now become public documents. These
new structures and processes are very new (within the week),
thus we are unable to assess their impact. Coordination of
the donor sector vis--vis GFATM roll-out and the wider
response has been driven by donors themselves rather than
under the guidance or leadership of CCM, NAC or other
elements of government.


11. (SBU) Political or other considerations: Attitudes
towards the non-governmental and private sector have been
mixed. It is generally felt that indigenous CBOs/FBOs have
a significant role to play, particularly in home-based care
and support to orphans and vulnerable children, and have
received funding. Faith-based health facilities have been
significantly engaged, and funded, for treatment roll-out.
However, private sector is often referenced as a source of
additional resources rather than a potential recipient of
funding for implementation of activities. There are regular
references to international NGOs as competitors for the
government's money. Policy decisions related to allowable
expenses have proved explicit barriers to international NGO
access of GFATM resources.
Due to political pressures it is difficult for funding
recipients to acknowledge, and therefore effectively
address, weaknesses and gaps in government capacity for
implementation. Also, the NGO sector, particularly
international NGOs with experience and presence in country,
is being underutilized. Finally, the "public-/private"
partnership is not well understood or valued at the senior
policy level.


12. (U) Embassy Point of Contact: Tyler Sparks, Political
Officer, SparksTK@state.gov, +265-1773-166 ext 3463.


GILMOUR