The strategy codifies much of the language we have been hearing from OGAC over the past few months. “Sustainability,” “country ownership,” “strengthening national health systems,” “emphasis on prevention,” “evidence-based programming,” “coordination and integration across health issues,” “multi-lateral cooperation,” “innovation,” “operations research,” “evaluation,” and a “woman-centered response,”—all ascendant PEPFAR vocabulary—are prominently utilized in the strategy. The language and general direction outlined in the strategy seems to recognize that PEPFAR—having taken an emergency response approach over the past five years—now faces major challenges to maintaining, sustaining, and expanding upon current successes (and to addressing nagging limitations in the global response). To address these concerns, PEPFAR and the new administration are now trying to take a long-term view on their role in the global fight against HIV, in the context of other health priorities. They also emphasize the U.S. government’s intention to build national health systems to be able to effectively plan and respond to broader health and development needs. This new global five-year strategy and the country Partnership Frameworks seem to have emerged as OGAC’s policy mechanisms for reforming PEPFAR into the “Presidents’ Sustainable Plan for AIDS Relief” (PSPFAR).

Evidence based Policy making and program design
OGAC and the administration are re-thinking policies based on evidence and learning from PEPFAR 1 to ensure that PEPFAR’s massive inputs have impacts well beyond the immediate outputs of enrolling millions in to treatment programs. For example, PEPFAR funding needs to do much better at prevention, and the strategy document acknowledges the need to scale up prevention efforts along with the scale up of treatment efforts. Earlier this week, PEPFAR released three annexes to accompany the strategy document which further detail how PEPFAR intends to create a “durable response” that transitions the U.S. led programs into country owned responses to HIV. The annex on prevention, treatment and care is divided into two phases: Phase one-spend the first two years working with governments to collect evidence on what works and develop the roadmap for a basic package of prevention, care and treatment services for countries; and Phase two-spend the following three years supporting countries to scale up the evidence-based approaches indentified in the first two years. The strategy and the annexes spell out the WHAT should be done to transition prevention, care and treatment efforts into greater country control over the response, but the HOW is an ongoing venture between PEPFAR and countries.

What’s ahead? Implementation and measurement challenges
At a recent town hall meeting, Ambassador Goosby mentioned that over the next year, PEPFAR will work with country stakeholders to develop an implementation plan and extensive changes will be made in the guidance offered to countries (COP and otherwise). The main goal of the changes will be to better inform countries on how to address the policies outlined in the strategy and shift to a more country-led, sustainable response. It seems that this guidance will come in addition to the Partnership Frameworks, which are already underway. These Frameworks, referred to by Ambassador Goosby as the “first step” towards a more sustainable response, are agreements between PEPFAR, the national government and other country partners to lay out a five year country strategy and an implementation plan building on existing national priorities for a coordinated and country led AIDS response.

So far so good. While others have been quick to criticize the Obama administration’s new strategy, it is important to acknowledge policy reform as an essential first step. Looking ahead, we find that there are some troubling questions about implementation and measuring results. These partnership frameworks have been in the works for over a year, four agreements have been signed, and all are still without accompanying implementation plans—the actual document meant to outline specific details of the activities and organizations responsible for carrying out and achieving the objectives, commitments and targets laid out in the agreement. While PEPFAR has strategically retained its treatment, prevention and care targets to report success—this time increasing the cumulative totals to 4+/12/12—it has also included laudable, but harder-to-measure goals and targets such as for country ownership, health system strengthening, integration of HIV with other health services, and sustainability of the response.

Without implementation plans and country specific indicators in the picture yet, it is very difficult to see how PEPFAR will translate these sound and welcome policies to a country led response that can deliver on yet to be defined (and measured) concepts like country ownership. Early signs of discordance between implementation and policy are emerging. For example, Ambassador Goosby has praised the CCM structure of the Global Fund as a decision-making model, and suggested that that PEPFAR move closer to this model, where country actors have more direct control over funding allocations. PEPFAR is trying to increase the amount of funding that goes to local, rather than international, recipients, but this does not address issues of ownership and sustainability of the program as a whole, particularly when PEPFAR funding will still be channeled mostly to non-government recipients and Country Operation Plans will still be developed by U.S. government teams. As far as we can tell, the design and management of the programs are still tightly controlled by the U.S. Government and accountability to the U.S. Congress is clearly of highest importance relative to the accountability to beneficiaries of these programs. So, how exactly will the government lead/steer the ownership of this response to national stakeholders?

Looking ahead to the implementation plans, we are hoping to see some sort of structural changes that will systematically shift planning and management functions, even if incrementally, to stakeholders in countries. Will implementation plans be backed up by some serious mechanisms for mutual accountability, built on a foundation of transparency? To be clear, will country partnership framework implementation plans address basic issues of accountability: a) who is accountable for what?; b) who will be accountable to whom?; c) how will accountability be monitored? ; and, d) what consequences will exist and for whom if commitments and targets are not met?

In sum, full marks for Act I to our friends at OGAC, several U.S.G agencies and at the State Department who have worked tirelessly to think through what constitutes evidence based policy in the fight against HIV/AIDS. Notwithstanding resource constraints, the stage is set with policies that can increase the flexibility of funding to improve programming options for better outcomes, but writing and acting Acts II, III and IV with partner countries for a grand finale in 2014 will be the defining moment for this administration’s role in the global response to HIV/AIDS.

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1. Michael Bernstein Says:
   December 15th, 2009 at 1:16 pm

   It sounds like PEPAR is moving in the right direction. To me, even more exciting than the stronger lean towards prevention is the attempt to be more country-focused. I doubt PEPFAR will ever really get away from a model that is focused on US government staff designing the program, but if these staff at least had more flexibility to design plans that were consistent with the country contexts that would be a huge leap forward. Looking forward to getting updates when the next act takes stage!

2. Ernest Says:
   December 15th, 2009 at 1:35 pm

   All the right things said with the right pitch. I wish more attention would be paid, as you allude to, performance systems. How can we know that we are doing what we say we are doing? This sounds like a simple statement, but describes the dilemma in full

3. Nandini Oomman Says:
   December 16th, 2009 at 6:29 am

   Thanks for you comments. Michael, indeed the country focus is exciting and your analysis is right on. At least the PEPFAR country teams will have more flexibility in designing country specific programs by working with country stakeholders including the Government this time around! Ernest, couldn’t agree more that the assessment of these efforts is critical and like you I am waiting to see how this administration does a better job of doing the difficult task of measuring outcomes and impact of PEPFAR dollars, and not just counting people who receive treatment, prevention and care.

4. William Okedi Says:
   December 17th, 2009 at 11:32 pm

   The policy statements and goals of PEPFAR 2 seem headed towards the right direction in addressing not only the disease specific technical challenges but also health systems challenges that have weakened service delivery over the past 3-4 decades. This is indeed a demonstration that PEPFAR is listening to sentiments expressed by its partners and stakeholders in the global South. The challenge however, as already pointed out by Nandini and Team is how to translate these goals to tangible outcomes at country level. To ensure the realisation of these goals, a top priority for PSPFAR should be addressing issues of national leadership and governance alongside the technical aspects of the program. Leadership and governance issues lie at the core of the failures in development initiatives in Africa today and unless they are addressed, the concepts of sustainability and ownership will remain hollow.

5. Tom Says:
   December 18th, 2009 at 10:37 am

   Building on this, it is interesting to note Dr Jack Lord’s comments for the Future Agenda programme that “in an ideal world the organizations responsible for global health would move from their marginalized roles to a lead role on the public stage” (http://www.futureagenda.org/?cat=9)

   Nowhere is this more important than in developing future policy frameworks, and PEPFAR have an important role to play in addressing HIV/AIDS.

6. Freddie Ssengooba Says:
   December 22nd, 2009 at 3:17 pm

   It is great to learn that a strategy about how PEPFAR-2 is going to address the accumulated evidence about the need for a sustainable response with effective partnership with national governments is now out. Although there are enormous challenges for recipientgovernments to shoulder the ownership of the response given their small budgets, PEPFAR-2 can start by providing cost information for putting people on treatments to governments and analysts. Ownership by Governemnts and the general public (in-recipient countries) rests on getting information about the dollar amounts of disbursed funds and performance of all grantees. Acurate information about these costs of the current models of care, treatement and prevention that PEPFAR-1 allowed to blossom as an emergency rollout will anable all stakeholders to plan and adjust programs for greater efficiency and sustainability. Now that the emergency is out and sustainability and ownership is back into the discourse, the power to set and design models for implementation need to be grounded more in local knowledge, expertize and implementation research/evidence. The next six years should be about supporting locally sustainable institutions and health systems to handle the response as opposed to PEPFAR-1 that invested more into international and global agencies to implement HIV programs among affected countries.

7. George Says:
   January 3rd, 2010 at 2:25 pm

   PEPFAR reform seems to be freeing up more money for other than treatment. The budget tripled and treatment(drugs) stayed the same or went lower. Sustainable means free health care, housing, food, etc. Since it’s in it’s second five year budget cycle sustainable might be interchangeable with entitlement. The money is expected always.

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