BURMA MEETING ON TB DRUGS; BIG PUSH FOR GLOBAL FUND

UNCLAS RANGOON 000920

SENSITIVE
SIPDIS

STATE FOR EAP/MLS, G, S/OGAC, OES
BANGKOK FOR USAID HEALTH OFFICE
DEPARTMENT PLEASE PASS TO USAID/AME

E.O. 12958: N/A
TAGS: SOCI EAID PHUM KHIV PGOV SENV BM
SUBJECT: BURMA MEETING ON TB DRUGS; BIG PUSH FOR GLOBAL FUND

REF: A. RANGOON 842

B. RANGOON 879

C. STATE 115494

D. STATE 105179

Summary
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1. (SBU) Pledged donor funding for anti-tuberculosis drugs
in Burma will decline in 2009 and fall off sharply
thereafter. At a GOB-convened meeting December 1 to address
this gap, the Health Minister committed to increase
government funding for anti-TB drugs to 3 percent of the 2010
requirement, a still-paltry sum of about USD 100,000. Most
donors at the meeting argued for the return of the Global
Fund (GF) -- though it appears the Health Minister may be
reconsidering a GF application in light of perceived U.S.
opposition. Charge attended the TB meeting and reiterated
U.S. views on the need for Burma to address in any
application the problems that led to the GF's withdrawal in

2005. Several donor reps approached Charge afterwards and
urged U.S. support for the GF, citing the humanitarian need
and the GOB's generally positive record in cooperating with
the 3 Diseases Fund (3DF) and combating TB. In doing so, the
UK Ambassador asked specifically whether the U.S. has any
flexibility on GF site access requirements, noting that the
3DF gains access to sites in "nearly all" cases, which the UK
considers acceptable. Embassy Rangoon requests guidance in
responding to the UK and other donors (see para 10). End
summary.

GDF winding up TB drug funding; Global Fund in the wings?
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2. (U) The GOB convened a meeting on December 1 in Nay Pyi
Taw with bilateral and NGO donors, UN entities, and others to
discuss how best to address a looming gap in funding for
anti-TB drugs. The Global TB Drug Facility (GDF),based in
Geneva, has provided the drugs for the past six years, the
usual maximum duration, and agreed to provide funding help on
an "exceptional" basis for 2009 at a cost of approximately
USD 2.5 million, leaving a gap for the coming year of USD
1.15 million. From 2010 on there is very little funding for
anti-TB drugs in the pipeline. GDF sees a 2010 need of USD
8.2 million (half for that year's use; half to create a
buffer stock),and intends to cover only pediatric drugs, a
small portion of the total. Possible 2010 funding sources
are the UN, the 3DF, bilateral aid, international NGOs, and
GDF. GDF informed the meeting that the only obvious sources
for 2011 and beyond are the GOB, itself, and/or the GF, which
often provides funds to GDF to purchase and provide TB drugs.


GDF assessment generally positive; emphasizes funding need
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3. (U) The GDF presented findings from a week-long
monitoring mission November 24-29 that generally observed a
successful anti-TB program in Burma. The assessment saw a
continued increase in detection of new cases, the maintenance
of high treatment success rates, and an uninterrupted supply
of anti-TB drugs and laboratory supplies over the past two
years, with "excellent" drug management practices at all
levels, and "highly competent and dedicated" staff. Prisons,
military, police, and others follow treatment guidelines and
"refer patients where and when possible and have access to
services and products." The study noted challenges,
including the funding gap, unfilled health positions, and
irregular supervision due to lack of resources. The study
recommended increased GOB funding and sustainable multi-year
support from donors, including the GF.

GOB to increase funding (from low base); most donors favor GF
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4. (U) Health Minister Kyaw Myint informed the meeting that
his ministry is prepared to commit "no less than 3 percent"
of the expected drug cost for 2010, about USD 100,000, with
an intention to augment that amount by no less than 1 percent
per year in the future. UN agency reps, GDF's General
Manager Dr. Robert Matiru (Geneva),and Dr. Mario Raviglione,
Director Stop TB Department (WHO Geneva),all argued that
Global Fund is the obvious long-term answer and that the GOB
should make every effort to apply in 2009 for Round 9.
Matiru said GF is a "realistic and viable" option for Burma.
He urged the GOB to look at the past and see how a future
program can be made to work. Raviglione said of all the
high-burden TB countries, Burma is the only non-participant
in the GF. He said WHO strongly recommends an application
and is keen to provide technical assistance. Per previous
reporting, the British and Australians are also urging a
Burmese Global Fund application, given what they see as
generally positive GOB behavior during the past two years in
implementing the 3DF (see Ref A).

USG views on the table
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5. (U) The Charge represented the USG at the meeting. Dr.
John MacArthur, USAID RDMA Bangkok's infectious disease team
leader, was unable to accompany due to the closure of the
Bangkok airports. In an intervention, the Charge noted a
recent large USG contribution to the Stop TB Partnership
(which includes the GDF),and a recent USD 1 million USG
contribution to WHO and PSI anti-TB efforts in Burma. As
advised by Dr. MacArthur, Charge said RDMA is looking to see
if it can find available funding to help cover the 2009 drug
gap. Charge noted the ongoing USG dialogue with the GOB
regarding the GF (refs B and C) including the marker that any
Burma application needs to address up front and
satisfactorily the past problems that brought GF withdrawal
from Burma in 2005. Charge joined other donors in urging the
GOB to increase its own contribution to the drug budget.

Minister asks USG support for GF application
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6. (U) In response Health Minister Kyaw Myint said he badly
wants to keep up momentum in the GOB's effort against TB. He
said he would "crawl on his knees" if necessary to GOB
decision makers (the senior generals) to try to increase GOB
TB-drug funding. The Minister asked for Charge's "blessing"
for USG support of a GOB GF application.

Pretty unambiguous signal: no GF application?
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7. (SBU) The UK and Australian Ambassadors were invited to a
short chat with Kyaw Myint prior to the donor meeting. After
the meeting, the Ambassadors informed Charge that the
Minister had left a "pretty unambiguous" impression that he
does not intend to apply for GF Round 9. The Minister said
he "doesn't want to be humiliated again" and will "err on the
side of caution." The Minister seemed convinced the USG
intends, in the end, to block an application.

UK believes USG should support GF for Burma
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8. (SBU) Per refs B and C, Charge in recent weeks provided
as clearly as possible USG views on the GF to the Health
Minister and one of the two Deputy Health Ministers, noting
U.S. understanding of Burma's health needs, but also
explaining the USG belief that the GOB must satisfactorily
address in its GF application several important problems from
the past: the need for full access to GF program sites; a
market-rate currency exchange mechanism; appropriate tax
exemptions; and assurance no funds would flow through the GOB
or its proxies. The UK Ambassador emphasized to us later his
government's agreement that the USG issues are important; but
the UK also believes the GOB in its work with 3DF (the
European/ Australian funding mechanism for Burma in the
absence of GF) is demonstrating its willingness to meet GF
requirements satisfactorily. The UK Ambassador, who chairs
the 3DF process, said "access" is the one question mark. The
GOB has provided nearly all the access 3DF has requested; not
always immediately and in a couple of cases not at all, but
nearly always, he stressed. The UK sees that "not black and
white but only a little gray" situation as acceptable, given
the life and death TB issues at stake. Charge promised to
convey, again, that view to Washington and seek any further
guidance, particularly on whether the USG can envision any
flexibility at all on the access issue.
Lack of message in Geneva...a worry
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9. (SBU) On the margins of a post-meeting luncheon, Stop
TB's Dr. Raviglione approached Charge to argue that the USG's
issues regarding a GF application should be addressed in
technical discussion down the road, not in the application
itself. Charge referred to Ref D instruction in which
Washington made clear it does not agree with that approach,
believing the GF's own rules for a Burma application require
addressing problem areas in the application. Raviglione
expressed puzzlement why the USG has not made its variety of
points to GF in Geneva. When Charge said he is quite sure
U.S. Mission Geneva has delivered the points, Raviglione said
the U.S. raised no such points at a GF Board discussion of
Burma in Geneva in early November.

Comment and action request
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10. (SBU) Given the GF previous withdrawal from Burma, the
USG has appropriately raised the issues that need addressing
in any new application process. The other participants at
this week's meeting seemed united in believing that the GOB's
overall positive record with the 3DF and its generally very
helpful approach in combating TB argue persuasively for a
return of the GF. A critical factor in that analysis is the
undoubted reality that a funding failure would, in this "high
burden" country, lead to the loss of many thousands of lives
and a significant public-health threat to the rest of the
Southeast Asia region. Factors weighing against include the
risk that the GOB will not satisfactorily meet or sustain
necessary GF commitments, and the paltry sums Burma's senior
generals are prepared to spend on health, compared to huge
amounts spent on major construction projects. At present,
most other donors perceive the USG stance on GF for Burma as
overly rigid, not acknowledging that useful work can be done
in the health sector with what most others perceive to be
adequate safeguards. We continue to urge Washington and GF
Geneva to engage in discussion regarding Burma. In the
meantime, we request guidance for responding to the UK
Ambassador on whether the USG is willing to accept some
"degree of gray" -- i.e., show some amount of flexibility --
in our view of how much access to GF sites in the future is
essential here. Please advise.
DINGER