Global AIDS Donors Share Challenges and Opportunities for Performance-Based Funding

On May 10 the HIV/AIDS Monitor invited key officials from OGAC/PEPFAR, the Global Fund for ATM, and the World Bank, and an expert on performance based funding (PBF) to discuss ways in which AIDS donors could improve the use of data about performance in their funding decisions. This panel discussed the findings and recommendations of our new report on PBF (read a blog on this report here, and see the related policy brief here).Nearly 100 attended what turned out to be a lively discussion that highlighted many of the opportunities and challenges facing AIDS donors as they try to apply the principles of PBF. For those who weren’t able to attend in person, below are a few highlights from the discussion, with a few links to related video clips.Nandini Oomman, director of the HIV/AIDS Monitor and CGD senior program associate, kicked off the event with a brief presentation, describing the research process and a selection of key findings and recommendations to the donors. Lawrence MacDonald, CGD vice president of communications and policy outreach, moderated a lively panel discussion to raise some important challenges and progress in defining and measuring performance, against which donors make payments. The panel included Beth Ann Plowman, an expert in performance based funding, and officials with direct responsibilities for designing performance monitoring and reporting systems in their respective agencies, specifically: Daniel Low-Beer from the Global Fund; Miriam Schneidman from the World Bank; and Paul Bouey from PEPFAR.Three topics (issues?) stood out to me during their discussion:1) Strengthening and relying on nation information systemsThe panelists generally agreed that AIDS donors should continue to increase their support of and use national information systems for their performance monitoring, analysis, and reporting needs, although this is easier said than done.

• AIDS donors are still hesitant to rely on national information systems, due to persistent weaknesses
• National systems are improving, but will need quite a bit of technical assistant to build capacity for monitoring and analysis
• Existing information sources—such as the Demographic Health Surveys (DHS)— are invaluable sources of information
• However, even the DHSs are limited; they only provide population level health trends, while many programs need data on sub-national trends
• Also, many countries don’t have clear plans for these national surveys, which leads to uncoordinated efforts to fill information gaps
• The World Bank is increasing its funding to national data collection like the DHSs, PEPFAR is continuing its support to these efforts, and the Global Fund will be able to align grant reporting with such national data collection and assessments through its new grant architecture
• CGD visiting fellow Rena Eichler made an excellent point from the audience that the ability to validate performance results is a critical component of national performance monitoring capacity.

“We do need to work together to support national systems and take mutual credit for results. Part of taking data out of a country involves investing in the generation of data in those countries. If we are taking data out of a country we should be paying for it. GF tries to invest 5-10%, currently 6%. We need to be taking that more seriously and supporting more data generation efforts as well as analytical capacity so that they can do the health reviews and reports.”- Daniel Low-Beer, Unit Director, Performance, Impact and Effectiveness at the Global Fund2) Harmonizing and aligning performance targets both among AIDS donors and with countries’ prioritiesAll three donors reaffirmed their commitment to improving country capacity for monitoring and for data analysis. More difficult perhaps, they also expressed some interest in relying on a joint national system for performance monitoring. However, shifting to a joint national system, will require donors to harmonize and align their performance targets with those that are or could be monitored and analyzed within the national system.Daniel Low-Beer admitted that relying on a joint performance monitoring systems would be a radical shift, requiring greater coordination among the donors. He suggested that it must start with moving toward using common results. He shared the example of Ethiopia, where the move towards common results allowed them to effectively redeploy resources, resulting in a 50% increase in performance on service targets for roughly the same amount of money (see video clip 3 to hear about this example).Paul Bouey stated that PEPFAR is progressing towards harmonizing results among donors and aligning them with national priorities. Over the past few years PEPFAR has been working with other international partners to agree on shared indicators, and these are reflected in PEPFAR’s Next Generation Indicators Guidance. PEPFAR also committed to greater country ownership and sustainability in their Five Year Strategy 2009-2013 and as part of the broader Global Health Initiative. However, Paul Bouey reminded the audience that OGAC has little control of performance monitoring of and reporting from individual recipients at the country level (see video clip 4).“OGAC is solely a coordinating agency and so doesn’t have any authority over contracts. That belongs to the implementing agencies that include USAID, CDC, DoD, etc. Those agencies follow their own contracting procedures and monitor their own contract and the performance of those. We don’t actually have direct access to the data that are received on those… We can request it… [but] there are always issues around ‘to whom does it actually belong and what is proprietary’, and at what point does the burden become greater than the utility.”- Paul Bouey, Deputy Coordinator, Office of the U.S. Global AIDS Coordinator, PEPFAR3) Attribution vs. ContributionAIDS donors are under pressure from their respective financiers (the U.S. Congress, the Global Fund Board, and the World Bank Board) to demonstrate the results of their specific investments. Yet, effective results at all levels (service delivery outputs, outcomes and impacts) usually require cooperative effort. For example, no ARV treatment service is supported solely by the inputs from one external donor. All donor-supported treatment services benefit from direct and indirect support from many different sources.In addition, for some program areas it is nearly impossible to draw a direct link between a single intervention/service and an outcome. For example, a person may only change their sexual behavior as the result of many exposures to various interventions over time. On top of that, it would be difficult to know even IF sexual behavior has changed, not to mention if this has had an effect on sexual transmission of HIV.An exciting exchange ensued over the question of attributing results to particular funders:

• Beth Ann Plowman argued that from the country perspective, systems set up for donors to claim attribution only increases reporting and administrative burdens
• Miriam Schneidman countered that the reality for donors is that they need to show results for their particular investments
• Paul Bouey shared that PEPFAR wants to report on their contribution (rather than attribution), but it would be a difficult transition given demand from the U.S. Congress to report PEPFAR specific results
• Miriam Schneidman suggested that AIDS donors could look for attribution between their funding and outputs, and contribution when it comes to how their finding has contributed to outcomes and impacts
• While this may work at some level, Daniel Low-Beer expressed skepticism at trying to draw such a simple line since even the simplest outputs within the facilities are the result of funding and resources from many different sources

“Institutions need to show results, so there is unfortunately some issue of attribution. And we can’t get away from it. We could get around it if donors were to take credit for outputs, and then anything related to outcomes and impact indicators could be held jointly.”- Miriam Schneidman, Lead Health Specialist, Africa Region, The World BankUltimately, it’s about donors working together, coordinating their unique strengths Across all of these topics, I was struck by how many of the ‘ways forward’ were about AIDS donors working together, and with the governments and other country stakeholders. AIDS donor improvements in applying principles of PBF will go hand-in-hand with improvements in how well they work together and with governments to set, monitor, analyze, report, and take credit for performance targets. At the heart of this issue is the need to agree to work toward common results at the country level. This sets the necessary foundation to build capacity for joint national and sub-national performance monitoring systems, which have to be sophisticated enough to analyze the contributions of different development partners, and even attribute responsibility for results among these partners as appropriate. This is no simple task, but many gains to performance monitoring, reporting, and achievements can be made by working together.