PEPFAR Earns an ‘A’…but See Me After Class

The GAO just released a report on PEPFAR and country ownership, which evaluated how well the U.S. government has aligned its PEPFAR programs with recipient countries’ national HIV/AIDS strategies. The report finds that PEPFAR’s recent efforts—notably the 5-year strategy, partnership frameworks, and OGAC guidance to country teams—have resulted in programs that, for the most part, align pretty well with national strategies, goals and priorities.This is very good news. First, as findings from one of our earliest reports showed, PEPFAR has not always scored well in this area. Measured against six key ‘best practices’ consistent with the principles of the Paris Declaration, we found that because of an emphasis on meeting ambitious programmatic treatment, prevention and care targets, PEPFAR prioritized speed and efficiency over building capacity for a sustainable response. While funding was disbursed quickly, it was channeled largely to international NGOs and recipient country governments had little oversight. Global earmarks made funding by program area remarkably uniform across countries, rather than focused on country-specific needs and priorities. In short, the partnership between country governments and PEPFAR was weak. It is promising to see improvement during its second phase.Second, the U.S. government is embarking on its new global health and development agenda, where country ownership and program sustainability are top priorities. And while the USG still lacks clear definition and guidelines on how to achieve and monitor these priorities (see information about the HIV/AIDS Monitor’s recent event on the topic here and the accompanying blog here), it is encouraging to see that in its second phase, PEPFAR—the flagship program of the Global Health Initiative—is trying to make recipient governments a real partner in the HIV/AIDS response.However, I remain cautiously optimistic. As the U.S. government is still in the beginning stages of rolling out these programs, it remains to be seen how the new PEPFAR and GHI policies will actually play out in practice. The GAO report’s only recommendation reveals, in my opinion, a major challenge in this shift toward a more country-owned response. Recognizing the importance of being able to measure the impact of these policies in order to make appropriate adjustments, the report draws attention to the fact that currently no indicators exist to collect baseline data that will allow countries and PEPFAR teams to measure the increase of country ownership (read: the impact of the Partnership Frameworks) over time. Ideally, these indicators should have been developed BEFORE the partnership framework agreements were signed, and should be referenced in each country’s implementation plan. (As of August 2010, Malawi was the only country to have officially completed an implementation plan, although according to OGAC, implementation has already begun in a number of countries).The U.S. government’s engagement in global health is evolving to foster better partnerships with countries to respond to their own challenges. While establishing partnerships and aligning donor priorities with country priorities are important, we cannot lose sight of the end goal—better health outcomes. Policy alignment can only be celebrated as a success if it has an impact on the problem at hand, not simply because it was done.