Donor Coordination on Health Issues

UNCLAS SECTION 01 OF 03 PRETORIA 001634 SIPDIS SENSITIVE DEPT. FOR AF/S; OES/IHB STATE PLEASE PASS OGAC: BPATEL; PMAMACOS, MLIDSTONE STATE PLEASE PASS TO USAID/W FOR GH AND AFR/SA HHS/PHS FOR OFFICE OF GLOBAL HEALTH AFFAIRS WSTEIGER CDC FOR GLOBAL HEALTH OFFICE SBLOUNT E.O. 12958: N/A TAGS: SOCI TBIO SENV EAID PGOV KHIV KSCA SF SUBJECT: Donor Coordination on Health Issues PRETORIA 00001634 001.2 OF 003 ¶1. (SBU) Summary: Health Minister Manto Tshabalala Msimang (Minister) at a recent high-level Annual Donor Consultation Meeting stressed that the national Department of Health (DOH) must coordinate donor efforts in the health arena in order to ensure equitable allocation of resources across provinces. She voiced concern that donors concentrate too much on HIV/AIDS to the detriment of other health priorities and urged donors to think about how resources intended for HIV/AIDS programs could also be used to support other DOH priority areas. The meeting came at a time when the Donor Community in South Africa is frustrated with the South African Government's lack of leadership with regard to improving donor coordination structures, especially with regard to HIV/AIDS programs. The existing Donor Coordination Forum (DCF) for HIV/AIDS housed within the Department of Health (DOH) is largely ineffective, with neither donors nor the DOH satisfied with its results. End Summary. -------------- Health Minister Urges Broader Approach -------------- ¶2. (U) The Minister voiced concern at a June 30 high-level Annual Donor Consultation Meeting organized by the Department Of Health (High-Level Meeting) that donors concentrate too much on HIV/AIDS to the detriment of other health priorities. (Comment: Although called "Annual High Level Meeting" by the DOH, the meeting had not been held in several years. End Comment.) The Minister emphasized at the High-Level Meeting that she would like to see a broader approach to health and is concerned that everyone who talks about health is really talking about HIV/AIDS. She discussed promoting wellness and wellness centers. The Minister urged donors that have prioritized HIV/AIDS to also think about how to use these resources to support other priority areas. She listed the health department's priorities as meeting the Millenium Development Goals; promoting wellness; developing a rural-health strategy; strengthening primary healthcare; managing the burden of disease from non-communicable diseases such as cancer, cardiovascular disease and diabetes; human resource issues; and the health information system. "You can't really run a department on the basis of HIV/AIDS or you might just as well change the name to the Department of HIV/AIDS," she commented in a discussion with the donors. She added that the DOH will be arranging bilateral meetings with donors to further discuss the resource gaps in priority areas and how donor support can be utilized in a more coordinated manner. ¶3. (U) The Minister also commented that the DOH experienced a "challenge" when "a development partner working with NGOs decided to have a national conference focusing on a particular disease, for which the DOH provides almost all health services." She said, "It cannot be correct that when the Department is largely responsible it does not play a significant role - this will not happen in most other countries." The Minister noted that she "deliberately" was not mentioning the partner or the specifics of the conference. ¶4. (U) EU Ambassador Lodewijk Briet addressed the High Level Q4. (U) EU Ambassador Lodewijk Briet addressed the High Level Meeting, noting that donors' funding of HIV/AIDS is important as antiretroviral treatment (ART) is still not reaching many who need it. (Comment: The latest UNAIDS estimate is that only 28% of South Africans in need of ART are receiving it. End Comment.) He added that we should be working in South Africa to achieve the Millennium Development Goals of reducing infant and maternal mortality and on the response to HIV/AIDS and other diseases. Briet commented that the donors would welcome DOH guidance on how to work better with the South African National AIDS Council (SANAC) to support South Africa's National Strategic Plan on HIV & AIDS and STI (Sexually Transmitted Infection). Other donors, including the U.S., the United Kingdom, and Belgium, all noted that they are in the process of putting together programs looking toward 2010 and would like to find better ways to harmonize programs among donors and with the South African Government (SAG). (Comment: The Citizen newspaper criticized the Minister for downplaying the HIV/AIDS crisis at the High-Level Meeting, especially since HIV/AIDS is South Africa's major health problem. End Comment.) ¶5. (U) DOH Director General Thami Mseleku committed to look at the DOH ten-point plan to determine where donors could best fit in. (Comment: A presentation on financial gaps in the health sector from the DOH Chief Financial Officer was planned for the meeting, but did PRETORIA 00001634 002.2 OF 003 not occur. Donors commented that the presentation would have been very helpful. End Comment.) The donors requested that the Minister circulate South Africa's Global Fund application for 2009 to them, and the Minister agreed to do so. The Minister expressed her appreciation to donors who have responded positively to her calls for assistance for the new clinical associates program. This is a three-year program designed to train a cadre of professionals that will have a defined scope of practice and is geared to provide assistance to doctors in community health centers and district hospitals. United States President's Emergency Plan for AIDS Relief (PEPFAR) funds are being provided to the professional associates program through the Centers for Disease Control (CDC). Donors requested to share more detailed information on all donor supported health programs at a follow-up meeting that could serve as a basis for future coordination. -------------- Donor Coordination Forum Is Ineffective -------------- ¶6. (SBU) Embassy Health Officer attended a meeting of the DCF on July 2, 2008 that focused on possible changes in its future structure. The DCF agreed that the DOH's International Health Liaison (IHL) Office will be asked to participate in the DCF's next meeting to report on ways to structure the DCF better, in line with the High-Level Meeting's outcomes. The structure of the DCF has been at issue for some time as donors are generally dissatisfied with its operation. Donors feel that coordination with other donors, as well as between donors and the SAG, is poor and that donors do not have an effective means to provide input to the SAG. Donors are so frustrated with the DCF that they have established an informal forum, the EU+ Donor Forum, coordinated by the Swedish Embassy. The group's goal is to improve information sharing and understanding among donors of the HIV epidemic. SANAC and DOH have made presentations to the EU+ group, and the U.S. actively participates. ¶7. (U) The DCF commissioned the firm Strategy and Tactics to review the role and functions of the DCF and make recommendations on how the DCF could more effectively fulfill its role of ensuring that donor funding appropriately supports the SAG response to HIV & AIDS in a coordinated manner. The April 2007 report (DCF Report) noted that HIV/AIDS is a key focus of donor funding, receiving approximately 95 percent of all donor funding to the health sector. The DCF had been meeting bi-monthly, chaired by the HIV, AIDS and STI (HAST) cluster, with the support of the department's IHL office. Members include UNAIDS, major donors, international development agencies, and the Treasury Department. No other governmental departments actually attend, nor does the South African National AIDS Council (SANAC),nor major donor-funded NGOs, despite the forum being multi-sectoral and open to other organizations. In addition, DOH representation does not reflect broader interests beyond the HAST cluster, such as pediatrics, maternal health, capacity development, or TB and other opportunistic diseases associated with Qdevelopment, or TB and other opportunistic diseases associated with HIV. There is also no forum to discuss the broader health issues that the Minister would like to receive increased donor attention. ¶8. (SBU) The DCF Report found that that the DCF had largely failed in its mandate to coordinate donors effectively. Comments from survey donor respondents included: "One gets a sense that the department is ambivalent about the DCF and that senior management does not really want it"; "No genuine dialogue where donors and government officials share their needs and views openly"; and "Government representatives were ill prepared and often meetings were postponed or agenda items dropped." Respondents from the DOH also voiced unhappiness with the existing mechanism, saying: "Donors have failed to reduce the high transaction costs associated with donor assistance"; "Donors have not harmonized their actions with each other, nor have they aligned to existing DOH strategies"; "Donor missions are not joint and remain time consuming, particularly for provincial-level staff." -------------- -- Recommendations for Improved Donor Coordination -------------- -- ¶9. (U) The DCF Report recommended the formation of two donor coordinating forums to replace the existing DCF. A forum to be located within SANAC would coordinate donors in the HIV & AIDS sector and ensure that development partners align and harmonize with PRETORIA 00001634 003.2 OF 003 the NSP. Membership could expand to include all key role-players. A second forum would be located within the IHL Office of the DOH to coordinate all donors in the health sector and membership expanded to include representatives from all clusters within the DOH. ¶10. (U) The DCF Report acknowledges that establishing the DCF within SANAC could be difficult because the existing SANAC structure emphasizes national representation within the council. However, the Report noted that donor coordination could be managed within the Resource Mobilization Committee (RMC) of SANAC, chaired by the Health Minister. The RMC emphasizes coordination and implementation of Global Fund Activities, but may also look at other opportunities for resource mobilization to support implementation of the NSP. (Comment: There is no current donor representation on SANAC unlike most National AIDS Councils in other African countries, although UNAIDS provides support to SANAC and attends meetings in an "observer" capacity. Since the RMC supervises the Global Fund process, this means that Donors have no real input into South Africa's applications to the Global Fund and no knowledge of its content while being formulated. End comment.) -------------- DOH Rejects Recommendations -------------- ¶11. (U) The DCF, at its October 2007 meeting, endorsed the recommendations of the Report to establish two donor coordinating forums, to replace the existing DCF. The DOH reported, at the April 23 DCF meeting, that it had rejected the Report's recommendations following its review. The DOH stated that since the SANAC Secretariat is in the process of restructuring and SANAC lacks the capacity for donor coordination, the Forum should stay as is, chaired by the DOH HAST Cluster. The UK Department for International Development (DFID) reported at the July 3 DCF meeting that it had written a formal request to outline the DCF recommendations to SANAC, but had not yet received a response. ¶12. (U) Many of the complaints outlined in the DCF Report were echoed in the Report on the First Phase of the Evaluation of the Implementation of the Paris Declaration Country Level Evaluations completed in February 2008 (PD Report). The PD Report states that while the Development Partners are frustrated by the lack of a national Development Partner coordination forum, South Africa does not see the need for one. It notes that continued "silo" thinking and capacity issues weaken interdepartmental coordination. The PD Report recommends that the parties discuss a mutually agreed way forward: "The national Development Partner coordination issue needs to be debated further by the Partner Country and Development Partners to unpack both the fears and motivations for and against such a forum and determine: What is the gap and how can it be filled? How should division of labor be decided?" ¶13. (SBU) Comment: The dysfunctional nature of the DCF was highlighted by the fact that none of the DOH participants at the July 2 DCF meeting had either attended the High-Level Meeting or been briefed on it. No one from the IHL office of the DOH was even present at the DCF meeting. Mrs. Mokgadi Phokojoe, Director of the Qpresent at the DCF meeting. Mrs. Mokgadi Phokojoe, Director of the HIV, AIDS and STI office within the DOH, is chair of the DCF, but is not perceived by donors to be sufficiently senior to be influential within the Department. There is no immediate impetus for reform of the coordination structures in view of the Mbeki administration nearing its end. It is likely that the donor community will remain frustrated with the coordination structures and maintain parallel efforts to coordinate among themselves, unless a new Health Minister in a new administration sees the need for more effective donor coordination. End comment. Bost