GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA, PHASE

UNCLAS DAKAR 000944 SIPDIS SIPDIS STATE FOR S/GAC - SALPINI AND JEFFERS, AF/EPS AND AF/W E.O. 12958: N/A TAGS: EAID KHIV TBIO SOCI SG SUBJECT: GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA, PHASE TWO RENEWAL OF SENEGAL'S MALARIA GRANT SNG-405-G05-M REF: STATE 027470 SUMMARY -------------- ¶1. Senegal's National Malaria Control Program (PNLP) is using this Global Fund grant to introduce new artemesinin-based combination therapy (ACT) drugs for treatment of uncomplicated malaria, provide intermittent preventive treatment for pregnant women, and distribute insecticide-treated bednets. We recommend that the Global Fund continue to support the procurement of ACTs; insist on the implementation of a pharmaco-vigilance plan; support revitalization of the National Malaria Coordination Committee; and insist that bednets be priced to ensure availability to vulnerable groups. This grant complements the President's Malaria Initiative (PMI),and Mission recommends that the USG support renewal. END SUMMARY. GRANT PERFORMANCE ASSESSMENT: SENEGAL MALARIA GRANT SNG-405-GO3-M -------------- ¶2. The Ministry of Health's National Malaria Control Program (PNLP) is the principal recipient of this grant. The PNLP's main activities with this grant include the introduction of the new artemesinin-based combination therapy (ACT) drugs for treatment of uncomplicated malaria, intermittent preventive treatment for pregnant women, and distribution of insecticide-treated bednets (ITNs). ¶3. Senegal has been selected as a focus country for the USG's President's Malaria Initiative (PMI). It is important to the USG and to the PNLP that PMI and Global Fund activities complement each other and are harmonized in order to achieve the best results. PMI counts the Global Fund as an important partner in Senegal, and we hope that the Global Fund will continue to fund this and future malaria grants in-country. ACTS AND MALARIA TREATMENT -------------- ¶4. In January 2006, the PNLP received the first 3 million doses of ACTs (half the total quantity ordered under this grant). Because expiry dates range from October to December 2007, there was concern regarding a potential over-estimate in quantity, so delivery of the second half of the order was stopped. However, a recent USG-supported quantification exercise showed that the current stocks should be exhausted before any expiration, and that the remaining 3 million doses can be ordered for delivery from the manufacturer at this time. 
¶5. Before the drugs arrived, the PNLP developed a plan for the introduction of ACTs at all levels of the health system, including at the village level where feasible. Private pharmacies were also given access to the Global Fund ACTs, on the condition that the pharmacies sell them to users at the same low price at which the public health system sells them. It is unclear whether all pharmacies actually follow this pricing policy, although they do obtain the drugs from the Ministry of Health's Central Medical Stores at a Global Fund-subsidized price. ¶6. At the community level, USAID-supported non-governmental organizations (NGOs) assist community health workers to provide malaria treatment with ACTs in 186 village health huts in USG focus regions; the PNLP reports that nationwide, 552 out of more than 1000 functional health huts provide the ACT treatment. In non-USAID-supported districts, the PNLP funds its district-level health structures to implement community-based activities rather than doing so via NGO accompaniment. The PNLP also gives grants to NGOs, but only for promotion and social mobilization activities. RECOMMENDATIONS -------------- ¶7. We recommend that the Global Fund continue to support procurement of ACTs through the life of this grant to ensure national availability of these drugs. Under PMI, the USG will continue to support health worker and village volunteer training to properly and effectively use the drugs provided by the Global Fund. Under PMI, NGO assistance to health huts for treatment using these ACTs will also expand to 1058 health huts nationwide. We also recommend that the Global Fund insist on the implementation of a pharmaco-vigilance plan during the second phase to ensure continued drug quality and efficacy. Based on the extremely successful experience with NGOs in training and supporting community health workers to treat malaria, we recommend that the PNLP increase the scope of such organizations in its grants to them, to include treatment activities in addition to education and communication activities. This will complement public health services and also reinforce civil society involvement in malaria programs. COORDINATION AND COMMUNICATION -------------- ¶8. We are pleased to observe improved communication between the PNLP and the Country Coordinating Mechanism (CCM). The PNLP made important efforts to provide necessary documents before the CCM meetings and allowed members more time to review them than in the past. However, there is still insufficient quality of the documents which are often quite difficult to read due to extremely small print or low quality reproduction. The documents routinely presented also cover a period that is six months behind actual time. The CCM proposed an improved format for principal recipients' presentations during CCM meetings, and things seem to be improving. ¶9. The National Malaria Coordination Committee, which is intended to oversee technical committees and partner coordination, exists but has not been functional for the past few years. However, as Senegal is receiving considerable resources for malaria control programs (PMI, World Bank River Basin Initiative, and Global Fund, among others),it is critical to ensure complementary, harmonization and efficient use of resources. PMI will strongly encourage the revitalization of this committee, as well as its sub-committees, which function as working groups in various technical areas. RECOMMENDATIONS -------------- ¶10. We encourage the Global Fund to support revitalization of the National Malaria Coordination Committee, as well as its sub-committees, and to encourage the PNLP to make every effort in this area. With the multitude of donors, prices, and distribution systems, harmonization is especially needed in the area of ITNs. A working sub-committee under a revitalized national coordination committee, as above, could help with this issue. The Global Fund should ask that ITNs provided by the PNLP under this grant are effectively targeted to reach the most vulnerable groups, rather than sold at a subsidized price to anyone, regardless of vulnerability. RESULTS AND DATA -------------- ¶11. In 2006, an evaluation was conducted by a local firm on the activities of the first year of this grant. The evaluation report states that the project made significant results in terms of ITN ownership (reported at 60 percent) and in terms of use of ACTs at the clinical level (with 78 percent of simple malaria cases among all ages correctly managed). 66.4 percent of pregnant women reportedly received the recommended drug to prevent malaria in pregnancy. In the report, these indicators exceed their targets, while the targets are not met for children under five years receiving treatment within 24 hours (28 percent),or use of ITNs for children under five (45 percent) and pregnant women (32.6 percent). ¶12. In the same timeframe as the evaluation, the U.S. Government (USAID and CDC),conducted a national Malaria Indicator Survey to measure baseline coverage of the PMI interventions. Though the final report has not yet been published, our survey found that 57 percent of households owned a bednet of some kind, with 36 percent of households owning a treated net. Treated net use was also lower in our survey compared to the PNLP's evaluation, at 16 percent and 17 percent for children and pregnant women, respectively. Only 11 percent of children were found to have received treatment within 24 hours for their last case of fever. These indicators are in line with a reasonable progression since the 2005 DHS and we believe them to be the correct ones. ¶13. All coverage indicators, by all accounts, are improving over time. However, we believe that the true coverage figures are likely to be substantially lower than those found in the evaluation, being used by the PNLP in its results reporting to the Global Fund. FINANCIAL MANAGEMENT -------------- ¶14. All documents and information available to us indicate that the PNLP has a good disbursement rate and that most of the planned activities have been implemented. No recommendations in this area. FUNCTIONING OF THE CCM -------------- ¶15. Senegal's CCM has 42 members representing virtually all government ministries and the presidency, UN health organizations, bilateral donor agencies, international NGOs, local faith-based organizations, and organizations representing women, youth, people living with HIV/AIDS, labor unions, and national business interests. The CCM has made important improvements in its functioning over time, developing new terms of reference and reviewing its composition and functioning. These new terms of reference led to establishment of a Technical Secretariat which greatly assists the CCM in administration and decision-making. It also helps to improve coordination among its members and communication with recipients. ¶16. The CCM recently received technical assistance to help develop monitoring tools and a manual of procedures. This will reinforce CCM capacity to better monitor the grants (both this malaria grant and Senegal's current HIV/AIDS grant) and ensure partner coordination and rational use of resources allocated to Senegal. RECOMMENDATION -------------- ¶17. The CCM should ensure the implementation of these tools for the grant monitoring and should be more proactive in problem-solving toward the principal recipients. JACOBS