PEPFAR Implementation Progress and Promise (2007) / Chapter Skim
Currently Skimming:
Part III Looking to the Future, 8 Toward Sustainability
Part III Looking to the Future, 8 Toward Sustainability
Pages 241-270
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Part III Looking to the Future
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• The continuing challenge for the U.S. Global AIDS Initiative is to simultaneously maintain the urgency and intensity that have allowed it to support a substantial expansion of HIV/AIDS services in a relatively short time while also placing greater emphasis on long-term strategic planning and increasing the attention and resources directed to capacity building for sustainability.
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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.
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leadership in addressing and controlling the HIV/AIDS pandemic. COMMON THEMES PEPFAR Has Supported Expanded Availability of HIV/AIDS Services In the 15 focus countries, the U.S.
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. Although data are not yet available with which to determine the quality or impact of these services, the Committee believes this substantial expansion of services represents inroads into the HIV/AIDS epidemics in the focus countries.
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Awareness of the 5-year life of the Leadership Act and the characterization of the strategy as a "Plan for Emergency Relief" has generated anxiety that the United States does not plan to be involved in the fight against HIV/AIDS for the long haul, as will be necessary to allow countries to develop sustainable programs. During the Committee's visits to the focus countries, it heard expressions of both deep appreciation and gratitude for U.S.
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PEPFAR has provided substantial funding and technical assistance for many activities intended to be of lasting benefit -- supporting focus country governments in the development of national plans and monitoring and evaluation systems; improving existing and building new facilities; developing curricula for and training a wide variety of health workers; strengthening and expanding laboratory, blood supply, and medical waste management systems; improving and expanding supply chains; and strengthening existing and fostering new communitybased organizations (OGAC, 2005a,b, 2006a)
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Increasing Focus on Status of Women and Girls Is Key to Sustainability The Leadership Act calls for a focus on women and girls and articulates the need to address their particular vulnerability if the response to the HIV/ AIDS pandemic is to succeed. Specifically, the act requires that the PEPFAR strategy provide the following: • A description of the specific strategies developed to meet the unique needs of women, including the empowerment of women in interpersonal situations, young people and children, including those orphaned by HIV/ AIDS and those who are victims of the sex trade, rape, sexual abuse, as sault, and exploitation.
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Although it was formed relatively late,2 OGAC has established a Technical Working Group on Gender. Its purpose is to support focus country programs in implementing "evidence-based, gendered approaches" in order to meet legislative requirements and PEPFAR goals (see Box 8-1)
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SOURCE: OGAC, 2006h, 2007. BOX 8-1 Objectives of the Gender Technical Working Group At the country level: • Provide targeted technical assistance to country programs to ensure that they meet PEPFAR legislative requirements related to gender issues.
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To be successful over the long term, the U.S. Global AIDS Initiative will need to continue to help increase the capacity of the focus countries to sustain and expand their gains against the epidemic, both directly by investing in capacity building and indirectly by implementing PEPFAR in a way that strengthens and does not undermine existing public health systems.
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This report was issued after the Committee had completed its visits to the focus countries, and thus the Committee was not able to confirm its effect with the Country Teams. Community-Based Organizations Although PEPFAR initially relied heavily on existing U.S.- and countrybased contractors and large contracts, it has several mechanisms in place to strengthen the civil sectors of the focus countries by increasing the number and capacity of indigenous, particularly community-based organizations (OGAC, 2005a, 2006a)
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OGAC and the ambassadors need to ensure that Country Teams have adequate resources for this critical capacity-building effort. Supply Chain Many aspects of the supply chain for public health commodities require strengthening in all of the focus countries, and PEPFAR supports the development of this crucial component of the public health infrastructure.
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While there are no estimates available of the additional health personnel needed to respond to the global HIV/ AIDS crisis, the World Health Organization (WHO) had estimated it would be necessary to train an extra 100,000 health workers just to meet its "3 by 5" program target of treating 3 million people by 2005 (WHO, 2004a)
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7) Retention strategies Shortages of health care personnel for ART are a problem in all focus countries, but the nature of the problem varies greatly, both qualitatively and quantitatively, among countries.
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Similarly, Kenya and Ethiopia now allow clinical officers to prescribe ARVs. Rwanda has adopted a pilot program that allows nurses to prescribe ARVs and now permits trained nurses to provide follow-up to patients on ART.
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As noted earlier, during its visits to the focus countries, the Committee saw many programs of all varieties -- particularly ART programs -- in need of additional staff. Some Country Teams expressed concern that they were not allowed to fund activities unless they were specifically part of the HIV/AIDS effort and thus could not support, for example, the training of new clinical officers, who in some countries are the mainstay of the treatment effort.
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One of the Committee's greatest concerns is that the current management of PEPFAR, in its attempt to design budgeting, planning, and reporting mechanisms responsive to the congressional budget allocations, actively works against integration. In countries that have undertaken integrated planning, Country Teams have reported struggling to provide responsive support.
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But the Committee also observed many missed opportunities for improving the comprehensiveness and effectiveness of services through better integration -- for example, between programs aimed at prevention of mother-to-child transmission and infant feeding programs; between counseling and testing services and further counseling services, ART, and other treatment; between counseling and testing and clinics addressing sexually transmitted infections and reproductive health; between HIV and tuberculosis testing and treatment services; among multisectoral services for orphans and other vulnerable children; and between HIV/AIDS and food aid programs. Faith-based organizations play an important role in the fight against HIV/AIDS and have a broad reach into communities in all the focus countries (WHO, 2004c; GHC, 2005; EPN, 2006)
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Increased Knowledge About What Works Against the AIDS Pandemic Is Needed Because of its magnitude and reach, the U.S. Global AIDS Initiative represents a golden opportunity to learn about what works best in addressing the pandemic.
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Improvements in and regularization of planning and reporting requirements, increased resources for the coordination function -- including the recently identified best practice of a PEPFAR Country Team coordinator -- and increased technical support for Country Teams are all promising developments. The Committee encourages OGAC to continuously solicit input from and be fully responsive to the Country Teams and to increasingly have the program directed from the field upward, particularly as the Country Teams continue to gain knowledge and understanding of effective implementation.
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Such evaluations would need to incorporate the concepts of "downward accountability" and "horizontal accountability," thus including solicitation of feedback from program participants at all levels -- partners, other donors, host country governments, and particularly people in the focus countries. Research The PEPFAR strategy commits to building the evidence base on what works against HIV/AIDS and fostering innovation (OGAC, 2004)
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materials provided to support the development of annual country operational plans, OGAC has also given the Country Teams a list of priorities for targeted evaluations (OGAC, 2006d,e)
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Global AIDS Initiative funds, provides a rich resource for exploring these questions in clinical research settings. PEPFAR support for operations research in all ART programs would serve to expand the global knowledge base for addressing critical questions, including how to provide high-quality, cost-effective ART; how to scale up ART to the national level; and how to sustain ART and avoid the development of widespread resistance.
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Recommendation 8-4: The U.S. Global AIDS Initiative should increase its contribution to the global evidence base for HIV/AIDS interventions by better capitalizing on the opportunity PEPFAR represents to learn about and share what works.
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To understand whether these ultimate goals are being achieved and what contributions the U.S. Global AIDS Initiative is making to their achievement, it will be necessary to study national trends, such as rates of new HIV and other infections; rates of survival from HIV/AIDS and other diseases; child survival, development, and well-being; and the general health status of the population and key subpopulations.
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Global Health Council Presentation, October 2006. Bethesda, MD: Abt Associates, Inc.
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2005c. The President's Emergency Plan for AIDS Relief: Indicators, reporting require ments, and guidelines for focus countries (revised for FY2006 reporting)
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2004b. Acute care -- Integrated management of adolescent and adult illness: Interim guidelines for first-leel facility health workers.
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