US embassy cable - 05LILONGWE402

UNCLAS SECTION 01 OF 02 LILONGWE 000402 
 
SIPDIS 
 
AIDAC 
 
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: SUCCESS OF AN ARV PROGRAM: IT'S NOT JUST ABOUT 
THE DRUGS 
 
Ref: A) STATE 202651 B) LILONGWE 497 C) LILONGWE 933 
 
1. Summary: Malawi has been making remarkable progress in 
the roll-out of its Global Fund for AIDS, TB and Malaria 
(GFATM) funded Anti-Retroviral (ARV) Program.    It 
appears that treatment goals will be met and testing goals 
exceeded.  Some government officials are now asking why 
Malawi cannot reach even further, asking the U.S. 
government for assistance particularly to increase the 
amount of ARVs in the country.  However, the ARV program 
faces many challenges and will struggle to stay on pace 
because of constraints unrelated to drugs, namely weak 
infrastructure, human resource constraints, and open 
questions regarding supervision.  End summary. 
 
Progress to-date on Malawi's HIV/AIDS ARV Program 
--------------------------------------------- ---- 
 
2. Per reftel C, Malawi's early progress in its GFATM 
funded ARV program has exceeded all expectations.  Over 
750 clinical staff have been trained with 34 facilities 
providing ARVs to 17,500 individuals as of March 2005 - a 
50 percent increase since late 2004.  A monitoring and 
supervision system has been created which includes a 
public reporting, on a quarterly basis, of progress and 
clinical outcomes.  The Clinton Foundation has recently 
signed an agreement with the Government of Malawi and the 
National AIDS Commission which will reduce the costs of 
drugs procured under GFATM by 22 percent.  Early reports 
are that 300,000 people accessed testing and counseling in 
2004.  At its current pace Malawi is very likely to 
achieve its 2005 goal of treating 44,000 and its 5-year 
goal of treating 80,000. 
 
The ARV pipeline: An impediment to continued scale-up? 
--------------------------------------------- ---------- 
 
3. Drug procurement was an early and persistent impediment 
to the rapid implementation of Malawi's HIV/AIDS ARV 
program.  The Government of Malawi felt that drug 
procurement should be undertaken by the Government's 
Central Medical Stores.  A World Bank assessment 
identified significant doubts as to CMS's financial and 
procurement integrity.  As a compromise, it was agreed 
that UNICEF would provide drug procurement services as 
well as capacity building to CMS. 
 
4. Unfortunately, drug procurement under UNICEF brought 
its own challenges.  Early problems included delays in 
funds transfers, unclear communication from NAC and the 
MOH, as well as WHO's de-certification of a key 
manufacturer.  Further delays directly attributable to 
UNICEF include a generally cumbersome procurement system, 
no full-time dedicated staff on the ground, and a reactive 
rather than proactive approach to procurement.  It now 
takes approximately 6 months from the time that funds are 
requested to be transferred to UNICEF for drugs to arrive 
in country. 
 
Request from Government 
----------------------- 
 
5. Malawi Minister of Health Ntaba recently requested a 
meeting with Charge Gilmour to discuss these matters. 
During the meeting the Minister expressed deep concerns 
regarding UNICEF's performance to date and their ability 
to meet growing procurement demands as the number of 
patients on ARVs increases.  The Minister questioned why 
only 80,000 will benefit from ARVs when the WHO estimates 
that 170,000 are currently eligible for treatment.  He 
noted that while 59 health facilities are ready to provide 
treatment there are only enough drugs for 34 of these 
sites.  The Minister highlighted the growing demand for 
ARVs created by dramatic increases in the number of 
Malawians getting tested.  (Note: the South Region Central 
Hospital, Queen Elizabeth, currently has a 5 month waiting 
list for those wishing to access ARVs).  He therefore 
requested that the Mission advocate to Washington for the 
release of PEPFAR funds for procurement of ARVs through 
Malawi's Central Medical Stores. 
 
Comment 
------- 
 
6. The problems identified in the World Bank's initial 
assessment of CMS persist, with no concrete action having 
taken place to date to ameliorate them.  Despite the 
Minister's assurances that any such problems could be 
quickly resolved, experience to date shows otherwise.  In 
addition, Mission consultations indicate that the quantity 
of ARVs is of less importance, in the long run, to 
reaching beyond the 80,000 target than issues of overall 
capacity.  Severely constrained human resources, limited 
infrastructure, and fragile monitoring and supervision 
systems are significant constraints to expansion in the 
public sector.  An example is a recently reported 
conversation with staff at Queen Elizabeth Central 
Hospital in which they unequivocally stated that, even if 
they had more ARVs, they simply did not have the human 
capacity to manage a greater influx of patients.  A recent 
back of the envelope estimation by the MOH indicated that 
25 percent of the current health sector workforce will 
need to be 100 percent dedicated to AIDS treatment if the 
goal of 80,000 on treatment is to be reached. 
Furthermore, critical questions of how to maintain current 
levels of supervision and monitoring have yet to be 
answered. 
 
7. However, positive action can be taken.  It is widely 
recognized that UNICEF has performed below expectations 
vis-a-vis procurement and, to date, has provided none of 
the promised capacity building to CMS.  Intervention by 
UNICEF head office to reduce delivery time, to increase 
proactive communication and attention to the Malawi 
situation, and to deliver on the promise of capacity 
building of CMS would be of great benefit.  Immediate 
improvements in current performance will keep the existing 
program on track, building on success, as issues of 
overall capacity are debated and addressed. 
 
Note:  USAID was recently selected, with the support of 
CDC, to represent bilateral donors on Malawi's Country 
Coordinating Mechanism-- the country's oversight body for 
GFATM activities.  This will facilitate greater 
involvement on the part of the USG as well as real-time 
monitoring of relevant policy decisions. 
 
GILMOUR