SCENESETTER FOR OGAC AMBASSADOR GOOSBY SEPTEMBER 26-30

UNCLAS SECTION 01 OF 04 KAMPALA 001098

SENSITIVE BUT UNCLASSIFIED
SIPDIS

FOR AMBASSADOR GOOSBY FROM AMBASSADOR LANIER
DEPARTMENT FOR OGAC AND AF/EX
USAID FOR BUREAU OF GLOBAL HEALTH
HHS/PHS FOR OFFICE OF GLOBAL HEALTH AFFAIRS
CDC FOR GLOBAL HEALTH OFFICE

E.O. 12958: N/A
TAGS: PGOV KHIV SOCI TBIO PHUM EAID UG
SUBJECT: SCENESETTER FOR OGAC AMBASSADOR GOOSBY SEPTEMBER 26-30
VISIT TO UGANDA

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SUMMARY
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1. (SBU) Summary: You are visiting Uganda when the long-running war
against the HIV/AIDS pandemic is at a crossroads. Under the
leadership of President Yoweri Museveni, Uganda was a pioneer in
recognizing and taking tangible action against HIV/AIDS in the
1990s. Prevalence rates plunged from nearly 20 percent then to
under seven percent today. But incidence is again on the rise in
the context of a rapidly expanding population, and growing
complacency, from both the Government of Uganda (GOU) and the
population at large. Much of Uganda's success since 2004 is the
success of PEPFAR, which began to ramp up that year. But Ugandan
complacency is also partly a legacy of PEPFAR. By scaling up so
rapidly in response to the emergency, and by largely bypassing GOU
entities in the process, we created donor dependence and diminished
any incentive for the GOU to lead the way, as it did pre-PEPFAR.
Your visit is an opportunity to start changing this dynamic through
engaging the leadership on sustainability and the potential offered
by a Partnership Framework. We urge you to consider in these
discussions the need to re-incentivize Uganda to take ownership of
its HIV/AIDS challenge. End Summary.


2. (SBU) The U.S. Mission in Uganda looks forward to your visit
September 27-30. We believe we have a strong program and we seek
your assistance in reinvigorating the national response to HIV/AIDS.
Your office asked for a brief response to several questions
regarding the next phase of PEPFAR and how it should be
operationalized. This cable addresses those questions and outlines
some of the challenges we face in Uganda.

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INCREASE COUNTRY OWNERSHIP
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3. (SBU) The GOU has failed to assume responsibility for the
HIV/AIDS problem for a number of years. There is a lack of
leadership at the highest levels and a sense that health, including
HIV/AIDS, is not a national priority, as shown by the GOU's small
budget allocations for the health sector. Management at the national
level is also weak, which results in a lack of coordination, poor
communication of strategies and guidance, and unclear direction.


4. (SBU) Corruption: Uganda is ranked 126th out of 180 in the
Transparency International Perception of Corruption Index, and its
performance is deteriorating. A draft report by the Anti-Corruption
Working Group of Uganda in June 2009 found that "Corruption remains
a major impediment to development and a barrier to reducing poverty
in Uganda," that it is "deeply imbedded, is not reducing, and has
the potential to get worse." "The analysis suggests that there are
high impact corruption risks on the immediate horizon" could
adversely affect the national benefit from the 2011 election and the
revenues from recently discovered oil.


5. (SBU) Partnership Framework issues: In April 2009, we wrote to
OGAC that "The PEPFAR team in Uganda, with concurrence from the
Ambassador, has decided not to request Partnership Framework funds
in FY 2009. We do not feel that the Government of Uganda is showing
a meaningful commitment to health, or that the Ministry of Health
itself is showing leadership and commitment. Recent experiences with
the Global Fund, the AIDS Indicator Survey, and the ARV stockout
have convinced us that the MOH is not currently a good steward of
its existing resources. Putting more money on the table now, before
we work out the conditionalities of framework money, would send
entirely the wrong signal to the Government at this time. We need
to have careful negotiations regarding our existing partnership with
the Government of Uganda before we expand that to a full Partnership
Framework. This will probably take a year; we certainly would not be
able to conclude these negotiations in time to submit requests for
FY 2009 funds." The GOU's failure to show leadership and commitment
to improving health, fighting corruption, and utilization of
resources has not changed our position.


6. (SBU) One positive step in building national ownership of the
HIV/AIDS program has been the recent change in the governance of
PEPFAR activities in Uganda. For the first five years of PEPFAR, an
ad hoc PEPFAR Advisory Committee, appointed by the Office of the
President, advised the USG to ensure that the PEPFAR program was
complementary to other HIV/AIDS programs, operated under the
National Strategic Plan for HIV/AIDS, and was supportive of Ugandan
policies. At the last meeting of the Committee, it was decided that

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a Partnership Committee (a GOU multisectoral HIV/AIDS committee
charged with coordinating the HIV response in the country) could
provide better oversight. Members of this committee also sit on the
Global Fund Country Coordinating Mechanism.

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EXPAND SUSTAINABILITY
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7. (SBU) The presence of strong local NGOs working in HIV/AIDS is
also a positive factor. For example, In FY 2009 The AIDS Support
Organization (TASO) was the second largest recipient of PEPFAR
funds, due to its strengths as a service delivery organization.
TASO, founded in 1987, now has 11 service centers and 22 smaller
facilities throughout Uganda. At the end of FY 2008, TASO was
providing direct ART treatment to 23,000 Ugandans. It was recently
awarded the contract to be the second Principal Recipient in Uganda
for the Global Fund. The third largest recipient of PEPFAR support
in 2009 is the Mulago Mbarara Teaching Hospitals' Joint AIDS Program
(MJAP). This collaborative partnership between Makerere University
Faculty of Medicine, Mbarara University Faculty of Medicine, Mulago
Hospital and Mbarara Hospital was established in 2004. It provided
ART services to 16,000 people at the end of FY 2008. The Joint
Clinical Research Center (JCRC) is another outstanding NGO. Founded
in 1991 at the height of the AIDS crisis in Uganda to serve as a
national AIDS research center, JCRC has become Uganda's pioneer
center of excellence for AIDS care, treatment, research, and
training. With PEPFAR funding, JCRC was providing direct ART
treatment to 40,000 people at the end of 2008, and referral
laboratory services throughout Uganda.

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IMPROVE INTEGRATION
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8. (SBU) Given the broad strengths that exist in USAID and CDC, we
will be able to coordinate HIV/AIDS activities with other USG health
initiatives during the next phase of PEPFAR. USAID and CDC jointly
participate in the President's Malaria Initiative, which already has
links with the PEPFAR care program. With USAID's experience and
funding in reproductive and child health and family planning, and
CDC's experience and funding in emerging infectious diseases, the
U.S. Mission is poised to expand the integration of health
activities in Uganda.


9. (SBU) There is a strong AIDS Development Partner group made up
of multilateral agencies (e.g., UNAIDS, UNICEF, WHO, UNFPA) and
bilateral donors (e.g., USG, DFID, Irish Aid, DANIDA, Italian
Cooperation). It meets monthly to share information, and works to
coordinate a common, integrated response to the HIV/AIDS epidemic.
Its major activity is to harmonize and coordinate those donors
working in HIV/AIDS to provide better support and oversight of the
Uganda AIDS Commission, which several of its members fund.
Integration and coordination with the broader Health Development
Partners group, however, could be improved.

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IDENTIFY AND DEVELOP EFFICIENCIES
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10. (SBU) Costing studies: The USG conducted costing studies for
HIV treatment programs in Uganda (pre-ART and ART) for a five year
period using the PEPFAR ART Costing Project Model. The MOH, in
partnership with Supply Chain Management Systems (SCMS),also
carried out national four-year (2009-12) ARV drug quantification to
determine country needs. The results are being utilized to ensure
more realistic, standardized, and efficient targeting, resource
allocation and tracking in the future. This will also assist the
GOU/MOH and stakeholders to mobilize required resources for care and
treatment given the current funding situation. Similar costing
studies in other areas (e.g., orphans and vulnerable children,
PMTCT) are being planned.


11. (SBU) As the PEPFAR Uganda program moves into PEPFAR II, the
USG team is reviewing its portfolio to build upon previous progress
and develop a strategic plan for HIV/AIDS treatment. This review is
a collaborative effort comprising the MOH, USG agencies and
partners, and consultants from the OGAC Adult Treatment Technical
Workgroup. The purpose of the assessment is to help the USG
in-country team develop a vision for the HIV care and treatment
program over the next 3-5 years, and to consult with participants to
develop 8-12 recommendations that are essential or very important to

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achieving the vision. The overarching issue is that as demand for
ART outstrips supply and PEPFAR country budgets remain flat, the
team needs to understand the clinical, programmatic and financial
dynamics of its ART programs.

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PROGRAM MANAGEMENT
(BOTH USG AND PARTNER COUNTRY)
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12. (SBU) The U.S. Mission is shifting its emphasis from the
emergency nature of the first phase of PEPFAR to one of making the
necessary investments in systems, infrastructure, and national
leadership and management that will enable Ugandans to take on
increasing ownership of health care in their country. We need
assistance from Ambassador Goosby and others in inspiring senior GOU
officials to again assume the leadership of the fight against
HIV/AIDS.


13. (SBU) We believe that OGAC itself needs to change to meet the
needs of the next phase of PEPFAR. As Ambassador Browning said in
his COP transmittal letter in 2008, "As we shift responsibility and
trust to our national partners, we believe OGAC will likewise have
to adjust to a new way of doing business. OGAC structures that were
perhaps needed for an emergency response will ideally devolve
responsibilities to the field and make do with less detailed
reporting. For example, as we move towards a Ugandan-owned program,
OGAC's twenty technical working groups, committees, and task forces,
made up of 500 experts, cannot expect to be able to make the same
requests for information to Ministries of Health that they now make
to Mission staff." For a Partnership Framework to have any chance
of incentivizing the GOU to take greater ownership of the HIV/AIDS
challenge, OGAC may also need to consider more direct forms of
support to GOU entities, in exchange for the GOU meeting simple and
realistic performance benchmarks. A program that continues to
provide resources directly to implementing partners on the ground,
bypassing the GOU as is largely the case now, has little chance of
inspiring and incentivizing GOU leadership and ownership.

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IMPLEMENTATION
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14. (SBU) Rationalize care and treatment services: There is need for
improved coordination of services at all levels USG, MOH, districts,
and facility. We will employ a number of strategies in FY 2010 to
accomplish this. First, we will reduce duplication. The USG will
focus on mapping care and treatment services by partner and program
area and work with the GOU/ MOH to minimize overlap and maximize
efficiencies. Second, we will advocate for support to
district-based programs that work in close partnership with the
district health management. Such support will promote integration
and improve alignment in planning, implementation and monitoring of
services in the district. USG district support will include
activities such as conducting situational analyses to guide
prioritization of implemented activities, providing annual
performance-based conditional grants to districts, mainstreaming
HIV/AIDS into district work plans, aligning reporting with national
requirements, improving data quality, availability and utilization,
and improving technical support supervision for ongoing activities.
Third, we will continue to expand program implementation through
indigenous NGOs and the public sector.

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TECHNICAL SKILLS/
HUMAN RESOURCES FOR HEALTH
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15. (SBU) A national training strategy does not currently exist.
While the USG plans to train at least 400 new health workers in FY
2010, future targets will be developed via a national training
strategy, and building institutional training capacity and
performance in FY2010. A new mechanism will be established to work
with the Ministry of Education and Sports, the MOH, and professional
councils to develop a national training strategy and plan, and to
establish national, standardized curricula and certification schemes
for all cadres of health workers. Support to build local capacity
and promote standardization will be provided directly to indigenous
training institutions, instead of to international organizations.

16. (SBU) To support recruitment and retention of staff in health
facilities, the USG plans to continue its support for the
finalization of a national retention and motivation strategy, and

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continue to provide technical assistance to districts to improve
their recruitment efforts. Scholarships and bonding schemes will be
developed for recruiting and retaining health workers in public
sector facilities. While these efforts are expected to improve
recruitment and retention, progress will be limited primarily by
inadequate funding for direct recruitment and retention activities.


17. (SBU) While there has been an increased focus and investment in
strengthening human resources for health (HRH) at the national
level, the GOU's overall leadership and investment for routine HRH
policy, planning, management and monitoring remains weak. This is
especially true at the subnational level, where HRH staff and
resources are scarce. HRH management is poor, with almost
non-existent performance management and disciplinary action. The
GOU's administrative capacity and political and financial commitment
does not currently appear to be sufficient to lead the development
and management of complex HRH schemes, such as performance-based
financing. The development of a task shifting policy has been
delayed due to the inability of the various line ministries and
professional societies to coordinate and reach consensus on
appropriate tasks, training, supervision and remuneration.

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HEALTH SYSTEMS STRENGTHENING
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18. (SBU) PEPFAR funds for focused interventions in Health Systems
Strengthening (HSS) are largely in the areas of human resources for
health (HRH),health information systems (HIS),
leadership/governance (L/G) and supply chain management (SCM).
There is less emphasis in the area of health finance (HF). Both L/G
and HF also receive substantial support through other USG and
non-USG donor mechanisms which have greater competitive advantage.
PEPFAR Uganda also tries to maximize intentional spillovers of
non-HSS focused activities to strengthen health systems. Finally,
the PEPFAR team actively leverages efforts to strengthen all
national systems that impact on health through relevant national
coordinating and technical bodies, such as the Health Policy
Advisory Committee, the Uganda AIDS Commission, the Health
Development Partners and the AIDS Development Partners.

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POINTS TO MAKE AND CONSIDER FOR YOUR VISIT
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19. (SBU) During your visit here, and in your meetings with the
Ugandan leadership and the HIV/AIDS community, we suggest that you
emphasize the following themes:

--Fighting HIV/AIDS is one of the strongest elements of our overall
bilateral relationship.

--The U.S. remains committed to supporting the GOU and the Ugandan
people in preventing HIV/AIDS, and in caring for and treating those
who are HIV-positive.

--But we can't do it alone; partnership is a two-way street that by
definition requires mutual commitment and accountability.

--Ultimately, managing the pandemic is a Ugandan responsibility.

--As we move away from the emergency phase of our PEPFAR program, we
need to create sustainability by strengthening health systems and
human capacity in Uganda.

--Through a Partnership Framework, the U.S. is able to provide
additional funding for building sustainability.

--Moving forward with a Partnership Framework will require stronger
Ugandan ownership of the HIV/AIDS challenge, and more focused
leadership from Ugandan leaders at all levels of government.

LANIER