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
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 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 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, 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 recommendations for how PEPFAR efforts can be improved to ensure that the evolving goals for sustainability can be met.
The Emergency Response
The first chapter of this report outlined the origins of the USG’s bilateral 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 activities as well as fiscal targets for some of these areas. It specifically identi-
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 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 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 challenge 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, antiretroviral 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 focused 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 intended 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 sustainable 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).
2Ibid., 301(a), 22 U.S.C. 2151 104A(d)(5)(C).
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).
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 investments 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 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
(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
5Ibid., 101, 22 U.S.C. 7611(a), (a)(29).
6Ibid., 301(a)(2), 22 U.S.C. 2151b-2(a),104A(b)(1)(D).
7Supra, note 4 at 301(a)(2), 22 U.S.C. 2151b-2(a), 104A(b)(3)(a-d).
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 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 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 “description of the criteria for selection, 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 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 Co-operation 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
8Ibid., 101, 22 U.S.C. 7611(b), 101(b)(2)(S)(i-iv).
9Ibid., 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.”
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 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, p. 4);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, p. 5).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 to build upon strengths and increase efficiencies (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.
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 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 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.
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, 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 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.
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-
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 (OAU, 2001).
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 develop-
ment 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 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 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).
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 framework—identify 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.
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; 331-3-USG; 166-3-USG; 542-2-USG), senior diplomatic staff have also played a key role 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 leadership 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 astounding 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 Country) Bilateral; OGOV = Other Government; ONGO = Other Country NGO.
15 Single quotations denote an interviewee’s perspective with wording extracted from transcribed 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.
“The government of [. . .] is hierarchical and to move things forward, often the ambassador has to get involved as with the Partnership Agreement Framework—it would not have happened without the ambassador.” (542-2-USG)
In addition to engagement with partner country counterparts and other stakeholders, beginning in FY 2005, program funds administered under the direct leadership of the Chiefs of Mission were made available for all PEPFAR countries and regional programs that followed specific criteria and reporting requirements to support the development of small, local partners (OGAC, 2009c). These funds were part of the Ambassador’s Self-Help Funds program for activities addressing HIV/AIDS. The total dollar amount of PEPFAR funds that could be dedicated to this program was to not exceed $300,000 or 5 percent of the country allocation, whichever is the lower amount (OGAC, 2009c) and the individual grants in the country were usually much smaller in amounts awarded. This discretionary fund has enabled the U.S. ambassadors in several countries to use PEPFAR small grants for capacity building of small, grassroots organization for program and budget management (331-47-USG; 636-16-USG; 461-19-USG; 166-15-USACA; 166-23-USG). The currently available funding is now known as the PEPFAR Small Grants Program. These grants are often administered by the missions’ Public Affairs Offices (166-23-USG). The Public Affairs office also works on publicizing PEPFAR’s activities in-country (934-2-USG) as part of the expression of goodwill described in the reauthorization legislation, which called for messaging that demonstrated that PEPFAR is a commitment by the citizens of the United States to the global fights against HIV/AIDS, tuberculosis, and malaria and “enhances awareness by program recipients that the program is an effort on behalf of the citizens of the United States.”16
Overall, the role of PEPFAR as a tool for diplomacy in the field and globally has grown over time and is largely seen as one of the successes of the program (NCV-16-USACA; NCV-12-USG; NCV-11-USG; NCV-14-ML; NCV-25-USNGO; 542-ES). The role of U.S. ambassadors in addressing the HIV/AIDS pandemic was described admiringly by a multilateral partner:
“What I was impressed with also very often is that most American ambassadors today, they can have a very serious conversation about AIDS. And that’s, I think another credit to PEPFAR, because the early decision was to put the ambassador in the country basically in charge of the program. Which meant, then, that they went through a fast learning curve. And I think that was, I always hoped
16Supra, note 4 at 101, 22 U.S.C. 7611(a), (h)(1-2).
that other nations would then, their ambassadors would get to the same level, which is actually only rarely the case.” (NCV-14-ML)
The Paris Declaration and other global accords described previously identified “country ownership” as an important element that influences sustainability. For PEPFAR, the Lantos-Hyde Act of 2008 explicitly referenced the principles of the Three Ones, the Abuja Declaration (discussed in Chapter 9), and the need to develop frameworks for program expansion or creation of new programs that emphasize increased country ownership and the promotion of sustainability of countries’ responses to their epidemics.17 The following paragraphs will discuss the concept of and perceptions about country ownership and efforts of the Office of the Global AIDS Coordinator to accelerate an alignment of its definition of country ownership with stakeholders in partner countries.
Definitions of Country Ownership
The term country ownership has not been well defined in the past, but commonly included phrases such as “effective leadership, planning, and oversight,” “country-led or country-driven,” or identified activities or outcomes that would be expected along with some kind of rating of country ownership. In recent years, OGAC has worked determinedly to articulate what country ownership is or what it entails because OGAC considers the concept as a critical tool to achieve sustainability (NCV-9-USG; NCV-20-USG; NCV-30-USG; NCV-12-USG). In 2010, OGAC engaged the consulting firm McKinsey &Company, with support from the Bill & Melinda Gates Foundation, to conduct a year-long review of PEPFAR’s country ownership strategy and “engage and align key domestic and international stakeholders on an action plan to accelerate country ownership of the HIV AIDS response.”18 As a part of this review, McKinsey & Company conducted interviews with high-level stakeholders in Washington, DC, including OGAC staff, as well as in-country stakeholders in two pilot countries, Botswana and South Africa. Based on these interviews and consultations, McKinsey & Company also worked with OGAC to conduct a facilitated self-assessment of PEPFAR’s country ownership strategy, articulate a clear definition for country ownership, develop a roadmap to roll out the implementation of the new PEFPAR
17Supra, note 4 at 2, 22 U.S.C. 7601(40).
18 McKinsey & Company/OGAC (Unpublished). “Accelerating HIV/AIDS Country Ownership: PEPFAR Roadmap.” Presentation to OGAC, July 8, 2011, slide 1. Used with Permission.
country ownership strategy, and create a toolkit to facilitate the implementation and measure progress of the new strategy. OGAC then piloted the rollout of the new strategy and toolkit in Botswana and South Africa.
Table 10-1 shows the culmination of their discussions to visually represent a multi-dimensional definition of country ownership and forms the foundation of the Country Ownership Assessment Tool (COAT), which would be used by the U.S. Mission Teams and national stakeholders in a participatory process “to assess a baseline of country ownership and use its finding to develop a thematic road map for country ownership . . . [and] develop an action plan and determine a path for monitoring and reporting, and evaluating impact” (GHI, 2012, p. 35).
A definition of country ownership, and its policy implications, was further articulated in the most definitive public statement by the USG-authored paper on the topic:
Countries that effectively manage their public health response demonstrate leadership over their health budgets, policies and strategies, and coordinate public health actions, including the contributions of the private sector, donors and civil society. Country ownership involves shared responsibility and mutual accountability with donors and other partners, particularly when outside financial and technical resources are needed to fully respond to the health sector needs of host countries. The USG fosters country ownership by investing in high impact and evidence-based country-led priorities, plans and systems. The USG also encourages country ownership when it promotes direct financing by recipient countries for priority interventions such as malaria and family planning commodities. Ultimately, a well-coordinated, country-led health response enhances efficient use of resources and contributes to long-term sustainability of global heath programming. (GHI, 2012, p. 4)
U.S. Secretary of State Hillary Clinton also clarified the USG definition and position on country ownership at the Global Health Summit in Oslo Norway in June 2012:
[It is] not just a matter of semantics, because if we are not clear about what country ownership means, we cannot know whether we are making progress toward achieving it. To us, country ownership in health is the end state where a nation’s efforts are led, implemented, and eventually paid for by its government, communities, civil society and private sector. To get there, a country’s political leaders must set priorities and develop national plans to accomplish them in concert with their citizens. . . . And these plans must be effectively carried out primarily by the country’s own institutions,
|Ownership Dimensions||General Characteristics|
|Political ownership and stewardship||
• Host government has a clear aspiration for what should be accomplished in each stage of program development, implementation and monitoring, generated with input from their own cities and rural areas, civil society, NGOs, and private sector, as well as their own citizens
• National plans are aligned to national priorities to achieve planned targets and results, with full costing estimates and plans incorporated
• Host country (public and private sectors) is the architect that fully implements and provides oversight of national plan to achieve results and applies and scales-up evidence-based best practices; this includes specific activities conducted by stakeholders in each stage from design to delivery of programs
|Institutional and community ownership||
• Host country institutions (inclusive of government, NGOs, civil society, and the private sector) constitute the primary vehicles through which health programs are delivered and take responsibility for each program
• Host country institutions adopt and implement transparent, evidence-based policies/regulations for priority areas that align with national plans
• Host country institutions manage funds
• Host country has effective workforce, organizations and systems at all levels able to perform activities and carry out responsibilities that achieve priority health outcomes
• National coordinating bodies and local institutions have the ability to gather and analyze epidemiological and program data to plan and measure program progress and results
• Host country institutions have the capabilities required to perform or oversee activities for programs
• Host country institutions have the ability to dynamically modify programs based on evidence and feedback from monitoring processes
|Mutual accountability, including finance||
• Host country is responsible to country citizens and international stakeholders for achieving planned results
• Host government is responsible for financing and financial stewardship over health
• Explicit roles and responsibilities are described with appropriate management of performance in place
• Measures are robust
• Information and processes are transparent and there are mechanisms for input and feedback from civil society, the private sector and donors
NOTE: NGO = nongovernmental organization.
SOURCE: McKinsey & Company/OGAC (Unpublished). “Accelerating HIV/AIDS Country Ownership: PEPFAR Roadmap.” Presentation to OGAC, July 8, 2011, slide 3. Used with permission.
and then these groups must be able to hold each other accountable. . . . So while nations must ultimately be able to fund more of their own needs, country ownership is about far more than funding. It is principally about building capacity to set priorities, manage resources, develop plans, and carry them out. We are well aware that moving to full country ownership will take considerable time, patience, investment, and persistence. But I think there are grounds for optimism. (Clinton, 2012)
While OGAC may have had an evolving vision for country ownership, and even based some of its policy and diplomatic decisions and programmatic activities on the principles of the global accords, it has had difficulty in articulating its definitions and expectations, how it would measure when or whether a partner country government had achieved country ownership, and thus make determinations about the country’s ability to sustain its current national HIV/AIDS responses, as well as plan for the future needs of their responses including gaps in services and populations who need to access them. Table 10-2 gives a summary of some of the high-level, but critical insights from PEPFAR’s self assessment and study of country ownership.
|Ownership Dimensions||How PEPFAR Contributes Today|
• While agencies feel they have cultures compatible with country ownership, there is a lack of shared vision across the program
• PEPFAR financial and reporting processes are seen as inconsistent with ownership and poorly understood by country stakeholders
• Real strength in civil society engagement, but with CSOs more as implementers than as patient advocates
• While PEPFAR readily engages in dialogue when there is disagreement, teams say they would benefit from clearer dispute resolution mechanisms, talking points, and proactive early engagement
• While there are many examples of capability activities, these are typically not part of an overall PEPFAR strategy, opportunity to take the best ideas and scale them more systematically
• PEPFAR’s organization structure, professional incentives, and skill sets at HQ and in country remain oriented toward PEPFAR I and are not set up to support country ownership
• Stakeholders do not understand some PEPFAR processes such as the COP and desire more transparency
• PEPFAR does not require accountability for country program performance
NOTE: COP = country operational plan; CSO = civil society organization; HQ = headquarters.
SOURCE: McKinsey & Company/OGAC (Unpublished). “Accelerating HIV/AIDS Country Ownership: PEPFAR Roadmap” Presentation to OGAC, July 8, 2011, slide 6.
Perceptions of Country Ownership in Partner Countries
The perceptions of mission teams, partner country governments, and implementing partners from the interview data collected by this IOM committee showed a range of comprehension and alignment, compared to OGAC’s perceptions and understanding, for not only the meaning of country ownership, but also of how the country should be assessed or measured for achievement. The most aligned of the field and OGAC headquarters (HQ) perspectives indicated that PEPFAR has been a country-driven process from the beginning:
“What has been remarkable has been the partnership. The interest on ground in solving a problem and working hand in hand as a partner has been amazing. Everyone feels this is a huge challenge, there is a level of respect that is unique, and everyone is considered a colleague—with the local partners as well [. . .] ‘we are all in it together we are going to innovate together. There is a misconception about PEPFAR that there is someone in DC turning the screw. That is not my experience you walk in country and see USAID, CDC, and country sitting together solving problems. It has been a country driven process from the beginning.’ [I] think PEPFAR has been country owned all along.” (NCV-5-USACA)
Others suggested that, in some cases, partner country stakeholders perceived that ownership was already attained: “is here” (166-ES) or “we own it,” (587-21-NGO) “the government takes it seriously and tries to get whatever they are responsible for right” (636-2-USG). Other partner country stakeholders perceived that ownership was more about owning HIV as a serious health problem rather than the actual HIV response (166-ES; 240-ES; 934-ES). By contrast, several partner country governments or national coordinating entities clearly stated their responsibility for the HIV/AIDS response:
“I accept this idea [of country ownership]. The government of each country should be responsible for the needs of the people. Donors should fill the gap, not replace government activities. The government should own/lead planning, implementation, and M&E—otherwise the program cannot be scaled up and sustained. Donor funding should slowly decrease and the country should use more of its own resources. The country should work with partners for how donor contribution can be replaced by the government gradually using an exit strategy.” (240-7-PCGOV)
“[The] country has the ‘liberty’ to prioritize what the money is for rather than have it be for pre-determined agenda in relation to what donors have money for [. . .] having [its] own group of
national experts to manage and plan the response—in-country expertise. [. . .] Having a system for assessing/evaluating programs, demonstration of national commitment to meeting costs . . . and no one stakeholder takes more ownership than any other including the government. We are in our country, we know our problem, we know what to do to stop our problem [. . .] they should listen to us too.” (331-6-CCM)
“It means that the country should finally start addressing the problem instead of relying on an outside agency addressing it. It’s like they have just taken a step back and let USAID [U.S. Agency for International Development] and PEPFAR address it.” (272-15-PCNGO)
Some interviewees saw country ownership as “a catch phrase where the country owns the issues and the fix, but is driving with donor money” (587-3-USG); ‘necessarily requiring a lot of time for coordination and meetings, but not having a lot of resources dedicated to its achievement’ (116-26-USG); or ‘feared it as an “exit strategy” to abandon countries’ (116-2-USG; NCV-16-USG; NCV-12-USG; NCV-30-USG).
IOM Country Visit Teams also heard various elements of country ownership (see Box 10-3) linked with country capacity (587-ES) including the existence of a national infrastructure (331-ES) to support the response, and country government-perceived responsibility for and commitment to leading, managing, and financing all aspects of the HIV/AIDS response (166-ES; 272-ES; 396-ES; 461-ES).
Interviewees also identified the need for both partner country governments and donors to facilitate country ownership and the transitioning from a donor-led emergency response to a more sustained country-led response (331-ES; 396-ES; 272-ES; 240-ES; 166-ES; 196-ES). Reduced donor dependency (272-ES) in concert with increased government leadership and commitment of resources ultimately contributed to country ownership. Additional potential contributors to country ownership included civil society, local organizations, other stakeholders, and the country coordinating mechanism (CCM). Some examples given of country-owned capacity for various parts of the HIV/AIDS response included fully and nationally managed procurement systems (587-11-PCGOV; 587-15-PCGOV/ML/USPS) to majority or increased funding for the procurement of antiretrovirals (ARVs) by partner country governments (542-9-PCGOV; 272-2-USG).
Two challenges to country ownership were uniquely identified by USG interviewees. The first was the USG organizational culture and mindset of some of the USG staff and implementing partners’ roles in facilitating both shifts in organizational culture and country ownership. Concerns of financial stewardship of U.S. taxpayer dollars and quality of services provided
• Country capacity (587-ES)
• Government/country perceived ownership of (or desire to own) the response (166-ES; 587-ES; 934-ES)
• Government committed to (166-ES) and responsible for response (166-ES)
• Government-led (331-ES; 461-ES), controlled (240-ES), funded (272-ES), planned (461-ES), set policy for (461-ES), managed (166-ES), and was accountable (396-ES) for the response (240-ES).
o Reduced donor dependency (272-ES)
o Government funding of part (461-ES) or all of the response (331-ES)
o Government-donor jointly developed donor exit strategy (240-ES)
o Government control of funding (331-ES; 396-ES)
o Existence of a national infrastructure (331-ES)
o Strong national plan (587-ES)
o Government-led response planning and prioritization (240-ES) of needs
o Strong local organizations (461-ES)
o CCM plays major role (331-ES)
o Stakeholders coordinated (331-ES)
o Donor funding reduced (272-ES) or eliminated (240-ES)
o PEPFAR support of country priorities (240-ES); provision of direct funding to government (166-ES)
o Track 1.0 Partners transition to local NGOs (166-ES)
o Activities aligned with National Strategic Plan (934-ES)
o OGAC leadership needed (272-ES)
to beneficiaries by implementing partners, coupled with a strong sense of ownership of the program by USG staff and implementing partners, may have contributed to the perception that country counterparts might not approach the stewardship the same way, with the same intensity, or with the same results for quality of services (NCV-9-USG; NCV-30-USG):
“And there’s no way around it because the culture and structure of our institutions are actually not built for that true transfer. That is not the culture or structure of our multilateral or bilateral insti-
tutions. We talk about it all the time and everyone talks about it but structurally we are actually not, or culturally we are not built for that. The culture of our institutions is still we are in control, we are the donors, as much as we try to say we’re not, that’s not the culture and it’s not the structure. The Global Fund is the only institution in a multilateral sense that was created to respond to those principles of fully country-owned. No other institution was, and the Global Fund hasn’t succeeded at it. PEPFAR was created as a bilateral but it’s really hard as a bilateral to force that. MCC [The Millennium Challenge Corporation] was created that way as a bilateral but it’s really hard.” (NCV-16-USG)
“And it’s like oh no, no, no, my sense of ownership you don’t understand this program is successful because of my blood and sweat. And I think we have to be very respectful of that, sensitive to that, because this change is not going to happen in Washington. So our Chiefs of Mission, our leadership is a good place to start because they can model the type of behavior, and it’s like no, that’s the kind of engagement [that we want].” (NCV-9-USG)
It was perceived by some interviewees that even PEPFAR’s operation through implementing partners itself could have created layers of distance that did not facilitate opportunities for oversight staff to be more directly engaged in the field with all of the stakeholders and leaders among whom partnerships and communication are needed for country ownership (NCV-9-USG; NCV-30-USG). Interviewees representing implementing partners and oversight staff in U.S. Missions generally offered a variety of reasons for their inability to engage partners and subpartners as often as they would have liked, primarily the time-intensive activities needed for program implementation including country operational planning and programmatic reporting requirements (542-23-USG; 166-26-USG; 636-23-USG).
“In the midst of all of these conversations we also know that your ability to move forward in this dialogue is as good as the partner who is across the table from you and sometimes you know we can blame our teams but sometimes there are legitimate barriers of just basically not having across the table a partner who wants to engage [. . .] especially when we’re getting to hear from the other side just what it’s really like for them sometimes in country and how really you know ‘yeah you can say that I wasn’t, I didn’t produce a lead for the ART program but I don’t recall anytime your people coming to ask us and things like that.’ So you know it’s not that easy to sometimes know what the reasons are. And so that all comes to play when you started to say okay let them decide.” (NCV-9-USG)
Another challenge identified by USG stakeholders was the way in which technical assistance is delivered by the USG for capacity building. In their piloted activities to better understand the facilitators and barriers to country ownership during the McKinsey & Company consultation, OGAC learned that they were more often providing technical assistance to USG staff in the field rather than the local partners for whom they needed to build in-country capacity. It was stated that change was needed for these challenges at both the headquarters and field levels to become more facilitative of country ownership and build in-country capacity for a sustainable response (NCV-9-USG).
IOM country visit team members identified impediments to country ownership that interviewees shared during the country visits where partner country entities, PEPFAR, or both contributed to what the committee characterized as impediments during analysis of interview data (see Box 10-4).
Efforts to Accelerate Country Ownership
From its consultation with McKinsey & Company, OGAC has developed insights into the differences between the perceptions and understandings of country ownership that it held compared to those by partner country stakeholders, as well as PEPFAR mission team members. As a result, OGAC has identified several important areas and strategies for accelerating the alignment of its definition in partner countries. For nearly each issue identified across the four domains of country ownership described in Table 10-2, OGAC identified a number of “priority themes for change” with 14 initiatives to address them (see Box 10-5).
Transitioning to Country-Led Responses
From interview data, some interviewees associated a planned or actual transition in leading, managing, and financing from donors to partner country as progress toward ownership. The pace of transition and the point at which countries were located on the continuum in the transition to ownership varied among countries. As PEPFAR and other donors facilitate country ownership, they will need recommendations from partner country entities on how best to shift direct funding to the government, decrease donor support (240-ES); align all activities with country priorities (240-ES) and national plans (166-ES; 934-ES); and shift implementation leadership and activities from donors to governments/ministries and local NGOs (166-ES). In addition, some interviewees believed that the country ownership directive should come “more from the top” (272-ES).
• Lack of capacity and resources to adequately and independently support the response (935-ES; 272-ES; 240-ES; 542-ES; 934-ES; 587-ES; 331-ES; 396-ES; 461-ES; 166-ES; 116-ES; 196-ES; 636-ES). Country ownership may be unrealistic given country lack of capacity and resources (116-ES)
• Lack of partner country or government commitment, responsibility for, or investment in the response (461-ES)
• Unpredictable partner country/government leadership and partners (166-ES)
• Fragmentation of the response (166-ES)
• Misaligned partner country and PEPFAR priorities (240-ES; 331-ES)
• Unclear role or recognition of civil society in country ownership (166-ES)
• A failure by OGAC to clearly define the concept “country ownership” (396-ES) presented issues because the concept then meant different things in different countries (272-ES)
• OGAC’s efforts to “roll out” concepts such as country ownership occurred with no input or guidance from the field (396-ES)
• Belief that OGAC should play a greater leadership role in country ownership efforts (272-ES)
• Lack of measures to demonstrate the progress or measure the impact of country ownership efforts (461-ES)
• Simultaneously addressing capacity building leading to ownership and also achieving PEPFAR annual targets was viewed as difficult to impossible to do—they are opposing tasks (166-ES)
• Misalignment of PEPFAR and partner country priorities (331-ES)
• Inadequate terminology, because the potential existed for partner countries to view the term “country ownership” as offensive or paternalistic (396-ES). Alternative terms for consideration might have included, country “leadership” or “stewardship” (396-ES)
• OGAC ignoring stakeholder-identified priorities (331-ES)
• Increasingly detailed directives from OGAC (331-ES)
• PEPFAR or implementing partner branding (396-ES)
1. Definition and second phase of PEPFAR change story: Align on a shared definition of country ownership and PEPFAR’s future vision, how the organization will achieve this vision, and communicate throughout all levels and agencies
2. Shared vision with development partners and multilaterals: Convene donors and international development partners to create a shared global vision for HIV/AIDS programs under full ownership, and roadmap for achieving it (including, e.g., roles of each stakeholder). Also align on international standards, such as harmonizing reporting requirements
3. Reform roles, responsibilities, and staffing processes: Institute a strategic staffing and role realignment process that ramps up staffing for results; identify, address, and track skill gaps in country and at HQ by developing slate of required technical and managerial skills in management, negotiation, and dispute resolution for advancing ownership and avoiding duplication between agencies; meaningfully enhance country coordinator role, including formal training and mentoring, establishing standard operating procedure/practices (SOPs), clear reporting lines to OGAC and decision rights in country; and require countries to assign relationship leads within partner country MoH [Ministry of Health], MoF [Ministry of Finance], NACs [National AIDS Councils]
4. SOPs for PEPFAR engagement and interactions in countries: Develop SOPs for country teams on interactions with stakeholders in-country, including flexibility of indicators/reporting schedule for teams to align with country response, talking points for USG team for negotiations with partner country government and clarifying USG policy (e.g., funding only evidence-based approaches). The SOP should address differing perspectives on funding priorities during COP development between agencies, country teams, and governments, with transparent publication of points of disagreement and rationale for ultimate decisions. Develop guidance for and leverage embassy support in appropriate countries for ensuring CSOs [civil society organizations] have a meaningful “seat at the table” in country planning processes at NACs and PFIP [Partnership Framework Implementation Plans] drafting. Develop SOP on best practices in country to promote efficiency and effectiveness
5. Communication platform for sharing best practices: Create a collaborative Web-based communication platform for rapidly and regularly sharing best practices among country teams, including CSO success stories and managerial innovations
6. Workshops and trainings for countries: Develop and deliver new workshops and trainings for countries on reviewing most recent epidemiological data on high-impact interventions to align on priorities, PEPFAR processes and reasoning for allocation decisions with local stakeholders, and exchanging views on priorities between governments, National AIDS Commissions/Councils, and country teams
7. Efficiency and effectiveness benchmarking: Advance efficiency and effectiveness in countries by conducting annual cross-country cost benchmarking by leveraging existing tools, investing in new data management and tracking systems (as needed), and clarifying data quality requirements for reporting. Benchmark cost-effectiveness data across PEPFAR countries and provide benchmarking data and additional capacity (staff and/or training) to pilot in-country performance management analysis and propose solutions for country teams
8. Transparent HQ data presentation: Create new read-outs of plans/allocations in COPs and PFIPs (e.g., in a user-friendly interactive website) outlining program priorities, financial decisions, and links to funded programs
9. Country segmentation and country ownership guidance by segment: Provide guidance tailored to countries’ ownership situation, segmenting countries according to their position on the ownership continuum, set in each segment performance milestones for second phase of PEPFAR and a view on long-term graduation. Issue clear guidelines for funding in each segment, and earmark a percentage of total country funds to be spent on capacity building with a focus on governance and advocacy. Develop exit plans from funds for CSOs to encourage their sustainability post-PEPFAR. Renew contracts to encourage transition from international partners to coalitions/local partners in mature programs, setting target percentages of funds to transition to local partners or coalitions. Pilot performance-based funding in two to three countries in the first year.
“I think that as country ownership becomes more of an explicit goal they [PEPFAR] could do more to guide international processes and national processes to sort of make sure that those things will continue to happen when they’re gone.” (NCV-24-ONGO)
PEPFAR’s shift from a USG-led and USG-funded program to its vision of a more country-led program has been an intentional and deliberate process over several years (NCV-9-USG).
10. COP reform: Revise COP templates and processes to include adding ownership actions into four technical area narratives, requiring teams to present a separate document on ownership during COP review. Meet with country stakeholders (including CSOs) during development and include country leadership in COP review presentation. Pilot full ownership metrics/assessment in this COP cycle with 5 countries. Move point of approval for high-level country program budget allocations earlier in COP review process to minimize later reworking of funding priorities
11. Metrics: Develop a country ownership index supported by objectively verifiable metrics to measure change and progress over time across each dimension and in the aggregate
12. Individual performance reviews: Create country ownership objectives for agencies to add to individual performance reviews so that success on advancing initiatives can be acknowledged and rewarded
13. Strategy reviews in-country: Pilot in-country cross-agency strategy reviews to include defined agency roles and competencies. Joint identification of areas or overlap and gaps between coverage and country team develops future state vision/plan and roadmap to address gaps
14. Revision of technical assistance model: Revise guidance so that all forms of technical assistance are shaped to advance ownership, e.g., consolidate guidance for all TWGs [Technical Working Groups] to create and monitor policy including standardized documents/reports which incorporate ownership principles
SOURCE: McKinsey & Company/OGAC (Unpublished). “Accelerating HIV/AIDS Country Ownership: PEPFAR Roadmap.” Presentation to OGAC, July 8, 2011, slides 37–43.
“The transition process is intended to facilitate a smooth transfer of the program‘s management, implementation, and ownership to the intended host country recipient. . . . It focuses primarily on technical, managerial, and financial aspects of the program. The ultimate intention of a transition is a changed relationship, one of a mutually-beneficial technical partnership between USG and the partner country. It is fully acknowledged that country progress may occur at different rates depending upon individual country
circumstances. . . . For example, a financial transition is more likely to occur with a faster pace in upper middle-income countries, later in lower middle-income countries and later still in low-income countries.” (GHI, 2012, p. 9)
USG Precedents in Transitioning Health Programs
Transitioning to a more country-led initiative with either reduced or no USG direct funding, as well as programmatic responsibility and oversight, is not without precedent in USG development assistance. Although not of the same scale and scope as PEPFAR, these precedents offer salient lessons. Family planning has been an area of long-standing support by USAID—in some developing countries for decades. When USAID’s family planning portfolio was evaluated by the Office of Management and Budget (OMB) in 2002 with the Program Assessment Rating Tool (PART),19 it was determined that USAID did not allocate these resources to the countries in greatest need. In response, USAID developed need-based assessment tools that also considered other criteria that affect budgeting, including “absorptive capacity, country stability, country commitment, and other donor contributions.” They used these tools to develop strategies that would enable USAID to gradually decrease funding in select, long-standing countries after it was determined by several measures that these countries could provide the service without USG assistance. This allowed for a strategic reallocation of funds to countries in greatest need. These transitions became gradual and were undertaken over a period of years to avoid abrupt termination of funding to countries (Bertrand, 2011). In 2006, USAID’s working group for this issue recommended that all USAID assistance programs in developing countries be designed and implemented “with the expectation that the host country program eventually will no longer require or receive direct support from USAID or other donors” (Bertrand, 2011).
A domestic example of health systems planning, ownership, and management may also be informative to PEPFAR’s transitional efforts in partner countries. Prior to 1968 all health care for Alaskan natives was provided by the USG. With the advocacy of the Alaska Native Health Board (ANHB), the Alaska Native Tribal Health Consortium (ANTHC) was formed in 1997. While operational funding is still received from the U.S. government, the consortium has increasingly assumed ownership and control from the USG for all statewide health programs that serve the more than 200
19 This tool was developed by the OMB to “assess and drive the improved performance of U.S. government programs by examining factors that affect and reflect program performance, such as program purpose and design, performance measurement, evaluations, strategic planning, program management, and results” (IOM, 2007).
federally recognized, sovereign tribes in Alaska. With this transference of ownership and control, all Alaska Natives are not only owners, but also customers of this consortium (ANTHC, 2008). The consortium’s Executive Leadership Team, comprising the CEO and 12 senior leaders, was responsible for assessing their organization and identifying the improvements needed in the system with the use of benchmarking and the Baldrige Criteria for Performance Excellence to assess their organizational performance and quality assurance needs (ANTHC, 2007).
The Alaska Tribal Health Compact, established through the USG Indian Health Service, is the umbrella agreement that outlines the tribal government–to–USG terms, as well as the conditions of the comprehensive health system; authorizing tribes and Native health organizations to operate health programs.20 The compact also stated that each tribe retains autonomy over its respective health priorities, services, and policies in its specific geographic area (Indian Health Service, 2012). The Alaskan natives are responsible for comprehensive services across the entire continuum of care (ANTHC, 2008), which includes but is not limited to managed hospitals, health centers, substance abuse treatment centers, specialty care, and health promotion/disease prevention programs (Indian Health Service, 2012). In fact, this model informed the early conceptual development of PEPFAR, especially in terms of approaches to local ownership by sovereign entities (NCV-16-USG).
The Consortium emphasizes working with partners to develop and enhance collaboration with health and funding agencies; promoting the use of the consortium services by Native beneficiaries and building capacity for Native health professional development; unifying and strengthening the health system; and creating the highest-quality health services by improving clinical outcomes and reducing rates of preventable disease and illness. The consortium identifies many successes that include the recognition of cultural competency of all ANTHC; their growing reputation; low to no cost services for beneficiaries; the provision of lifelong care; and community involvement. The main challenges that the association currently faces are the current competition of federally run hospitals within Alaska, “Alaska Native health status, budget/reimbursement, access to care, workforce development and management, relationship management and infrastructure improvement” (ANTHC, 2007).
20 Tribes and Tribal Organizations operate under the authority of Indian Self-Determination and Education Assistance Act, P.L. 93-638.
Metrics for Progress Toward Country Ownership
PEPFAR has often identified outcomes of country ownership, such as sustainable procurement, improvement of supply chain systems, and strengthened capacity in local institutions; however, metrics and indicators for progress toward country ownership, especially in the four domains identified by OGAC, is very newly published. Mapping and using national indicators as metrics for progress toward country ownership, rather than relying only on the amount of money the government contributes as evidence of commitment are possible measures (NCV-9-USG; NCV-30-USG). Illustrative examples of other metrics from the USG Interagency Paper on Country Ownership include domestic health and HIV/AIDS spending; expenditure reports; indigenous prime partners; and transitioned management of USG programs (GHI, 2012). Box 10-6 provides other USG-identified examples of potential measures of success for country ownership. The use of these measures to assess the transition to country ownership could address concerns identified by interviewees in order for all to know where a country stood in each of the OGAC-identified domains for country ownership (396-ES; 461-ES; NCV-2-USG; NCV-30-USG).
Different Models of USG Assistance
The USG has described different models of support to countries along a continuum varying by the degree of direct assistance for service delivery versus technical assistance for collaboration. The model to offer for each partner country is dependent upon the progress toward country ownership and sustainability. In countries with high HIV burden and U.S. geopolitical interest, other factors including unmet need, high resource needs, Global Fund financing availability, and capacity gaps, might warrant a long-term engagement strategy for service delivery through mechanisms that allow PEPFAR to fund implementing partners in a country—from the national government to local nongovernmental organizations (NGOs). This would be the case for countries like Haiti and Sudan that are experiencing setbacks in their HIV/AIDS response because of external shocks like natural disasters or post-internal conflict efforts (GHI, 2012). Countries with high poverty and development needs might also qualify for this type of long-term engagement. The next model is described as a blend of technical assistance for priority areas or key populations with some funding for capacity building for direct service delivery for this targeted population. Countries in the Caribbean region were identified as recipients of this type of assistance. Another model is focused on technical collaboration for continued in-country capac-
ity building as countries have demonstrated management, technical, and financial capacities, as well as an increased ability to wholly or cofinance the response. This cofinancing expectation is based on a targeted range of annual economic growth, and South Africa, Botswana, and Namibia were provided as examples of these countries. The last model was described as a sole technical collaboration for innovation and joint research between or among countries themselves that have advanced country ownership, implementation, and management of their HIV/AIDS responses. The countries highlighted for this model included Brazil, India, and Mexico (GHI, 2012) (NCV-9-USG; NCV-12-USG; NCV-30-USG). It was stated that OGAC could learn from these advanced countries in terms of best practices and forming partnerships in the private sector that could contribute to sustainable responses to apply to other countries including nascent or continued emergency responses in countries (NCV-12-USG).
The committee learned that PEPFAR assistance in a country may start with a technical assistance model only, but that does not necessarily mean that the country might not also receive assistance for direct service provision if the HIV burden is high. Complexities in the interaction of the dimensions of country ownership may produce the need for flexibility in the type of assistance that PEPFAR provides without strict demarcations. For example, the USG may not have a strong relationship with the political leadership of a country with high burden, but PEPFAR may provide services through NGOs as implementing partners (NCV-12-USG; NCV-9-USG; NCV-30-USG).
As previously noted, Secretary Clinton described sustainability as a partner country being able to assume greater to complete responsibility to plan, cost, oversee or manage, monitor, and evaluate its current HIV/AIDS response. While this was not limited to a country being able to pay for the entirety of its response, it did include cofinancing and increasing financial contributions by the national government to meet the Abuja targets for national financing for health and HIV/AIDS, as well as efficient and maximal mobilization and use of all of its diverse resources for fiscal management and oversight of the response including addressing gaps in services for improved access and coverage (NCV-30-USG). The planning of the response should not only use available epidemiological, programmatic, financial, clinical, surveillance, and special survey data for identification of current needs and gaps, but also to project and anticipate the trajectory of need and correspondingly plan for implementation and management of their response. These data should also be used to determine the costs of their national strategic plans and services, and maintain gains in the current response.
Even if a country cannot increase its own funding contribution, it is the critical responsibility of the partner country government to ensure and oversee the development of a resource mobilization and diversification plan specific to that country that reflects its understanding of the financial need
USG Country Teams Interaction with Host Country Partners:
• USG COP alignment with government plans
• USG engagement as a key stakeholder as part of the national strategic planning process
• USG transparency in sharing its total funding for programs in country and making the information available to partner governments in an understandable manner
• USG engagement with partner government in resource allocation discussions and decision for prioritized programs
Promoting and Engaging In-Country Partners—Governments:
• Increased domestic government health spending over time
• Increased number of programs of proven efficacy taken to scale by local entities
• A shift and/or expansion of direct funding to government institutions
• A shift and/or expansion of direct funding to nongovernmental local institutions
• Use of government planning and management systems
• Demand created at the community level, which enhances accountability for government and/or local service delivery
Promoting and Engaging In-Country Partners—Civil Society:
• Increased percentage of USG funding that is awarded to local partners through contracts, cooperative agreements, and grants
• Number of new prime partners in fiscal year who were sub-awardees in the past
• Number of effective civil society organizations with mechanisms in place for citizens to express views to government bodies (social responsiveness and accountability)
• Average percentage change in organizational capacity among USG direct local NGO implementing partners as measured by a defined organizational capacity assessment tool (e.g., Organizational Capacity Assessment [OCA], Organizational Capacity Assessment Tool [OCAT], Institutional Development Framework [IDF], Discussion Oriented Organizational Self Assessment [DOSA])
to pay for its response and its responsibility to help find the resources instead of the heavy reliance of many countries on PEPFAR or other donors to project the costing and pay for the response. Finally, the USG and its partner countries need to use benchmarks or metrics to measure success and progress toward sustainability (NCV-30-USG).
• Representation of community members and active participation of communities in governance structures
Promoting and Engaging In-Country Partners—Private Sector:
• Increased number of trainings in financial management convened by the private sector for the public health sector
• Joint financing agreement is developed with the private sector and government
• Increased number of private health facilities certified by the government
• Increases in the percentage of Total Health Expenditure (THE) attributed to the private sector
• Increases in the percentage of out-of-pocket expenditure for health attributed to the private sector
Promoting and Engaging In-Country Partners—Bilateral/Multilateral Organizations and Regional Bodies:
• Government reveals a costed health strategy budget that is inclusive of Global Fund, USG, and other donor annual contributions
• The government annual work plan includes the activities being conducted by all stakeholders
Promoting and Engaging In-Country Partners—Academia:
• Increased number of health-related research projects conducted and disseminated by host country academic institutions
• Increased number of research conferences convened by host country academic institutions
• Increased number of local academic institutions engaged in health surveillance, research, and evaluation
SOURCE: GHI, 2012.
As indicated in Box 10-6, one of the measures of country ownership is USG transparency of its funding with the partner country government in an understandable way. While PEPFAR ranked 29th out of 72 donors in
the 2012 Aid Transparency Index published by Publish What You Fund,21 there were variable perceptions among interviewees regarding the extent of PEPFAR’s transparency on the amount of funding that would be allocated to partner countries (116-ES; 166-ES). Some interviewees perceived that PEPFAR is more transparent than other external donors (NCV-9-USG; 116-5-PCGOV; 116-16-PCGOV), while others suggested that PEPFAR continues to need improvement in transparency (934-ES; 331-ES; 636-ES; 116-ES; 166-ES). PEPFAR is currently working on increasing transparency to country governments about the funding provided by external donors, even if the funds were not placed into common-fund mechanisms that would allow the country direct access and complete control of the disbursements (331-ES; 461-ES).
Partnership Frameworks and Partnership Framework Implementation Plans
In addition to the Country Ownership Assessment Tool described previously, OGAC has identified other tools to shepherd increased country ownership and the promotion of sustainable responses—the Partnerships Frameworks (PFs) identified in the reauthorization legislation.22 OGAC reports that during the past 2 years, PFs have been established with all funded countries with the first being signed in Malawi in 2009. This PF model has been developed to “strengthen country capacity, ownership, and leadership” (OGAC, 2009b) and increase partner country government autonomy in decision making by promoting harmonization with national AIDS plans. Furthermore, the reauthorization process required that all frameworks “shall include provisions to promote local and national efforts to reduce stigma associated with HIV/AIDS and work with and promote the role of civil society in combating HIV/AIDS.”23
PFs were described as a product of OGAC functioning as a learning organization (NCV-16-USG). The development of the PFs was based on the understanding of the principles of the Paris Declaration, the achievements and challenges of PEPFAR implementation, and other goals and considerations of USG bilateral development assistance. OGAC strived to use policy principles of country ownership and strong leadership and governance to
21 Publish What You Fund is the global campaign for aid transparency. It works to make comprehensive, timely, and comparable information about foreign aid available and accessible. The Campaign seeks to empower civil society advocates, parliamentarians, and officials with information, both in aid dependent countries and the donor countries assisting them. It receives financial support from the William and Flora Hewlett Foundation, Christian Aid, Development Initiatives, ONE, Tiri, Water Aid and World Vision (Publish What You Fund, 2012).
22Supra, note 4 at 301(c)(6), 22 U.S.C. 2151b-2(d)(8).
23Supra, note 4 at 104A(e)(2)(C)(i-ii).
progressively build in-country capacity for an HIV response that would be sustainably managed by partner countries (NCV-16-USG).
“Partnership Frameworks were one of the most significant policy shifts [for PEPFAR] under the leadership of Ambassador Mark Dybul, and Ambassador Goosby has continued it full force with the umbrella of country ownership as the route and path to sustainability.” (NCV-11-USG)
“[I] must commend the efforts that PEPFAR has made in recent years. PEPFAR has tried as much as possible to harmonize and align with country priorities, for example, through the Partnership Framework. This has been advocated at the highest level. This is a strong achievement.” (116-16-PCGOV)
While the PFs were intended to articulate goals, activities, and accountabilities for the USG and the partner country governments, the Partnership Framework Implementation Plans (PFIPs) are to include specific actions to be taken by specific stakeholders and metrics for documenting progress toward accelerating country ownership (OGAC, 2009a). PFIPs would then represent the primary considerations for countries to increasingly manage and ultimately sustain their responses (see also Chapter 9 on health systems strengthening). As of July 5, 2012, 19 countries and 2 regions have signed PFs. The first PF was signed in Malawi in 2009. Fourteen of these countries have completed the next step of the process and have drafted PFIPs, but only four PFIPs had been signed as of July 2012 (OGAC, 2012a). Several years may be needed for countries or regions to have both a PF and a PFIP. This delay may be due in part to the length of time that it takes to reach an agreement on the content between the USG and the partner country government (including multisectoral input), as well as the time it might take to obtain the high-level signatures required from the U.S. Mission Senior Leadership and the partner country government’s senior leadership. PFIPs have been developed in more than a dozen countries that would presumably document the differences among the countries’ epidemics, their commensurate responses, and their variant PEPFAR experiences in terms of implementation, achievements, and challenges for sustainability. The focus of this section will be the PFIP between the government of the Republic of South Africa (SAG) and the USG, even though the committee understands that PEPFAR is conducting very similar activities to promote sustainable responses across many countries with PFIP development and execution.
The South Africa Example
South Africa, one of the largest PEPFAR countries, was a focus country with substantial initial and ongoing PEPFAR investments, and its PFIP was one of two that were publicly available (the other being Swaziland). Therefore, the committee focused on the PFIP between the SAG and the USG, which covers the period from 2012/2013 to 2016/2017 for its examination of OGAC and partner country government process and activities, resonance of stakeholder roles and accountability resonance with articulated principles, and identification of benchmarks. South Africa was also identified by the USG as one of the countries furthest along the pathway in terms of transitioning to a more country-led and country-financed response with more elements of sustainability than many other PEPFAR countries (GHI, 2012). The governments’ representatives signed the document on August 8, 2012; the copy available to the committee was a duplicate that had been translated into English. It was not possible for the committee to assess the implementation of the PFIP, because it would occur primarily after the committee’s data collection period had ended, making this examination more descriptive than interpretive. Even though PFIPs have been developed in other countries, specific examples of the application of the PF and PFIP guidance outside of South Africa will be limited in this section.
Overall, the PFIP commits the two country governments, with signatures from the U.S. ambassador to and the Minster of Health of the Republic of South Africa, to the principles of “South African leadership; alignment; sustainability; innovation and responsiveness to the epidemic; mutual accountability; multi-sectoral engagement and participation; gender sensitivity; financial commitments and transparency; and finally, fostering a collaborative and not contractual partnership” (SAG and USG, 2012, p. 7). The roadmap for the PFIP is reportedly South Africa’s National Strategic Plan (NSP) for HIV, sexually transmitted infections (STIs), and tuberculosis (TB)—described “as a multi-sector national plan that lies at the heart of the development agenda of the South Africa government” and also spans the same 5-year timeframe as the PFIP (SAG and USG, 2012, p. 7). Eight other intermediate and long-term social, health, economic, and health financing, and education development plans were identified as influencing the activities of the two governments outlined in the PFIP.
Other important framing for the PFIP included a mutual intergovernmental decision that PEPFAR’s investments in South Africa will gradually transition from support of direct clinical care treatment toward support for health and social systems strengthening. The strengthening of these systems aimed to increase the efficiency of implementation of the national response, which includes activities related to “integration of HIV services, referrals systems, training, mentorship, supervision, quality improvement,
health planning/budgeting, human resource management, supply chain management, information management, and monitoring and evaluation” (SAG and USG, 2012, p. 20). The PFIP also calls for a strategic focus on HIV and TB prevention among key populations. PEPFAR will support the SAG’s combination HIV prevention efforts focusing on key populations as part of comprehensive prevention interventions for people living with HIV and those affected by it. These key populations include orphans and vulnerable children, migrant and mobile populations, people living in informal settlements, and in- and out-of-school youth, “populations most at risk of acquiring new infections, and populations where new infection rates are high” (SAG and USG, 2012, p. 18). It was also noted that several PEPFAR-supported care and treatment implementing partners tailor services to “special populations [including] very remote populations, undocumented foreigners, men who have sex with men, and other marginalized or key population groups” (SAG and USG, 2012, p. 22). In addition, the PFIP identified the need for proper assessment and planning to leverage the programmatic value and that “treatment services continue to be made available to the most vulnerable populations” (SAG and USG, 2012, p. 22).
The SAG is expected to increase the number of patients on treatment through its public health system, prioritize the prevention of new HIV infections, and have a more integrated response to the country’s HIV and TB epidemics. PEPFAR has supported several models for antiretroviral therapy (ART) provision: (1) the General Practitioner (GP) model, which capitalizes on South Africa’s extensive capacity in the private sector (this model was expected to be fully phased out by the end of 2012); (2) capacity building in non-public facilities with engagement of a number of NGOs, many of which are faith-based organizations with existing health infrastructure (e.g., hospitals, clinics, programs), especially in rural areas; and (3) capacity building in the public sector, largely focused on strengthening public-sector facilities to increase access to ART. The PFIP reports that “the majority of PEPFAR support (>97%) is in the public sector to support the South African government’s efforts to increase access to ART” (SAG and USG, 2012, p. 20). As public health clinics are capacitated, PEPFAR and the SAG intend to ensure patients currently treated in NGO sites under PEPFAR funding are transitioned to other non-PEPFAR models of support (whether nearby public health facilities or NGO facilities with other sources of funding) (SAG and USG, 2012). “Since 2010 there has been an extensive effort to ensure that PEPFAR-support (through all models of care) was provided in a more synergistic manner by working closely with province, district and sub-district management to direct support to areas of greatest need. In order to reduce duplication and improve efficiencies, one PEPFAR partner was designated to work in a district or sub-district, covering all 52 districts” (SAG and USG, 2012, p. 20).
The aforementioned goals track with the metrics identified in Box 10-6 for systems strengthening and in-country capacity building by PEPFAR engaging the host country in allocation decisions, and the SAG increasing its domestic spending on health over time (SAG and USG, 2012). The PFIP described the mutually-recognized need to strengthen capacity at provincial and district levels for financial management and to increase efficiency and effectiveness of resources in response to increasing the SAG expenditure to scale up much needed HIV and TB services, especially since provincial and district leadership will have increasing responsibility as they seek to further integrate a multisectoral HIV and TB response more broadly. Consistent with the indicators for potential measurement of success for country ownership in Box 10-6, the PEPFAR Expenditure Analysis Initiative (described previously in Chapter 4) should help facilitate transparency of the PEPFAR budget and joint planning of future activities by identifying PEPFAR financial inputs by program and geographic area; as well as provide the necessary information per district for the National AIDS Spending Assessment. All of these data can contribute to the country’s ability to develop costed national strategic HIV/AIDS plans.
Management structure The PFIP described an established management structure for leadership of South Africa’s development assistance for health that is spearheaded by South Africa’s National Department of Health (NDOH) which is “taking ownership of strategies, action plans, and review mechanisms. In collaboration with development partners, the NDOH focuses on results, links activities to outputs, ensures clear and unambiguous expectations, and facilitates the process of alignment and coordination. This framework ensures that development partner resources are used more efficiently and effectively, fulfilling resource gaps” (SAG and USG, 2012, p. 12). The South African National AIDS Council (SANAC), which oversees the implementation of the NSP, has national and subnational representatives, as well as from civil society and various government sectors.
There is also a steering committee scheduled to meet twice a year to provide strategic oversight and direction for the PFIP. The PFIP suggested that it be co-chaired by the U.S. ambassador to South Africa and the South African Minister of Health. Proposed membership included USG implementing partner directors, senior members of various ministries of SAG, a representative from the Deputy President’s office, delegates for each province, and the Executive Officer of the SANAC. The timing of the meeting was to coincide with periods that are more aligned with the planning and budgeting processes of the SAG, which would then feed into annual USG COP planning for the COP to be reviewed by this same steering committee before it is submitted to OGAC (SAG and USG, 2012).These efforts track
with several of the metrics in Box 10-2 and Box 10-6 to measure the success in engaging partner country government for improved communication and coordination and the success of USG involvement in the host country planning process, as well as improving transparency and contributing to a culture of mutual accountability, which is evidence of considerable improvement from earlier PEPFAR planning and coordination with the partner country.
A management committee, with a subset of members from the steering committee structure, was tasked to carry out the objectives of the steering committee. It had several deliverables that specifically included active discussion of national priorities and needs during the Country Operational Plan (COP) process and a review of targets and geographical coverage; a review of PFIP progress for all parties including the transition of PEPFAR-supported activities outlined in the PFIP monitoring and evaluation (M&E) framework; and the review of and potential recommendations for new funding opportunities for PEPFAR funds while adhering to necessary confidentiality agreements for that process. Again, consistent with measures in Box 10-6 to assess potential success for country ownership, there were also objectives and intentions to confirm that the SAG’s basic accounting system could generate timely reports on government spending for HIV and TB at the national and provincial levels and that the PEPFAR Expenditure Analysis could do the same for USG expenditures. As previously mentioned, these expenditure data could be used to inform the SAG’s budgeting process, as well as to enhance PEPFAR coordination at the provincial level because provinces would be expected to play a critical role for PEPFAR implementation at these levels for activities and outcomes of the PFIP (SAG and USG, 2012).
“PEPFAR is supporting a Results for Development consultancy to identify countries’ spending on health, in South Africa, Nigeria, and 13 other countries. They are trying to develop a practical set of tools as a fair method to identify what the country is investing on health in order to help PEPFAR to be fair and put them in the right trajectory.” (NCV-12-USG)
There was also a Transitional Task Team for Clinical Service, which was intended to engage with PEPFAR implementing partners to better understand the realities and challenges to implementation, address issues as they arose, and to highlight successes of the transition. Initially established to address the immediate issue of ensuring the continuum of care with new implementing partner agreements and those existing agreements with partners that were ending, it would oversee the broader transition of clinical services. These services included provision of strategic direction to
the transition of direct service delivery to health systems strengthening and monitoring government’s efforts to assume direct service delivery currently provided by PEPFAR. “The transition of the PEPFAR program within the broader development agenda of the SAG is expected to need support from both the USG and the SAG to ensure that the South African system is adequately prepared to absorb the programmatic elements that PEPFAR built up over the years, particularly the clinical services, without compromising patient access to care and treatment, quality of services and continuum of care. In addition, PEPFAR is to maintain its strategic focus on prevention to address critical areas of intervention. It is critical therefore that the strategic focus is built around the themes of the NSP, which are embedded in the development agenda of government” (SAG and USG, 2012, p. 17).
For multisectoral engagement including the role of civil society, “PEPFAR enhances the multi-sectoral response of SAG by working with key departments at the national level and in all provinces. These include the Departments of Health; Social Development; Basic Education; Higher Education and Training; Correctional Services; Defense; Public Service and Administration; Women, Children and People with Disabilities; National Prosecuting Authority; National Treasury, and the South African Police Service. In addition, PEPFAR engages with SANAC and the private sector. PEPFAR has direct funding agreements with more than 120 prime implementing partners, including the SAG, parastatals, non-governmental organizations, unions, private entities, and universities. Approximately 10% of PEPFAR’s budget directly funds and provides technical assistance to several national departments and parastatals” (SAG and USG, 2012, p. 12).
System strengthening activities and capacity building Shortages of critical human resources, especially doctors and pharmacists, has led to the adoption of a nurse-based model of treatment and care by the SAG as well as support that incorporated community-based services to ensure equitable access of high-quality HIV and TB services. Coordination, leadership, and management skills are needed to mobilize all sectors around a common vision that takes into account the nature of the epidemics in their locality. For community systems strengthening, PEPFAR was responsible for building capacity of community structures and leadership to coordinate with relevant SAG departments to improve and sustain the HIV/TB response by actively linking the community to HIV/TB services and addressing social, cultural, and gender norms that underpin the epidemics. As the PEPFAR program transitions from direct service provision, the focus would be on strengthening the capacity at provincial and district levels along the World Health Organization (WHO) six building blocks (SAG and USG, 2012).
Select activities highlighted for building block foci include the development of several health information systems to track health outcomes for people on ART, a TB surveillance system, supporting the country’s information system that provides information on service delivery for orphans and vulnerable children (OVC), and support the SAG’s development of an M&E framework to track the implementation of the NSP and progress toward achieving national HIV, STI, and TB targets. The PFIP is expected to also promote an environment of data transparency and sharing between PEPFAR and the SAG in order to maximize data use and streamline reporting, including the development of a joint data sharing agreement. In collaboration with the SAG and other in-country partners, PEPFAR is expected to contribute to monitoring of national targets for impact and outcome indicators (SAG and USG, 2012). A final technical assistance and capacity building monitoring system is expected to be developed by PEPFAR in consultation with the SAG and partners, which should leverage in-country and headquarters PEPFAR support and be completed by the end of 2012. This system is expected to enable PEPFAR to quantify its contribution to NSP targets through technical assistance activities (SAG and USG, 2012). Specific impact monitoring goals in the South Africa PFIP include reduce new HIV infections by at least 50 percent using combination prevention approaches; initiate at least 80 percent of eligible patients on ART, with 70 percent alive and on treatment 5 years after initiation; reduce the number of new TB infections, as well as the number of TB deaths by 50 percent; and reduce reported stigma and discrimination related to HIV and TB by 50 percent (SAG and USG, 2012).
The multisectoral response also included strategies and prioritized activities for the Department of Basic Education and the Department of Social Development. While the USG is identified as being responsible for services for OVC, the SAG is identified as strengthening interventions for childhood morbidity and mortality. The SAG was expected to add a focus beyond the Life Skills program for 15- to 19-year-olds to more comprehensively respond to the epidemic and to improve physical and psychological safety in all schools with an increase in education to reduce HIV incidence among 15- to 19-year-olds, while also improving the sexual and reproductive health knowledge of students, staff, and other school officials. The Department of Social Development was to also “ensure provision of comprehensive social services which are designed to protect the poor and vulnerable within the South African Constitution and other legislation in the country;” as well as create an enabling environment for sustainable development; and deliver integrated, sustainable, and quality services in partnership with all those committed to building a caring society (SAG and USG, 2012). Specifically, the PFIP aims to reduce new HIV and AIDS infections through social and behavioral change; mitigate the psychosocial and economic impact of
HIV and AIDS as well as TB and other chronic illnesses; and strengthen community capacity and systems” (SAG and USG, 2012, p. 10).
Improving the health of all South Africans was identified as the fifth strategic priority in the PFIP. This included phasing in a national health insurance system and increasing institutional capacity to deliver health system functions. It also included initiating major structural reforms to improve health services management that not only emphasized the treatment of drug-resistant TB, but also enhanced public health services to respond to a range of chronic diseases, injuries, and trauma. Lastly, it included the introduction of new child vaccines to reduce significant causes of childhood morbidity and mortality (SAG and USG, 2012).
Other key foci of the South Africa PFIP included facility-, district, and provincial-level capacity building for supply chain management for pharmaceuticals and commodities to ensure continuous supply of medicines such as ARVs, medicines to treat opportunistic infections, TB prophylaxis and treatment, and commodities such as condoms and test kits. Health service delivery innovation was described as needing continued support to create service delivery models and new prevention and treatment guidelines. Country-specific research, innovation, surveillance, and program evaluations were reported as activities to improve health outcomes including for HIV and TB and to prevent new infections as well as an outcomes-based planning model to make progress in curbing the epidemic (SAG and USG, 2012).
PEPFAR-Wide Multisectoral Capacity Building and System Strengthening
PEPFAR has supported partner countries to build capacity in multiple sectors and supported policy-enabling environments that would assist a partner country government in planning, executing, and overseeing a multisectoral HIV/AIDS response. These efforts were broad across sectors for HIV/AIDS, but specific activities were identified by inclusion in specific sector programming in the countries. For example, to address the combination of needs and interventions for the prevention and intervention of gender-based violence and the risks of HIV transmission, clinical PEP services were provided at different facilities for victims of sexual assault, as well as integration of gender-based violence issues for detection and support of victims into training for health care workers (166-17-USG). Capacity building and partnerships with ministries of education were often cited in countries with the inclusion of HIV/AIDS, health, and nutrition, into school curricula (587-8-PCGOV), the training of teachers, the workforce development for social workers and para-social workers with pre- and in-service training and salary support for their hiring, and increased services for out-of-school youth were also highlighted (542-14-PCGOV). PEPFAR supported the U.S. Department
of Defense in its efforts for HIV prevention and HIV counseling and testing activities for military forces in partner countries (196-2-USG; 331-17-USG; 934-ES) and also included laboratory infrastructure improvements and functioning (331-17-USG). Lastly, PEPFAR supported ministries of labor efforts in partner countries for the development of workforce programs for HIV prevention programs, HIV testing, care, and treatment, as well as training and information systems development to track participants in the ministries’ programs (587-14-PCGOV; 587-17-PCNGO; 396-50-PCGOV).
In the Lantos-Hyde Act of 2008, Congress stated:
The Secretary of the Treasury, acting through the head of the Office of Technical Assistance, is authorized to provide assistance for advisors and partner country finance, health, and other relevant ministries to improve the effectiveness of public finance management systems in partner countries to enable such countries to receive funding to carry out programs to combat HIV/AIDS, tuberculosis, and malaria and to manage such programs.24
Local Capacity for Program and Fiscal Management of the HIV Response
Though country ownership may be a starting point for sustainability in OGAC’s view, there has also been an historical focus in PEPFAR on building local capacity in partner countries, from the national to the civil society levels for HIV/AIDS planning, policy, implementation, and accountability to move toward a goal of shared responsibility and accountability. During the committee’s country visits, the greatest challenge and need that interviewees widely identified was a deficit of trained and skilled personnel in all sectors of the response, including health care, and the retention of such personnel once trained. They noted the existence of sometimes severely limited human resource capacity in health including a deficit of management knowledge and skills in a diversity of sectors, including technical, program, commodities, financial, and personnel management (166-ES; 461-ES; 542-ES; 587-ES; 240-ES; 934-ES; 116-ES). Of the primary USG implementing partners, USAID has more often focused more resources on building capacity of local NGOs to play various roles in the response—from advocacy to service provision (587-21-PCNGO; 587-23-USG; 116-3-USG; 166-14-PCNGO; 196-3-USG; 542-13-USG; 636-16-USG; 461-10-PCNGO).
Conversely, a different experience was described as awkward between the sectors since PEPFAR directly funded NGOs and provided technical assistance including program and fiscal management, monitoring and evaluation, and resource diversification using grant writing as a fundraising tool. The partner country government saw the NGOs as competition for external
24Supra, note 4 at 204, 22 U.S.C. 7621, 204(b)(1).
resources, yet the NGOs felt that they were providing invaluable services to people affected by HIV/AIDS and that their communities looked to them for services that were not accessible or available elsewhere (587-21-PCNGO; 166-14-PCNGO). In many cases, the NGOs were long-standing agencies in the country, and once respected for their efforts and activities, were sought after by the country government for active partnerships in HIV/AIDS planning and implementation. Their involvement with the government ranged from developing training materials and curricula for use in government facilities to serving on national-level technical working groups that also made recommendations for policy making related to HIV/AIDS (240-ES; 542-ES; 166-ES; 116-ES). OGAC financially incentivized broader efforts for local capacity building for NGOs by awarding points that would result in increased funding for prime partners that used umbrella grant mechanisms for capacity building (NCV-16-USG). Civil society was described as having a “watchdog role” for governmental accountability for service provision and efforts for supply to keep pace with demand for quality services (542-5-USPS). In almost every partner country visited, there was a description of individual and institutional local capacity building efforts for the maintenance and sustainability of the HIV/AIDS response in nearly every area (monitoring and evaluation and research are further discussed in Chapter 11 on knowledge management). PEPFAR annual reports, from the very beginning, have also reported that “the investment in capacity building through bilateral programs reflects the United States’ commitment to helping nations increase their ability to respond to both current and future HIV/AIDS challenges and establish programs that are sustainable in the long term” (OGAC, 2005, p.75).
Track 1.0 partners deserve credit and acknowledgment for much of the capacity building for the provision of prevention, care, and treatment services for adults and children, including training of health personnel, as well as for rapid scale-up in the early days of PEPFAR and continuing through the transition of their programs to local entities within the countries they have worked (OGAC, 2005). The USG has consistently emphasized scaling up of services using core competencies of USG agencies (and their partners) across sectors (Goosby et al., 2012a). While workforce capacity building efforts are largely described in the chapter on health systems strengthening (Chapter 9), it should be noted that the reauthorization legislation highlighted the need for local capacity—“foreign service nationals provide critically important services in the design and implementation of United States country-level HIV/AIDS programs and their skills and experience as public health professionals should be recognized within hiring and compensation practices.”25
25Supra, note 4 at 103, 22 U.S.C. 7612(d)(2).
New Partners Initiative
In PEPFAR I, USAID was the lead agency for the New Partners Initiative (NPI), which was started in 2005 and aimed toward improving local capacity and increasing the number of local partners. A director for NPI was situated at OGAC headquarters. Early in the program, NPI offered nearly $200 million to new community-based organizations through cooperative grants in the 15 focus countries. These organizations may have had experience providing prevention, treatment, and care services, but little experience working with the USG (USAID OIG, 2007).
Under PEPFAR, NPI was created to build the capacity of organizations at the community level to achieve local ownership and enhance the long-term support and viability of HIV/AIDS responses. Specifically, NPI’s goals are to (1) increase PEPFAR’s ability to reach people with needed services by identifying potential new PEPFAR partner organizations, (2) increase the total number of partner organizations and their capacity to provide prevention and care services, and (3) build capacity in host nations by developing indigenous capacity to address HIV/AIDS to promote the sustainability of host nations’ efforts. (USAID OIG, 2007, p. 3)
USAID’s Office of the Inspector General (OIG) had several audit findings. First, mission teams reported an increase in their workloads, including for their technical officers, because of the new initiative and uncertainty about the future residence of the partners had a negative effect on USAID interaction with these partners. Secondly, these partners did not have the capacity to comply with USAID administrative requirements tested, though partner improvements in some of those areas were identified during the audit. “Specifically, the audit noted weaknesses in NPI partners’ ability to comply with program and financial reporting, accounting practices, and work plan requirements” and USAID OIG made recommendations to the Office of HIV/AIDS for corrective action to address these deficiencies (USAID OIG, 2007, p. 1). Despite the weaknesses in the organizational assessments, USAID’s OIG also recognized that many of the deficiencies were being addressed. During the partner country visits, the committee overall heard from the NGOs, partner country government, and USG representatives that local capacity building was having a net positive effect. Even non-country visit interviewees noted that early introductions and efforts were critical to developing or building relationships.
“Another area not appreciated enough is the effort getting PEPFAR programs going on the ground, building the partnerships and ownership with the people running the programs. Getting the buy-in
of the people living in the community working in the facilities. Also training peer workers, supporting networks of people to start groups. Building a supportive community and engaging community partners has been a process and a huge effort.” (NCV-5-USACA)
Transitioning of Programs to Local Prime Partners
The first phase of transitioning programs began with the PEPFAR original Track 1.0 partners, which were all required to complete transitioning of their programs and services to local entities in the partner countries in which they operated by February 2012 (NCV-9-USG; NCV-12-USG; NCV-30-USG; NCV-11-USG). Some of the entities are partner country governments at the national and subnational levels and their implementing partners, while others are local NGOs (NCV-5-USACA; 166-33-PCGOV; 636-9-USACA; 636-19-USNGO; 166-10-USNGO). Reportedly, entity readiness for accepting management of programs was based on formal and informal assessments of local partners including ministries of health, health facilities, district government entities, and NGOs before they received direct USG funding to serve as prime partners (NCV-4-USACA; NCV-5-USACA; NCV-6-USNGO). Some assessment tools were developed by USG partners, including USG agencies, but they vary in complexity in terms of what they measure and their ease of use. The Track 1.0 partners’ transition is offered as an example of what the USG would like to achieve across similar health programs (USG, 2012).
“The transition has to occur with trust, they shouldn’t be afraid to let go but at the same time they need to have systems in place to make sure the quality of the care provided is ensured. There is anxiety about readiness, for example with the Track 1.0 transitions. It’s time to change the relationship with the countries, changing the role of PEPFAR staff from the person who manages the program to the person who is with the person who manages the program.” (NCV-12-USG)
The Track 1.0 partner experience was also identified as an opportunity to learn lessons about what needs to be done or avoided, at what pace, and how to measure success for transferring programs to local partners:
“we haven’t actually taken the time to learn, no one has actually studied Track 1.0 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 [. . .] 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.” (NCV-16-USG)
For some long-term partners, the transfer of money was not the sole issue or concern. Performance was identified as equally important—the transfer of work once the money is transferred (NCV-5-USACA; NCV-8-USACA). Once programs and services have been transferred, other practical considerations were raised: “What are the parameters to monitor and who is responsible for it? How do you see the effect beyond the actual transition of the money?” (NCV-5-USACA). The measure itself might also determine whether there is success:
“If competitive awards for money to local groups were the measure, then we would say it’s successful because the local groups and government could actually win the funds. Most of these efforts are just being started, we will have to see over time how implementation goes.” (NCV-5-USACA)
Private-Sector Capacity Building and Involvement
In its eighth annual report to Congress in 2012, OGAC identified public–private partnerships (PPPs) as a tool to enhance country health system strengthening and to leverage PEPFAR resources and complementary technical focus. The report further stipulates that the business sector has other specific skills and technical expertise, such as marketing, distribution networks, and laboratory and information capacity, and PEPFAR is working to establish more linkages and partnerships to contribute to a collective effort toward sustainability (OGAC, 2012c).
PPPs were also important for health workforce development and health system strengthening, themes that were described in every single country the IOM committee visited as tremendous challenges. PPPs had similar roles for health and other workforce development, national policy development including clinical guidelines, and provision of services for both adult and especially pediatric care and treatment services, including the establishment of Centers for Excellence for training and capacity building (Damonti et al., 2012). Salient examples of other critical roles for PPPs in the HIV/AIDS response include Becton, Dickinson and Company’s expertise to improve laboratory infrastructure, quality, and operation; the Partnership for Supply Chain Management role in strengthened supply chains; Together for Girls’ focus on prevention and reduction of sexual violence; and Voxiva’s role in supplying information technologies to deliver interactive mobile health services (Sturchio and Cohen, 2012). In September 2011, the Pink Ribbon Red Ribbon initiative was launched by PEPFAR, along with the PPP among the
George W. Bush Institute, Susan G. Komen for the Cure, and UNAIDS. This innovative partnership leveraged public and private investments targeting breast and cervical cancer, which are described as two of the leading cancer causes of death for women in low- and middle-income countries (OGAC, 2012c). This initiative is also discussed in the services integration section of the health systems strengthening chapter (Chapter 9).
Increased partnerships with the private sector were identified for untapped potential and innovation for “system-strengthening efforts,” including “forecasting and distribution, mobile services, worker outreach through their extensive networks,” and “use and development of different technologies for point of care diagnostics for structural system changes for service delivery, communication systems, and community education in rural areas through mobile technology such as mHealth.” (NCV-12-USG)
“The system could be planned around the assets they bring and they could be embraced more within the system. Not all the activities have to be done by the government. 50-55 percent of the health care delivered in [a PEPFAR country] is done through the private sector. Therefore, there are lots of opportunities in the private sector that should be considered such as help with supply and distribution challenges. This would also get more than just the government invested in success. Looking at the program with private-sector eyes, including different financing options, provides a different and possibly very beneficial insight. This is not PEPFAR’s area of expertise but others can bring this.” (NCV-12-USG)
“The government also needs to not leave it to others; partners are putting in a big contribution. Supply management, prevention, ARVs. When you have a donor that is bringing in a lot of money and technical resources, and you know that this is what they are going to help you with, it’s easy to say “okay, that is covered,” but sometimes isn’t good enough. It is not just capacity building. It’s a sense of ownership of what needs to be done. The partners have ideas and money, but when the government lets go, is it really something you’re leaving behind. There is something there that needs to change.” (166-9-ML/OBL/USACA/USNGO/PCNGO/PCPS)
There is eager interest from partner country stakeholders to not only explore increasing financial resources from the private sector to diversify HIV/AIDS responses, but also to have the sectors learn from each other in terms of best practices that can be applied for sustainability of country responses to HIV/AIDS and other health issues (NCV-30-USG; NCV-12-USG).
Greater Focus on Prevention
There is some global enthusiasm that OGAC quickly moved forward to respond to emerging scientific evidence from the results of recent biomedical interventions showing an impact on ART on HIV transmission. To determine how best to incorporate this evidence into the PEPFAR portfolio for prevention, OGAC convened a consultation on “unresolved issues in HIV prevention in generalized epidemics” (Ryan et al., 2012, p. S75). This consultation focused on the available evidence and determined a set of “core interventions” which had the strongest evidence. The consultation acknowledged that “treatment would play a critical role in reducing new infections and that behavioral interventions to support these core interventions and reduce risk are critical” (Ryan et al., 2012, p. S75). Even though the Five-Year Strategy for the reauthorization legislation emphasized prevention as a high priority toward sustainability, as discussed in Chapter 5 of this report there is still a concern about the focus and prioritization of behavioral interventions for their singular as well as combinative contribution to prevention of sexual transmission, as well as the funding that is allocated programmatically and the way in which these interventions are studied and measured, despite this scientific advancement. Palen et al. (2012, p. S117) stated that “if low-income countries do not do better with prevention, all ‘efficiencies’ achieved within their delivery systems are simply more efficient ways to commit ever-expanding resources to an interminable pandemic.” Some interviewees also voiced a similar concern that behavioral and structural prevention has been largely ignored compared to scaling up of care and treatment (636-ES; 953-ES). Chapter 5 on prevention and Chapter 6 on care and treatment also discuss the role ART can have on prevention of HIV transmission.
The committee heard specific concerns from country visit interviewees about the link between prevention and sustainability. Participants in nearly all countries visited associated prevention with the concept of sustainability and several participants noted that their country would be unable to maintain all of its current activities, including prevention activities, if 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 $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 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 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 initiative, 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 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, 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
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 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 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 chapter (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 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 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 alleviate 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 regional missions as part of the longer-
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-
26There are some exceptions to the eligibility for technical support for focus countries under 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).
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)
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 sustainability 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 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; 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 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; 396-ES; 196-ES) or that transitioning would take time (NCV-8-USACA) for sustainability. 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 concerned about achieving the transition effectively and about finding efficiencies, 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, interviewees 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 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 the USG, partner country governments,
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 challenges 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)
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 toward 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.
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 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 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 for 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 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.
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 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 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.
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