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10
Progress Toward Transitioning to a Sustainable Response in Partner
Countries
Main Messages
PEPFAR is actively engaging in activities and processes to transition to a more
sustainable response in partner countries.
Country Ownership has not always had an agreed-upon definition once it was
adopted from the development assistance lexicon and applied to PEPFAR. Recent
efforts by OGAC have provided clarity for its definition and how partner countries should
assess their achievement of its critical components.
OGAC sees country ownership as a fundamental element of progress toward more
sustainable management of the HIV/AIDS response by partner country governments and
other relevant and engaged stakeholders in the country. In the transition to increasing
country ownership, by necessity, PEPFAR will gradually cede control as partner
countries adopt more dominant roles in setting strategic priorities for investments in their
HIV response and in accounting for their results.
The transition to a more country-led and -sustained response will take time; it cannot
be achieved on a proscribed generic timeline for all PEPFAR countries. It will be affected
by many criteria and decisions, which will vary by country, including where the country
falls in the country ownership spectrum when it is evaluated across all four domains of
political ownership and stewardship, institutional and community ownership, capabilities,
and mutual accountability including finance. Along the way, major dilemmas, such as
differences in how to prioritize services and target populations, will require mutual
resolution. Inherent risks during the transition period may be reaching smaller targets,
reduced service access, or the diminishing of the quality of services, programs, and data.
At the same time, greater embedding of HIV services in national health systems may
offer opportunities for better integration of care, greater efficiencies, and broader health
benefits.
PEPFAR has focused efforts on capacity building for all levels of stakeholders and
attempts to bring many stakeholders to participate in the planning and oversight
processes for the Partnership Framework Implementation Plan for country-led response
and leadership but with multsectoral participation. It will be a serious impediment to
country ownership if the stakeholders expected to be involved in a country’s HIV
response do not all build their capacity.
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The over-reliance on external donor funding in partner countries creates funding
fragility and the possibility that the HIV response would be critically disrupted if funding
were to be discontinued or severely reduced. It is not realistic to expect that partner
countries would be able to independently finance the entirety of HIV programming as it is
currently implemented. Yet, this does not abate the importance of partner country
governments finding ways to reduce the fragility and dependence of their response by
increasing their funding contributions, diversifying the sources of external funding that
they receive, and making efficient, albeit difficult, strategic decisions about the use of
available resources. Even when countries are not able to substantially increase their own
funding for HIV/AIDS or health, it is critically important that they demonstrate the
leadership to understand their current and future needs by developing their own
resources plan, including the responsibility they will undertake to mobilize the needed
resources.
Recommendations Discussed in This Chapter
Recommendation 10-1: To contribute to a country-owned and sustainable
HIV response, the Office of the U.S. Global AIDS Coordinator should
develop a comprehensive plan for long-term capacity building in partner
countries. The plan should target four key areas: service delivery, financial
management, program management, and knowledge management.
Further considerations for implementation of this recommendation:
In all four key areas, OGAC should invest more resources in initiatives for
long-term capacity building and infrastructure development such as
strengthening in-country academic institutions, degree programs, and long-
course trainings, to improve in-country capacity and to accelerate progress
toward country ownership and sustainability. These investments should foster
the placement and retention of trained personnel in partner countries.
These initiatives should be monitored routinely at the country level to assess
progress and identify necessary modifications. Special periodic multi-country
studies could be used to evaluate the outcome and impact of the PEPFAR
capacity building initiative. To achieve this, OGAC should, using input from
country programs, identify milestones towards achieving specified goals,
define core metrics to assess capacity building efforts, encourage innovative
approaches through pilot initiatives and develop tools to help country
programs monitor and evaluate these efforts, and encourage innovative
approaches through pilot initiatives.
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Recommendation 10-2: Building on the Partnership Framework
implementation process, PEPFAR should continue to work with partner
country governments and other stakeholders to plan for sustainable
management of the response to HIV. PEPFAR should support and
participate in comprehensive country-specific planning that includes the
following:
Ascertain the trajectory of the epidemic and the need for
prevention, care and treatment, and other services.
Identify gaps, unmet needs, and fragilities in the current
response.
Estimate the costs of the current response and project
resource needs for different future response scenarios.
Develop plans for resource mobilization to increase and
diversify funding, including internal country-level funding
sources.
Encourage and participate in country-led, transparent
stakeholder coordination and sharing of information
related to funding, activities, and data collection and use.
Establish and clearly articulate priorities, goals, and
benchmarks for progress.
Further considerations for implementing this recommendation:
PEPFAR is not alone in trying to achieve locally-led, sustainable health and
development objectives. Contributing stakeholders, including partner
countries, will need mutually-agreed, principle-based resource allocation to
achieve a strategic and ethical balance among the priorities of maintaining
current coverage, expanding to meet existing unmet needs, and increasing
coverage eligibility. Having processes in place to support this arduous
decision making is a critical part of achieving sustainable HIV programs and
sustainable management of the HIV epidemic in partner countries.
Partners in developing resource mobilization plans and potential sources for
more diverse funding and other resources could include national and
subnational governments other bilateral donors, multilateral agencies, global
and regional development banks, and private sector consultants.
There may be learning opportunities at both headquarters and country level
for PEPFAR and other USG entities involved in development assistance to
exchange strategies, best practices, and lessons learned for sustaining
development objectives.
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10
Progress Toward Transitioning to a Sustainable Response in
Partner Countries
For years, donors have been globally responding to the challenge of HIV/AIDS in many
countries by funding efforts to avert new infections, to provide treatment and other clinical and
psychosocial support services to people living with and affected by HIV/AIDS, and to assess and
strengthen the general societal response, including the health and other sectoral systems. The
largest portion of these resources has been provided by the bilateral support of the U.S.
government through PEPFAR, as well as by its support to the Global Fund (Kates and Summers,
2004). Given that the burden of the disease has historically been highest in low- and middle-
income countries, especially those in sub-Saharan Africa, the focus has been the provision of
emergency assistance to countries with many competing development and health needs that were
often addressed though fragile and frequently deficient health systems. This type of emergency
assistance is akin to global responses to natural disasters, albeit the sheer scope and magnitude of
the resources needed to accomplish the current achievements in HIV prevention, treatment, and
care is unprecedented for a single-disease focus.
The global landscape is changing. Some countries with high or growing HIV prevalence
may still need more urgent and immediate efforts, but in many countries HIV has become more
endemic and there has been commensurately growing expectation from the global community
about a country’s own ability to sustain, and to even expand, its HIV response to meet and
manage the trajectory of growing need for prevention and intervention services for its
population, as well as to sufficiently address coverage gaps in all services. In addition, the
current depressed and tumultuous economies in donor countries is affecting the way in which
countries are viewing and in comes cases revamping their development aid strategies.
PEPFAR’s progress in transitioning to a more sustainable response in PEPFAR partner
countries was not explicitly identified in the legislative mandate as a content area for this
evaluation. Nonetheless, given that this was a major goal set forth in the Lantos-Hyde Act of
2008 and the second PEPFAR Five-Year Strategy, in the planning phase for the evaluation it was
determined to be an essential element underlying the whole of the requested assessment across
specific content areas requested by Congress (IOM and NRC, 2010).
During the timeframe of this evaluation, PEPFAR was early in the implementation of
changes to in response to the reauthorization, including efforts to improve sustainability of the
response over time, to enhance coordination with partner governments and other global funding
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10-1
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10-2 EVALUATION OF PEPFAR
partners, and to support accountable ownership of HIV program delivery by countries
themselves. The timing of this evaluation made it difficult to assess the outcomes or impact of
these recently implemented changes, for which the full effect might not be realized for several
years or even decades. Therefore, the committee assessed efforts in these areas in order to
understand whether PEPFAR is making reasonable progress toward its goals for sustainability
To present that assessment, this chapter begins with some brief background on the
evolution of U.S. and global approaches to increasingly focus on sustainability. This is followed
by a discussion of country ownership, which the Office of the U.S. Global AIDS Coordinator
(OGAC) has identified as one of the most crucial elements that influences sustainability. This is
followed by sections on other important elements and efforts related to sustainability and on the
most critical barriers to achieving country ownership and sustainability. Finally, the chapter
presents the committee’s overall conclusions and its recommendations for how PEPFAR efforts
can be improved to ensure that the evolving goals for sustainability can be met.
EVOLUTION OF THE U.S. RESPONSE TO GLOBAL HIV
The Emergency Response
The first chapter of this report outlined the origins of the U.S. government’s bilateral
emergency response to the HIV/AIDS pandemic (PEPFAR I) and the second iteration of the U.S.
government’s global contribution to the HIV pandemic (PEPFAR II). The authorizing
legislation of PEPFAR I emphasized rapid implementation and scale-up of interventions and
services and established programmatic goals and objectives for prevention, treatment and care
activities as well as fiscal targets for some of these areas. It specifically identified 14 focus
countries that received the bulk of the initial, intense PEPFAR investment (a 15th focus country
was later identified); these were known as the “focus” countries. It also described the essential
elements for program implementation (see Chapter 3 for more information on PEPFAR’s
organization and implementation). While the focus as an emergency suggested a time-limited
response, PEPFAR’s authorizing legislation did suggest the need for sustainability of some key
interventions and areas to
“Expand [the] basic interventions to prevent new HIV infections and to bring care and
treatment to people living with AIDS, such as voluntary counseling and testing and
mother-to-child transmission programs, [that] are achieving meaningful results and are
cost-effective, from a pilot program basis to a national basis, in a coherent sustainable
manner.” 1
A sustainable supply of quality “HIV/AIDS pharmaceuticals, antiretroviral therapies, and
other appropriate medicines.” 2
“Promote sustainability for medical and support services to HIV positive parents and
their children identified through existing programs to prevent mother-to-child
transmission” that were established though a pilot program authorized by the President. 3
1 United States Leadership against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, Public Law 108-25, 108th
Cong.,1st Sess. (May 27, 2003) §2(16).
2 Ibid. §301(a), 22 U.S.C. 2151 §104A(d)(5)(C).
3 Ibid. §315(a).
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PROGRESS TOWARD A SUSTAINABLE RESPONSE 10-3
While there was limited direction mention of sustainability beyond the larger emergency
response, these examples do indicate that Congress intended at the beginning of the program that
some activities would not only continue into the future, but would also be expanded to national-
level programs in a coherent manner.
Toward a Sustainable Response
The Lantos-Hyde Act of 2008 reauthorized PEPFAR and it differs significantly from the
emphasis of PEPFAR I by specifically focusing on a transition to activities and goals intended to
contribute to a more sustainable HIV response in and by partner countries. 4 Even after the
Lantos-Hyde Act, the Center for Strategic and International Studies’ Commission on Smart
Global Health Policy report in 2010 continued to call for “maintaining the USG commitment to
fight HIV/AIDS, malaria, and tuberculosis on a consistent trajectory” as part of a smart, long-
term global health policy that would also see an “ushering in of a new era where partner
countries take ownership of goals and programs” (Fallon and Gayle, 2010, p. 9) and would use
the leverage of existing disease-focused investments to build longer-lasting health systems and
partner country capacity solutions to address health needs.
The previous Institute of Medicine (IOM) evaluation of PEPFAR recommended that “the
U.S. Global AIDS Coordinator should continue to focus on planning for the next decade of the
U.S. Global AIDS Initiative, taking full advantage of the knowledge gained from the early years
of PEPFAR about the focus countries’ epidemics and how best to address them. The next
strategy should squarely address the needs and challenges involved in supporting sustainable
country HIV/AIDS programs, thereby transitioning from a focus on emergency relief” (IOM,
2007 p.6). There has been clear uptake of these recommendations in the reauthorization
legislation that calls for “a longer-term estimate of the projected resource needs, progress toward
greater sustainability and country ownership of HIV/AIDS programs, and the anticipated role of
the United States in the global effort to combat HIV/AIDS during the 10-year period beginning
on October 1, 2013.” 5 Additionally, the Lantos-Hyde Act called for a USG commitment to
“help partner countries to develop independent, sustainable HIV/AIDS programs.” 6 Various
other sections of the reauthorization legislation promote the idea of sustainable approaches for
programs, activities, and initiatives, including the statement that the USG should “help countries
to assume leadership of sustainable campaigns to combat their local epidemics [that] should
place high priority on
(A) the prevention of the transmission of HIV;
(B) moving toward universal access to HIV/AIDS prevention counseling and services;
(C) the inclusion of cost sharing assurances that meet the requirements under section 110;
and
4
Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008, Public Law 110-293, 110th Cong., 2nd sess. (July 30, 2008).
5
Ibid, §101, 22 U.S.C. 7611(a), (a)(29).
6
Ibid §301(a)(2), 22 U.S.C. 2151b-2(a), §104A(b)(1)(D).
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10-4 EVALUATION OF PEPFAR
(D) the inclusion of transition strategies to ensure sustainability of such programs and
activities, including health care systems, under other international donor support, or
budget support by respective foreign governments.” 7
The Lantos-Hyde Act also identified compacts and framework agreements (also
discussed in Chapter 9 on Health Systems Strengthening) that would be important tools to assist
in the transition towards sustainability. The purpose of such compacts and agreements are
aligned with the type of assistance provided by the USG (direct services or limited technical
assistance connected to services in countries or regions—both of which are discussed in
subsequent sections of this chapter). The reauthorization legislation also identified the need for
an updated, comprehensive, 5-year global strategy that called for maintaining gains to date in the
respective technical areas. Specific strategic components for sustainability were also identified in
the reauthorization legislation including:
Requirements supporting “descriptions of criteria for selection, objectives, methodology,
and structure of these frameworks with countries or regional organizations including the
role of civil society, the degree of transparency, the benchmarks for success, and the
relationship between such agreements and the national HIV/AIDS and public health
strategies and commitment of partner countries” 8
Approaches to address investments in health by external donors and increased national
funding for HV/AIDS with “descriptions of capacity-building efforts undertaken by
countries themselves that included assessments of the impact of IMF macroeconomic and
fiscal policies on national and donor investments in health.” 9
Definition of Sustainability
Neither the authorizing legislation nor the subsequent PEPFAR strategies or annexes
formally define sustainability. For the purposes of this evaluation, the definition proposed by the
Development Assistance Committee of the Organisation for Economic Cooperation and
Development (OECD-DAC) is used. It defines sustainability as “the continuation of benefits
from a development intervention after major development assistance has been completed”
(Development Assistance Committee, 2002). 10 Given the focus of programmatic efforts that are
funded by many external donors, development assistance should be viewed not strictly as
financial, but should also be thought of as technical and managerial assistance (Merson et al.,
2012). While the continuation of benefits into the future is the ultimate goal, PEPFAR’s
strategies and the Paris Declaration on Aid Effectiveness suggest a number of intermediate
outputs or outcomes posited to improve sustainability:
Affordability, which is the extent to which countries can bear the cost of programs,
7
Supra., note 4 at §301(a)(2), 22 U.S.C. 2151b–2(a) , §104A(b)(3)(a-d).
8
Ibid. §101, 22 U.S.C. 7611(b), §101(b)(2)(S)(i-iv).
9
Ibid. §101, 22 U.S.C. 7611(b), §101(b)(2)(Q).
10
Two alternate definitions are also offered but are not being used by the IOM evaluation committee: (a) “the
probability of continued long-term benefits”; and (b) “the resilience to risk of the net benefit flows over time.”
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PROGRESS TOWARD A SUSTAINABLE RESPONSE 10-5
Efficiency/cost-effectiveness as a measure of how economic resources or inputs such as
funding, expertise, and time are converted to results (Development Assistance
Committee, 2002),
Country capacity, which is the ability of the government, the private sector, and civil
society to “plan, manage, implement, and account for results of policies and programs”
(OECD, 2005, 2008), 11 and
Coordination and harmonization with donors and governments to “implement common
arrangements at country level for planning, funding, disbursement, monitoring,
evaluating and reporting to government on donor activities and aid flows” (OECD, 2005,
2008). 12,13 It is also important that this harmonization, reporting, and accountability be
multidirectional, flowing between and among donors and partner country governments, to
demonstrate transparency as part of their communication, coordination, and
collaboration.
These outputs and outcomes are resonant with the new PEPFAR emphasis on
sustainability for HIV/AIDS responses: they must be “country-owned” and “country-driven;”
“address HIV/AIDS within a broader health and development context,” and “build upon
strengths and increase efficiencies” (IOM and NRC, 2010).
Global Accords That Influence Sustainability
PEPFAR’s new 5-year strategy also stated that management of the response to HIV and
its effects must not only be increasingly planned and led by countries, with support from bilateral
or multilateral partners and national funding, but also increasingly owned with processes of
monitoring, evaluating and responding to the unique characteristics of the epidemic in their
countries (OGAC, 2009a). These objectives are aligned with the principles of country ownership,
leadership and governance, harmonization of donor and partner county government priorities and
activities, and national responsibility for a country’s social and economic development
articulated in several global accords that are framing OGAC’s strategies and activities that
support sustainability of responses. A number of select global accords, summarized in Box 10-1,
influence PEPFAR’s efforts and goals for transitioning to sustainable HIV responses. Box 10-2
lists indicators to measure progress and achievements of the Paris Declaration in the areas of
ownership, alignment, harmonization, measuring for results, and mutual accountability—
principles that are discussed in PEPFAR’s concepts of country ownership and in the Partnership
Frameworks and Partnership Framework Implementation Plans, which are all discussed in
subsequent sections of this chapter.
11
The Paris Declaration does not specify whose capacity within countries this defines, but it is assumed to be the
government’s capacity. Thus, this proposed definition is somewhat broader.
12
Harmonization is explained as the “donor countries coordinate, simplify procedures, and share information to
avoid duplication.”
13
As the extent to which PEPFAR has contributed to harmonization has been evaluated by the U.S. Government
Accountability Office, it will not be explicitly addressed in the present evaluation.
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10-6 EVALUATION OF PEPFAR
BOX 10-1
Select Global Accords That Influence Sustainability of HIV/AIDS Responses
Abuja Declaration (2001)
In 2001, African heads of state gathered at a special summit in Abuja, Nigeria, focused on HIV/AIDS,
tuberculosis, and other related infectious diseases. They undertook an assessment and critical review of the
consequences of these diseases in Africa. The importance of other agreements and action plans for HIV/AIDS
from African development forums was also acknowledged. These leaders made several pledges, including to
increase spending on health to at least 15 percent of government spending in what became known as the Abuja
Declaration on HIV/AIDS, Tuberculosis, and Other Related Infectious Diseases.
The Monterrey Consensus on Financing for Development (2002)
The United Nations’ International Conference on Financing for Development held in Monterrey, Mexico,
in 2002 resulted in a consensus that has since been adopted as a major reference for what constitutes good
international aid cooperation. Attendees at the conference committed to “address the challenge of financing for
development around the world, particularly in developing countries . . . [with the goal] to eradicate poverty,
achieve sustained economic growth, and promote sustainable development” (United Nations, 2003). It
emphasizes six key areas of financing for development including but not limited to mobilizing domestic and
international financial resources for development; external debt; and addressing systemic issues to enhance
coherence and consistency in using international monetary, financial, and trading systems to aid in development.
It also emphasized the primary responsibility each country has for its economic and social development, further
highlighting the importance of external donors committing to the use of development frameworks that embody
poverty reduction strategies and that are “owned and driven by developing countries” (United Nations, 2003).
The Paris Declaration on Aid Effectiveness (2005)
This declaration, in which signatories from the governments of more than 90 donor and developing
countries, as well as multilateral development organizations, development banks, and other international
agencies resolved to “take far-reaching and monitorable actions to reform the ways we deliver and manage aid,”
represented a new paradigm with broad international consensus on how to make aid more effective (OECD,
2005). The concept of country ownership is at the heart of the Paris Declaration and is a key guiding document
for OGAC’s newly articulated definition and strategy for country ownership. With the five fundamental principles
of ownership, alignment, harmonization, managing for results, and mutual accountability, the Paris Declaration
emphasizes the importance of strengthening the national systems in low- and middle-income countries by
building measurable development capacity to strengthen public financial management capacity and national
procurement systems in countries. The Declaration also has a monitoring and evaluation component to promote
the concept of mutual accountability with diagnostic reviews and performance assessments by outlining 12
indicators for national measurement and international monitoring progress on the five principles with defined
targets for 11 of their proposed indicators (see Box 10-2).
Accra Agenda for Action (2008)
Signed at the Third High Level Forum on Aid Effectiveness in Accra, Ghana by Ministers of low- and
middle-income and high income countries, as well as heads of multilateral and bilateral development institutions,
the Accra Agenda for Action recognized that the international community had made progress on the
implementation of the Paris Declaration, but that more needed to be done and at a faster pace to meet targets as
set and measured by the Declaration. The Accra Agenda highlighted three focus areas for more intense and
faster-paced action: (1) strengthening country ownership over development by having countries strengthen their
capacity to lead and manage development,( 2) building more effective and inclusive partnerships for
development by harnessing the energy, skills, and abilities or all stakeholders including external donors, civil
society, and the private sector; and (3) delivering and accounting for development results by focusing on greater
transparency and increasing the medium-term predictability of aid (OECD, 2008).
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PROGRESS TOWARD A SUSTAINABLE RESPONSE 10-7
BOX 10-2
Indicators to Measure Progress and Achievements of the Paris Declaration
Ownership: Percentage of partner countries have operational development strategies, including Poverty
Reduction Strategies, that have clear strategic priorities linked to medium-term expenditure frameworks and are
reflected in annual budgets.
Alignment: Reliable country systems—number of partner countries that have procurement and public financial
management systems that either (a) adhere to broadly accepted good practices or (b) have a reform program in
place to achieve these. Aid flows are aligned on national priorities – Percent of aid flows to the government
sector that is reported on partners’ national budgets. Strengthen capacity by coordinated support – Percent of
donor capacity-development support provided through coordinated programs consistent with partners’ national
development strategies. Use of country public financial management systems – Percent of donors and of aid
flows that use public financial management systems in partner countries, which either (a) adhere to broadly
accepted good practices or (b) have a reform program in place to achieve these. Use of country procurement
systems – Percent of donors and of aid flows that use partner country procurement systems which either (a)
adhere to broadly accepted good practices or (b) have a reform program in place to achieve these. Strengthen
capacity by avoiding parallel implementation structures – Number of parallel project implementation units (PIUs)
per country. Percent of aid disbursements released according to agreed schedules in annual or multi-year
frameworks and Percent of bilateral aid that is untied.
Harmonization: Use of common arrangements or procedures – Percent of aid provided as program-based
approaches and encouragement of shared analysis – Percent of (a) field missions and/or (b) country analytic
work, including diagnostic reviews that are jointly performed.
Managing for results: A Results-oriented frameworks – Identity the number of countries with transparent and
performance assessment frameworks that could be monitored to assess progress against the national
development strategies and sector programs.
Mutual accountability: Number of partner countries that undertake mutual assessments of progress in
implementing agreed commitments on aid effectiveness including those in this Declaration.
SOURCE: (OECD, 2005)
The Role of Health Diplomacy
According to Katz et al. (2011), global health diplomacy has several different meanings,
but it is a term regularly used by policymakers and academics as the utilization of “new
mechanisms to implement ambitious global health initiatives while at the same time securing
favorable perceptions in a changing diplomatic space . . . with activities ranging from formal
negotiations to a vast array of partnerships and interactions between governmental and
nongovernmental actors” (Katz et al., 2011). By early design, high-level embassy staff,
specifically country Ambassadors and Deputy Chiefs of Mission (DCMs), have been actively
engaged in PEPFAR implementation and oversight. According to Collins et.al (2012) health
diplomacy has in some cases, also been a strong tool for the USG to promote the connection
between human rights and health by encouraging partner governments to weigh the scientific
evidence and the possible consequences for the country’s epidemic when determining whether
national policies would jeopardize the country’s HIV/AID response by marginalizing or
excluding key vulnerable populations from access to HIV/AIDS services.
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10-38 EVALUATION OF PEPFAR
PEPFAR funding were withdrawn. Some interviewees in national planning positions stated that
their national attention to HIV prevention had waned and prevention as a stronger part of the
national response needed re-emphasis (166-7-PCGOV; 636-4-PCGOV; 240-ES) to yield a longer return
investment to reduce incidence, which in turn makes sustainability more likely (934-12-CCM). A mix
of USG and partner country interviewees identified a shift to prevention activities as a step on
the path to sustainability (240-2-USG; 331-43-USG; 587-1-USG; 116-23-USPS; 461-10-PCNGO; 934-12-CCM). There was
more concern among participants in different countries about the reach of prevention messaging
and the differential coverage for funding allocated to support population-based prevention
messages compared to the coverage and reach for the amount of funding supporting individual
treatment activities:
“So we would rather have, it’s more sustainable to have
prevention than treatment. And prevention is cheaper. Prevention
is much, much cheaper than treatment. You talk about messages on
TV, messages on radio. . . . But you do that one message for eight
thousand dollars, you reach the 7 million, 15 million people, I
mean, 13 million people in [this country] by one message, for a
thousand dollars. But you procure ARVs for a thousand dollars
that don’t reach that number of people. And they need such
procurements every other time. So prevention to sustain this one is
a key issue.” (934-12-CCM)
The most frequently repeated concern, across most countries by all types of stakeholders
and across multiple interviews in a country, was how inadequate supply chain management could
have crippling effects on prevention programs without continued a supply of condoms, test kits,
reagents, and circumcision kits (636-16-USG; 636-19-USNGO ;166-5-USG; 166-13-PCGOV; 396-12-USG; 934-45-USNGO;
934-18-PCGOV; 934-39-PCGOV; 116-18-PCNGO; 542-8-USNGO):
“There are [national] condom manufacturers and with donors
leaving, having a huge number of free condoms or even socially
marketed condoms is just completely unsustainable. So we’re
really working now towards trying to stimulate [this country’s]
condom market to get them to be a lot more engaged. It turns out
that there . . . I know there’s about 300 different brands of
condoms. A lot of them—even within the price range of the
socially marketed condoms available” (396-12-USG).
At the 14th International AIDS Conference, Ambassador Eric Goosby publicly reinforced
his concerns when he expressed that he is humbled by the fact that all of the programmatic and
collective progress in the individual and population cascade from prevention to treatment can be
seriously affected, if not completely disrupted, due to inadequate supply chain management
issues in a country.
The Integration of PEPFAR and other U.S. Programs
Though the committee was not tasked with evaluating the Global Health Initiative (GHI),
it is at least important to acknowledge that this initiative, which was launched by President
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PROGRESS TOWARD A SUSTAINABLE RESPONSE 10-39
Obama in May 2009, PEPFAR is reported to serve as a central part of GHI as the largest U.S
bilateral health program, affording a “forum for interface between PEPFAR and other U.S.
programs in strengthening health systems, improving monitoring and evaluation, adopting a
woman and girl-centered approach to health and gender equity, and integrating across health and
development programs” (Goosby et al., 2012a).
“[OGAC] is responsible for the policy priorities of this program, but
OGAC does not work in isolation and you know there’s a deputy
principles group within OGAC that basically provide a lot of
recommendations to Ambassador Goosby that he then makes on behalf of
the program. But because our health programs are so integrated in
many countries we realize that we all need to go hand in hand, so we
can’t have a country ownership agenda for PEPFAR that USAID’s
maternal health program isn’t also considering. So we all came
together, we actually came together not just as PEPFAR, our dialogue
has included MCC as well who have a lot of good practices in country
ownership, and tried to have a common message that we could present to
partner governments around country ownership and what it is U.S.
government means.” (NCV-9-USG)
Technical Assistance and Longer-Term Capacity Building for the Global Fund
Despite the continuum of rate-limiters for capacity building efforts at any level,
PEPFAR’s alternate method for technical assistance could engage multiple stakeholders and
country leadership at different levels with its larger and longer-term capacity building for and
technical assistance to the Global Fund. As discussed in the Funding chapter, there is
collaboration and cooperation between the Global Fund and PEPFAR. Given that they are the
two largest sources of external funding in nearly every county, their existence and
collaborative relationship affect the performance of each. They have been described as having
different and complementary models of assistance from their very beginnings. With country
leadership, the new paradigm for the future response entails more joint planning, cognizance of
their shared responsibility to people who need their services, to donor countries, and to the
U.S. taxpayers to be assured of effective and efficient use of their resources (Goosby et al.,
2012b). The U.S. Congress permits the U.S. GAC “to withhold up to five percent of the
Foreign Operations appropriation for the U.S. contribution to the Global Fund to provide
technical assistance (TA) to improve grant implementation and build capacity. From FY 2005
through FY 2010, the Coordinator has made over $160 million available for centrally-funded
TA activities for Global Fund grants” (USG, 2011a). As previously discussed in the chapter on
Health Systems Strengthening, there are 19 USG-supported Global Fund Liaisons, requested
by the Mission Teams, placed into key bilateral and regional missions as part of the longer-
term capacity building and technical support for the Global Fund during the last 2 years. These
Liaisons “support Global Fund grant implementation and oversight including improving
coordination between USG bilateral programs and Global Fund-financed disease programs”
(USG, 2011a), can provide broad assistance for areas mentioned above or narrower technical
assistance, such as with Global Fund’s financed laboratory program, and they communicate
monthly with OGAC about issues in their respective countries (NCV-20-USG).
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10-40 EVALUATION OF PEPFAR
The USG-supported Grants Management Solutions (GMS) project was used to provide
shorter-term or more urgent technical assistance and grant management support to primarily the
Country Coordinating Mechanisms (CCMs) and the Principal Recipients in countries with
current Global Fund grants. 25 The purpose of this urgent attention was to “unblock bottlenecks
and resolve systemic problems that hinder the response to AIDS, tuberculosis, and malaria GMS
provides this support in four technical areas: Organizational development including leadership
and governance; Program and Financial Management; Procurement and Supply Management;
and Monitoring and Evaluation” (USG, 2011b). This headquarters-funded technical assistance
can augment rather than duplicate support already provided by USG teams through the USG
bilateral programs for the three focal diseases of the Global Fund, which can include
development of future Global Fund proposals as well as overall longer-term systems
strengthening and capacity building (OGAC, 2012a). The GMS program is coming to an end and
is being replaced with another iteration that will continue to focus on addressing these issues
(NCV-20-USG).
OGAC senior leadership recognizes the importance of the Global Fund as a large-scale
financing mechanism for the three diseases, especially where large-scale bilateral assistance is
not available in countries. However, the United States is leveraging its contributions to the
Global Fund from other donors to “multiply the impact beyond what U.S. dollars could do
alone” and for the two initiatives to discover new and complementary ways of doing business
(Goosby et al., 2012b). Within the last few years, OGAC developed a more strategic approach to
the use of PEPFAR-funded support for technical assistance to maximize the performance of the
Global Fund overall. Other PEPFR-supported efforts include improving their collaboration and
communication includes an appointed HQ-level liaison from OGAC to Global Fund
headquarters in Geneva beginning in 2011; the use of PEPFAR technical working groups and
field expertise to provide effectiveness and efficiency considerations for renewal of grants;
participating as a permanent member of the Global Fund Board; and review of Global Fund
issues during OGAC headquarters COP reviews (NCV-20-USG).
“Ambassador Goosby [wanted] . . . some kind of strategy, some
kind of approach that took this TA money, expended it in a way
that could show measureable results, and have a clear sense of
why it was expended in a certain way. . . So there’s a really very
active participation and really concern and desire for this
administration to see this Global Fund work in the best way
possible, in a way that’s the most efficient, the most effective, and
really to have an impact on what it is that we’re trying to do in
these countries, which is save lives.” (NCV-20-USG)
25
There are some exceptions to the eligibility for technical support for focus countries under PEPFAR I in which
PEPFAR team are instructed to address their technical support needs though their Country Operational Plans or for
countries that are listed by the U.S. State Department as sponsors of terrorism.
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PROGRESS TOWARD A SUSTAINABLE RESPONSE 10-41
KEY BARRIERS TO ACHIEVING COUNTRY OWNERSHIP AND SUSTAINABILITY
Financial Responsibility with High Numbers of External Donors and Large Magnitude of
External Assistance
Country contributions to their own HIV responses varied widely. Contrast, for example, a
contribution of 10 percent to the HIV response budget provided by one country—“This is quite
worrisome for the sustainability of the program” (166-16-PCGOV), with 70 percent of the budget
allocated by another country (272-ES). Of all donors, the USG provided the majority of funds in
support of the HIV response in countries visited (461-ES). In some cases, governments could
partially support their response (587-ES; 542-ES, 240-ES; 116-ES; 636-ES), but clearly not at the level afforded
by the support of PEPFAR and other donors. The likelihood of a country to sustain its own HIV
response without external funding (166-ES) and support was interrelated to issues that included
prevailing economic conditions (240-ES), political will (396-ES); prioritization of the response by the
government; deflection of attention to competing government priorities (166-ES), including other
prevalent and serious health problems (587-ES); level of donor contribution (461-ES), and capacity to
manage the response (166-ES) financially and in other ways. According to some interviewees, the
presence of so many donors and so much funding in a country may present a deterrent to country
acceptance of responsibility, including financial responsibility, for its HIV response (461-ES) with
some suggesting inviting contributions from the private sector (166-ES; 331-40-PCPS), shifting
treatment costs to the government (461-ES, 542-13-USG; 636-4-PCGOV), exploring innovative financing
such as social insurance schemes or performance-based financing (461-ES; 116-23-USPS) or requiring
matching funds between donors and the government (461-ES). Interviewees noted that the
consequences of generous donor funding and support of the HIV response led to reliance on
donors. Donor support could precipitate reduced or absent government urgency to allocate
funding earmarked for HIV/AIDS (461-ES) or use such funds as they were intended (272-ES). Willing
and generous donor support thus provided opportunities for governments to address other
pressing health issues (461-ES) or de-prioritize health in general (272-ES). In contrast, anticipation of
withdrawal of donor funding can serve as a trigger to leverage multiple funding sources for
national level HIV-related planning and budgeting and the country’s response (587-ES).
Timeline for Transitioning and Quality of Services
A recurring refrain by interviewees was the “need [for] time to plan” (587-ES, NCV-5-USACA)
for sustainability. Interviewees observed that sustainability cannot be undertaken in “fast
forward,” (396; NCV-9-USG, NCV-16-USG) but instead should be viewed as a gradual process (240-ES; 272-
ES). Above all, interviewees across stakeholders were concerned about achieving the transition
effectively and about finding efficiencies, such as task-shifting to nurse-provided ART and
reducing duplication among implementers, without having to sacrifice quality (272-ES, 240-ES, 587-ES,
116-ES NCV-24-USNGO). Interviews recognized that the process entails making arduous choices and
being selective about the best programs to offer.
Furthermore, interviewees observed that many countries were not yet ready yet to
shoulder complete responsibly (272-ES; 934-ES; 166-ES; 116-ES; 331-ES; 587-ES; 636-ES; 935-ES; 461-ES; 542-ES) for
their response given major gaps in resources, deficits in realistic planning (240-ES), and other
issues. One interviewee observed that “As an emergency response, PEPFAR was not designed to
be sustainable” (331-43-USG). For these countries, interviewees perceived the timing of the
transition to a country-led response to be critical (272-ES). In addition to a financial commitment
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10-42 EVALUATION OF PEPFAR
critical improvements were potentially needed in overall economic conditions (240-ES) as
(461-ES),
well as capacity and accountability. Government commitment to service delivery might require
both program improvement and scale up (272-ES). In order to achieve sustainability, governments
must be organized, have a plan, and demonstrate capacity at the highest levels (272-ES). Even
within countries, some regions had greater capacity and potential to transition to sustainability
more than others.
There is concern from vested stakeholders that the move to country-ownership and
financial responsibility not transfer prematurely in PEPFAR, or occur in such a way that
PEPFAR’s clear progress with country partners to date, the ‘foreign policy dividends’, or its
‘diplomatic leverage’ to influence global HIV and health policy are undermined (Collins et al.,
2012). This was a repeated and frequent theme in the IOM interviews across the types of
interviewees including USG, partner country government, local NGOs, INGOs, global
stakeholders, the global policy community, and implementing partners.
“I think everybody understands we need to be moving towards
country ownership. I’m really worried this is happening on much
too accelerated basis and we’re looking at real divestment in terms
of resources from PEPFAR going to countries all over Africa, all
over Asia before those countries are willing to or are able really
to, willing and able to devote more [resources] to their
epidemics.” (NCV-22-INGO).
“It’s going to take a lot of time, and too fast of a push is actually
counterproductive—not only are people going to suffer because
things aren’t going, you’re not going to have continuity of services,
but you’re also going to reflexively have people say that doesn’t
work so let’s go back to the old way of doing it. And this has
happened in the past where people have pushed too hard to have
partners, local partners take on stuff and 6 months later it was a
disaster and had to go back and then take it over again. So what’s
going to be the instinct the next time you try that? We tried that it
doesn’t work. So pushing too hard on this stuff is actually
counterproductive and we haven’t actually taken the time to learn,
no one has actually studied Track 1 to say what are, this massive
transition of hundreds of millions of dollars a year and hundreds
of thousands of people in chronic care, we haven’t actually sat
down to look at that and say what’s worked, what hasn’t worked,
what lessons are in here for the bigger, if that works or doesn’t
work and we learn from that, that’s what we can actually begin to
do globally and you learn what the right pacing is and you learn
what the benchmarks are, and you learn how to do this well. The
biggest challenge is moving too quickly to implement stuff that
isn’t ready to be implemented and that’s true globally as well as on
the ground. The capacity challenges are enormous. Now what
we’ve also learned is those capacity challenges everyone throws
up is not a reason to do something, cause everyone said ten years
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PROGRESS TOWARD A SUSTAINABLE RESPONSE 10-43
ago that you couldn’t possibly get 2 million, let alone 6 million
people in Africa on treatment.” (NCV-16-USG)
SUMMATION
The committee concluded that many PEPFAR-supported activities and policy initiatives
are contributing toward partner country stakeholder capacity building, particularly for partner
country governments through national HIV planning, service provision, quality-assurance
initiatives, and health systems strengthening that are needed to sustain an effective HIV
response. Gains made in partner countries in terms of provision of services and management of
the response are a critical focus of sustainability; it will be a serious impediment to country
ownership if the stakeholders expected to be involved in a country’s HIV response do not all
build their capacity. There has been improvement from PEPFAR I to PEPFAR II in
communication, coordination, and transparency for more joint strategic planning between
PEPFAR and the partner countries on HIV responses that are led by partner country priorities.
Recommendation 10-1: To contribute to a country-owned and sustainable
HIV response, the Office of the U.S. Global AIDS Coordinator should
develop a comprehensive plan for long-term capacity building in partner
countries. The plan should target four key areas: service delivery, financial
management, program management, and knowledge management.
Further considerations for implementation of this recommendation:
In all four key areas, OGAC should invest more resources in initiatives for long-
term capacity building and infrastructure development such as strengthening in-
country academic institutions, degree programs, and long-course trainings, to
improve in-country capacity and to accelerate progress toward country ownership
and sustainability. These investments should foster the placement and retention of
trained personnel in partner countries.
These initiatives should be monitored routinely at the country level to assess
progress and identify necessary modifications. Special periodic multi-country
studies could be used to evaluate the outcome and impact of the PEPFAR
capacity building initiative. To achieve this, OGAC should, using input from
country programs, identify milestones towards achieving specified goals, define
core metrics to assess capacity building efforts, encourage innovative approaches
through pilot initiatives and develop tools to help country programs monitor and
evaluate these efforts, and encourage innovative approaches through pilot
initiatives.
Overall, the committee concluded that the fact that PEPFAR and the Global Fund are the
primary donors in most countries creates a potentially vulnerable situation for partner countries.
While PEPFAR’s efforts to assure maximal performance of the Global Fund in many countries is
critical for the future, it is even more critical for countries to not only increase their own funding
for health, but to also diversify their sources of funding and reduce their overreliance on external
funding. Even when countries are not able to substantially increase their own funding for
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10-44 EVALUATION OF PEPFAR
HIV/AIDS or health, it is critically important that they demonstrate the leadership to understand
their current and future needs by developing their own resource plans that will transparently
inform everyone, including external donors, of the funding that is needed and the responsibility
that the countries will undertake to mobilize the needed resources.
Recommendation 10-2: Building on the Partnership Framework
implementation process, PEPFAR should continue to work with partner
country governments and other stakeholders to plan for sustainable
management of the response to HIV. PEPFAR should support and
participate in comprehensive country-specific planning that includes the
following:
Ascertain the trajectory of the epidemic and the need for
prevention, care and treatment, and other services.
Identify gaps, unmet needs, and fragilities in the current
response.
Estimate the costs of the current response and project resource
needs for different future response scenarios.
Develop plans for resource mobilization to increase and
diversify funding, including internal country-level funding
sources.
Encourage and participate in country-led, transparent
stakeholder coordination and sharing of information related to
funding, activities, and data collection and use.
Establish and clearly articulate priorities, goals, and
benchmarks for progress.
Further considerations for implementing this recommendation:
PEPFAR is not alone in trying to achieve locally-led, sustainable health and
development objectives. Contributing stakeholders, including partner countries,
will need mutually-agreed, principle-based resource allocation to achieve a
strategic and ethical balance among the priorities of maintaining current coverage,
expanding to meet existing unmet needs, and increasing coverage eligibility.
Having processes in place to support this arduous decision making is a critical
part of achieving sustainable HIV programs and sustainable management of the
HIV epidemic in partner countries.
Partners in developing resource mobilization plans and potential sources for more
diverse funding and other resources could include national and subnational
governments other bilateral donors, multilateral agencies, global and regional
development banks, and private sector consultants.
There may be learning opportunities at both headquarters and country level for
PEPFAR and other USG entities involved in development assistance to exchange
strategies, best practices, and lessons learned for sustaining development
objectives.
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PROGRESS TOWARD A SUSTAINABLE RESPONSE 10-45
OGAC has recently articulated PEPFAR’s understanding of country ownership and
provided clarity about ways to mutually assess progress towards sustainability of a more
country-led response. This transition to sustainability will be affected by many criteria and
decisions, most of which will vary by country. Transitioning will take time; it cannot be achieved
on a prescribed generic timeline across PEPFAR. Along the way, major dilemmas, such as
differences in how to prioritize services and target populations, will require mutual resolution. In
addition, transitioning to new models of PEPFAR support, including less direct support for
service delivery and more technical assistance and systems strengthening, is part of a reasonable
strategy for achieving sustainable management, but it also carries the inherent risks that in the
transition period the same level of targets and access to services will not be achievable and that
the quality of services, programs, and data may diminish. At the same time, greater embedding
of HIV services in national health systems may offer opportunities for better integration of care,
greater efficiencies, and broader health benefits. The U.S. government, like all donors, has its
own considerations and requirements for funding decisions, but PEPFAR has made progress in
making its considerations a part of joint planning processes rather than a displacement of country
priorities. This joint planning includes both local processes for national plans as well as
PEPFAR-specific processes, especially Partnership Frameworks. By necessity, PEPFAR will
gradually cede control as partner countries adopt more dominant roles in setting strategic
priorities for investments in their HIV response and in accounting for their results.
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10-46 EVALUATION OF PEPFAR
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