Many policymakers and program implementers agree that PEPFAR is at a key turning point; the biggest challenge going forward is to transform this successful global AIDS initiative from an emergency response in the face of a worldwide epidemic into a sustainable chronic disease program.
The Obama Administration’s plans for that transformation have been the subject of much debate (and the source of some anxiety), since the president has said little about global AIDS since taking office. But we got a few hints about the Administration’s vision this week when a letter surfaced from Obama’s Global AIDS Coordinator, Dr. Eric Goosby, to US ambassadors in PEPFAR countries.
The letter, and a four-page accompanying blueprint for moving PEPFAR forward (both pasted below), focus heavily on sustainability, country ownership, and technical assistance.
“The landscape around us is changing, with the need to balance a broad portfolio of global challenges at a time of financial crisis,” Dr. Goosby wrote in the Aug. 7 missive. “As a result, we need to plan for the next stage of PEPFAR’s development in this context and cannot assume the dramatic funding growth of PEPFAR’s early years will be repeated.”
The attached note describes the need of PEPFAR programs to engage and encourage countries in strengthening their own long-term national HIV/AIDS programs. “Based on country-specific levels of progress, they [PEPFAR programs] may in many instances still need to serve as implementers, but the goal must to be to shift their capacities and emphases to provision of technical assistance as quickly as possible, ensuring that their contributions support an integrated, durable national effort.”
The note, presumably written by Dr. Goosby’s staff at the Office of the US Global AIDS Coordinator, goes on to say: “Moving in this direction reaffirms the long-standing goal for each country to assume primary responsibility for the national responses to HIV/AIDS, both strategically and financially.”
Of course, many PEPFAR countries are in no position to take strategic or financial ownership of their AIDS programs, a reality the OCAG letter readily acknowledges. But PEPFAR programs must begin to move toward that goal, the letter says, stating that “Unless that capacity grows, it is hard to see how efforts can be durable for the long term.”
I am writing to introduce myself in my new role as U.S. Global AIDS Coordinator (S/GAC), and
to ask, in response to the current economic and budget environment, for your partnership in
enhancing the sustainability of the President’s Emergency Plan for AIDS Relief (PEPFAR).
As Secretary Clinton has noted, PEPFAR has been an extraordinary success, restoring hope to
millions through support for HIV prevention, treatment, and care. The leadership of our
Ambassadors has been critical to this success. With the many competing priorities you face, I
deeply appreciate the commitment you have shown to this lifesaving work, which has conveyed
a strikingly positive image of the United States around the world.
To build on the achievements to date as we enter the second phase of PEPFAR, we must have a
clear vision of a path from an emergency focus toward an emphasis on sustainability. Our work
with partner nations on Partnership Frameworks provides a vehicle for achieving this, and I want
to make sure that, together, we make the most of this opportunity.
The particular focus on supporting partner governments described in the attached note, while far
from a new concept for PEPFAR, is a key theme I intend to emphasize and for which your
support will be critical. I recognize the challenges that this change in emphasis will pose for you
and your teams, but I believe you will agree that these steps are essential if the work done to date
is to endure for the long term.
Our programs have achieved remarkable results in recent years, thanks in large part to the work
of your PEPFAR country teams. At the same time, the landscape around us is changing, with the
need to balance a broad portfolio of global challenges at a time of financial crisis. As a result, we
need to plan for the next stage of PEPFAR’s development in this context and cannot assume the
dramatic funding growth of PEPFAR’s early years will be repeated.
A shift toward a greater emphasis on sustainability can help deliver more effective programs that
can thrive even in a more constrained budget environment. The attached note describes several
key steps we can collectively take to develop such an emphasis. We will also send the note to the
PEPFAR country coordinators to share with the interagency PEPFAR teams.
In this effort to promote sustainability, you, as a U.S. Ambassador, play a central role. You have
an unparalleled opportunity to command the attention of your government counterparts, and to
demonstrate our nation’s willingness to support them as they assume increased leadership.
Thank you for your remarkable efforts to date, which have supported incredible achievements by
the people and nations with which we partner. As PEPFAR moves forward, thank you in
advance for working with partner nations to ensure that our achievements will be sustained for
the long term.
Ambassador Eric Goosby
U.S. Global AIDS Coordinator
Attachment: “Focus on supporting partner country ownership of HIV/AIDS responses through
PEPFAR Partnership Frameworks”
Focus on supporting partner country ownership of HIV/AIDS responses through PEPFAR
The central role of partner governments
A critical role of international development partners such as PEPFAR is to develop and support
country-level leadership. As PEPFAR moves into the next five years, a principal focus will be
building long-term sustainability of national HIV
five-year joint strategic plans designed to fully align PEPFAR support with national strategies
HIV/AIDS efforts, along with strong civil society and community participation. Some country
teams have no doubt already focused their work with partner governments on moving in this
direction, but these Framework discussions provide a vital opportunity to intensify our focus on
providing technical assistance. Through such assistance, PEPFAR country programs can expand
partner government capacity to plan, oversee and manage programs, to deliver quality services
with the participation of local civil society and communities, and ultimately, to finance health
Each nation’s HIV epidemic poses its own set of unique challenges and obstacles, and national
health systems are at different levels of development. Through an inclusive process that involves
nongovernmental participants, governments can identify unmet HIV need, craft national
strategies to respond, engage with indigenous partners in the private for-profit and not-for-profit
sectors to extend equitable services, and convene bilateral and multilateral partners such as
PEPFAR, the Global Fund, and UNAIDS and its co-sponsors to support national responses to
these needs. PEPFAR should provide the technical assistance to support them in the role of
coordination across different funding lines, to improve critical health system functions, and help
them better ensure consistency with their national priorities and plan.
In order to respond urgently to the HIV/AIDS emergency in the first phase of PEPFAR,
programs have relied heavily on external organizations, such as nongovernmental organizations
and universities based in developed countries, for service delivery. Working through them
PEPFAR has accomplished much. Because of the need to ensure that quality services are
maintained, these organizations will necessarily continue to play significant roles. Based on
country-specific levels of progress, they may in many instances still need to serve as
implementers, but the goal must be to shift their capacities and emphases to provision of
technical assistance as quickly as possible, ensuring that their contributions support an
integrated, durable national effort. It is also important to note that the levels of knowledge and
expertise in developing nations have grown dramatically in recent years, and programs must
work to ensure that governments are able to make full use both of indigenous expertise and that
of other developing nations in their region.
Moving in this direction reaffirms the long-standing goal for each country to assume primary
responsibility for the national responses to HIV/AIDS, both strategically and financially. The
majority of countries hardest hit by the epidemic are unable to assume every aspect of this role
right now – particularly with respect to financing – or in the near future. But PEPFAR programs
must work as supportive partners as they build their capacity to respond. Unless that capacity
grows, it is hard to see how efforts can be durable for the long term.
In many countries, a significant share of USG funding for HIV/AIDS is provided through the
mechanism of the Global Fund – a mechanism that must work for the global response to be
successful. PEPFAR teams invest time and resources in supporting partner governments in
developing the capacity to manage and implement these grants effectively. PEPFAR’s capacity building support of partner governments will thus have a positive impact on this important
tranche of funding as well. It is also worth reemphasizing that discussions with partner
governments around Partnership Frameworks – and especially Partnership Framework
Implementation plans (PFIPs) — represent a key opportunity for integration and strengthening
linkages between PEPFAR programs and broader global health programs in country.
To address a possible question, however, this emphasis does not represent a turn toward direct
funding of partner governments through Sector-wide Approaches (SWAPs) or similar pooled
New emphasis for additional funds under Partnership Frameworks
From the beginning of the Partnership Framework initiative, supporting sustainable country
responses has been an essential focus. As a general matter, promoting sustainability along the
lines described – rather than simply further scaling up existing activities through existing
partners — should be a primary focus of additional Framework funding. As noted, each partner
government is at a different place on the continuum of capacity to lead and manage its programs,
and PEPFAR must respond accordingly. Complex factors over which the USG has little control
influence health systems in many countries. But in every country, PEPFAR must start
more to help the government, with the active involvement of civil society and communities,
move farther along the continuum toward the ultimate goal of responsibility and capacity. It is
necessary to assess where on the continuum each country is, in order to make decisions about
how best to support progress for each country. Recognizing that in all countries this will take
time, headquarters will work with each country team to develop a realistic timeframe and
benchmarks for progress.
The following examples seek to clarify how this approach might play out in different types of
countries, and are provided to assist teams in developing their Partnership Frameworks and
In countries with generalized or mixed epidemics but where PEPFAR programs have been
relatively small, program scale-up to meet the needs identified by the government and at the
government’s request should be considered an appropriate focus of the Framework and any
additional funding provided under it. But scale-up approaches should be carefully thought
through to promote a more sustainable approach. To the extent country programs rely on external
organizations to conduct that scale-up, a major, inherent part of the organizations’ work from the
very beginning must be technical assistance to build the capacity of the government to manage
and oversee the program, and a strategy for transitioning control of the program to the
government-coordinated system over an appropriate timeframe. Mentoring of government
workers, especially career and clinical personnel, by personnel from the USG (including locally employed staff) and other partner organizations will be critical. These steps promote the vision
that programs, including the important contributions of civil society and communities, will be led
and overseen by the government rather than being a parallel system run from outside the country.
In countries where technical assistance has always been the main focus of the Partnership
Framework effort, it will be critical to ensure that the support provided with additional
Framework funds emphasizes building sustainable national systems (with civil society and
community participation), rather than parallel systems.
And in countries with the largest, most established PEPFAR programs, while there is some
latitude to use additional Framework funds to support scale-up with a plan for convergence of
externally-led programs with public systems over time, there is also an opportunity to fund
additional scale-up by finding efficiencies in the existing large programs. In these cases,
technical support to strengthen the government’s overall capacity to meet its responsibility to
lead and manage all the programs in the country should be a major focus of any additional
While there are countries where government involvement is a severe challenge or extremely
limited, there should still be an attempt to engage. Country teams have identified several
approaches that may be successful. When the national level is preoccupied or unwilling, but open
to the USG working with other levels of government, the focus can be on supporting regional or
provincial governments; if these are unwilling or unable, consideration should be given to a
focus on district and village levels. Technical assistance from civil society and external
organizations to build the capacity of various levels of government may be helpful. If
government involvement remains impossible, supporting indigenous non-governmental
organizations may be an option, and in some cases an external organization-based model may be
the only option for the time being. Even in this scenario, sustainability demands that the USG
persist in seeking to re-engage with the government at each level.
In any of these scenarios, in countries where some significant proportion of overall health care
delivery capacity is represented by local civil society and communities, capacity-building and
technical assistance should also be considered for these providers, consistent with government
strategies and priorities.
Change in Partnership Framework timing and review of additional funding levels
We realize that many country teams are rushing to complete Partnership Frameworks by
September 1, in order to access FY09 funds before the close of the fiscal year. Ambassador
Goosby has concluded that many teams would benefit from additional time, and that this
deadline does not remain appropriate. Approval of additional FY09 Framework funds will
therefore take place as part of the approval of the Partnership Framework Implementation Plan
(PFIP) and FY10 COP, which teams have the options to submit in either October or January.
Any FY09 Framework additional funds that have been approved will then be notified as part of
the Congressional Notifications following each of those PFIP/COP approval cycles. Each
country program should submit the Framework itself for approval whenever it is ready, but there
is no longer a reason to rush for September 1.
Please take as long as you need to work with your partner government to ensure that your
Framework fully reflects the sustainability principles outlined above. These principles will be
central in the review and approval process, so focusing on them now will mean a smoother
approval process later.
Your FY10 budget level, as well as your FY09 maximum Partnership Framework additional
funding level, will be sent in the next few weeks. During this time, the maximum additional
FY09 and FY10 funding levels related to Frameworks that were previously communicated to
you will be reviewed. These levels were originally set about 2 years ago, and there have been
changes in both the world economy and countries’ epidemiology since that time.
Among the factors to be considered in reviewing these levels of additional funds will be country
population (total and people living with HIV), HIV prevalence, number of new infections per
year, unmet need for treatment and PMTCT, current PEPFAR funding level, amount and quality
of management of Global Fund grants, partner government capacity to contribute financially, and
other factors drawn from the PEPFAR experience to date in each country.
To be clear, this review will be of the additional FY09 and FY10 Framework funds, not of the
‘base’ pre-Framework funding levels. Programs have made commitments to people on services,
and so except for the very few programs with which the possibility of declining PEPFAR
resources over time has previously been discussed, there is not an intention to reduce the FY10
‘base’ to levels lower than the FY09 ‘base.’ As always, of course, even the pre-Framework
‘base’ is subject to appropriations.
It is worth reemphasizing that the additional Framework planning levels have always been
communicated to country teams as dependent on approval of a Framework and PFIP, and that
they are at a lower level. Technical assistance to governments, while not cheap, is anticipated to be less expensive than expanding direct service delivery through existing programs that rely on external
capacity to provide services. For this reason, some country teams will submit PFIPs that request
lower levels of funding in some or all years than the maximum available levels. In many cases,
the right approach may be to invest more in the early years and less in later years. PFIPs should
indicate how much of the maximum additional Framework funding level is requested for each
year, beginning with FY09.
The challenging budget environment also serves to highlight the importance of seeking
efficiencies in PEPFAR programs. The needs faced by most of our countries remain great, and it
is a shared responsibility to make sure every dollar is being stretched as far as possible. It also
highlights the importance of the effort currently under way to better understand PEPFAR
treatment costs in order to ensure that treatment services continue in a responsible, sustainable