US embassy cable - 05ALMATY2689

UNCLAS  ALMATY 002689 
 
SIPDIS 
 
 
DEPARTMENT FOR S/GAC: CRConnelly, PPearson 
DEPARTMENT PLS PASS TO USAID/E&E: TAlexander; USAID/GH: 
MMiller 
 
 
E.O. 12958: N/A 
TAGS: EAID, KZ 
SUBJECT: KAZAKHSTAN: RECOMMENDATIONS ON GLOBAL FUND 
PHASE 2 RENEWAL 
 
REF: STATE 129571 
 
1. (U) Summary:  This cable responds to reftel request 
for post input into the decision of whether Grant Number 
KAZ-202-G01-H-00 from the Global Fund to Fight AIDS, 
Tuberculosis and Malaria (GFATM) should receive funding 
beyond its initial two years.  Progress in Kazakhstan 
has been on track for several components of the grant, 
while issues have arisen regarding the use of 
substitution therapy, delays in initiation of treatment, 
and changes have altered the Country Coordination 
Mechanism (CCM).  Despite these implementation issues, 
given the measurable progress in grant implementation to 
date, the USG's substantial involvement in Kazakhstan's 
national HIV/AIDS program, and the opportunity to stem 
the epidemic, Post recommends that Kazakhstan receive 
the second tranche of its GFATM grant for HIV/AIDS. 
 
Summary Data on Kazakhstan's GFATM Grant 
 
2. (U) The start date of the grant, for a total of 
$22,360,000, was December 1, 2003.  Under Phase 1, 
$6,502,000 has been approved, with $6,201,999 disbursed 
to date.  The Principal Recipient for the grant is the 
Republican AIDS Center (RAC). A total of $15,858,000 has 
been requested for Phase 2 of the grant.  The Local 
Funding Agent is KPMG.  The USG has been represented on 
the CCM by USAID and provided technical assistance in 
the preparation of both this and other grant 
applications from the Government of Kazakhstan (GOK) to 
the GFATM. 
 
Comments on Kazakhstan's GFATM Grant Performance 
 
3. (U) In December, 2003, Kazakhstan was awarded a five- 
    year, 
$22.4 million grant from the GFATM.  Written in support 
    of the 
national HIV/AIDS program, the main goals of the grant 
    are to 
prevent HIV infections among vulnerable groups, and to 
    expand 
care and support of those living with HIV, including the 
provision of treatment, primarily antiretrovirals (ARV). 
 
4. (U) The GFATM grant supports Kazakhstan's national, 
    multi- 
sectoral HIV/AIDS program.  Originally developed in 2001 
    and 
slated to run through the end of 2005, it is currently 
    being 
updated and renewed for the next five years.  The 
    program's 
three key strategies are: prevention of HIV and sexually 
transmitted infections among vulnerable groups, 
    including 
injecting drug users (IDUs); HIV prevention among youth 
    through 
education, information and communication; and treatment, 
    care 
and support for people with HIV/AIDS. 
 
5. (U) The GFATM's own indicators show that the grant in 
Kazakhstan is performing well in all but two areas, 
substitution therapy and ARV therapy.  The GOK concluded 
that substitution therapy is unnecessary and therefore 
this approach to reducing injecting drug use (the major 
route of transmission of HIV in Kazakhstan) will not be 
implemented.  The GFATM has decided to accept this GOK 
decision and, as a result, may reduce the grant by $1 
million, although the request for the second tranche 
remains based on the full amount of the grant.  ARV 
therapy was delayed because of procurement problems, 
while other progress to initiate this component remains 
slow.  Given the status of the epidemic, and the 
relatively low numbers planned for ARV therapy, 
prevention efforts undertaken through the grant should 
be a priority.  These other areas of performance have 
essentially met the expected targets to date. 
 
Post's Recommendation on Phase 2 Funding 
 
6. (U) The still relatively low infection rate offers a 
    unique 
opportunity for Kazakhstan to be successful in its 
    efforts to 
prevent a generalized epidemic.  USG assistance on 
    HIV/AIDS 
 
 
prevention, provided primarily through USAID's Regional 
    Mission 
for Central Asia, with technical support from the U.S. 
    Centers 
for Disease Control and Prevention (CDC) and other 
    implementing 
partners, averages $1 million per year in Kazakhstan and 
includes components for improved data gathering, 
    prevention, 
treatment and care, and systems development.  In light 
    of the 
USG's substantial involvement in Kazakhstan's national 
    HIV/AIDS 
program and the measurable progress in GFATM grant 
implementation to date, Post recommends that Kazakhstan 
    receive 
the second tranche of its GFATM grant for HIV/AIDS. 
 
GFATM Grant Technically Sound 
 
7. (U) The GFATM strategies are technically appropriate, 
and the RAC's role as Principal Recipient represents a 
sound decision, given its leadership role in almost all 
GOK HIV/AIDS initiatives.  The GFATM grant targets 
prostitutes, IDUs, men who have sex with men (MSM), and 
vulnerable youth.  These are all groups known to be at 
high risk for HIV due to their practice of risky 
behavior.  (In fact, USAID targets the same groups.) 
Given the need to reach these high-risk groups with 
information and services, most experts in the country 
acknowledge that coverage is inadequate.  Increasing 
coverage is one of USAID's priorities and an emphasis of 
its joint efforts with the RAC.  Nonetheless, overly 
ambitious targets for coverage under the GFATM grant 
were revised in coordination with its Portfolio Manager. 
 
8. (U) The RAC has a monitoring and evaluation (M&E) 
plan, and data for measuring progress against the target 
indicators is being collected.  The United Nations and 
the CDC have conducted trainings on M&E as well.  USAID 
plans to place an M&E specialist within the RAC to 
assist with improving the system for assessing GFATM 
grant activities as well as the overall national AIDS 
program. 
 
Country Coordination Mechanism (CCM) In Flux 
 
9. (U) Kazakhstan formerly had a Country Coordination 
Mechanism (CCM) solely for the purpose of the GFATM 
HIV/AIDS grant. A new CCM created this past year, 
however, will also oversee a hoped-for grant on 
tuberculosis control.  Some CCM members believe that the 
current model, which is much smaller, and linked closely 
to a new GOK National Coordination Council on Health 
Care, may turn out to be more efficient than that of the 
past.  The new CCM is small but flexible and includes 
important representation: 40% are non-government 
members, including representatives of UNAIDS, the USG, 
the NGO sector and people living with HIV/AIDS.  The 
new, overarching National Coordination Council should 
serve as a broad-based health coordination body, with 
responsibilities to include oversight of the national 
plan for health sector reform.  USAID sees benefits to 
including the CCM under the Council; the last meeting of 
the Council focused on HIV/AIDS, elevating the issue to 
a national level and engaging GOK representatives 
outside the Ministry of Health.  The link between the 
CCM and the Council may help to reduce the vertical 
nature of the country's HIV/AIDS efforts and promote 
further integration with other health sector reforms. 
 
10. (U) The former CCM exhibited poor communication with 
and from local HIV/AIDS-related NGOs and a top-down 
decision-making process, in spite of a mandate for 
decisions by consensus.  The RAC played the role of 
Secretariat for the CCM.  The Secretariat's role 
 
SIPDIS 
included collecting information, developing meeting 
agendas, communicating the meetings' protocols, 
distributing information related to the CCM meetings, 
and collecting recommendations of partners on the issues 
related to analysis, programming, and implementation. 
The RAC continues to be represented on the new National 
Coordination Council, but the Secretariat function 
remains unclear.  USAID and its partners will continue 
to work with these national bodies to improve overall 
coordination and national stewardship of the fight 
against HIV/AIDS. 
 
 
Collaboration Continues and To Be Further Encouraged 
 
11. (U) The U.S. Mission has found the GFATM Principal 
Recipient (the Republican AIDS Center, RAC) to be 
willing and interested in collaboration.  USAID is 
working with the RAC to establish it as the national 
steward for coordinating the implementation of the 
overall national GOK HIV/AIDS program, including and 
beyond the GFATM grant-funded activities.  The RAC also 
serves as the lead partner for CDC's USAID-supported 
work in Kazakhstan on HIV sentinel surveillance, and RAC 
staff have served as consultants for CDC as other 
countries in the region embark on this USG-supported and 
important aspect of monitoring the epidemic. 
 
12. (U) As Principal Recipient, the RAC should improve 
its collaboration with the HIV/AIDS-related NGO and 
civil society sector.  (New GOK legislation on NGOs may 
also impact this aspect of its work.)  Improving this 
coordination is another USAID priority.  RAC and other 
GOK health officials are actively involved in the 
development of planned regional HIV/AIDS programs with 
other donors, such as the World Bank and the British 
Department for International Development (DFID), as well 
as with ongoing USG HIV/AIDS activities.  Overall, the 
GOK HIV/AIDS response has been confined to the Ministry 
of Health (although this concern may be removed if GFATM 
approves Kazakhstan's new grant application for HIV/AIDS 
prevention in the military and prison system), and 
general reluctance throughout society to confront the 
disease continues.  There has been limited private 
sector involvement in the GFATM and other HIV/AIDS 
initiatives.  USAID also seeks to address this gap 
through pursuit of it Global Development Alliances 
between the public and private sectors. 
 
Points of Contact 
 
13. (U) For further information, please contact Kerry 
Pelzman, Regional HIV/AIDS Advisor, USAID/Central Asia 
(kpelzman@usaid.gov); Andreas Tamberg, Public Health 
Advisor, USAID/Central Asia  (atamberg@usaid.gov); or 
Almaz Sharman, Kazakhstan Country Office Coordinator for 
Kazakhstan, USAID/Central Asia (asharman@usaid.gov), the 
USG representative on the GOK CCM and National 
Coordination Council on Health Care. 
 
14.  (U) Minimize considered. 
 
Ordway 
 
 
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