Partnership Framework Document to Support Implementation of the Malawi National HIV and AIDS Response between the Government of the United States of America and the Government of the Republic of Malawi (May 2009)

A Five-year Strategy to Jointly Implement the Malawi National Action Framework (NAF)

1.1: PURPOSE

The national response to the HIV and AIDS epidemic in Malawi is led and coordinated by the Government of Malawi (GOM). The GOM prioritized combating the HIV and AIDS epidemic in the Malawi Growth and Development Strategy (MGDS), and oversight for the response is provided by the Office of the President and Cabinet (OPC) through the Department of Nutrition, HIV, and AIDS, which operates under the 2003 Malawi HIV/AIDS policy currently under review. The National AIDS Commission (NAC), a semi-autonomous government body governed by an independent Board of Commissioners, is responsible for managing and coordinating the national HIV and AIDS program. The HIV response is coordinated through a national strategy for HIV and AIDS, the National Action Framework (NAF). In 2009, the NAF was reviewed, updated, revised, and extended to 2012 with the following goals: 1) to prevent the spread of HIV infection among Malawians, 2) to provide access to treatment to people living with HIV (PLHIV), and 3) to mitigate the health, socio-economic and psychosocial impacts of HIV and AIDS on individuals, families, communities and the nation.

The NAF covers seven priority areas:

• Prevention and Behavior Change
• Treatment, Care and Support
• Impact Mitigation
• Mainstreaming and Decentralization
• Research, Monitoring and Evaluation
• Resource Mobilization and Utilization
• Policy and Partnerships

In 2004, the GOM recognized an opportunity to better coordinate and align support to these priority areas from various development partners and stakeholders and established a Memorandum of Understanding (MOU) to support implementation of the national response. Financial support for the NAF is provided through direct budget support provided to the GOM as well as pooled support provided by funding partners (Appendix 1). As prescribed by the MOU, the Pool Funding Partners (PFP) subscribe to one national plan led by the GOM. An operational plan, the Integrated Annual Work Plan (IAWP) is submitted to the PFP yearly, prior to annual disbursements¹. The Global Fund for AIDS Tuberculosis and Malaria (GFATM) disburses funds into the pool through this funding arrangement.

In 2009, GOM, the United States (U.S.), through the President’s Emergency Plan for AIDS Relief (PEPFAR), and all funding and implementing Partners revised the national HIV and AIDS strategy, the National Action Framework (NAF) for the years 2010 – 2012. The NAF revision was informed by a review of the first 5 years of the NAF (2005 - 2009) and coincided with an invitation to be considered for GFATM funding through the National Strategy Application (NSA). GOM through the NAC held extensive and expansive consultations using the coordinating structures built to support the NAF (technical working groups and policy oversight groups). Central and district level GOM partners, development partners, local and international implementing partners and civil society came together to review the NAF, align priorities, and disclose available resources during the NAF revision and NSA application development.

The GOM and PEPFAR recognized this exercise provided a timely opportunity to align the development of the Partnership Framework process with the NAF as well as with the NSA application process, and PEPFAR was fully engaged in the entire process. Both this Partnership Framework and NAF development resulted in an open discussion and collaborative decision-making process around progress in achieving national HIV goals, gaps in the existing response, emerging program priorities, and funding and technical needs for implementing, scaling-up and increasing the quality of HIV and AIDS programs nation-wide. This discussion was mutually reinforcing and resulted in a Partnership Framework fully embedded within the national HIV and AIDS strategy, with PEPFAR and GOM identifying which strategic directions and program areas would be supported by PEPFAR through this new mechanism of support.

In 2008, the U.S. Congress reauthorized PEPFAR for five additional years (2009 – 2013). During the first phase, PEPFAR had succeeded in assisting host countries save the lives of millions of people across Sub-Saharan Africa by partnering with the GFATM to bring antiretroviral therapy to over 2 million people globally, and to strengthen programs in other critical areas including HIV prevention through sexual and mother-to-child transmission, and care for orphans and other vulnerable populations. With such phenomenal achievements, particularly in treatment, there was a recognition that the second phase of PEPFAR would focus on sustainability in part by building local capacity, supporting country ownership and leadership, and strengthening the health systems to deliver and monitor health services for people living with HIV and AIDS. Equally important in this second phase is a commitment to the PEPFAR goals for prevention, treatment, care, and health systems strengthening.

The overall goal of this Partnership Framework is to partner with the GOM to contribute to the implementation of the goals, objectives, strategies and action points of the NAF in the fight against HIV and AIDS. In doing so, this Partnership Framework will also significantly contribute to the global PEPFAR goals.

1.2: PRINCIPLES

In implementing this Partnership Framework, PEPFAR and the GOM intend the Partnership to be governed by the following guiding principles:

• High-level government commitment, national leadership and continued ownership of the response by the government and people of Malawi;
• Promoting the principles of the “Three Ones”; One National Strategy which is the NAF, One National Authority which is the National AIDS Commission (NAC) and One National Monitoring and Evaluation System. In doing so, the Partnership intends to operate under independent financing arrangements for United States Government foreign assistance;
• Greater transparency and joint decision-making in the implementation of programs and allocation of resources for the national response including reporting PEPFAR budgets, expenditures and results within the GOM mechanisms for reporting the achievements of the overall national response;
• Promoting good stewardship of GOM, U.S., and other pooled funds;
• Recognition that U.S. and GOM resources are limited and investments are subject to the availability of funds;
• Strongly aligning with the support provided by the GFATM grants;
• Strong aligning with the comparative strengths of the U.S. government agencies implementing PEPFAR including technical support and strengths of implementing partners to deliver services;
• Increasing results for programs based on scientific evidence and best practices, implemented in the highest quality and most cost effective manner achievable, and held fiscally accountable;
• Clearly defining the roles and commitments of all partners;
• Maximizing public-private partnerships to enhance sustainability, coordination, and sharing of best practices between development partners and implementers;
• Meaningful involvement of PLHIV in program development, implementation, and evaluation; and
• Recognition that achievement of the partnership goals requires resource flows beyond the ability of any one partner, and that constraints on availability of funding from either signatory or from other key partners could lead to a review and revision of goals.

1.3: COUNTRY OWNERSHIP

The HIV and AIDS response in Malawi has been effectively led by the GOM since 1997 and the GOM has successfully developed the architecture to support implementation of the NAF. Of particular note are the HIV Pool and Health Sector Wide Approaches (SWAp's) that have advanced development partner coordination. While funding modalities continue to challenge the timeliness and predictability of financial and technical resources, the GOM has brought its funding partners into a reasonably effective working relationship. GOM has also recognized that support of the major discrete partners such as PEPFAR and the UN family permits a more robust and flexible response. This Partnership Framework aims to enhance a policy environment in which diverse modes of implementation can positively contribute to the Malawi national HIV and AIDS goals by providing a supportive environment for greater country ownership through joint decision-making. In addition, PEPFAR brings a proven network of technical expertise to support Malawi’s needs for high quality data, increased data reporting and use, and monitoring and evaluating the country’s efforts. These combined strengths of PEPFAR expect to bring a new advantage to the GOM to leverage PEPFAR support for a sustainable, long-term HIV and AIDS response.

2. FIVE-YEAR STRATEGIC OVERVIEW

2.1: High Level Partnership Framework Goals:

This Partnership Framework represents an enhanced engagement by the Government of Malawi, with support from PEPFAR, to fight the HIV and AIDS epidemic in Malawi. Recognizing the importance of country ownership and sustainability, the hallmark of the new partnership is joint decision-making in setting programming priorities in the HIV and AIDS sector, and joint commitment to greater transparency in reporting information to achieve greater impact.

This Partnership Framework is built on a strong five-year strategy based on the Government of Malawi’s National Action Framework (NAF) which supports the health priorities laid out in the Malawi Growth and Development Strategy (MGDS). The Partnership Framework is focused on four goals:

• To reduce new HIV Infections in Malawi
• To improve the quality of treatment and care for Malawians impacted by HIV
• To mitigate the economic and psychosocial effects of HIV and AIDS and improve the quality of life for PLHIV, OVC and other affected individuals and households
• To support the above listed goals in Prevention, Treatment and Care by providing discrete systems strengthening support in five key areas – laboratory services, information systems, human resources, procurement and supply chain management and health finance.

These goals represent a subset of program-specific priorities of the national strategy developed by GOM and its partners. GOM has established a fitting architecture of relevant technical working groups (TWGs) and appropriate oversight bodies for financial management and monitoring to ensure results in the national response to HIV and AIDS.

The overarching goal of this Partnership Framework is to facilitate implementation of the goals, strategies and objectives of the NAF. GOM and PEPFAR have taken a strategic approach to identifying the areas of the NAF to be supported by this partnership. Extensive consultations and discussions have occurred over the past year to define the priorities in the Framework document. Important guiding principles included strong alignment with the support provided by the GFATM grants and the direction of the Malawi National Strategy Application (NSA) to the GFATM, and the comparative strengths of the U.S. government agencies implementing PEPFAR. This includes technical support and strengths of implementing partners to deliver services.

The GOM intend to make progress in the following four areas over the next five years, with support from PEPFAR and other partners:

Goal I: PREVENTION - To reduce new HIV infections in Malawi²

1. National Indicator and Targets:
   • To reduce the number of new adult and infant HIV infections from 90,000 per year in 2009 to 45,000 per year by 2013, preventing an estimated total of 150,000 infections over five years.
2. Program Areas: Sexual Prevention; PMTCT; Biomedical prevention (Blood Safety and Male Circumcision); HIV Counseling and Testing (HTC); Strategic Information; Health Systems Strengthening; Human Capacity Development; Gender as a cross-cutting issue
3. Key Policy Reforms
   • MOH plans to develop male circumcision guidelines and policy to enable scale-up of access to safe male medical circumcision services in Malawi (Tier 3³)
   • See goal #2 below for key HTC policy reforms also related to prevention.
4. Five Year Benchmarks/Measurements of Success
   • Estimated reduction in incidence in adult populations of 40percent from baseline using mathematical modeling and laboratory-based methods. The DHS 2009 will provide population-level data for baseline estimations.
   • High uptake of a quality PMTCT program has ensured that over 75percent of HIV+ pregnant women in the nation receive ARV prophylaxis or ART, and national mother-to-child transmission prevalence at 6 weeks postpartum is estimated to be less than 5percent for children born to HIV-infected pregnant women. Breastfeeding transmission has also dramatically declined due to optimization of infant feeding, ARV treatment for eligible lactating women, and other postnatal ARV prophylaxis regimens as these emerge.
   • More than 75percent of adult Malawians report being counseled and tested within the past four years and a functional national database system is in place to monitor linkage to longitudinal care for those who test positive.

PEPFAR intends to partner with the GOM to support nationwide implementation of evidence-based and comprehensive interventions for adults in keeping with Malawi’s new 5-year prevention strategy. These may include activities to reduce multiple and concurrent partnerships, increase access to HIV testing and counselling strongly linked to prevention interventions targeting discordant couples, integrate prevention with positives interventions within the national care and treatment program, increase condom utilization among both high-risk groups and the general population, and scale-up safe medical circumcision services.

The approach to supporting the prevention goals strongly complements GFATM-funded activities. While PEPFAR intends through this Partnership Framework to support the GOM in reaching national goals in preventing transmission among general and higher risk adult populations over the next five years, GFATM intends to support prevention interventions in youth over the same period. Similarly, while the GOM, GFATM, UNICEF and other private development partners provide the funding and support for all of the basic infrastructure, commodities, and staffing for the PMTCT program, PEPFAR intends to focus its support on improving the quality and impact of services by strengthening linkages and patient monitoring across PMTCT and care and treatment, increasing implementation of more effective combination prophylaxis regimens, and improving infant feeding practices. The overall goal of these combined efforts is not only to prevent an estimated 150,000 new infections over five years, but also to bring about sustainable changes in institutional norms to enable the gains to be sustained, thereby preventing at least 500,000 additional infections from 2013 – 2023.

Please note that Goal I is closely linked and interconnected with Goal II of the Framework, with each of the two goals being dependent on one another and mutually reinforcing. For example, a key focus of prevention activities intends to be prevention with positives, which is dependent upon the development of a national pre-ART program. Concurrently, PMTCT accounts for about one-third of all counseling and testing in Malawi each year and therefore optimizing antenatal care as an entry-point into HIV care is pivotal for the success of the national pre-ART program. Additionally, by increasing access to regular CD4 testing for pre-ART patients and for HIV-positive pregnant woman, not only will lives be saved by timely treatment initiation, but the prevention benefits of treatment will also be maximized. PEPFAR intends to link its support for PMTCT and pre-ART with its support to maternal and child health, family planning, nutrition, and malaria programming in order to maximize maternal and child survival and strengthen the overall health system.

Goal II: TREATMENT, CARE AND SUPPORT - “To improve the quality of treatment and care for Malawians impacted by HIV⁴”.

1. National Indicators and Targets:
   • The number of people alive and on treatment at the end of the reporting period increases from an estimated 196,368 at the beginning of the Framework to 334,000 at the end of five years.
   • The number of adults with HIV who are still alive and on ART at 12 months after initiation of treatment from 76percent to 85percent over the five-year partnership period.
2. Program Areas: Adult and Pediatric care and treatment laboratory infrastructure; HIV Counseling and Testing (HTC); TB/HIV; Strategic Information; Health Systems Strengthening; Human Capacity Development; Gender as a cross-cutting issue.
3. Key Policy Reforms
   • MOH expects to implement HTC guideline 2.61 changing “anonymous” reporting to “confidential” reporting in order to permit a name-based referral system at all HTC sites to commence (Tier 1) and revise guidelines to support provider-initiated routine CT in health facilities (Tier 1)
   • MOH plans to develop and distribute a national plan for CD4 and infant diagnosis and treatment scale-up, and extend the lab quality assurance strategy implementation as a component of the national strategic plan for laboratory support to the national response (Tier 1)
   • MOH plans to revise the national community home-based care policy and guidelines to put more emphasis on early referral and retention in care through an effective pre-ART program, and make stronger linkages between services (pre-ART community and facility-based services, including TB services. (Tier 1)
4. Five Year Benchmarks/Measurements of Success
   • Malawi meets its national goal of having 334,000 people alive and on ART by 2013
   • An effective pre-ART program has decreased the proportion of people starting ART at a late stage as a result of a Stage IV condition from 11percent to 5percent.
   • The case detection rate for TB has increased from the current national estimate of less than 50percent to the WHO target of 70percent by the end of the Framework, in part due to the support of PEPFAR for TB microscopy and case-finding

In order to increase survival within the national care and treatment program, GOM, with support from PEPFAR, intends to focus its support on enabling patients to access ART in a timelier manner to reduce the proportion of patients starting treatment at a late stage of disease when outcomes are suboptimal. Towards this strategic objective, four complementary areas are expected to be supported: 1) implementation of a national pre-ART program to roll out a basic care package of prioritized essential interventions including increased access to HTC, staging for ART eligibility including CD4 testing and infant diagnosis, co-trimoxazole prophylaxis, TB screening, nutrition assessment and referrals, prevention with positives, and linkages/integration with family planning, 2) improving referrals and linkages to strengthen the continuum of care between HTC, ART, PMTCT, pre-ART, CBHC, and other health programs (i.e. family planning, MCH), 3) focused laboratory assistance to help scale up access to quality-assured CD4 testing, early infant diagnosis, TB microscopy, and cost-effective methods for screening for virological treatment failure, and 4) building capacity for zones and districts to train, mentor, and supervise staff in labs and sites of health care delivery to improve the quality of care within the national program. Goal II is linked to Goal III. GOM endeavors to make intentional efforts to link PLHIV in both pre-ART care and ART to impact mitigation interventions in the areas of economic strengthening, agriculture, and food security thus contributing to the larger development agenda of Malawi.

Goal III: CARE FOR ORPHANS AND VULNERABLE CHILDREN - “To mitigate the economic and psychosocial effects of HIV and AIDS and improve the quality of life for PLHIV, OVC and other affected individuals and households”

1. National Indicators and Targets:
   • The number of OVC who receive high quality essential services (education, economic strengthening, health, protection, nutrition, psychosocial support, shelter) at the end of the reporting period increases by 400,000 at the end of five years from the baseline to be estimated at the beginning of the Framework.
   • The number of households in HIV-affected communities that are linked to impact mitigation efforts in economic strengthening, agriculture and food security at the end of the reporting period increases from an estimated 10,458 at the beginning of the Framework to 100,000 households at the end of five years.
2. Program Areas: OVC, Strategic Information; HBHC; Health Systems Strengthening; Human Capacity Development; Gender; Public Private Partnerships
3. Key Policy Reforms
   • MOWCD plans to revise and implement the National OVC plan of action (NPA), revise and implement the M&E framework and system to monitor the National Plan of Action (NPA), and strengthen the capacity of GOM, communities and families to care, support and protect OVC (Tier 1)
   • OPC and MOWCD should advocate for passage of the child protection and justice bill in Parliament (Tier 2)
   • MOWCD plans to implement its restructuring and functional review of staffing and career path structures (Tier 2)
4. Five Year Benchmarks/Measurements of Success
   • GOM can coordinate effective care, support and protection for OVC, as evidenced by improvements in the lives of Malawian children
   • A national system is in place to monitor and evaluate the quality of services being provided to OVC
   • The number of OVC receiving quality services per the national standards has at least doubled between the beginning of the Framework agreement and its end.

An effective referral system has been developed between the national HIV care and treatment program and community-based impact mitigation efforts, and a significant increase in such referrals can be measured. GOM, with support from PEPFAR, intends to support Malawi’s national goal to improve care for orphans and vulnerable children by supporting the MOWCD improve its capacity to lead, coordinate and source additional resources to enhance access of orphans and vulnerable children to essential (education, health, protection, nutrition, psychosocial support, shelter) services. GOM, with support from PEPFAR, plans to also support MOWCD to develop and implement standards that will improve the quality of OVC programs in Malawi and ensure programs make a measurable difference in the lives of OVC. Given that there are many partners on the ground already providing services to OVC through private funding, PEPFAR seeks to build public-private alliances with some of these partners to enable them to expand the coverage of their activities, improve the quality of the interventions with one another, link to other service providers, share best practices, and better coordinate their activities with the MOWCD. Additionally, PEPFAR plans to further support GOM by intentionally integrating PEPFAR OVC programming with other PEPFAR-supported programs in education, economic growth, food and nutrition, and agriculture.

Goal IV: CROSS CUTTING SYSTEMS STRENGTHENING - “To provide targeted, discrete systems strengthening in 5 key areas (laboratory services, health information systems, human resources, procurement and supply chain management, and health finance) to support the Prevention, Treatment, Care and Support goals”

1. Indicators and Targets:
   • Lab Systems for Service Delivery (Lab): Number of laboratories with capability to provide quality assured CD4 testing and courier-linked to more rural health facilities = 64 (all zonal and district government labs, private and Ministry of Defense facilities)
   • Health Management Information systems (HMIS): Number of high-volume ART sites implementing electronic data system = 40 sites
   • Commodities/Procurement: Percentage of maternal and child health sites reporting on a monthly basis to districts sites on PMTCT commodities = 90percent of 544 sites by the end of the Framework period
   • Human Resources: Number of health (clinical and laboratory) and social welfare workers graduating from training institutions = 1,000; Number retained in Malawian health and social welfare workforce = TBD during the implementation plan development phase ( target will reflect 50percent of current vacancies being filled in health and social welfare workforce)
   • Health Finance: To be determined following a needs assessment and guidance from GOM and NAC.
2. Program Areas: Laboratory infrastructure; Strategic information; Health systems; strengthened supply chain management; Human capacity development including human resources for health and social welfare.
3. Key Policy Reform
   • Lab: Establish national government leadership in expanding and increasing the quality of laboratory services, including development of a new national laboratory strategy (Tier 1)
   • HMIS: Name-based confidential referrals allowed to enable electronic data systems (EDS) to capture pre-ART patients (see Goal II) (Tier 1)
   • Commodities/Procurement: Use the GFATM central coordinated procurement assistance while in-country reform processes develop (Tier 1)
   • Health Finance: National Health Accounts (NHA; National AIDS Spending Accounts (NASA)) developed (Tier 2) and institutionalized.
4. Five Year Benchmarks/Measurements of Success
   • Lab: The proportion of patients starting treatment based upon CD4 criteria is raised to 75percent, from the current level of approximately less than 25percent.
   • HMIS: At least 33percent of patients in the national care and treatment program are tracked within the EDS
   • Commodities/Procurement: HIV commodities are fully-integrated into the nation supply chain system with other health commodities through Central Medical Stores (CMS) by the end of the five years
   • Human Resources: Increased percentage of the vacant positions in MOH and MOWCD filled and increased percentage of new graduates from the pre-service training schools entering the workforce in Malawi.

Discrete and targeted investments in these 5 systems-strengthening areas are pivotal to enabling the achievement of the Framework’s other 3 goals. For example, improved laboratory support for timely CD4 testing and early infant diagnosis would make it possible to initiate more adults and children on treatment in a timely fashion in order to prevent their mortality (Goal II), while also enabling the identification of more treatment-eligible pregnant women who can receive ART to prevent mother-to-child transmission of HIV (Goal I). Similarly, investments in the HMIS and strengthening data use can improve the quality of care and treatment services (Goal II) by helping to reduce loss-to-follow-up of patients and provide better information to health care providers and managers. Commodities, including ARV drugs, test kits, condoms, and medicines for opportunistic infections, are necessary for both the prevention and care and treatment goals of the agreement to be achieved (Goal I and Goal II). Strategic investments in strengthening human resources and financial systems in the health and social welfare sectors can enhance the sustainability of all three goals, helping to ensure that prevention gains are maintained and future generations of Malawians receive services that continue to improve in quality.

Through these focused investments in key areas of system strengthening, GOM, with support from PEPFAR, plans not only to support the achievement of HIV/AIDS objectives, but also to support Malawi’s broader national goal of achieving a strengthened health system as part of the Malawi Growth and Development Strategy. The five-year strategy for Health Systems Strengthening during the life of the Framework is to invest in lab systems that support service delivery in the health sector; support GOM build its information systems, add human capital to the health sector and provide targeted inputs around health finance and commodities and procurement. The Framework provides an opportunity to impact the broader health system in a deliberate and positive manner, and to partner with other development partners to find solutions that are sustainable - preventative maintenance, rather than a repair and replacement strategy.

2.2 TABLE 1: GOALS AND HIGH LEVEL COMMITMENTS

3. PARTNERS: ROLES AND COMMITMENTS

Substantial support for the national response in Malawi is provided by the Ministry of Finance, GFATM, DFID, The Kingdom of Norway and the World Bank (HIV Pool Funding Partners (PFP)). This new Partnership Framework is supported and welcomed by these stakeholders. PEPFAR and UNAIDS joined the PFP group in a new oversight arrangement formed in 2009 to provide consistent support from the largest partners under one mechanism (see Section 5 below and Appendix 1).

The UN under the new United Nations Development Assistance Framework (UNDAF) (2008-2011) plans to work with the Partnership Framework to improve planning through shared operational plans with the GOM to avoid duplication of efforts related to OVC, PMTCT, labs, coordination, treatment, procurement and supply chain, workplace policy efforts, data management and policy advocacy. The UN, in particular UNAIDS, has a comparative advantage in mobilizing resources for technical assistance, coordinating development partners, and advocacy. WHO and UNICEF serve as strong partners in several aspects of the national response.

Several large indigenous partners including the Lighthouse Trust, the National Association of People Living with HIV/AIDS in Malawi (NAPHAM), the Malawi AIDS Counseling and Testing Organization (MACRO), the Malawi Business Coalition Against HIV/AIDS (MBCA), Malawi Interfaith AIDS Association (MIAA), Baobab Health Trust, and the Christian Health Association of Malawi (CHAM) are jointly supported by GOM and PEPFAR. Under this Partnership Framework, the GOM intends to partner with PEPFAR, the Pool Partners and the UN family to build the technical, financial, and management capacity of civil society and the private sector in a strategic manner.

In its support for GOM, PEPFAR intends to seek to further leverage financial and technical resources of the private sector and non-governmental development partners, attempting to intentionally link the programs they support to the private sector and also to develop public-private alliances through which United States Government assistance can complement the support of other private development partners in areas such as OVC service delivery and improving the quality of care and treatment. The support of private development partners and companies for many programs in Malawi is currently not well-captured under the NAF arrangements since reporting is voluntary and not a GOM requirement. Through maximizing public-private alliances, GOM intends to enhance sustainability and coordination between development partners and implementers, including PEPFAR.

Architecture does exist in Malawi to ensure success of this Partnership Framework. The Pooled Funding Partners Group, TWGs, and the national annual reviews provide an excellent platform for alignment and harmonization of development partners and the GOM inputs with a focus on meeting annual performance goals and accountability of each partner (see Appendix1).

If U.S. assistance is provided directly to the GOM under this Partnership Framework, GOM contributions would be expected to meet host country cost sharing requirements under U.S. foreign assistance programs. Details regarding the GOM’s financial and/or in-kind contributions to programs under this Partnership Framework are to be provided in the Partnership Framework Implementation Plan.

4. PLANS FOR DEVELOPING THE PARTNERSHIP FRAMEWORK IMPLEMENTATION PLAN

Success of this Partnership Framework is dependent on an effective implementation plan that is jointly implemented by the GOM through MOH, NAC, PEPFAR and all partners. The opportunity presented by the NSA application to the GFATM is recognized by all parties in country as a truly watershed moment in which effective planning in key areas should contribute to major successes in the 5-year timeline of the Framework. Two guiding principles for the implementation have been promoted by the GOM:

• Commitment to joint planning of activities to achieve the overall goals of the NAF
• Commitment by the GOM to promote the types of policy, strategies and guidelines which should help sustain joint investments

5. MANAGEMENT AND COMMUNICATIONS

An effective joint governance system has been put in place by GOM and Partners to oversee implementation of this Partnership Framework.

• Technical Oversight: This Partnership Framework intends to utilize existing in-country coordination mechanisms such as the fifteen technical working groups to plan and execute technical support to achieve the goals of the NAF. Annual reviews of the Framework may be incorporated into national systems and occur at the bi-annual and annual reviews of the HIV and AIDS and health sector reviews by the GOM.
   
• Strategic Oversight: To coordinate with Pool Partners, Partnership Framework implementation should be reviewed within the quarterly meetings that currently take place between the Pool Funding Partners, and the GOM through NAC. These meetings are expected to include the NAC, MOH, and MOWCD, and have Civil Society representation.
   
• Use of the Malawi Global Fund Coordinating Committee (MGFCC): PEPFAR and the GOM intend to incorporate this Partnership Framework into the CCM structure such that oversight provided to GFATM grants can also monitor the Framework progress. The MGFCC consist s of representatives of the GOM, the NGO community; the faith based community, the private sector, civil society and development partners. Over the five-year period, PEPFAR and the GOM plan to strengthen the MGFCC.
   
• High Level GOM oversight of the Partnership Framework: Oversight should be provided through meetings between the President of the Republic of Malawi, the Minister of Finance, the Minister of Health, the Chief Secretary to the President and Cabinet and the U.S. Ambassador to Malawi.

Appendix 1⁶

¹Some development partners such as the United Kingdom’s Department For International Development (DFID) retain approximately $1.6M USD per year for discrete programming.

²NAF Goal: To reduce new HIV infections in Malawi. Core Indicators: HIV prevalence among pregnant women (15- 24 yr) attending ANC – baseline 12.3% (2007); 2010 (12%); 2012 (11%); HIV incidence rate among adult population (15-49) - baseline 1.6 (2007); 2010 (1.4); 2012 (1.0)

³ Tier 1 – success expected in the short term; Tier 2 – success expected in the medium term; Tier 3 – success anticipated in the long term and requires extensive consultations and high level advocacy

⁴ NAF Goal: To provide and expand equitable treatment for PLHIV and mitigate the health impact of HIV and AIDS. Core Indicators Percentage of adults with HIV still alive 12 months after initiation of ART. Baseline (76%); 2010 (80%) 2012 (85%): Number of people alive and on ART in Malawi

⁵ Guideline 2.61 - "CT should be done anonymously without a client’s name or information being linked to HIV status, service or medical records. The request for HIV testing and test results are provided using unique identifiers (code numbers) rather than client names. This form of identification adds to clients’ confidence in and acceptance of the services. No written result should be provided to clients after testing, except where CT service is being used as an entry point for other medical services provided for in the guidelines document."

⁶ U.S. Agencies who implement PEPFAR report to the Office of Debt and Aid in the MOF and currently support the NAF at the level of the NAC, MOH, LA and Civil society. The Government of Malawi (GOM) established two funding streams for support to the health sector: The HIV/AIDS pool is managed by the NAC and the Health Sector pool governed by an MOU in the MOH. HIV/AIDS Sector is supported through the Pool Funding Partners - the GFATM, the British Government’s Department For International Development (DFID), The Kingdom of Norway, and the World Bank through the Second Multi-Country HIV/AIDS Program (MAP2) for the Africa region. The Health Pool partners are DFID, Norway, GFATM, the German Government, UNFPA and UNICEF. DFID, Norway and the European Union also provide budget support to Treasury which the GOM may use as it sees fit including disbursing into the health sector. Funds are deposited into pool accounts in the Treasury Department of the MOF. Each pool partner agrees when its disbursements will be made in an attempt to assure predictability of funding at the start of the funding cycle. However GFATM is performance based and its disbursements cannot be on a predictable cycle. Nonetheless, Treasury makes predictable disbursements quarterly to the MOH. GOM and Development Partners pool financial resources in one basket and fund agreed upon priorities. A joint M&E plan is utilized; Joint procurement /financial/M&E audits used; Joint reporting and joint reviews used. The Health Sector is funded by GOM through two streams: funds go to the MOH and funds go to the district local assemblies. These resources support the delivery of “milestones” determined from the annual review of the program of work for the health sector that supports eleven high burden diseases including HIV/AIDS, TB and Malaria.

The NAC makes disbursements into the HIV sector through a Grants Management Unit. Proposals are sent to NAC to support the integrated annual work (IAWP) which NAC reviews and funds. The IAWP is created from two separate work plans: one developed by NAC that addresses the NAF, the GFATM activities and targets, and the aide memoire from the preceding national reviews. The second comes from the districts that prepare one district implementation plan (DIP) for all sectors in the district and receive funding from MOLG through the LA for the health sector, and from NAC for the HIV sector. NAC receives monthly, quarterly and annual reports from all GROs, and carries out audits to monitor performance and check data quality.

MOF – Ministry of Finance; NAF – National Action Framework; NAC – National AIDS Commission; MOH – Ministry of Health; LA – Local Assembly; MOWCD – Ministry of Women and Child Development; MOLG – Ministry of Local Government; MOE – Ministry of Education; MDF – Malawi Defense Force; OPC – Office of the President and Cabinet; GRO – Grant Recipient Organization