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Cablegate: Global Fund to Fight Aids, Tuberculosis and Malaria, Phase

VZCZCXYZ0008
PP RUEHWEB

DE RUEHDK #0944/01 1171512
ZNR UUUUU ZZH
P 271512Z APR 07
FM AMEMBASSY DAKAR
TO RUEHC/SECSTATE WASHDC PRIORITY 8193
INFO RUEHGV/USMISSION GENEVA 0815

UNCLAS DAKAR 000944

SIPDIS

SIPDIS

STATE FOR S/GAC - SALPINI AND JEFFERS, AF/EPS AND AF/W

E.O. 12958: N/A
TAGS: EAID KHIV TBIO SOCI SG
SUBJECT: GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA, PHASE
TWO RENEWAL OF SENEGAL'S MALARIA GRANT SNG-405-G05-M

REF: STATE 027470

SUMMARY
-------
1. Senegal's National Malaria Control Program (PNLP) is using this
Global Fund grant to introduce new artemesinin-based combination
therapy (ACT) drugs for treatment of uncomplicated malaria, provide
intermittent preventive treatment for pregnant women, and distribute
insecticide-treated bednets. We recommend that the Global Fund
continue to support the procurement of ACTs; insist on the
implementation of a pharmaco-vigilance plan; support revitalization
of the National Malaria Coordination Committee; and insist that
bednets be priced to ensure availability to vulnerable groups. This
grant complements the President's Malaria Initiative (PMI), and
Mission recommends that the USG support renewal. END SUMMARY.

GRANT PERFORMANCE ASSESSMENT:
SENEGAL MALARIA GRANT SNG-405-GO3-M
-----------------------------------
2. The Ministry of Health's National Malaria Control Program (PNLP)
is the principal recipient of this grant. The PNLP's main
activities with this grant include the introduction of the new
artemesinin-based combination therapy (ACT) drugs for treatment of
uncomplicated malaria, intermittent preventive treatment for
pregnant women, and distribution of insecticide-treated bednets
(ITNs).

3. Senegal has been selected as a focus country for the USG's
President's Malaria Initiative (PMI). It is important to the USG
and to the PNLP that PMI and Global Fund activities complement each
other and are harmonized in order to achieve the best results. PMI
counts the Global Fund as an important partner in Senegal, and we
hope that the Global Fund will continue to fund this and future
malaria grants in-country.

ACTS AND MALARIA TREATMENT
--------------------------
4. In January 2006, the PNLP received the first 3 million doses of
ACTs (half the total quantity ordered under this grant). Because
expiry dates range from October to December 2007, there was concern
regarding a potential over-estimate in quantity, so delivery of the
second half of the order was stopped. However, a recent
USG-supported quantification exercise showed that the current stocks
should be exhausted before any expiration, and that the remaining 3
million doses can be ordered for delivery from the manufacturer at
this time.

5. Before the drugs arrived, the PNLP developed a plan for the
introduction of ACTs at all levels of the health system, including
at the village level where feasible. Private pharmacies were also
given access to the Global Fund ACTs, on the condition that the
pharmacies sell them to users at the same low price at which the
public health system sells them. It is unclear whether all
pharmacies actually follow this pricing policy, although they do
obtain the drugs from the Ministry of Health's Central Medical
Stores at a Global Fund-subsidized price.

6. At the community level, USAID-supported non-governmental
organizations (NGOs) assist community health workers to provide
malaria treatment with ACTs in 186 village health huts in USG focus
regions; the PNLP reports that nationwide, 552 out of more than 1000
functional health huts provide the ACT treatment. In
non-USAID-supported districts, the PNLP funds its district-level
health structures to implement community-based activities rather
than doing so via NGO accompaniment. The PNLP also gives grants to
NGOs, but only for promotion and social mobilization activities.

RECOMMENDATIONS
---------------
7. We recommend that the Global Fund continue to support
procurement of ACTs through the life of this grant to ensure
national availability of these drugs. Under PMI, the USG will
continue to support health worker and village volunteer training to
properly and effectively use the drugs provided by the Global Fund.
Under PMI, NGO assistance to health huts for treatment using these
ACTs will also expand to 1058 health huts nationwide.
We also recommend that the Global Fund insist on the implementation
of a pharmaco-vigilance plan during the second phase to ensure
continued drug quality and efficacy.
Based on the extremely successful experience with NGOs in training
and supporting community health workers to treat malaria, we
recommend that the PNLP increase the scope of such organizations in
its grants to them, to include treatment activities in addition to
education and communication activities. This will complement public
health services and also reinforce civil society involvement in
malaria programs.

COORDINATION AND COMMUNICATION
------------------------------
8. We are pleased to observe improved communication between the

PNLP and the Country Coordinating Mechanism (CCM). The PNLP made
important efforts to provide necessary documents before the CCM
meetings and allowed members more time to review them than in the
past. However, there is still insufficient quality of the documents
which are often quite difficult to read due to extremely small print
or low quality reproduction. The documents routinely presented also
cover a period that is six months behind actual time. The CCM
proposed an improved format for principal recipients' presentations
during CCM meetings, and things seem to be improving.

9. The National Malaria Coordination Committee, which is intended
to oversee technical committees and partner coordination, exists but
has not been functional for the past few years. However, as Senegal
is receiving considerable resources for malaria control programs
(PMI, World Bank River Basin Initiative, and Global Fund, among
others), it is critical to ensure complementary, harmonization and
efficient use of resources. PMI will strongly encourage the
revitalization of this committee, as well as its sub-committees,
which function as working groups in various technical areas.

RECOMMENDATIONS
---------------
10. We encourage the Global Fund to support revitalization of the
National Malaria Coordination Committee, as well as its
sub-committees, and to encourage the PNLP to make every effort in
this area. With the multitude of donors, prices, and distribution
systems, harmonization is especially needed in the area of ITNs. A
working sub-committee under a revitalized national coordination
committee, as above, could help with this issue. The Global Fund
should ask that ITNs provided by the PNLP under this grant are
effectively targeted to reach the most vulnerable groups, rather
than sold at a subsidized price to anyone, regardless of
vulnerability.

RESULTS AND DATA
----------------
11. In 2006, an evaluation was conducted by a local firm on the
activities of the first year of this grant. The evaluation report
states that the project made significant results in terms of ITN
ownership (reported at 60 percent) and in terms of use of ACTs at
the clinical level (with 78 percent of simple malaria cases among
all ages correctly managed). 66.4 percent of pregnant women
reportedly received the recommended drug to prevent malaria in
pregnancy. In the report, these indicators exceed their targets,
while the targets are not met for children under five years
receiving treatment within 24 hours (28 percent), or use of ITNs for
children under five (45 percent) and pregnant women (32.6 percent).

12. In the same timeframe as the evaluation, the U.S. Government
(USAID and CDC), conducted a national Malaria Indicator Survey to
measure baseline coverage of the PMI interventions. Though the
final report has not yet been published, our survey found that 57
percent of households owned a bednet of some kind, with 36 percent
of households owning a treated net. Treated net use was also lower
in our survey compared to the PNLP's evaluation, at 16 percent and
17 percent for children and pregnant women, respectively. Only 11
percent of children were found to have received treatment within 24
hours for their last case of fever. These indicators are in line
with a reasonable progression since the 2005 DHS and we believe them
to be the correct ones.

13. All coverage indicators, by all accounts, are improving over
time. However, we believe that the true coverage figures are likely
to be substantially lower than those found in the evaluation, being
used by the PNLP in its results reporting to the Global Fund.

FINANCIAL MANAGEMENT
--------------------
14. All documents and information available to us indicate that the
PNLP has a good disbursement rate and that most of the planned
activities have been implemented. No recommendations in this area.

FUNCTIONING OF THE CCM
----------------------
15. Senegal's CCM has 42 members representing virtually all
government ministries and the presidency, UN health organizations,
bilateral donor agencies, international NGOs, local faith-based
organizations, and organizations representing women, youth, people
living with HIV/AIDS, labor unions, and national business interests.
The CCM has made important improvements in its functioning over
time, developing new terms of reference and reviewing its
composition and functioning. These new terms of reference led to
establishment of a Technical Secretariat which greatly assists the
CCM in administration and decision-making. It also helps to improve
coordination among its members and communication with recipients.

16. The CCM recently received technical assistance to help develop
monitoring tools and a manual of procedures. This will reinforce CCM
capacity to better monitor the grants (both this malaria grant and
Senegal's current HIV/AIDS grant) and ensure partner coordination

and rational use of resources allocated to Senegal.

RECOMMENDATION
--------------
17. The CCM should ensure the implementation of these tools for the
grant monitoring and should be more proactive in problem-solving
toward the principal recipients.

JACOBS

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