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 the Office of the U.S. Global AIDS Coordinator (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 prescribed 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 when it is evaluated across all four domains of political ownership and stewardship, institutional and community ownership, capabilities, and mutual accountability including finance in the OGAC-generated country ownership spectrum. 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.



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10 Progress Toward Transitioning to a Sustainable Response in Partner Countries MAIN MESSAGES •  EPFAR is actively engaging in activities and processes to transition P to a more sustainable response in partner countries. •  ountry ownership has not always had an agreed-upon definition C once it was adopted from the development assistance lexicon and applied to PEPFAR. Recent efforts by the Office of the U.S. Global AIDS Coordinator (OGAC) have provided clarity for its definition and how partner countries should assess their achievement of its critical components. •  GAC sees country ownership as a fundamental element of progress O toward more sustainable management of the HIV/AIDS response by partner country governments and other relevant and engaged stake- holders in the country. In the transition to increasing country own- ership, 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. •  he transition to a more country-led and -sustained response will T take time; it cannot be achieved on a prescribed generic timeline for all PEPFAR countries. It will be affected by many criteria and deci- sions, which will vary by country, including where the country falls when it is evaluated across all four domains of political ownership and stewardship, institutional and community ownership, capabilities, and mutual accountability including finance in the OGAC-generated country ownership spectrum. 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 dimin- ishing 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. 539

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540 EVALUATION OF PEPFAR •  EPFAR has focused efforts on capacity building for all levels of P stakeholders and attempts to bring many stakeholders to participate in the planning and oversight processes for Partnership Framework Implementation Plans for country-led response and leadership but with multisectoral 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. •  he over-reliance on external donor funding in partner countries cre- T ates 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 contribu- tions, 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 substan- tially 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, in- cluding 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 sustain- able 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: •  n all four key areas, OGAC should invest more resources in initiatives I 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 ac- celerate progress toward country ownership and sustainability. These investments should foster the placement and retention of trained personnel in partner countries. •  hese initiatives should be monitored routinely at the country level T to assess progress and identify necessary modifications. Special pe- riodic 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 toward achieving specified goals, define core metrics to assess capac-

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TRANSITIONING TO A SUSTAINABLE RESPONSE 541 ity building efforts, encourage innovative approaches through pilot initiatives, and develop tools to help country programs monitor and evaluate these efforts. Recommendation 10-2: Building on the Partnership Framework im- plementation 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 par- ticipate in comprehensive country-specific planning that includes the following: •  scertain the trajectory of the epidemic and the need for preven- A tion, care and treatment, and other services. •  dentify gaps, unmet needs, and fragilities in the current response. I •  stimate costs of the current response and project resource needs E for different future response scenarios. •  evelop plans for resource mobilization to increase and diversify D funding, including internal country-level funding sources. •  ncourage and participate in country-led, transparent stakeholder E coordination and sharing of information related to funding, activi- ties, and data collection and use. •  stablish and clearly articulate priorities, goals, and benchmarks for E progress. Further considerations for implementing this recommendation: •  EPFAR is not alone in trying to achieve locally-led, sustainable health P 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 pri- orities 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. •  artners in developing resource mobilization plans and potential P sources for more diverse funding and other resources could include national and subnational governments other bilateral donors, multi- lateral agencies, global and regional development banks, and private sector consultants. •  here may be learning opportunities at both headquarters and coun- T try level for PEPFAR and other U.S. government entities involved in development assistance to exchange strategies, best practices, and lessons learned for sustaining development objectives.

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