This record is a partial extract of the original cable. The full text of the original cable is not available.

UNCLAS SECTION 01 OF 03 LILONGWE 000933 
 
SIPDIS 
 
DEPT FOR S/GAC, AF/S, AF/EPS, OES/IHA 
USAID FOR GH/AA (APETERSON) 
HHS/PHS/OFFICE OF GLOBAL HEALTH AFFAIRS (WSTEIGER) 
HHS ALSO FOR NIH (MDYBUL AND JLEVIN), HRSA (DPARHAM) 
GENEVA FOR DHOHMAN AND MCGREBE 
 
E.O. 12958: N/A 
TAGS: KHIV EAID SOCI TBIO ECON PGOV MI HIV AIDS
SUBJECT: GLOBAL FUND: BUYING ON CREDIT IN MALAWI 
 
REF: A. STATE 202651 (NOTAL) 
 
     ¶B. LILONGWE 497 (NOTAL) 
 
¶1. Per reftel A request, post provides the following update 
on Global Fund activities in Malawi. 
 
SUMMARY 
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¶2. As the end of year two of Global Fund in Malawi 
approaches, the GOM will likely exceed anti-retroviral (ARV) 
treatment and voluntary counseling and testing (VCT) goals, 
but will fall short of meeting prevention of 
Mother-to-Child-Transmission (PMTCT) and care and support 
targets.  At present, over 8,000 individuals are enrolled in 
anti-retroviral therapy (ART) programs, and 312 clinical 
staff have been trained and certified as ARV providers.  By 
December 2004, ARVs are planned to be offered at 54 sites, 21 
of which are currently operational.  The Global Fund 
implementation process, which was stymied in bureaucracy six 
months ago, has been turned around by three principal 
factors: NGOs' willingness to begin ARV programs, with their 
own funding, in expectation of receiving Global Fund money; 
design of an explicit operational plan; and improved 
coordination within the Ministry of Health.  Without the 
expectation of forthcoming Global Fund resources, the current 
expansion of HIV/AIDS treatment and care facilities in Malawi 
would be very unlikely.  END SUMMARY. 
 
THE INITIAL LOAN: CURRENT STATUS OF PROGRAMS 
-------------------------------------------- 
¶3. With over 8,000 individuals enrolled in ARV programs, the 
GOM is on track to exceed its initial goal of providing ARVs 
to 10,000 individuals by the end of the Global Fund's second 
year in Malawi.  312 clinical staff have been trained and 
certified as ARV providers, and 21 ARV sites are operational. 
 Through co-opting NGO clinics already providing health care 
services and rapid preparation of key GOM facilities, such as 
the three central hospitals, 54 sites are slated to offer ART 
by year's end.  These recently published numbers suggest that 
the GOM will meet its original target of 25,000 individuals 
on ARVs after 5 years. 
 
¶4. The GOM is also set to exceed its VCT goal of having 
75,000 individuals tested by year's end.  Of the 118 VCT 
sites in country, over 100 of them have opened in the last 18 
months in anticipation of increased access to ARVs through 
Global Fund resources.  Many of the VCTs are also positioning 
themselves to be ARV providers.  The Ministry of Health (MOH) 
is currently assessing and certifying VCT sites.  Given the 
requirement for all ARV sites to provide VCT services, rapid 
VCT expansion is clearly a result of the general expectation 
that Global Fund resources will bring greater access to ARV 
programs. 
 
¶5. Less driven by the expectation of Global Fund resources, 
expansion of PMTCT and basic care and support services has 
been delayed, primarily due to the absence of a readily 
accessible network of providers.  Reaction to recent 
technical recommendations about Niverapine mono-therapy has 
also slowed PMTCT expansion. 
 
THE CREDITORS: NGOs WILLING TO INVEST 
------------------------------------- 
¶6. The recent expansion of ARV programs, VCT services, and 
other HIV/AIDS-related initiatives is principally a result of 
the expectation of forthcoming Global Fund resources, not 
Global Fund resources themselves.  NGOs (and to a lesser 
extent GOM agencies) have been willing to use their own funds 
to start ARV programs with the expectation that the programs 
will begin using Global Fund resources once available.  This 
pre-establishment of Global Fund-driven programs, NGOs 
anticipate, will allow for more rapid expansion of services. 
(NOTE: Most of the NGOs operating such programs have already 
been approved by the National AIDS Commission as Global Fund 
grant recipients. END NOTE.) 
HELPING WRITE THE CHECK: WHAT'S DRIVING IMPLEMENTATION 
--------------------------------------------- --------- 
¶7. In addition to NGOs' willingness to act before receiving 
funding, strong leadership in creating an explicit 
operational plan and in improving coordination within the 
Ministry of Health (MOH) has helped remove technical hurdles 
and concentrate on action.  Two USAID/Malawi-funded technical 
advisors, one who works on ARV expansion planning and one who 
problem solves coordination efforts, have been key components 
to helping GOM agencies work with themselves and with the 
Global Fund bureaucracy.  National AIDS Commission (NAC) and 
MOH's perception that they could lose Phase II Global Fund 
resources if they do not perform well against their original 
goals has also helped speed implementation along.  If a Phase 
II grant is approved prematurely, the GOM's implementation 
momentum may lessen slightly. 
 
CHECKING THE BALANCE: GOOD INFORMATION SHARING 
--------------------------------------------- - 
¶8. The HIV/AIDS Unit of the Ministry of Health is the lead on 
information collection and progress tracking for clinical 
elements of the Global Fund program.  The Unit has 
established its own data collection system, and, to date, has 
been able and willing to provide up-to-date data on progress 
against clinical service goals.  NAC has also launched a 
national monitoring and evaluation system to track all 
HIV/AIDS activities in Malawi, regardless of funding source. 
Information that NAC collects, though sometimes limited by 
fragile data bases and voluntary reporting, is willingly and 
regularly shared.  In addition, NAC quarterly publishes and 
distributes Global Fund expenditure data.  Mechanisms for 
tracking other outputs attributable to Global Fund have been 
unclear. 
 
POTENTIAL DEBITS: CHALLENGES FOR YEAR THREE 
------------------------------------------- 
¶9. Potential challenges as Malawi enters its third year of 
engagement with Global Fund are as follow: 
 
-- Delays in Drug Procurement: Global Fund and UNICEF 
(contracted by NAC to procure and distribute drugs and 
clinical supplies) have averaged ten weeks from order 
placement to supply arrival.  If ARV sites have unanticipated 
increases in patients, adequate drug provision could be 
delayed for three to five months. 
 
-- Adequate Oversight: With rapid ARV program expansion 
planned as soon as Global Fund resources are available, there 
is question as to whether the MOH and NAC will be able to 
provide adequate supervision and quality control. 
 
-- Loss of Momentum: In the face of dramatic patient 
increases and greater demands on health care facilities, 
momentum to expand ARV services may wane before Global Fund 
goals are reached. 
 
-- Stigma and Loss of Focus on Prevention: Stigmatization of 
HIV/AIDS infected individuals and a loss of focus on 
prevention also remain concerns. 
 
COMMENT 
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¶10. Since the January 2004 release of the second tranche of 
funding, the GOM has made genuine and tangible efforts to 
facilitate rapid, effective utilization of funding and to 
avoid leaving resources idle.  Moreover, there is no evidence 
that funds have been diverted for other purposes.  While 
Global Fund resources in and of themselves have not resulted 
in many of the recent HIV/AIDS treatment initiatives in 
Malawi, it is clear that if the funding was not anticipated, 
those expansions would not be taking place.  END COMMENT. 
RASPOLIC