Detailed Mechanism Funding and Narrative

Details for Mechanism ID: 9611
Country/Region: Malawi
Year: 2009
Main Partner: To Be Determined
Main Partner Program: NA
Organizational Type: Implementing Agency
Funding Agency: HHS/CDC
Total Funding: $0

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $0

New Activity - MOH HIV/AIDS Unit

Compact goal 4

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.01:

Funding for Sexual Prevention: Abstinence/Be Faithful (HVAB): $0

Continuing Activity - GHAI

Sexual prevention compact goal

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.02:

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $0

Continuing Activity

- Sexual prevention compact goal

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.03:

Funding for Biomedical Prevention: Blood Safety (HMBL): $0

Continuing Activity - MBTS GHAI

Sexual prevention compact goal

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.04:

Funding for Care: Adult Care and Support (HBHC): $0

New Activity - CHAM

Compact goal 2

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.08:

Funding for Treatment: Adult Treatment (HTXS): $0

New Activity - CHAM

Compact goal 2

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.09:

Funding for Treatment: Adult Treatment (HTXS): $0

Continuing Activity - Howard University

Adult care and treatment

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.09:

Funding for Care: Pediatric Care and Support (PDCS): $0

Continuing Activity - Howard University

Compact goal 2 - Quality and access of care and treatment services

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 11 - PDTX Treatment: Pediatric Treatment

Total Planned Funding for Program Budget Code: $435,000

Total Planned Funding for Program Budget Code: $0

Table 3.3.11:

Funding for Treatment: Pediatric Treatment (PDTX): $0

Continuing Activity - Howard University

Compact goal 2 - Quality and access...

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.11:

Funding for Care: TB/HIV (HVTB): $0

Continuing Activity - MOH NTP

Compact goal 2 -

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.12:

Funding for Testing: HIV Testing and Counseling (HVCT): $0

Continuing Activity - MACRO GHAI

Sexual prevention compact goal

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.14:

Funding for Laboratory Infrastructure (HLAB): $0

Continuing Activity - Howard University

Compact Goal number 4 - systems strengthening

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.16:

Funding for Laboratory Infrastructure (HLAB): $0

Continuing activity - Because the GAP account begins FY09 spending in October of 2008, and because

there is insufficient funding in the CDC base for increased management and staffing costs, we have had to

signal our intention of using Compact funds to partially fund year 2 of the Lab Advisor position. Since

recruitment is ongoing at this time, and salaries will not have to be paid for a few months, we have chosen

to use our limited GAP funds for activities that need funding immediately.

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.

This activity is split funded with activity #27133

The new Lab Advisor on the USG Team will provide technical oversight for the expansion of lab services in

support of the Malawian national efforts for treatment and care. The technical lead will oversee and provide

empirical data for monitoring the effectiveness of the interventions during the scale-up phase of the new

partnership.

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 17 - HVSI Strategic Information

Total Planned Funding for Program Budget Code: $4,243,796

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Overview

Within the National AIDS Framework (NAF), SI encompasses monitoring and evaluation, health management information systems

(HMIS) and surveillance at the national, sub-national and program levels. The data generated through these complementary

systems serve as the cornerstone of evidence-based HIV/AIDS prevention, care and treatment programs throughout the country.

Malawi has taken a leadership role in advancing strategic information systems in Sub-Saharan Africa, particularly in its proactive

use of evidence to guide national strategic planning and resource allocation. However, the country faces many challenges in this

area including the need to increase staffing levels and technical capacity, institutionalize routine supervision of monitoring

activities, upgrade technology and infrastructure to support more advanced data management and communications systems.

USG is playing an integral role in providing the necessary information to effectively scale-up and decentralize services, evaluate

the national response, and monitor changes in epidemic dynamics.

i. Functioning of USG Strategic Information Team

The USG SI team is comprised of an SI Liaison, housed within USAID who serves the entire USG team; two Monitoring and

Evaluation Officers (including a non-PEPFAR funded USAID mission M&E Officer) and an Epidemiologist. The SI Liaison

ensures systems are in place at USG and amongst implementing partners to effectively plan and monitor programs according to

PEPFAR requirements. The Epidemiologist provides technical leadership and program management over all HIV/AIDS

surveillance, public health evaluations and management for a subset of USG partners in SI. The PEPFAR-funded Monitoring and

Evaluation (M&E) Officer provides technical leadership and program management for M&E and HMIS activities with the Ministry of

Health (MOH), which includes strategic planning, routine monitoring and evaluation, capacity building, and data quality

assessments. The non-PEPFAR funded M&E Officer provides technical and capacity building support to civil society partners.

ii. Surveillance and Surveys

USG has a long history of supporting population and sub-population-based HIV biological and behavioral surveillance in Malawi.

In 2009, USG will again be the primary funder of the Malawi Demographic and Health Survey (MDHS), including a behavioral

component, HIV biomarkers, and oversampling for district-level HIV prevalence estimates. Funding and technical assistance for

the implementation, analysis and dissemination of the HIV integrated Behavioral Surveillance Survey (BSS) with HIV and syphilis

biomarkers among key high risk populations has been provided for two previous national surveys. Funding for the design and

methodological revision of the 2009/2010 third round of BSS and strengthened data use will continue to be a primary objective of

USG in the FY09 COP.

To date, Malawi has relied on modeled estimates of new HIV infections based on prevalence data. As the successful national

treatment program reaches almost 70% coverage, prevalence data has become less reliable in identifying where, and among

whom, the bulk of new infections are occurring. In order to increase the information foundation for program planning, particularly

for prevention activities, in-country laboratory and epidemiological training and support for incidence estimation using BED assay

will be provided to the MOH, College of Medicine and partners. Incidence estimates will be conducted among the general

population 2009 MDHS sample as well as in other important sub-populations in Malawi.

Since 2005, USG Malawi has assisted the MOH and WHO in developing and implementing an HIV drug resistance surveillance

system including supporting the national HIV Drug Resistance Technical Working Group, monitoring of Early Warning Indicators,

conducting threshold surveys of transmitted drug resistance, and implementing baseline prospective surveillance of acquired drug

resistance at four high-volume ART sites. The first round of prospective surveillance will be completed in FY09 and a second

threshold survey and continued Early Warning Indicator detection will be implemented. In addition, a National HIV Drug

Resistance Strategy, incorporating both WHO and USG recommendations, will be developed with USG assistance. This

framework will be used to lobby for Global Funds for longer-term drug resistance surveillance support.

With USG support, Malawi has been a global leader in systematically incorporating data into the national decision-making. In

FY09, USG will continue to support national data use activities including data triangulation, modeling national estimates and

projections, and developing data-driven briefings for policy makers. In addition, USG will support the development of an

innovative district and local-level data use model to guide decentralization of prevention, care and treatment programs.

Beyond providing funding for HIV surveillance activities, direct -almost daily - technical assistance to strategic information

activities is fundamental to the Malawi program. The USG Epidemiologist is a member of the MOH Health Impact Study Technical

Working Group, and provides technical support for surveillance activities including ANC sentinel surveillance, drug resistance

surveillance and BSS. In addition, trainings were held on data triangulation, and drug resistance surveillance. BED assay training

will take place in December 2008. Capacity building and documentation activities will continue to be at the forefront of FY09

surveillance activities.

iii. Health Management Information Systems

Health Information Systems are essential for effective monitoring and evaluation and require reliable, standardized data collection.

In 2002, the MOH began to implement the national HMIS to support routine data collection, analysis and dissemination for health

sector data, including indicators on HIV/AIDS, malaria, TB, reproductive health and other health programs. Facility-level HMIS

indicators are aggregated on a quarterly basis at the district level and sent via email or floppy disk to the national level. However,

the accuracy, completeness, and timeliness of data are limited.

Baobab Health, a USG supported Malawi-based trust and NGO, has been addressing this issue for the past eight years by

applying medical informatics principles to resource-poor settings. The core of Baobab's approach is the application of easy-to-use

touch screen clinical workstations at the point of patient care. This system efficiently and accurately guides low-skilled healthcare

workers through the diagnosis and treatment of patients according to national protocols. Baobab Health has deployed Electronic

Data Systems (EDS) at 7 of the largest ART clinics throughout the country. Currently, 16,699 ART patients are captured by this

system - or approximately 13% of Malawi's 121,707 patients who are alive and on treatment. Each deployment has also resulted

in the training of 5 - 20 users To address challenges of data quality, in FY08 the MOH, in partnership with USG and Baobab

Health, initiated a feasibility project of using EDS to capture out-patient registry data in rural health facilities to explore the use of

alternative energy sources (e.g. windmill and solar panels); and remotely transmit data to a newly established central repository

housed within the MOH. The challenge for FY09 will be the conversion of the paper-based record keeping system to the national

scale up of EDS, The EDS scale up will include the development of modules to transfer of patient files and to transfer data to

central repository. In FY09, USG will continue to provide TA support in preparation for the scale up. The only impediment to the

scale up is the availability of resources. In FY09, in order to increase their organizational capacity, Baobab will receive a Pfizer

Global Health Fellow as part of a new public private partnership initiative.

In Malawi there are a number of indicators collected at the national level which do not support program-level information needs.

As a result, many vertical program-specific health information systems are being developed. In FY09, the USG will provide TA

and support to explore potential for integrating systems through the use of national standards. To initiate the process of system

integration, the MOH, WHO and USG conducted a 3-day workshop on standards in order to build consensus around a national

health infrastructure strategy for Malawi, including governance structures, operational policies and processes to promote ongoing

collaboration and coordination between stakeholders. One outcome of this workshop will be the identification of a Standards Task

Force that will play an instrumental role in 1) developing a national framework for data analysis, patient referral and medical

record management, 2) designing a roll-out plan for EDS, 3) harmonizing partner reporting to feed into the HMIS; and 4)

developing specifications for a central data repository. This effort supports the objective of the National M&E Plan as well as the

goal of the ‘Third One'.

iv. Monitoring and Evaluation

To help support the National M&E plan, USG recently identified the need for four staff within the newly formed M&E Unit of the

Ministry of Health, including an M&E TA, an M&E Fellow and two IT Fellows. A new facility on the Community Health Science

Unit (CHSU) campus is also underway to house the HIV/AIDS Unit, the central data repository, and additional rooms to support

trainings and conferences.

In FY08, USG supported assessments for 1) the Touch Screen Electronic Data System (EDS), 2) the Logistics Management

Information System (LMIS) for HIV test kits and ARVs, 3) the integration of the ARV Supply Chain System into Central Medical

Stores (CMS) and its Regional Medical Stores (RMS), 4) the Situational Analysis of HIV services, and 5) M&E Systems for OVC

at the Department of Women and Child Welfare (MOWCD). Within the next two years, recommendations from these

assessments will be incorporated into scale-up and data quality improvement plans for each of these Information Systems. The

EDS will be scaled up to high-burden ARV public and private service delivery sites (approximately 12 per year) and will include

the ability to transfer patient files from one facility to another. The LMIS will fully use standardized ARV recording, reporting and

transaction forms documented in Standard Operating Procedures (SOP). A Training of Trainers on the SOP will result in all

health workers trained at ARV service delivery sites and routinely using the forms. The CMS will have improved quantification

capabilities which will be verified by stock reports from hospitals and facilities using remote reporting systems. USG played a

critical role in planning, data collection and report writing of the 2007 Situational Analysis.

The MOWCD has an M&E plan for OVC which was written in 2007. The plan describes the use of four tools which provide the

basis for data to move from communities to districts and the national level. The tools are: 1) the Household Listing Book; 2) the

OVC Community Register; 3) the OVC Community Quarterly Report; and 4) the Community Based Structures Report. USG will

provide a needed dimension to these M&E activities by supporting GIS mapping to improve coordinated service delivery and

monitoring

In 2008 the USG funded a Human Capacity Review of the MOWCD to assist the Ministry to meet the funding requirements of the

Global Fund Round 5 Phase 2. The MOWCD is in the process of completing a functional analysis of M&E standard operating

procedures as well as all other service delivery activities. The analysis should be completed in 2009.

In FY08, the SI team instituted a Semi Annual Progress Report (SAPR) to promote the use of up-to-date data for program

management and planning. Aggregate summary reports were included in the Portfolio Review template which consolidated

partner specific life-of-project results and were used at the first Inter Agency Portfolio Review. The objectives of the Portfolio

Review were to conduct a situational analysis of partners for past, present and future activities, and identify linkages amongst

USG agencies. From the Portfolio Review four key priority themes were identified and used for planning activities in the Compact

and FY09 COP. In addition, the USG team reviews partner performance after the APRs are received.

In FY08, the USG prioritized improving data quality at the national and partner levels. USG conducted a Data Quality Workshop

for USG Project Managers and Implementing Partners in developing Performance Management Plans (PMP) and conducting

Data Quality Assessments (DQA). At the national level, data quality improvements include a comparison of the results of the

Situational Analysis and data collected by the routine HMIS. Variations will be identified and a data quality plan will be developed.

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. SI is a priority area under consideration.

Should the Compact be approved, additional FY09 compact funds would go towards the full scale up of the EDS by developing

and implementing a roll-out plan (approximately 1 site per month); developing EDS modules for Counseling and Testing, PMTCT

and TB; designing the architecture to transfer patient files from one facility to another; setting up a central repository/data

warehouse within the MOH; and developing policies on governance structures. In addition, Compact funds will be used in

surveillance to train and support laboratory and data analysis needs for BED assay incidence estimation with BSS and DHS

samples; expanding HIV drug resistance monitoring (threshold, early warning indicators and prospective monitoring) to more sites

including urban and rural areas and public and private service providers; developing a pediatric ART drug resistance monitoring

program; and providing technical assistance and support in district-level triangulation of monitoring and evaluation data.

Table 3.3.17:

Funding for Strategic Information (HVSI): $0

Continuing Activity - MACRO GHAI

Sexual prevention compact goal

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.17:

Funding for Strategic Information (HVSI): $0

Continuing Activity - Lighthouse GHAI

Cross cutting compact goal

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.17:

Funding for Strategic Information (HVSI): $0

Continuing Activity - Baobab

Compact goal 2 - Improving quality of and access to care...

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.17:

Funding for Strategic Information (HVSI): $0

Continuing Activity - Howard University

Compact goal - cross cutting

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.17:

Funding for Strategic Information (HVSI): $0

Continuing Activity - CDC LES Technical staff salary for data management

Compact goal - cross cutting

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.17:

Funding for Health Systems Strengthening (OHSS): $0

Continuing Activity - University of Malawi (College Of Medicine)

Compact goal 4

Summary

This includes USG-supported activity through CDC's Sustainable Management Development Program

(SMDP) will be implemented through the College of Medicine in 2009

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.18:

Funding for Management and Operations (HVMS): $0

UPDATED FOR FY09 - Continuing Activity - CDC M&S

This activity is split funded with activity #21376

This narrative describes the CDC Malawi M&S needs for both GHAI and the Global AIDS Program (GAP)

funds. The CDC Malawi M&S budget, including GHAI and GAP funding, has been vetted through the

interagency decision making process and agreed to as presented in the FY09 COP submission.

Malawi is not a PEPFAR focus country but Malawi receives significant resources from the Global Fund for

AIDS, TB and Malaria (GFATM). Because of the very limited human and technical capacity to implement

programs in Malawi, the GFATM depends on the USG to complement their efforts by providing critical

technical staff to assist with program design and implementation. The USG Malawi team's M&S goals

reflect a strategic approach to both addressing the needs of the GFATM programs, and that of the programs

directly supported by the USG. The M&S plan for the HHS/CDC office in Malawi is designed to have

sufficient staff during the FY09 period and beyond, to provide appropriate technical and programmatic

oversight and assistance to all implementing partners in Malawi. The CDC M&S budget in FY09 COP

supports the USG interagency team process of providing technical assistance and monitoring of PEPFAR

activities across a significant array of implementing partners in Malawi. CDC currently has nine cooperative

agreements supporting a broad range of implementing partner activities including GFATM activities in nine

program areas. Upcoming RFA awards will add two new partners in calendar year 2009.

To achieve the goals of effective technical assistance to the Government of Malawi and its implementing

partners, the CDC GAP Office in Malawi had planned for 18 positions in FY09. This is an increase of one

previously approved technical position (Laboratory Advisor), and 3 new LES administrative positions

(Program Management Assistant, Cooperative Agreements Manager and Data Manager) over the previous

year. If funding is available, we plan to be able to fill these positions in FY09.

The FY09 COP, HHS/CDC staffing plan includes 5 USDH that are comprised of the Chief of Party, Deputy

Director, Medical Officer, and Epidemiologist. The Laboratory Advisor was planned for in FY 2007. However

limits in our budget did not permit the addition of this staff member. This position is currently being recruited

for with approved funding made available from reprogramming FY08 Compact resources. The current

HHS/CDC staffing plan also includes two PSC positions; a Monitoring and Evaluation Officer and a

Counseling and Testing Advisor (both are PS contracts through CDC). Additionally we have eight FSNs

which include a Program Management Officer, an Administrative Officer, 2 IT support staff, 3 drivers and 1

custodian.

M&S costs are inclusive of rent for offices, utilities, office operational costs, M&S specific equipment, travel

for M&S staff, training for M&S staff, residential leases and post allowance for the 5 USDH and 2 PSC M&S

positions, and increased communications costs related to enhancement of office communications and

connectivity. This FY09 COP submission does not include HQ TA support in keeping with FY09 COP

guidance that this will be funded through the Headquarters Operational Plan process.

ICASS charges of $400,000 and CSCS charges $200,000 are budgeted separately in their own activities

with the prime partner listed as State as required by FY09 COP guidance.

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.19: