US embassy cable - 05LILONGWE509

UNCLAS SECTION 01 OF 02 LILONGWE 000509 
 
SIPDIS 
 
SENSITIVE 
 
STATE FOR AF/S GALANEK 
STATE PASS TO USAID/GH MILLER 
HHS FOR WSTEIGER 
STATE FOR S/GAC PEARSON 
 
E.O. 12958: N/A 
TAGS: EAID, KHIV, SOCI, TBIO, MI, HIV/AIDS 
SUBJECT: MALAWI: POST RECOMMENDATIONS ON GLOBAL FUND PHASE 2 
RENEWALS 
 
REF: SECSTATE 103678 
 
1. (U) Malawi 
 
2. (U) Grant No: MLW-102-G01-H-00 
Phase 1 amount: $41,751,500.00 
Phase 2 amount requested in proposal: $155 million 
 
3. (SBU) Overall Comments/Recommendations: Post recommends 
funding Malawi's Phase II, HIV/AIDS proposal at the levels 
requested.  However, approval of Phase II should be 
accompanied by more attentive and probing monitoring on the 
part of GFATM staff.  Field visits should extend beyond a 
day or two and include solicitation of feedback from a wider 
representation of stakeholders.  PR must be held accountable 
for performance against all aspects of the grant, not just 
treatment. 
 
4. (SBU) Grant Performance: The performance of the grant has 
been mixed.  While achievements in ARV treatment are 
exceeding expectations and HIV testing proceeding apace, 
performance in the areas of Prevention of Mother to Child 
Transmission (PMTCT) and Home Based Care (HBC) are 
foundering.  There are no measurable service achievements in 
these last two categories. The ARV achievements are due to 
national political support and pressure, MOH and NAC 
management attention, and the provision of critical 
technical assistance particularly from the USG.  The Public 
sector funding is hindered by weak proposal and budget 
development capacity and lack of urgency outside of 
expansion of access to ARVs. 
 
5. (U) Technical Considerations: The proposal is technically 
sound.  However, the monitoring plan includes critical, some 
would say doubtful, assumptions related to management 
commitment to release staff to tend to monitoring duties 
and/or contracting out this function. 
 
6. (SBU) Degree of Coordination:  To date the Country 
Coordinating Mechanism (CCM) has been reactive to issues 
brought to its attention rather than providing proactive 
oversight and attending to accountability.  Its irregular 
meetings are typically scheduled to facilitate GFATM 
deliverables.  CCM members are not active, as CCM members, 
outside of these meetings.   Other than pressure to meet 
treatment goals and ensure provision of funds to the public 
sector, CCM has not held PR accountable to performance. 
 
7. (SBU) CCM processes lack transparency and accountability 
to stakeholders who are not members.  Stakeholders external 
to the CCM have been told that meetings are minuted but that 
minutes are not publicly available.  Therefore, 
documentation of process or outcome cannot be verified. 
Those that wish to observe CCM proceedings are instructed to 
formally request to do so.  Invitations would then be issued 
at the pleasure of the Chair.  Verbal requests on the part 
of USAID, on two occasions, did not result in an invitation. 
General interest is not considered a sufficient reason for 
participation.  It should be noted, however, that this 
policy does not seem to have been universally applied 
particularly to the UN and government. 
 
8. (SBU) The President selected representatives to the CCM. 
Although these individuals represented a perspective (e.g. a 
person living with AIDS) they were not held accountable to a 
constituency body either to raise particular issues/concerns 
or to debrief after CCM meetings.  The Government holds the 
largest number of seats.  Seats vacated due to death or 
resignations have not been filled.  Meetings were not 
publicly announced making requesting an invitation 
difficult.  In addition, meetings were frequently called at 
the last minute creating a crisis in decision making, 
basically extracting desired outcomes because time 
constraints prohibited the exploration of alternative 
measures.  Materials were frequently provided to CCM members 
on very short notice, making thorough review extremely 
doubtful. 
 
9. (SBU) The CCM self-assessment was seen by many as 
generous and not a good faith effort at elucidating 
challenges and gaps in performance.  It has, and continues, 
to be, chaired by the Principal Secretary of Health.  At 
times this has resulted in muted responses on the part of 
the CCM regarding performance of the MOH as a sub-recipient. 
In general, the role of the CCM versus the National AIDS 
Commission (NAC) is somewhat murky, leading to disagreements 
over authority.  A Trust Deed has been drafted which 
clarifies these matters.  It is to be presented to 
Parliament during the current sitting. 
10. (U) Recent events, however, raise the possibility of 
significant improvements in CCM performance.  In response to 
GFATM guidance, the NAC has convened several constituency 
groups who have selected their own representative to the 
CCM.  These representatives are called on to solicit and 
raise concerns as well as convene their constituencies for 
consultation and briefing.  NAC is providing funding for 
this process.  USAID fills a new seat that was created for 
discrete donors. Although the Principal Secretary of Health 
is still the chair, it is recognized that a conflict-of- 
interest process must be developed.  It should also be noted 
that there is a new PS for Health who seems more 
constructive in his management of the CCM.  We understand 
that CCM minutes will now become public documents.  These 
new structures and processes are very new (within the week), 
thus we are unable to assess their impact.  Coordination of 
the donor sector vis--vis GFATM roll-out and the wider 
response has been driven by donors themselves rather than 
under the guidance or leadership of CCM, NAC or other 
elements of government. 
 
11. (SBU) Political or other considerations: Attitudes 
towards the non-governmental and private sector have been 
mixed.  It is generally felt that indigenous CBOs/FBOs have 
a significant role to play, particularly in home-based care 
and support to orphans and vulnerable children, and have 
received funding.  Faith-based health facilities have been 
significantly engaged, and funded, for treatment roll-out. 
However, private sector is often referenced as a source of 
additional resources rather than a potential recipient of 
funding for implementation of activities.  There are regular 
references to international NGOs as competitors for the 
government's money.   Policy decisions related to allowable 
expenses have proved explicit barriers to international NGO 
access of GFATM resources. 
Due to political pressures it is difficult for funding 
recipients to acknowledge, and therefore effectively 
address, weaknesses and gaps in government capacity for 
implementation.  Also, the NGO sector, particularly 
international NGOs with experience and presence in country, 
is being underutilized.  Finally, the "public-/private" 
partnership is not well understood or valued at the senior 
policy level. 
 
12. (U) Embassy Point of Contact: Tyler Sparks, Political 
Officer, SparksTK@state.gov, +265-1773-166 ext 3463. 
 
 
GILMOUR