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10 Progress Toward Transitioning to a Sustainable Response in Partner Countries
Pages 543-600

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From page 543...
... government (USG) through PEPFAR, as well as by its support to the Global Fund (Kates and Summers, 2004)
From page 544...
... 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)
From page 545...
... 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.
From page 546...
... . 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]
From page 547...
... Specific strategic components for sustainability were also identified in the reauthorization legislation, including • Requirements supporting "description of the criteria for selec tion, objectives, methodology, and structure of compacts or other framework agreements with countries or regional organizations including the role of civil society, the degree of transparency, the benchmarks for success of such compacts or agreements, and the relationship between such compacts or agreements and the national HIV/AIDS and public health strategies and commitment of partner countries."8 • Approaches to address investments in health by external donors and increased national funding for HV/AIDS with "a description of capacity-building efforts undertaken by countries themselves, including adherents of the Abuja Declaration and an assessment of the impact of International Monetary Fund macroeconomic and fiscal policies on national and donor investments in health."9 Definition of Sustainability Neither the authorizing legislation nor the subsequent PEPFAR 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)
From page 548...
... 5) .12,13 It is also important that this harmonization, report ing, and accountability be multidirectional, flowing between and among donors and partner country governments, to demonstrate transparency as part of their communication, coordination, and collaboration.
From page 549...
... . 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.
From page 550...
... It also emphasized the primary responsibility each country has for its economic and social development, further highlighting the importance of external donors committing to the use of develop ment frameworks that embody poverty reduction strategies and that are "owned and driven by developing countries" (United Nations, 2003)
From page 551...
... Global AIDS Coordinator's newly articulated definition and strategy for country ownership. With the five fundamental principles of ownership, alignment, harmonization, managing for results, and mutual accountability, the Paris Declaration emphasizes the importance of strengthening the national systems in low- and middle-income countries by building measurable development capacity to strengthen public financial management capac ity and national procurement systems in countries.
From page 552...
... have a reform program in place to achieve these. Use of country procurement systems -- percent of do nors and of aid flows that use partner country procurement systems which either (a)
From page 553...
... 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.
From page 554...
... 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)
From page 555...
... 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.
From page 556...
... . 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 dem onstrate leadership over their health budgets, policies and strategies, and coordinate public health actions, including the contributions of the private sector, donors and civil society.
From page 557...
... constitute the primary vehicles through which health programs are delivered and take responsibility for each program •  country institutions adopt and implement Host transparent, evidence-based policies/regulations for priority areas that align with national plans •  country institutions manage funds Host Capabilities •  country has effective workforce, organizations and Host 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 •  country institutions have the capabilities required to Host perform or oversee activities for programs •  country institutions have the ability to dynamically Host modify programs based on evidence and feedback from monitoring processes Mutual accountability, •  country is responsible to country citizens and Host including finance international stakeholders for achieving planned results •  government is responsible for financing and financial Host 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)
From page 558...
... 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.
From page 559...
... . 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]
From page 560...
... . 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)
From page 561...
... 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)
From page 562...
... 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.
From page 563...
... . 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)
From page 564...
... • 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)
From page 565...
...  4.  SOPs for PEPFAR engagement and interactions in countries: De velop 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)
From page 566...
...  Country segmentation and country ownership guidance by seg ment: 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.
From page 567...
... 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
From page 568...
... . A domestic example of health systems planning, ownership, and management may also be informative to PEPFAR's transitional efforts in partner countries.
From page 569...
... . 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)
From page 570...
... 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)
From page 571...
... 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
From page 572...
... Finally, the USG and its partner countries need to use benchmarks or metrics to measure success and progress toward sustainability (NCV-30-USG)
From page 573...
... attrib uted 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 con ducted 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.
From page 574...
... 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)
From page 575...
... 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)
From page 576...
... . 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.
From page 577...
... , especially in rural areas; and (3) capacity building in the public sector, largely focused on strengthening public-sector facilities to increase access to ART.
From page 578...
... 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)
From page 579...
... 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.
From page 580...
... . 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.
From page 581...
... . 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.
From page 582...
... . 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.
From page 583...
... . 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 ad visors and partner country finance, health, and other relevant min istries 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.
From page 584...
... . 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)
From page 585...
... 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.
From page 586...
... . 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)
From page 587...
... Most of these efforts are just being started, we will have to see over time how implementa tion 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)
From page 588...
... 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)
From page 589...
... . 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)
From page 590...
... 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 (63616-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]
From page 591...
... 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)
From page 592...
... . 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)
From page 593...
... KEY BARRIERS TO ACHIEVING COUNTRY OWNERSHIP AND SUSTAINABILITY Financial Responsibility with High Numbers of External Donors and Large Magnitude of External Assistance Country contributions to their own HIV responses have varied widely. Contrast, for example, a contribution of 10 percent to the HIV response budget provided by one country -- "This is quite worrisome for the sustainability of the program" (116-16-PCGOV)
From page 594...
... . This was a repeated and frequent theme in the IOM interviews across the types of interviewees, including the USG, partner country governments,
From page 595...
... SUMMATION The committee concluded that many PEPFAR-supported activities and policy initiatives are contributing toward partner country stakeholder capacity building, particularly for partner country governments through national HIV planning, service provision, quality-assurance initiatives, and health systems strengthening that are needed to sustain an effective HIV response. Gains made in partner countries in terms of provision of services and management of the response are a critical focus of sustainability; it will be a serious impediment to country ownership if the stakeholders expected to be involved in a country's HIV response do not all build their capacity.
From page 596...
... 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.
From page 597...
... Contributing stakeholders, in cluding partner countries, will need mutually agreed, principle based resource allocation to achieve a strategic and ethical balance among the priorities of maintaining current coverage, expanding to meet existing unmet needs, and increasing coverage eligibility. Hav ing processes in place to support this arduous decision making is a critical part of achieving sustainable HIV programs and sustainable management of the HIV epidemic in partner countries.
From page 598...
... 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.
From page 599...
... 2009a. Guidance for PEPFAR partnership frameworks and partnership framework implementation plans.
From page 600...
... 2011a. The President's Emergency Plan for AIDS Relief fiscal years 2009-2010 report on the Global Fund to Fight AIDS, Tuberculosis and Malaria http:// www.pepfar.gov/documents/organization/178816.pdf (accessed November 17, 2012)


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