New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.17:

Summary

USG along with national counterparts will conduct the fourth Demographic and Health Survey (DHS) and

the second DHS + survey which includes biomarkers for HIV. DHS surveys are conducted every four to

five years, to allow comparisons over time. The next one will be scheduled for 2009 after the National

Census is conducted in 2008.

Background

The DHS surveys are household surveys with a sample that represent the general population. DHS

surveys provide data for a wide range of monitoring and impact evaluation indicators in the areas of

population, health and nutrition. The basic approach is to collect and make available data that are

comparable across countries. In recent years, an HIV module with HIV testing was added to the survey in

order to provide nationally representative HIV data including prevalence. The data are crucial for planning

resources and in developing the national HIV prevalence estimate.

In Malawi, DHS has been conducted in 1992, 2000 and 2004. In addition, an interim Knowledge, Attitude

and Practice Survey was conducted in 1996. The next DHS + is scheduled for 2009 and planning for it will

commence in 2008. The DHS in 2004 had a sample size of 13,664 and included questions on HIV

Behavior, HIV Knowledge as well as HIV testing. The findings from the latest survey were released in FY

2006 and will be compared to findings in FY 2009.

This activity is cost-shared with funding from USAID's Operational Plan.

Activity 1: DHS+ Survey

Funding in FY 2008 will be used to initiate the planning process for the second DHS+ in Malawi. USG and

national counterparts will ensure that proper guidance is in place, budgets, schedules are managed and

standard procedures are followed for training, implementation, analysis, dissemination, and further

analyses. USG will partner with the National Statistics Office (NSO) to implement the survey. Preliminary

meetings will be held with NSO and other partners to develop a work plan for administering the DHS.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17772

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17772 11409.08 U.S. Agency for Macro 7867 5672.08 DHS+/Macro Int $62,300

International International CSH

Development

Program Budget Code: 18 - OHSS Health Systems Strengthening

Total Planned Funding for Program Budget Code: $4,472,800

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Overview

Malawi's HIV/AIDS response continues to suffer from a severe crisis in the quantity, coverage and quality of its health-related

workforce and institutions, which results in limited access and sustainability of prevention, care and treatment services. Broad-

based health system strengthening and human resource (HR) inputs comprise a significant portion of the donor support through

the Sector Wide Approach (SWAp) and Global Fund for AIDS, TB and Malaria (GFATM) grants. Nonetheless, SWAp partners,

stakeholders and discrete partners alike have voiced major concerns over continuing weak leadership for systems strengthening

and related policies which do not foster sustainability in human capacity development or commodity security. This situation is

further complicated by recent decentralization efforts where power and decision making has nominally shifted to the Districts,

while ultimate authority, as well as mechanisms for accessing funds, remain centralized. In addition, roadblocks exist for Central

Medical Stores (CMS) reform including bottlenecks which force emergency procurements and result in costly overheads. Finally,

the overall financial and program management capacity of local government assemblies and local organizations is still low, which

limit the impact of indigenous efforts.

Previous USG Support

PEPFAR has previously supported the Government of Malawi (GOM) in providing technical assistance (TA) to build and

strengthen systems and provide coordination capacity of the Ministry of Health (MOH) to effectively plan, manage, and implement

HIV programs. PEPFAR resources were implemented largely through technical assistance (TA) provided to Malawi government

institutions - this included funding TA (International consultants, Peace Corps Response Volunteers (PCRVs), Fellows, and

implementing partners) who worked within ministries, National AIDS Commission (NAC) and CMS. PCRVs were placed in district

assemblies throughout the country to support Malawi's HIV/AIDS efforts. The Ministry with overall authority for the districts is the

Ministry of Local Government (MOLG). PCRVs support the HIV/AIDS Sector at the district level by strengthening the Office of the

District AIDS Coordinator and the Office of Social Welfare, the latter being an office of the Ministry of Women and Child

Development (MOWCD).

In addition, USG strengthened the capacity of district and community HIV/AIDS committees and other local organizations to

design, coordinate, implement and evaluate HIV prevention, care and treatment initiatives across many implementing partners.

USG and implementing partners play a key role in national technical working groups (TWGs) to develop national policies,

guidelines, protocols, curricula and strategic plans around HIV-related interventions. At the national level, USG has actively

participated in the management group of the HIV unit, a key decision making body which ensures the AIDS response is dynamic

and responsive to the changing needs in Malawi. To address issues of stigma and discrimination which continue to hamper the

response to HIV and AIDS in Malawi, USG with PEPFAR funding provided training to social and religious leaders on stigma and

discrimination. A gender assessment conducted for the health portfolio at USAID in 2008 provided recommendations to reduce

stigma and ensure gender is adequately and accurately considered across our programs.

FY09 USG Support

Many of the activities proposed to strengthen the health system fall under specific program areas (Laboratory infrastructure, ARV

drugs, PMTCT) and are found under those areas of the COP. Only cross-cutting activities are described here. The broad

approach of USG is to build upon prior years activities and continue to strengthen systems and foster greater integration of health

care services (especially at the facility level). At the national level, FY09 funding will strengthen the capacity of the GOM to plan,

manage and implement HIV programs through a stronger health workforce, improved institutions and systems, and greater

transparency and accountability.

USG will approach two distinct aspects of the challenge; human capacity development (HCD) and systems strengthening; the

latter an opportunity where PEPFAR and President's Malaria Initiative (PMI) have seamlessly merged common interests for the

most effective outcome for USG inputs. While HCD is discussed at greater length in its own narrative, key to all of the programs

is the emphasis on HR. The USG Malawi team will continue to leverage support to address this issue by seconding technical staff

to the MOH and NAC, addressing retention and incentive schemes within its service delivery partners, focusing on task-shifting to

informal cadres under community care programs, encouraging volunteer programs, especially Peace Corps, and supporting HR

Gap Analysis work with the MOWCD. In terms of strengthening the systems which support integration and sustainability in

Malawi, USG activities fall under three broad areas:

• Supporting national procurement and logistics systems

• Increasing local capacity in essential management and supervision skills to create greater impact

• Fostering a policy environment that encourages sound leadership and governance in addressing road blocks to implementation

through our partners and coordination with other key stakeholders.

i. Support to the national procurement and logistics systems

USG through PEPFAR will increase its funding of USAID/Deliver, a platform which has broad support from the GOM and other

key stakeholders. The project's approach in working directly with, and co-located at, CMS, has been extremely successful in

achieving buy-in and influencing decision making. It also provides USG with an essential perspective in meeting the needs of

CMS as they face recapitalization into a Trust; a more transparent, semi-autonomous organizational framework. The Deliver

platform is a wrap-around activity closely tied to other USG programs in family planning, maternal and child health and PMI.

While DFID and GFATM provide greater financing to CMS reform efforts, USG fills a recognized essential technical gap.

Assessments of ARV integration (which now runs as a parallel system) and warehouse optimization from FY08 are now ready for

implementation. These assessments will allow USG to prioritize funding needs to match our available budget in order to catalyze

technical steps which must take place for the process as a whole to succeed. Specific activities in systems strengthening include:

developing standardized ARV recording, reporting and transaction forms to collect information for program and planning purposes

and harmonize reporting format and information with the national Logistics Management Information System (LMIS); installing

Supply Chain Manager Software at the HIV/AIDS Unit, and working with MOH to determine re-supplies and monitoring the ARV

stock status throughout the supply chain, and extending remote reporting beyond districts to the facility level through piloting a

PDA or cell phone data collection mechanism for the routine reporting by health facilities (beginning with ART sites).

A complementary piece of the USG response will be through SPS (Strengthening Pharmaceutical Management) for strengthening

the pharmaceutical management for HIV/AIDS commodities at facility level in line with MOH policy to integrate HIV/AIDS

pharmaceuticals into the national's supply system and the rational use of ART drugs. SPS and USAID/Deliver now have joint

work-plans which will ensure linkages are effective, eliminate duplication, and leverage the skills and abilities of each partner as

well as PEPFAR funding. Deliver uses a "top-down" approach from CMS, while SPS uses a "bottom-up" approach from facilities.

Activities will focus on training service providers, developing Standard Operating Procedures (SOPs) and facilitating their

implementation at the facility level, and introducing management information system tools. Training participants will be drawn

from the zonal office, all government and Christian Health Association of Malawi (CHAM) facilities providing HIV/AIDS services,

and the private sector through the Malawi Business Coalition for HIV/AIDS. Through a cooperative agreement with a local NGO,

USG will develop and maintain existing partnerships with academia in Malawi and introduce medical informatics content into the

pre-service curricula of health care professionals. In addition, TA will be provided to the MOH to review and update the

dissemination of essential drugs lists and standard treatment guidelines.

In logistics management, PEPFAR will continue to wrap-around the PMI support to USAID/Deliver and SPS to strengthen CMS.

These activities target the interface between CMS, Regional Medical Stores, and the district and community level health centers.

USG support has strengthened logistical and informatics support and currently provides warehousing for USG malaria

commodities for CMS.

ii. Increasing local capacity in essential management and supervision skills to create greater impact

PEPFAR support in this area is provided by Pact Malawi (Pact). Pact has global and local expertise in organizational

development, financial management, and HIV/AIDS policy and technical areas, which it draws upon to provide TA and capacity

building for its local partners in Malawi. Through workshops and work with individual grantees, Pact provides TA in program

implementation, administration, governance, and resource mobilization. Through this mechanism and with support from other

implementing partners, USG leads nation-wide institutional capacity building of small community-based organizations to increase

grantees' effectiveness to achieve expanded, high quality services and strengthen financial management, strategic planning, and

monitoring and reporting systems.

With FY09 funds, Pact will focus more resources on graduating sub-grantees to sustain the response even in the absence or

decrease of USG funding. This effort of increasing sustainable local capacity is further supported by the efforts in HCD mentioned

above, and in the HCD narrative.

With FY09 funds, USG partners Howard and BASICS will provide leadership training and development for clinical and laboratory

staff. PCRVs will be placed in additional district assemblies. In addition, USG will continue to provide TA to national efforts in

ART, HCT, PMTCT, and to overall HIV/AIDS coordination at the MOH and NAC.

FY09 PEPFAR funds will be used to launch a new OVC RFA that focuses on strengthening the media, national, regional, and

local government bodies, non-government, faith-based, and community based organizations to run as independent entities

utilizing evidence-based practices for interventions and best practices for organizational capacity.

In addition to organizational development issues, the chosen partner will provide TA and workshops related to technical

considerations for HIV prevention in high risk populations and reducing stigma. Regular meetings for partners will be convened

so as to share data, formative research and evidence regarding effective HIV prevention interventions; discussing implications for

prevention programming; and harmonizing HIV prevention messages (see sexual prevention narrative).

Additionally, Management Science for Health (MSH) will support the GOM goal of promoting reproductive health through informed

choice and integration with HIV/AIDS. The program has three main components: behavior change and communication, outreach,

and health provider capacity building. It is a wrap-around activity which will promote linkages between HIV/AIDS and

Reproductive Health (RH). Activities are implemented through a TA who sits at and works directly with the MOH. Lack of

supervision has contributed greatly to poor quality HIV service provision, and USG will continue to provide significant support to

develop and expand supervision and mentoring systems to all HCT and ART sites each quarter, as well as to the laboratory

facilities.

iii. Fostering a policy environment that encourages sound leadership in addressing road blocks to implementation through our

partners and coordination with other key stakeholders

USG works continuously to assure coordination with other stakeholder that encourages sound leadership and best use of

resources. USG will continue to participate in the Malawi Global Fund Coordinating Committee (the CCM) to optimize use of

GFATM resources, and influence national policy. USG also maintains leadership roles in the Health Donor Group (HDG) and the

HIV/AIDS Development Partners Group (HADG). To secure new financing for Malawi, USG will continue to provide TA to the

MOH to coordinate efforts for drafting and finalization of all GFATM proposals for HIV/AIDS for Rounds 10 and 11 during FY09.

Compact Funding Program Plans

GOM and PEPFAR have discussed a framework under which a new partnership agreement will be developed using FY08 and

FY09 Compact funds. In September 2008, a Concept note was submitted to OGAC, and the country team was given approval to

begin developing a partnership compact with the GOM. Strengthening health systems is a priority area under consideration.

USG, GOM, and partners agree that an effective supply chain management system in Malawi is a high priority because of the

large investments in health commodities supported through our bilateral PEPFAR, PMI, contraceptive logistics resources and

multilateral support through the GFATM. With additional resources, USG's strategy will be to address specific systems-wide

reforms to aid Malawi in strengthening its national supply and distribution system and to ensure the development of in-country

technical competency for procurement. We will also encourage Malawi to adopt the central procurement service through SCMS

offered by the GFATM. Scale-up in FY09 will stress informatics, quality assurance and human capacity issues, which will build on

the platforms currently supported by USAID/Deliver and SPS, and focus on intense supportive supervision and forecasting at the

regional and central levels. There will also be an increased focus on maximizing investments made in HR reforms within the MOH

and MOWCD by USG, DFID and UNICEF.

Table 3.3.18: