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 (USG) 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 (UNAIDS, 2006), and that this region continues to bear the burden (UNAIDS, 2012) the focus has been the provision of emergency assistance to countries with many competing development and health needs that were often addressed through 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



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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 sys- tems. The largest portion of these resources has been provided by the bilateral support of the U.S. government (USG) 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 (UNAIDS, 2006), and that this region continues to bear the burden (UNAIDS, 2012) the focus has been the provision of emergency assistance to countries with many competing development and health needs that were often addressed through fragile and frequently deficient health systems. This type of emer- gency assistance is akin to global responses to natural disasters, albeit the sheer scope and magnitude of the resources needed to accomplish the cur- rent achievements in HIV prevention, treatment, and care is unprecedented for a single-disease focus. The global landscape is changing. Some countries with high or grow- ing 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 543

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544 EVALUATION OF PEPFAR intervention services for its population, as well as to sufficiently address coverage gaps in all services. In addition, the current depressed and tu- multuous economies in donor countries are affecting the way in which countries are viewing and in some 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 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 partners, and to support accountable ownership of HIV program delivery by coun- tries 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 back- ground on the evolution of U.S. and global approaches to increasingly focus on sustainability. This is followed by a discussion of country ownership, other important elements and efforts related to sustainability, and the most critical barriers to achieving country ownership and sustainability. Finally, the chapter presents the committee’s overall conclusions and its recom- mendations 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 USG’s bilat- eral emergency response to the HIV/AIDS pandemic (PEPFAR I) and the second iteration of the USG’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 ac- tivities as well as fiscal targets for some of these areas. It specifically identi-

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TRANSITIONING TO A SUSTAINABLE RESPONSE 545 fied 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 orga- nization 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 such as: • “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, are achieving meaningful results and are cost-effective. The chal- lenge is to expand these interventions from a pilot program basis to a national basis in a coherent and sustainable manner.”1 • A sustainable supply of quality “HIV/AIDS pharmaceuticals, anti- retroviral therapies, and other appropriate medicines.”2 • To pilot the use of public-private partnerships to provide medical care and support services to HIV-positive parents and their children who were identified through existing country programs aimed at prevention of mother-to-child transmission. These efforts were fo- cused in countries with or at risk for severe HIV epidemics with particular attention in resource-constrained countries. These efforts were also intended to promote sustainability.3 While there was limited direct mention of sustainability beyond the larger emergency response, these examples do indicate that Congress in- tended at the beginning of the program that some activities would not only continue into the future, but 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 sustain- able HIV response in and by partner countries.4 Even after the Lantos-Hyde 1  United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, P.L. 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). 4  Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, P.L. 110-293, 110th Cong., 2nd sess. (July 30, 2008).

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546 EVALUATION OF PEPFAR Act, the Center for Strategic and International Studies’ Commission on Smart Global Health Policy report in 2010 continued to call for the USG to maintain commitment to fight HIV/AIDS, malaria, and tuberculosis on a consistent trajectory as part of a smart, long-term global health policy that would “usher in a new era in which partner countries take ownership of goals and programs” and would leverage existing disease-focused invest- ments to build longer-lasting health systems and partner country capacity solutions to address health needs (Fallon and Gayle, 2010, p. 9). The previous Institute of Medicine (IOM) evaluation of PEPFAR rec- ommended 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, sustain- able HIV/AIDS programs.”6 Various other sections of the reauthorization legislation promote the idea of sustainable approaches for programs, ac- tivities, 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 counsel- ing and services; (C) the inclusion of cost sharing assurances that meet the requirements under section 110; and (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 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). 7  Supra, note 4 at §301(a)(2), 22 U.S.C. 2151b-2(a), §104A(b)(3)(a-d).

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TRANSITIONING TO A SUSTAINABLE RESPONSE 547 The Lantos-Hyde Act also identified compacts and framework agree- ments (also discussed in Chapter 9 on health systems strengthening) that would be important tools to assist in the transition toward sustainability. The purpose of such compacts and agreements are aligned with the type of assistance provided by the USG (direct services or limited technical as- sistance connected to services in countries or regions—both of which are discussed in subsequent sections of this chapter). The reauthorization legis- lation 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 “description of the criteria for selec- tion, objectives, methodology, and structure of compacts or other framework agreements with countries or regional organizations including the role of civil society, the degree of transparency, the benchmarks for success of such compacts or agreements, and the relationship between such compacts or 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 “a description of capacity-building efforts undertaken by countries themselves, including adherents of the Abuja Declaration and an assessment of the impact of International Monetary Fund macroeconomic and fiscal policies on national and donor investments in health.”9 Definition of Sustainability Neither the authorizing legislation nor the subsequent PEPFAR strat- egies or annexes formally define sustainability. For the purposes of this evaluation, the definition proposed by the Development Assistance Com- mittee of the Organisation for Economic Co-operation and Development (OECD-DAC) is used. It defines sustainability as “the continuation of benefits from a development intervention after major development assis- tance has been completed” (Development Assistance Committee, 2002).10 Given the focus of programmatic efforts that are funded by many external 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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548 EVALUATION OF PEPFAR donors, development assistance should be viewed not only as financial, but also 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; • Efficiency/cost-effectiveness as a measure of how economic re- sources 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 pri- vate sector, and civil society to “plan, manage, implement, and ac- count for results of policies and programs” (OECD, 2005, p. 4);11 and • Coordination and harmonization with donors and governments to “implement common arrangements at country level for plan- ning, funding, disbursement, monitoring, evaluating and reporting to government on donor activities and aid flows” (OECD, 2005, p. 5).12,13 It is also important that this harmonization, report- ing, 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 em- phasis 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 to build upon strengths and increase efficien- cies (IOM and NRC, 2010). Global Accords That Influence Sustainability PEPFAR’s new 5-year strategy also indicated that management of the response to HIV and its effects must not only become increasingly planned 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  Because 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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TRANSITIONING TO A SUSTAINABLE RESPONSE 549 and led by countries, with support from bilateral or multilateral partners and national funding, but also increasingly owned with processes of moni- toring, evaluating, and responding to the unique characteristics of the epi- demic in their countries (OGAC, 2009a). These objectives are aligned with the principles of country ownership, leadership and governance, harmoni- zation of donor and partner country 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 indica- tors 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. 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 percep- tions in a changing diplomatic space . . . with activities ranging from for- mal negotiations to a vast array of partnerships and interactions between governmental and nongovernmental actors” (Katz et al., 2011, p. 505). 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 con- sequences 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. The use of health diplomacy was also a theme that resonated in the committee’s interview data (331-14-USG; 331-44-USNGO; NCV-11-USG; NCV-24-USNGO; NCV-22-

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550 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 con- sequences of these diseases in Africa. The importance of other agree- ments 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 (OAU, 2001). The Monterrey Consensus on Financing for Development (2002) The United Nations’ International Conference on Financing for Devel- opment 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 do- mestic and international financial resources for development; external debt; and addressing systemic issues to enhance coherence and consis- tency 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 develop- ment 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 develop-

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TRANSITIONING TO A SUSTAINABLE RESPONSE 551 ment organizations, development banks, and other international agen- cies 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 Dec- laration and is a key guiding document for the Office of the U.S. Global AIDS Coordinator’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 capac- ity 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 assess- ments by outlining 12 indicators for national measurement and interna- tional 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 coun- tries, as well as heads of multilateral and bilateral development institu- tions, the Accra Agenda for Action recognized that the international community had made progress on the implementation of the Paris Dec- laration, 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 high- lighted 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 harness- ing the energy, skills, and abilities or all stakeholders including external donors, civil society, and the private sector; and (3) delivering and ac- counting for development results by focusing on greater transparency and increasing the medium-term predictability of aid (OECD, 2008).

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552 EVALUATION OF PEPFAR BOX 10-2 Measures of Progress and Achievements in the Paris Declaration Ownership: Percentage of partner countries have operational develop- ment 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 coor- dinated support—percent of donor capacity-development support pro- vided 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 do- nors 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 frame- works 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 framework—identify the number of countries with transparent and performance assessment frameworks that could be monitored to assess progress against the national develop- ment strategies and sector programs. Mutual accountability: Number of partner countries that undertake mu- tual assessments of progress in implementing agreed commitments on aid effectiveness, including those in this Declaration. SOURCE: OECD, 2005.

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TRANSITIONING TO A SUSTAINABLE RESPONSE 553 USNGO).14 An overarching description of the value of health diplomacy from USG interviewees aligns with the concept of securing favorable perceptions in the changing diplomatic space: “The value of health diplomacy cannot be underestimated. This is a precious asset that PEPFAR brings, that needs to be highly valued and cared for in terms of the goodwill it gains.”15 (NCV-12-USG) In addition to providing leadership for PEPFAR mission teams (240-33-USG; , senior diplomatic staff have also played a key role 331-3-USG; 166-3-USG; 542-2-USG) in engaging with partner country governments and other donors in their response to HIV (116-2-USG; 166-23-USG); this engagement is a critical part of the principles laid out for transitioning to sustainability. Because ambassadors were described as already having a strong background for how to discuss things with governments, an important goal for ambassadors to achieve was to understand not only the larger country context but also how to place HIV/AIDS within that context. Over time the role of senior leader- ship expanded beyond the Chief of Mission; in the beginning, missions “did not systematically utilize the Deputy Chiefs of Mission, they are now seen as an important part of the program for health diplomacy” (NCV-11-USG). During country visit interviews, the committee also heard about the use of formal and informal health diplomacy in many areas, including not only the highest levels for engagement of country government counterparts but also other technical levels to achieve PEPFAR goals, including planning and execution of Partnership Frameworks, Strategic Plans, and Partnership Framework Implementation Plans (272-ES; 116-ES; 542-6-ML; 542-13-USG). “[This] is [a] very top heavy country. Lots of things (and an as- tounding level of detail) go through the Prime Minister’s box so requires high level of U.S. involvement and involves the Embassy automatically. So here, the team needs ambassador engagement on more issues.” (166-3-USG) 14   Country Visit Exit Synthesis Key: Country # + ES Country Visit Interview Citation Key: Country # + Interview # + Organization Type Non-Country Visit Interview Citation Key: “NCV” + Interview # + Organization Type Organization Types: United States: USG = U.S. Government; USNGO = U.S. Nongovernmental Organization; USPS = U.S. Private Sector; USACA = U.S. Academia; Partner Country: PCGOV = Partner Country Government; PCNGO = Partner Country NGO; PCPS = Partner Country Private Sector; PCACA = Partner Country Academia; Other: CCM = Country Coordinating Mechanism; ML = Multilateral Organization; OBL = Other (non-U.S. and non-Partner Coun- try) Bilateral; OGOV = Other Government; ONGO = Other Country NGO. 15  Single quotations denote an interviewee’s perspective with wording extracted from tran- scribed notes written during the interview. Double quotations denote an exact quote from an interviewee either confirmed by listening to the audio-recording of the interview or extracted from a full transcript of the audio-recording.

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590 EVALUATION OF PEPFAR 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 $8,000, you reach the 7 million, 15 million people, I mean, 13 million people in [this country] by one message, for $1,000. But you pro- cure 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 all programming, but particularly on prevention programs without a continued 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) 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 this initia- tive, which was launched by President Obama in May 2009. PEPFAR is reported to serve as a central part of the 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 moni- toring 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, p. S53). “[OGAC] is responsible for the policy priorities of this program, but OGAC does not work in isolation and you know there’s a

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TRANSITIONING TO A SUSTAINABLE RESPONSE 591 deputy principals 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 consid- ering. 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 method for technical assistance with on-the-ground personnel 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 chap- ter (Chapter 4), 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 country, their existence and collaborative relation- ship affect the performance of each. They have been described as having dif- ferent and complementary models of assistance from their very beginnings. With country leadership, the new paradigm for the future response entails more joint planning and 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). There are two main channels by which the USG provides technical assistance (TA): through a centrally funded TA portfolio and through the USG bilateral programs. All efforts are made to ensure that the two streams of TA complement and coordinate with one another” (USG, 2011a, p. 14). The U.S. Congress permits OGAC “to withhold up to five percent of the Foreign Operations appropriation of the U.S. contribution to the Global Fund to provide TA to al­ leviate grant implementation bottlenecks and improve grant performance” (USG, 2011a, pp. 14–15). “From FY 2005 through FY 2010, the Coordinator has made over $160 million available for centrally-funded TA activities for Global Fund grants” (OGAC, 2012a). 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 re­ ional missions as part of the longer- g

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592 EVALUATION OF PEPFAR term capacity building and technical support for the Global Fund during the past 2 years. These liaisons “support Global Fund grant implementation and oversight and [. . .] improve coordination between U.S. Government bilateral programs and Global Fund-financed disease programs” and can provide broad assistance for areas mentioned above or narrower technical assistance, such as with the Global Fund’s financed laboratory program, and they communicate monthly with OGAC about issues in their respective countries (NCV-20-USG) (OGAC, 2012b). 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 (PRs) in countries with current Global Fund grants (OGAC, 2012b).26 The purpose of this urgent attention was “unblocking bottlenecks and resolving systemic problems that hinder the response to AIDS, tuberculosis, and malaria. GMS provides this support in four technical areas: CCM governance and oversight; PR organizational and financial management; procurement and supply management; and monitoring and evaluation” (OGAC, 2012b). 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, 2012b). 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 “multiplying 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, p. S162). Within the past few years, OGAC has 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 PEPFAR-supported efforts to improve 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 ef- 26  There are some exceptions to the eligibility for technical support for focus countries un- der PEPFAR I in which PEPFAR teams are instructed to address their technical support needs though their COPs or for countries that are listed by the U.S. Department of State as sponsors of terrorism (USG, 2011b).

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TRANSITIONING TO A SUSTAINABLE RESPONSE 593 fectiveness 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 measurable 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) 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 have 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 sustain- ability of the program” (116-16-PCGOV), with 70 percent of the budget allocated by another country (272-ES). In other countries, of all donors, the USG pro- vided the majority of funds in support of the HIV response in countries visited (461-ES). In some cases, governments could partially support their re- sponse (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 sus- tain 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; deflec- tion 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; 587-ES; 331-ES; 396-ES; 166-ES; 542-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 insur- ance schemes or performance-based financing (461-ES; 116-23-USPS), or requiring matching funds between donors and the government (461-ES). Interviewees

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594 EVALUATION OF PEPFAR 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; 396-ES; 196-ES) or that transitioning would take time (NCV-8-USACA) for sustain- ability. Interviewees observed that sustainability cannot be undertaken in “fast forward,” (396-ES) but instead, should be viewed as a gradual process (935-ES; 240-ES; 461-ES; 272-ES). Above all, interviewees across stakeholders were con- cerned about achieving the transition effectively and about finding efficien- cies, such as task-shifting to nurse-provided ART and reducing duplication among implementers, without sacrificing quality (272-ES; 240-ES; 587-ES; 116-ES; NCV-24- USNGO). Interviewees also 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 to shoulder complete responsibility (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. For these countries, interview- ees perceived the timing of the transition to a country-led response to be critical (272-ES). One interviewee observed that, as an emergency response, “PEPFAR was not designed to be sustainable” (331-43-USG). In addition to a financial commitment (461-ES), critical improvements were potentially needed in overall economic conditions (240-ES) as well as capacity and accountability. Government commitment to service delivery might require both program improvement and scale up. 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 than others (NCV-8-USACA). 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 dividend’s, or its ‘diplomatic leverage’ to influ- ence 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 the USG, partner country governments,

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TRANSITIONING TO A SUSTAINABLE RESPONSE 595 local NGOs, international NGOs, 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 to their epidemics.” (NCV-22-USNGO) “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. [. . .] 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 chal- lenges everyone throws up is not a reason to do something, cause everyone said 10 years 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 ca- pacity building, particularly for partner country governments through na- tional 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 communi- cation, coordination, and transparency for more joint strategic planning between PEPFAR and the partner countries on HIV responses that are led by partner country priorities.

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596 EVALUATION OF PEPFAR 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 man- agement, and knowledge management. Further considerations for implementation of this recommendation: • In all four key areas, OGAC should invest more resources in ini- tiatives for long-term capacity building and infrastructure devel- opment 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 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 capacity building efforts, encourage innovative approaches through pilot initiatives, and develop tools to help country pro- grams monitor and evaluate these efforts. 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 also to 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 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 fund- ing that is needed and the responsibility that the countries will undertake to mobilize the needed resources.

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TRANSITIONING TO A SUSTAINABLE RESPONSE 597 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: •  scertain the trajectory of the epidemic and the need for A prevention, care and treatment, and other services. •  dentify gaps, unmet needs, and fragilities in the current I response. •  stimate costs of the current response and project resource E needs for different future response scenarios. •  evelop plans for resource mobilization to increase and D diversify funding, including internal country-level funding sources. •  ncourage and participate in country-led, transparent stake- E holder coordination and sharing of information related to funding, activities, and data collection and use. •  stablish and clearly articulate priorities, goals, and bench- E marks 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, in- cluding 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. Hav- ing 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 for developing resource mobilization plans and potential sources for more diverse funding and other resources could include national and subnational governments, other bilateral donors, mul- tilateral agencies, global and regional development banks, and private-sector consultants. • There may be learning opportunities at both the headquarters and country levels 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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598 EVALUATION OF PEPFAR OGAC has recently articulated PEPFAR’s understanding of country ownership and provided clarity about ways to mutually assess progress toward sustainability of a more country-led response. This transition to more sustainable responses 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 car- ries 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 require- ments 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 and PFIPs. 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. REFERENCES ANTHC (Alaskan Native Tribal Health Consortium). 2007. Alaska native tribal health con- sortium: Organizational profile. Anchorage, Alaska: ANTHC. ANTHC. 2008. About the Alaska tribal health system. https://www.alaskatribalhealth.org/ about/aboutATHS (accessed November 22, 2012). Bertrand, J. T. 2011. USAID graduation from family planning assistance: Implications for Latin America. Tulane University School of Public Health and Tropical Medicine. Clinton, H. R. 2012. Clinton’s remarks at the global health summit. http://www.cfr.org/global- health/clintons-remarks-global-health-summit-june-2012/p28420 (accessed October 14, 2012). Collins, C., M. Isbell, A. Sohn, and K. Klindera. 2012. Four principles for expanding PEPFAR’s role as a vital force in US health diplomacy abroad. Health Affairs 31(7):1578-1584. Damonti, J., P. Doykos, R. Sebastian Wanless, and M. Kline. 2012. HIV/AIDS in African children: The Bristol-Myers Squibb Foundation and Baylor response. Health Affairs 31(7):1636-1642. Development Assistance Committee. 2002. Glossary of key terms in evaluation and results- based management. Paris: OECD. Fallon, W. J., and H. D. Gayle. 2010. Report of the CSIS Commission on Smart Global Health Policy: A healthier, safer, and more prosperous world. Washington, DC: CSIS.

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