Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 7874
Country/Region: Malawi
Year: 2009
Main Partner: Management Sciences for Health
Main Partner Program: NA
Organizational Type: NGO
Funding Agency: USAID
Total Funding: $500,000

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $125,000

NOTICE - Per the recommendation from OGAC that Malawi as an FY2008 Compact Country, submit a mini

-COP (i.e. program area level narratives only), this activity level narrative has not been updated prior to the

submission of the FY09 Full COP. The Malawi country team anticipates updating narratives upon

completion and final approval of the negotiated 5-year Compact between the United States Government

and the Government of Malawi.

Summary

Management Sciences for Health (MSH) recently won the TASC III award. This activity will support the

Government of Malawi's (GoM) goal of promoting reproductive health through informed choice and

integration with HIV/AIDS. The program has three main components: behaviour change and

communication; outreach; and health provider capacity building. The overall purpose of this task order is to

promote through informed choice, safer reproductive health practices by men, women and young people,

and increased use of high quality, accessible Family Planning/Reproductive Health (FP/RH) and HIV/AIDS

services.

Background

Integration of HIV and FP has proven to be an effective approach to stimulate new activities and meet

active demand for HIV Counseling and Testing (HCT) by overcoming constraints to accessing services. The

overall purpose of this task order is to promote integration of family planning and HIV/AIDS through

increased use of high quality, accessible FP/RH services, and HIV/AIDS services. The activities to be

implemented in FY 2008 are part of an initiative to be undertaken starting in October 2007 through TASC-III

in eight districts with Child Survival and Health Population funds (POP) and 2007 Emergency Plan (EP)

funding. In achieving the purpose, the program will undertake various activities in three programmatic areas

of other prevention, HCT, and systems strengthening to accomplish the following results: increased

community knowledge and interest in FP and HIV/AIDS services; improved social norms for

SRH/FP/HIV/AIDS; increased access and utilization of FP/HIV/AIDS services in communities; increased

integration of HIV issues into FP services and vice versa; improved linkages between point of service and

the community and household levels; and a strengthened enabling social environment for FP/RH and

HIV/AIDS services and behaviors. Achievement of these results shall be carried out principally through

partnerships with the district health offices in Malawi.

Cross cutting among health issues is the high fertility rate, which undermines the poverty reduction efforts,

contributes to high maternal and infant mortality levels, and exacerbates the AIDS-related orphan problem.

Considerable progress has been made over the last decade in reducing total fertility from 6.7 in 1992 to 6.0

in 2005. At the same time the contraceptive prevalence rate (CPR) for modern methods has raised from

7% in 1992 to 28% in 2004. FY 2008 HIV/AIDS funds will wrap around larger programs in Family

Planning/Reproductive Health which are funded with POP Child Survival and Health funds.

Activity 1: Dual Protection

TASC-III will integrate HIV/AIDS, family planning and sexually transmitted infections (STI's) prevention

through promotion of dual protection, encompassing condom promotion and other behavioral change efforts

to reduce pregnancy and STI/HIV risk. Integration of family planning counseling and services (or referral for

services) into HCT centers for women and men who wish to avoid future childbearing will include programs

focused on mother to child transmission.

Activity 2: Gender

TASC-III will incorporate a gender approach into family planning and HIV/AIDS services by training

providers to address gender-related barriers/issues, including identifying signs of gender-based violence

that should be addressed as part of family planning and HIV/AIDS counseling. Steps will be taken to ensure

that protocols address legal and support services in the community to mitigate impact (e.g. partner testing

and notification to support disclosure).

Activity 3: Behavior Change Communication

Behavior change communication (BCC) will be incorporated into TASC III activities and shall portray

adequately family planning and HIV testing and treatment as mainstream health interventions. BCC

messages should include those targeted at men as clients, allies/supportive partners, and agency of change

toward more positive norms.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17788

Continued Associated Activity Information

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

System ID System ID

17788 17788.08 U.S. Agency for Management 7874 7874.08 MSH TASC III $125,000

International Sciences for

Development Health

Table 3.3.03:

Funding for Prevention: HIV Testing and Counseling (HVCT): $250,000

NOTICE - Per the recommendation from OGAC that Malawi as an FY2008 Compact Country, submit a mini

-COP (i.e. program area level narratives only), this activity level narrative has not been updated prior to the

submission of the FY09 Full COP. The Malawi country team anticipates updating narratives upon

completion and final approval of the negotiated 5-year Compact between the United States Government

and the Government of Malawi.

Summary

Management Sciences for Health (MSH) recently won the TASC III award. This activity will support the

Government of Malawi's 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. The overall purpose of this task order is to promote through informed

choice, safer reproductive health practices by men, women, and young people, including increased use of

high quality, accessible family Planning/Reproductive health (FP/RH) and HIV/AIDS services.

Background

Integration of HIV/AIDS and FP has proven to be an effective approach to stimulate new demand as well as

meet active demand for HIV counseling and testing (HCT) by overcoming constraints to accessing services.

The overall purpose of this task order is to promote integration of family planning and HIV/AIDS through

increased use of high quality, accessible FP/RH and HIV/AIDS services. The activities to be implemented in

FY 2008 are part of an initiative to be undertaken starting in October 2007 through TASC III in eight districts

with USAID Child Survival Health Population funds (POP) and 2007 Emergency Plan (EP) funding. The

program will implement various activities in three program areas: Condoms and Other Prevention,

Counseling and Testing, and Other Policy and Systems Strengthening, to accomplish the following results:

•Community knowledge and interest in FP and HIV/AIDS services increased

•Social norms for SRH/FP/HIV/AIDS improved

•Access and utilization of FP/HIV/AIDS services in communities increased

•Increased integration of HIV issues into FP services and vice versa

•Linkages between point of service and the community and household levels improved

•An enabling social environment for FP/RH and HIV/AIDS services and behaviors strengthened.

Achievement of these results shall be carried out principally through partnerships with the district health

offices in Malawi.

Expansion of HCT is a critical step towards achieving Malawi's ambitious universal access targets of having

at least 250,000 patients with advanced HIV disease alive and on ART by 2010. Malawi's Universal Access

target for HCT is to attain a testing rate of 993,000 people per year by 2010. Although the country has

recorded a large increase of testing sites from 39 in 2001 to 351 in 2006, and a correspondingly sharp

increase in number of people tested annually from about 52,000 to 661,400; knowledge of HIV sero-status

among adults over 15 years is only 15%. The expansion of HCT services in Malawi still faces many

challenges including inadequate human resource capacity for program coordination at a national level,

shortage of trained counselors, and weak coordination of testing activities in medical settings. Other

challenges include low testing rate for couples and children.

Activity 1: Community Based Counseling and Testing

TASC III will initiate community-based family planning and CT services in eight districts and scale up

operations by expanding coverage, access, and consistent use of FP/RH and HIV services. The focus of

the expansion should be in rural and underserved areas and among high risk populations defined by high

unmet demand for services or marginalized groups. Consideration will be given to cost effectiveness and

potential health impact in identifying areas and population for expansion. TASC III will focus on consistent

family planning use and look for windows of opportunity to leverage increased access to HIV/AIDS services,

particularly in HIV counseling and testing and positive living as well as addressing gender related reasons

for lack of access such as women's limited financial resources and lack of partner support for contraceptive

use.

Activity 2: Post Test Clubs

TASC III will support post test clubs that are designed to decrease stigma and discrimination experienced

by PLWHA. Innovative approaches to expand use of HIV and other RH services available to women

through community-based distributors (CBDs) thereby increasing women's access to services in rural areas

shall be strengthened. CBDAs will include HIV/AIDS prevention messages, support testing, treatment

seeking, and adherence behaviors.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17790

Continued Associated Activity Information

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

System ID System ID

17790 17790.08 U.S. Agency for Management 7874 7874.08 MSH TASC III $125,000

International Sciences for

Development Health

Program Budget Code: 15 - HTXD ARV Drugs

Total Planned Funding for Program Budget Code: $650,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Context

Of the approximately 120,000 people currently alive and on antiretroviral therapy (ART) in Malawi, greater than 95 percent are

receiving the country's recommended first-line regimen of a twice daily fixed-dose combination of d4T/3TC/ NVP. With the

exception of pediatric ARVs which are procured partially with UNITAID funding until 2010, ARVs for the national program are

procured exclusively with Global Fund for AIDS, TB and Malaria (GFATM) resources through UNICEF, and supplied to sites

through SDV, a private company funded by UNICEF with GFATM resources.

SDV operates through a parallel system outside of the weak national Central Medical Stores (CMS) system, which is responsible

for supplying almost all other health commodities in Malawi, including HIV test kits and OI drugs. Unlike programs which depend

on commodities through CMS, Malawi's ART program has not experienced any ARV stock-outs to date, although the increasing

demand on the current supply chain for HIV/AIDS-related commodities requires streamlining certain pharmaceutical management

and monitoring functions. This will be particularly true in the future as the number of patients on ART continues to rise and the

proportion of patients requiring alternative and second-line regimens increases.

The Government of Malawi (GOM) has expressed a strong desire to integrate ARVs into the CMS procurement and distribution

system, but an assessment in 2008 by the USG-funded Deliver project indicated that CMS currently did not have the capacity to

take on the responsibility of procuring and distributing ARVs in the near future. The findings of this assessment, which were widely

accepted by the GOM and other stakeholders, including the GFATM, led to the recent decision by Malawi to competitively

advertise for a third-party procurement agent. This agent would replace UNICEF in procuring ARVs and possibly other GFATM

commodities, and provide technical assistance to strengthen the capacity of CMS. The goal of this arrangement is for CMS to be

capable of managing ARV and other HIV-related supplies procurement within 3-5 years. At the request of the Ministry of Health

(MOH), USG is supporting a consultant to prepare the terms of reference for the third-party agent, and it is expected that this

agent will be in place by the spring of 2009.

In addition to the issues related to procurement and supply of ARV drugs, there are operational challenges which need to be

addressed including how to optimize use of the specific drug regimens recommended by the current guidelines, and to ensure that

patients receive alternative and second-line regimens when these are indicated as a result of toxicity or treatment failure. MOH

adopted new treatment guidelines in April 2008 which built on the highly successful public health approach to the delivery of ART,

and recommended continued use of d4t/3TC/NVP as the first-line regimen. However, during a PEPFAR Adult Care and Treatment

TWG assessment held in October 2008, interviews with clinicians and nurses providing ART in Malawi confirmed widespread side

-effects related to the use of the first-line regimen, including debilitating peripheral neuropathic pain due to d4T, and severe rashes

due to NVP. While the current guidelines include relatively straightforward guidance for switching for NVP hypersensitivity based

on visual examination of rash, MoH has set a high bar for switching from d4T to ZDV for peripheral neuropathy. These criteria

have led to a reluctance of providers to switch to a ZDV-based first-line regimen to address d4T toxicity. This reluctance to switch

was confirmed in a recent GOM survey that found only 4 percent of patients on ART have switched to an alternative ARV

regimen, in contrast to rates of 20 percent or higher in studies from Uganda, Kenya and South Africa.

In addition to a reluctance to change regimen based on side-effects, minimal attention is being made to treatment failure; less

than 1 percent of patients on ART have been switched to second-line regimens with treatment failure cited as the cause for

change. Although the public health approach in Malawi has appropriately concentrated efforts on expanding the use of first-line

regimen, a growing number of patients are no longer benefiting from first-line therapy. Current Malawi guidelines for switching

patients from first- to second-line therapy requires multiple steps, including referral to a central facility, which may be contributing

to the lower than expected uptake of second-line ART.

Previous USG Support

Given the fact that procurement of ARVS has been funded by other donors in Malawi, PEPFAR is currently utilizing its limited

FY08 resources in two areas: Funds were given to the USAID/Deliver project to perform a comprehensive assessment of ARV

procurement and related supply chain issues in Malawi, and to MSH, to strengthen the management of ARVs through the

Strengthening Pharmaceutical Services (SPS) project. Activities under the SPS project are at the facility-level, and include training

and mentoring the health workers in pharmacies and clinics on appropriate management of ARV drugs, and equipping them with

tools and systems to support them in their positions.

With FY08 resources, 340 health workers (at least two from each ART site) from the public sector as well as the private sector are

being trained through SPS in partnership with the Malawi Business Coalition against HIV/AIDS. Training focuses on adherence

monitoring, recognizing suspected Adverse Drug reactions (ADRS) and how to report them, medication counseling, and

pharmaceutical stock management. SPS is also developing standardized drug management procedures for ART management in

both public and private sector facilities, and will introduce these standardized procedures in all 170 ART sites. SPS is also

introducing an electronic ART dispensing tool for use in district hospitals.

FY09 USG Support

USG will continue to focus on improving the management of ARVs and other HIV-related pharmaceutical products at the health

facility level through a Monitoring, Training, and Planning (MTP) approach in FY09. USG will also expand complementary efforts

on the national level to support technical leadership, enabling appropriate use of ARV drugs consistent with the Malawi's new ART

guidelines. Through more accurately quantifying the extent to which patients need to switch regimens, either for toxicity or

treatment failure, SPS efforts will also support the MOH and ARV procurement agent's forecasting for ARVs.

i. On-site mentoring to strengthening pharmaceutical management at ART facilities

SPS will use FY09 funds to train staff in pharmaceutical management at new ART sites beyond the 170 sites which are receiving

training with FY08 funds, and provide training for health care workers at sites where already trained pharmacy staff have now left.

However the focus for FY09 funding will primarily be on site-based mentoring of multidisciplinary teams, including pharmacy staff

but also clinical service providers to help ensure they are following correct procedures with regard to stock management,

dispensing, medication counseling, adverse event reporting, medication errors, and side effects management. SPS staff will visit

all ART sites in the country at least twice yearly, with larger sites receiving quarterly visits, and will report any relevant findings to

the MOH Pharmaceutical Services on a regular basis so it can take any further actions if needed.

ii. Provide technical assistance to help optimize implementation of new ART guidelines

As noted above, health care workers in pharmacies are strategically placed to monitor for Adverse Drug Reactions (ADRs) and

provide other support and counseling which can help improve the clinical management of patients who are having side-effects on

their current regimens. One key recommendation which arose during a visit from the PEPFAR Adult Treatment TWG in October

2008 was for PEPFAR/Malawi team and its partners to assist the MOH in efforts to reduce the severity and incidence of side

effects, particularly chronic side effects, through giving providers the capacity and support to make the decision to switch to

alternative regimens.

SPS will work closely with mentoring pharmacy staff as well as other health care providers at ART facilities throughout the

country, in order to ensure they are helping to monitor for d4T and NVP-related toxicities, appropriately informing clinical officers

and nurses who prescribe these medicines about toxicities that may not have recognized during clinic visits and reporting

information to MoH about the prevalence of these toxicities and frequencies of drug regimen switches to the better inform ART

policy and planning. Pending further discussions with the MOH, SPS can help develop standardized tools to assist sites in more

accurately quantifying the frequency and severity of ADRs. SPS can also assist in the process of identifying highly functioning

ART sites which have the capacity to initiate and monitor patients on second-line ARVs, ensuring they have both appropriate

standardized operating procedures (SOPs) in place and consistent availability of alternative and second-line ARVs, including

ZDV, efavirenz (EFV), tenofovir (TDF), and lopinavir/ritonovir (LPV/r).

iii. Review and dissemination of the Essential Drugs List (EDL)

The procurement of all medicines and medical supplies in Malawi is done in accordance with the Malawi National Drug List and

the Essential Health Package. The National Drug Committee is charged with the responsibility of selecting drugs and reviewing

the Essential drug list and standard treatment guidelines (STG). In 2009, MSH/SPS will support an annual review/updating and

dissemination of the Malawi Essential Drugs List (MEDL) and Malawi Standard Treatment Guidelines (MSTG) to incorporate the

new drugs being used for treatment of many conditions, including HIV/AIDS, opportunistic infections, and in PMTCT. This will be a

wraparound initiative with the Presidential Malaria Initiative (PMI), as the review and dissemination will include the new Malaria

drugs (i.e. ACT) into the MEDL and MSTG. PEPFAR funds for this activity will be used to support 3 review workshops of the

National Drug Committee, and dissemination of guidelines through training of 1325 health workers on the proper use of the

guidelines.

iv. Incorporating HIV pharmaceutical use into pharmaceutical training curricula

In FY09 SPS will support the incorporation of a management for HIV/AIDS medicines module in the pre-service pharmaceutical

training curriculum for all health workers. The revised curricula will address issues of pharmaceutical management of HIV/AIDS

medicines, including prevention of adverse drug reactions, the promotion of drug safety including rational use, preventing

medication errors, and minimizing factors that contribute to therapeutic ineffectiveness. Examples of topics include non

adherence, poor quality drugs, drug interactions, and microbial resistance. These topics will be covered during pre-service

training for health workers directly involved in ART as well as other health staff working in primary health care settings. The

activity will target the Malawi College of Health Sciences and Christian Health Association of Malawi (CHAM) training schools.

iv. Building capacity of CMS and the MOH pharmaceutical services unit

FY09 PEPFAR funds will support the USAID/Deliver project to build the capacity of CMS to manage procurement and supply of a

wide range of pharmaceutical products, including HIV-test-kits and OI drugs. While ARV drugs will remain in a parallel system

outside of CMS in the near future, these capacity building efforts will potentially bear fruit over the long-term if ARV drugs can

eventually be transitioned successfully into the CMS systems after 2010. (Please see OPSS section for more information). SPS

will also coordinate national stakeholders for policy decisions leading to the development of an ART inventory management

system in the MOH pharmaceutical management services unit to track ART consumption at facility level, identification, and

installation of inventory management software that can accommodate the ART management information system.

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. Support for health commodities is a priority area under consideration.

In collaboration with the GOM, USG would prioritize the expansion of long-term capacity building efforts at CMS to move towards

Malawi's stated goal of fully integrating ARV drugs into the broader national supply chain system over the next five years.

Additional funds could also be used to expand a more robust surveillance system for ADRs and treatment failure in cooperation

with SPS and other partners. This would inform ongoing discussions with the National HIV Technical Working Group which

addresses issues related to regimen changes. USG will also integrate into training programs, initiatives that target members of

the military for support.

Table 3.3.15:

Funding for Health Systems Strengthening (OHSS): $125,000

NOTICE - Per the recommendation from OGAC that Malawi as an FY2008 Compact Country, submit a mini

-COP (i.e. program area level narratives only), this activity level narrative has not been updated prior to the

submission of the FY09 Full COP. The Malawi country team anticipates updating narratives upon

completion and final approval of the negotiated 5-year Compact between the United States Government

and the Government of Malawi.

Summary

Management Sciences for Health (MSH) recently won the TASC III award. This activity will support the

Government of Malawi (GoM) goal of promoting reproductive health through informed choice and

integration with HIV/AIDS. The program has three main components: behaviour 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).

Background

Integration of HIV and Family Planning (FP) has proven to be an effective approach to stimulate new, and

meet active, demand for HIV Testing and Counseling (HCT) by overcoming constraints to accessing

services. The overall purpose of this task order is to promote integration of family planning and HIV/AIDS

through increased use of high quality, accessible Family Planning/Reproductive health (FP/RH) and

HIV/AIDS services.

The activities to be implemented in FY 2008 are part of an initiative to be undertaken starting in October

2007 through TASC-III in eight districts with POP (CSH population funds) and 2007 Emergency Plan (EP)

funding. In achieving the purpose, the program shall undertake various activities in three programmatic

areas of other prevention, counseling and testing and systems strengthening to accomplish the following

results: Increased community knowledge and interest in FP and HIV/AIDS services; improved social norms

for SRH/FP/HIV/AIDS; increased access and utilization of FP/HIV/AIDS services in communities; increased

integration of HIV issues into FP services and vice versa; improved linkages between point of service and

the community and household levels; and strengthened social environment for FP/RH and HIV/AIDS

services and behaviors. Achievement of these results shall be carried out principally through partnerships

with the district health offices in Malawi.

Activity 1: District Health Management Team (DHMT) Support

TASC-III will strengthen District and Community Provision and management of FP/RH and HIV and AIDS

services by supporting the district health management team (DHMT) so that they provide their mandated

supervisory and support functions to the health centers. By directing efforts towards the district level, the

program can create sustainable supervision and management capacity.

The TASC-III order activities will also focus on strengthening the capacity of the DHMT members to support

community based providers, as well as DHMT's capacity in performance monitoring and improvement as

related to HIV.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17791

Continued Associated Activity Information

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

System ID System ID

17791 17791.08 U.S. Agency for Management 7874 7874.08 MSH TASC III $250,000

International Sciences for

Development Health

Table 3.3.18: