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Cablegate: Donor Coordination On Health Issues

DE RUEHSA #1634/01 2071445
R 251445Z JUL 08




E.O. 12958: N/A
SUBJECT: Donor Coordination on Health Issues

PRETORIA 00001634 001.2 OF 003

1. (SBU) Summary: Health Minister Manto Tshabalala Msimang
(Minister) at a recent high-level Annual Donor Consultation Meeting
stressed that the national Department of Health (DOH) must
coordinate donor efforts in the health arena in order to ensure
equitable allocation of resources across provinces. She voiced
concern that donors concentrate too much on HIV/AIDS to the
detriment of other health priorities and urged donors to think about
how resources intended for HIV/AIDS programs could also be used to
support other DOH priority areas. The meeting came at a time when
the Donor Community in South Africa is frustrated with the South
African Government's lack of leadership with regard to improving
donor coordination structures, especially with regard to HIV/AIDS
programs. The existing Donor Coordination Forum (DCF) for HIV/AIDS
housed within the Department of Health (DOH) is largely ineffective,
with neither donors nor the DOH satisfied with its results. End

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Health Minister Urges Broader Approach

2. (U) The Minister voiced concern at a June 30 high-level Annual
Donor Consultation Meeting organized by the Department Of Health
(High-Level Meeting) that donors concentrate too much on HIV/AIDS to
the detriment of other health priorities. (Comment: Although
called "Annual High Level Meeting" by the DOH, the meeting had not
been held in several years. End Comment.) The Minister emphasized
at the High-Level Meeting that she would like to see a broader
approach to health and is concerned that everyone who talks about
health is really talking about HIV/AIDS. She discussed promoting
wellness and wellness centers. The Minister urged donors that have
prioritized HIV/AIDS to also think about how to use these resources
to support other priority areas. She listed the health department's
priorities as meeting the Millenium Development Goals; promoting
wellness; developing a rural-health strategy; strengthening primary
healthcare; managing the burden of disease from non-communicable
diseases such as cancer, cardiovascular disease and diabetes; human
resource issues; and the health information system. "You can't
really run a department on the basis of HIV/AIDS or you might just
as well change the name to the Department of HIV/AIDS," she
commented in a discussion with the donors. She added that the DOH
will be arranging bilateral meetings with donors to further discuss
the resource gaps in priority areas and how donor support can be
utilized in a more coordinated manner.

3. (U) The Minister also commented that the DOH experienced a
"challenge" when "a development partner working with NGOs decided to
have a national conference focusing on a particular disease, for
which the DOH provides almost all health services." She said, "It
cannot be correct that when the Department is largely responsible it
does not play a significant role - this will not happen in most
other countries." The Minister noted that she "deliberately" was
not mentioning the partner or the specifics of the conference.

4. (U) EU Ambassador Lodewijk Briet addressed the High Level
Q4. (U) EU Ambassador Lodewijk Briet addressed the High Level
Meeting, noting that donors' funding of HIV/AIDS is important as
antiretroviral treatment (ART) is still not reaching many who need
it. (Comment: The latest UNAIDS estimate is that only 28% of South
Africans in need of ART are receiving it. End Comment.) He added
that we should be working in South Africa to achieve the Millennium
Development Goals of reducing infant and maternal mortality and on
the response to HIV/AIDS and other diseases. Briet commented that
the donors would welcome DOH guidance on how to work better with the
South African National AIDS Council (SANAC) to support South
Africa's National Strategic Plan on HIV & AIDS and STI (Sexually
Transmitted Infection). Other donors, including the U.S., the
United Kingdom, and Belgium, all noted that they are in the process
of putting together programs looking toward 2010 and would like to
find better ways to harmonize programs among donors and with the
South African Government (SAG).
(Comment: The Citizen newspaper criticized the Minister for
downplaying the HIV/AIDS crisis at the High-Level Meeting,
especially since HIV/AIDS is South Africa's major health problem.
End Comment.)

5. (U) DOH Director General Thami Mseleku committed to look at the
DOH ten-point plan to determine where donors could best fit in.
(Comment: A presentation on financial gaps in the health sector from
the DOH Chief Financial Officer was planned for the meeting, but did

PRETORIA 00001634 002.2 OF 003

not occur. Donors commented that the presentation would have been
very helpful. End Comment.) The donors requested that the Minister
circulate South Africa's Global Fund application for 2009 to them,
and the Minister agreed to do so. The Minister expressed her
appreciation to donors who have responded positively to her calls
for assistance for the new clinical associates program. This is a
three-year program designed to train a cadre of professionals that
will have a defined scope of practice and is geared to provide
assistance to doctors in community health centers and district
hospitals. United States President's Emergency Plan for AIDS Relief
(PEPFAR) funds are being provided to the professional associates
program through the Centers for Disease Control (CDC). Donors
requested to share more detailed information on all donor supported
health programs at a follow-up meeting that could serve as a basis
for future coordination.

Donor Coordination Forum Is Ineffective

6. (SBU) Embassy Health Officer attended a meeting of the DCF on
July 2, 2008 that focused on possible changes in its future
structure. The DCF agreed that the DOH's International Health
Liaison (IHL) Office will be asked to participate in the DCF's next
meeting to report on ways to structure the DCF better, in line with
the High-Level Meeting's outcomes. The structure of the DCF has
been at issue for some time as donors are generally dissatisfied
with its operation. Donors feel that coordination with other
donors, as well as between donors and the SAG, is poor and that
donors do not have an effective means to provide input to the SAG.
Donors are so frustrated with the DCF that they have established an
informal forum, the EU+ Donor Forum, coordinated by the Swedish
Embassy. The group's goal is to improve information sharing and
understanding among donors of the HIV epidemic. SANAC and DOH have
made presentations to the EU+ group, and the U.S. actively

7. (U) The DCF commissioned the firm Strategy and Tactics to review
the role and functions of the DCF and make recommendations on how
the DCF could more effectively fulfill its role of ensuring that
donor funding appropriately supports the SAG response to HIV & AIDS
in a coordinated manner. The April 2007 report (DCF Report) noted
that HIV/AIDS is a key focus of donor funding, receiving
approximately 95 percent of all donor funding to the health sector.
The DCF had been meeting bi-monthly, chaired by the HIV, AIDS and
STI (HAST) cluster, with the support of the department's IHL office.
Members include UNAIDS, major donors, international development
agencies, and the Treasury Department. No other governmental
departments actually attend, nor does the South African National
AIDS Council (SANAC), nor major donor-funded NGOs, despite the forum
being multi-sectoral and open to other organizations. In addition,
DOH representation does not reflect broader interests beyond the
HAST cluster, such as pediatrics, maternal health, capacity
development, or TB and other opportunistic diseases associated with
Qdevelopment, or TB and other opportunistic diseases associated with
HIV. There is also no forum to discuss the broader health issues
that the Minister would like to receive increased donor attention.

8. (SBU) The DCF Report found that that the DCF had largely failed
in its mandate to coordinate donors effectively. Comments from
survey donor respondents included: "One gets a sense that the
department is ambivalent about the DCF and that senior management
does not really want it"; "No genuine dialogue where donors and
government officials share their needs and views openly"; and
"Government representatives were ill prepared and often meetings
were postponed or agenda items dropped." Respondents from the DOH
also voiced unhappiness with the existing mechanism, saying: "Donors
have failed to reduce the high transaction costs associated with
donor assistance"; "Donors have not harmonized their actions with
each other, nor have they aligned to existing DOH strategies";
"Donor missions are not joint and remain time consuming,
particularly for provincial-level staff."

--------------------------------------------- --
Recommendations for Improved Donor Coordination
--------------------------------------------- --

9. (U) The DCF Report recommended the formation of two donor
coordinating forums to replace the existing DCF. A forum to be
located within SANAC would coordinate donors in the HIV & AIDS
sector and ensure that development partners align and harmonize with

PRETORIA 00001634 003.2 OF 003

the NSP. Membership could expand to include all key role-players.
A second forum would be located within the IHL Office of the DOH to
coordinate all donors in the health sector and membership expanded
to include representatives from all clusters within the DOH.

10. (U) The DCF Report acknowledges that establishing the DCF
within SANAC could be difficult because the existing SANAC structure
emphasizes national representation within the council. However, the
Report noted that donor coordination could be managed within the
Resource Mobilization Committee (RMC) of SANAC, chaired by the
Health Minister. The RMC emphasizes coordination and implementation
of Global Fund Activities, but may also look at other opportunities
for resource mobilization to support implementation of the NSP.
(Comment: There is no current donor representation on SANAC unlike
most National AIDS Councils in other African countries, although
UNAIDS provides support to SANAC and attends meetings in an
"observer" capacity. Since the RMC supervises the Global Fund
process, this means that Donors have no real input into South
Africa's applications to the Global Fund and no knowledge of its
content while being formulated. End comment.)

DOH Rejects Recommendations

11. (U) The DCF, at its October 2007 meeting, endorsed the
recommendations of the Report to establish two donor coordinating
forums, to replace the existing DCF. The DOH reported, at the April
23 DCF meeting, that it had rejected the Report's recommendations
following its review. The DOH stated that since the SANAC
Secretariat is in the process of restructuring and SANAC lacks the
capacity for donor coordination, the Forum should stay as is,
chaired by the DOH HAST Cluster. The UK Department for
International Development (DFID) reported at the July 3 DCF meeting
that it had written a formal request to outline the DCF
recommendations to SANAC, but had not yet received a response.

12. (U) Many of the complaints outlined in the DCF Report were
echoed in the Report on the First Phase of the Evaluation of the
Implementation of the Paris Declaration Country Level Evaluations
completed in February 2008 (PD Report). The PD Report states that
while the Development Partners are frustrated by the lack of a
national Development Partner coordination forum, South Africa does
not see the need for one. It notes that continued "silo" thinking
and capacity issues weaken interdepartmental coordination. The PD
Report recommends that the parties discuss a mutually agreed way
forward: "The national Development Partner coordination issue needs
to be debated further by the Partner Country and Development
Partners to unpack both the fears and motivations for and against
such a forum and determine: What is the gap and how can it be
filled? How should division of labor be decided?"

13. (SBU) Comment: The dysfunctional nature of the DCF was
highlighted by the fact that none of the DOH participants at the
July 2 DCF meeting had either attended the High-Level Meeting or
been briefed on it. No one from the IHL office of the DOH was even
present at the DCF meeting. Mrs. Mokgadi Phokojoe, Director of the
Qpresent at the DCF meeting. Mrs. Mokgadi Phokojoe, Director of the
HIV, AIDS and STI office within the DOH, is chair of the DCF, but is
not perceived by donors to be sufficiently senior to be influential
within the Department. There is no immediate impetus for reform of
the coordination structures in view of the Mbeki administration
nearing its end. It is likely that the donor community will remain
frustrated with the coordination structures and maintain parallel
efforts to coordinate among themselves, unless a new Health Minister
in a new administration sees the need for more effective donor
coordination. End comment.


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