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OO RUEHGI RUEHRN RUEHROV
DE RUEHKM #1098/01 2661257
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O 231257Z SEP 09
FM AMEMBASSY KAMPALA
TO RUEHC/SECSTATE WASHDC IMMEDIATE 1800
INFO RUEHXR/RWANDA COLLECTIVE IMMEDIATE
RUCNIAD/IGAD COLLECTIVE IMMEDIATE
RUEAUSA/DEPT OF HHS WASHINGTON DC IMMEDIATE
RUEHPH/CDC ATLANTA GA IMMEDIATE

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 
 
-------- 
SUMMARY 
-------- 
 
¶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. 
 
-------------------------- 
INCREASE COUNTRY OWNERSHIP 
-------------------------- 
 
¶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 
 
KAMPALA 00001098  002 OF 004 
 
 
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. 
 
---------------------- 
EXPAND SUSTAINABILITY 
---------------------- 
 
¶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. 
 
------------------- 
IMPROVE INTEGRATION 
------------------- 
 
¶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. 
 
--------------------------------- 
IDENTIFY AND DEVELOP EFFICIENCIES 
--------------------------------- 
 
¶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 
 
KAMPALA 00001098  003 OF 004 
 
 
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. 
 
------------------------------ 
PROGRAM MANAGEMENT 
(BOTH USG AND PARTNER COUNTRY) 
------------------------------ 
 
¶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. 
 
--------------- 
IMPLEMENTATION 
--------------- 
 
¶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. 
 
-------------------------- 
TECHNICAL SKILLS/ 
HUMAN RESOURCES FOR HEALTH 
-------------------------- 
 
¶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 
 
KAMPALA 00001098  004 OF 004 
 
 
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. 
 
---------------------------- 
HEALTH SYSTEMS STRENGTHENING 
---------------------------- 
 
¶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. 
 
------------------------------------------ 
POINTS TO MAKE AND CONSIDER FOR YOUR VISIT 
------------------------------------------ 
 
¶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