INTRODUCTION
Through the President's Emergency Plan for AIDS Relief (PEPFAR), the United States has made an extraordinary contribution to the global AIDS response. PEPFAR has spurred unprecedented progress in saving lives from AIDS, while also improving a broad range of health outcomes by strengthening country platforms for the delivery of basic health services. Now, a new endpoint is in sight—an AIDS-free generation—together with the opportunity to change the trajectory of global health through the investments made and lessons learned in doing this work. PEPFAR's success is contributing to a sea change in the way that global health is pursued, raising the bar for what programs are expected to achieve, and how all partners must work together to gain durable results.
Less than a decade ago many experts counseled against scaling up antiretroviral treatment in the developing world. They feared that patients would be unable to adhere to their regimens, that resistant strains of the virus would evolve and prevail, and that the need to sustain daily treatment for millions of people in poor settings would overwhelm fragile health systems. Today, more than 6.6 million men, women, and children are on treatment, and incidence is dropping in many of the hardest-hit countries. By adopting a targeted approach to address one of the most complex global health issues in modern history, and then taking it to scale with urgency and commitment, PEPFAR has both forged new models and challenged the conventional wisdom on what is possible. That wide-ranging gains of this magnitude can be achieved—with this uniquely difficult disease in difficult environments—holds promise and hope for what can be achieved with new paradigms of engagement for global health.
This is an appropriate moment to look to the future, for PEPFAR and the global AIDS response, but also for the broader global health effort. The opportunity is at hand to realize a future when the AIDS epidemic is a thing of the past, by bonding science and partnerships to turn the tide. As we strive to reach this goal and strengthen the platform for health care in countries, a path is laid for the global community to join in the challenge of our shared responsibility for global public health.
COUNTRY OWNERSHIP: THE STARTING POINT
As the AIDS response enters its next stage, it is critical that partner countries be in the driver's seat. Not only is this important for sustainable models of care, but co-ordination across all resource flows can maximize the impact of each dollar invested by reducing duplication and addressing prioritized gaps. When the term “country ownership” is used in the AIDS context, it is sometimes misunderstood to signal a complete absence of external support for a country's response. What it does mean, however, is that the overall leadership role belongs to the country, not to external partners. Every government has a unique responsibility to its people that flows from its sovereignty. In terms of health, this leadership means planning and overseeing its health sector, including the national system of care. We must acknowledge that there is a long history of external partners playing these leadership roles in many countries, creating an unhealthy donor–recipient relationship of dependence that over time diminishes the capacity of the government and civil society to ensure that services persist and are of high quality. Through the commitment to country ownership of PEPFAR and others, this is changing to a vision of partner countries identifying unmet needs, prioritizing the unmet needs, and making the allocation decisions using diverse funding lines so they are additive and complementary.
For external partners such as PEPFAR, support for country ownership means organizing ourselves to support a country-led framework for a continuum of care. This is reflected as a national system organized around the needs of the country's population, rather than around the needs of donors, laying out the standard of care and delivery system planned to provide it.
Each country's continuum of response must include many elements, but the government must orchestrate it as a responsibility to its citizens. All PEPFAR partner countries have adopted national HIV/AIDS strategies that must in turn be translated into an actual plan for an effective continuum of response. This involves high-level coordination and definition of the roles of the National and Provincial or State ministries and their relationship to the district and village service levels. It requires tools to map and inform programmatic decision-making to minimize duplication and ensure coverage. Each of these components is challenging, and none of them are met without focused effort and unified leadership. PEPFAR support for country ownership has advanced this new model of partnership and is adapting to enhance local capacities as appropriate and sought by partner countries.
PEPFAR is often described as a “vertical” program, with an implication that its impact is limited to AIDS. Although PEPFAR has primarily focused on reducing new HIV infections and saving lives, its investments have also yielded far broader health benefits. Working in collaboration with partner countries, PEPFAR is strengthening national systems so they can effectively deliver essential services, not only for AIDS but also for the needs of the general population. In addition to relieving medical clinics and hospitals often overwhelmed with the needs of HIV-infected people, there have been additional benefits to the broader medical service needs of the broader population—both those HIV-infected and HIV-affected, and the population at large. Examples of these inputs include improving the physical infrastructure of clinics, health centers, and hospitals, increasing the quality and numbers of trained health care workers, and supporting infrastructure for laboratories and drug and commodities procurement and distribution, enabling access to basic health care where little or none existed. This platform for health care can in turn be leveraged by partner countries and other development partners to expand other maternal and child health care, malaria, noncommunicable diseases, and more, in a more efficient and effective manner.
Reduction in maternal, child, and tuberculosis-related mortality, increased utilization of antenatal care, and improved blood safety, are among the improving health indicators now seen in countries with substantial PEPFAR health investments.1,2 The critical element is now working under the country's leadership so that all partners—bilateral, multilateral, private sector, and civil society including people living with HIV—can bring their human and financial resources to bear in the most impactful way possible to save lives. At this point, it is no longer appropriate to settle for anything less.
SHARED RESPONSIBILITY
To move forward, we must acknowledge that AIDS—like global health and development more broadly—is a shared responsibility that must be funded from multiple sources.
PEPFAR represents a bilateral US contribution to this global responsibility. Yet we are only 1 of 3 essential funding sources in the developing countries in which we work. The country's government itself is the second. Other donor investments, such as those of other bilateral programs, foundations, and those made through multilateral mechanisms—such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria—represent the third. The Global Fund serves as a vital mechanism for nations and organizations to contribute to the global response to these 3 diseases, in addition to, or in place of, bilateral programs. These resource streams are all still needed in many places, though the relative proportions will shift over time based on country circumstances. It is the partner government's role and responsibility to coordinate and give direction to these resource streams so that investments are optimized, although also remaining ultimately accountable to its citizens for adequately responding to their needs.
This shared responsibility is not the purview of government alone, but also the private sector, civil society, faith-based organizations, and communities who together contribute to the fabric of needed health care. The generosity of the American people and commitment to saving lives and communities devastated by AIDS, together with other donors, has ushered in a new era of hope, but this success is yet fragile and all bear a responsibility to save many lives yet in the balance.
In line with country ownership, shared responsibility has also meant changing the way donors do business, by making the choice to step back and support country leadership rather than reserving the leadership role for ourselves. External partners have a responsibility and even greater role to play in building capacity through technical support, as countries assume increased managerial and financial responsibilities stretching to the periphery level of services.
The 2 largest external funding sources for the AIDS response, PEPFAR and the Global Fund, have represented different and complementary models of assistance from their inception a decade ago. PEPFAR is oriented toward deployment of US technical and financial assets guided by a bilateral planning process overseen by US Government staff in country. The Global Fund is a financing mechanism to fund country-initiated proposals, with much (though not all) of its resources flowing through country governments. PEPFAR's initial design was geared toward saving lives as rapidly as possible through an emergency response relying predominantly on nongovernmental implementing partners, whereas the Global Fund was designed to recognize and increase country ownership for the long term. The reality is that we need both of these strategies to successfully respond to the challenges. Together with country leadership, PEPFAR and the Global Fund are increasingly engaged in joint planning, recognizing our shared responsibility to individuals using these services, donor countries, and the US taxpayers to ensure that these resources are used as efficiently and effectively as possible.
In summary, the experience of the past decade has paved the road for a new model for the global response. In this new paradigm, at the country level, the partner government, civil society, beneficiaries of programs, private sector, bilateral partners, multilateral financing mechanisms, and multilateral technical partners work together to meet a shared responsibility for health. The government plays the convening role, but all partners are accountable to play their role—not only for smarter planning and use of resources, but also to expand each country's capacity to reach more people with the services they need and ultimately to change the trajectory of the country's epidemic in a lasting way.
PEPFAR: PUTTING NEW PARADIGMS INTO ACTION
PEPFAR's current activities reflect the paradigms of country ownership and shared responsibility in a variety of ways. As we move forward, experience drawn from some facets of PEPFAR's work offers important lessons for our future work on global health and development.
Dialogue With Country Partners
With its 2008 reauthorization, PEPFAR entered a second phase marked by a more explicit focus on strengthening local capacity and country ownership. As the principal mechanism to operationalize this transition, Congress provided authority for Partnership Frameworks. These were designed as joint strategic roadmaps on AIDS between PEPFAR and partner governments, promoting greater mutual accountability and sustainability.
Partnership Frameworks have ushered in a new era of dialogue and collaborative planning between PEPFAR country teams and partner governments essential to ensure the success and sustainability of the AIDS response. Discussions surrounding these Frameworks have enabled greater coordination between national strategic AIDS plans, development of PEPFAR's annual Country Operational Plans, and broader donor coordination. These dialogues are expanding partner governments' ability and willingness to identify areas of unmet need, prioritize among them, and agree to a clear division of labor among partners for addressing them. In addition, the discussions are creating a new level of trust and transparency among those involved, as partners reveal vulnerabilities and limitations in a shared effort to prevent gaps in services.
Prioritizing Evidence-Based, Country-Specific Interventions
In recent years, scientific innovation and programmatic experience have coalesced around a combination of evidence-based HIV interventions that, when implemented together, offer impressive possibilities to move us toward an AIDS-free generation. These include treatment as prevention, prevention of mother-to-child transmission, voluntary medical male circumcision, and condoms, among others. Advanced modeling has shown that by rapidly scaling up this combination prevention package, there is the potential, for the first time in history, to see a path to an AIDS-free generation.
Yet it is not enough to have evidence-based interventions; if they are to support country ownership and shared responsibility, they must be planned, targeted, implemented, and evaluated in partnership with the country and tailored to local circumstances and changing needs of the impacted population. In its “Guidance on Prevention of Sexual Transmission,”3 PEPFAR provides its country teams information on how to work with partner countries to optimize evidence-based prevention programming in light of the country epidemic and other contextual factors—including the recent evidence on the prevention impact of treatment. For example, PEPFAR works with partners to emphasize the importance to public health of respect for human rights. For prevention and other programs to maximize impact and stop new transmission, it is essential to serve the marginalized populations that often bear the consequences of expanding epidemics. Countries are at different points in terms of recognizing this reality, but PEPFAR bears the responsibility to bring the science to the table and pursue dialogue to as important step in promoting responses that are both country-owned and maximally effective.
PEPFAR is a founding partner of the “Global Plan towards the Elimination of New Pediatric Infections and Keeping Mothers Alive”4 along with UNAIDS and other partners. The plan's central goal is to reduce the number of new pediatric infections by 90% by 2015 by supporting accelerated action in 22 priority countries that carry 90% of the global MTCT burden. Critically, the plan focuses on support for national ownership and unified action and leadership at all levels, with visibility and accountability for results.
For an inclusive country-led planning process to be fully effective at optimizing service delivery, it requires solid information on the costs of interventions. Given the difficult environments in which global AIDS programs operate, understanding costs has been a persistent challenge. PEPFAR has made it a priority to support countries in developing the capacity to gather and use information on program costs, a key step toward maximizing the human impact of available resources.
Evaluating Impact
PEPFAR is positioned at the intersection of scientific innovation and implementation experience, allowing it to draw lessons to improve programs and continually bring rigor to the work. Our ability to scale up interventions relies heavily on an evaluation framework focused on implementation science and impact evaluation, drawing on data from the millions of people served by PEPFAR programs. By contributing to the global evidence base in more than 75 countries, PEPFAR is enabling all stakeholders, including partner countries, to benefit from the best available information about what works, and how to optimize health outcomes in country-wide scale-up efforts.
Programs must demonstrate value, impact, and effectiveness to be prioritized within the complex and resource-constrained environments of developing countries. To meet these rigorous standards, PEPFAR adopted an implementation science framework to improve the development and effectiveness of programs. To help stay current on an expanding evidence base, PEPFAR has constituted a Scientific Advisory Board, which includes many of the world's leading HIV scientists, clinicians, and thought-leaders, to advise on key scientific, implementation, and policy issues.
In addition, PEPFAR has funded 3 large implementation science projects along with partner US agencies, and awarded 3 landmark grants for trials of combination prevention. These studies are using the best available tools of implementation science, scaled to high levels, to rigorously evaluate the population-level effects of combination prevention. Going forward, PEPFAR will continue to strengthen the evidentiary feedback loop among science, policy, and program. As new breakthroughs are made in the laboratory, these findings are used to inform policy and continually improve program implementation. Our ability to identify bottlenecks in putting a continuum of services in place, matched with the demonstrated impact of these services, creates a self-correcting implementation path. The ability to measure and understand program implementation issues in real time will be one of the lasting contributions of PEPFAR to our ability to advance global health.
Investing in Local Institutions
PEPFAR invests heavily in supporting African health care systems, a critical dimension of country ownership and sustainability. It has established a number of initiatives to help partner countries improve the sustainability of programs and to ensure that quality is at the heart of this work. Although there is a long history of global assistance to institutions, it is understanding the role that these play in undergirding durable country responses beyond the time frames of elected governments that makes these investments so important.
Working closely with governments and local and external partners, PEPFAR has responded to the need to dramatically transform African education of health workers, both to increase the number of qualified health care providers and to develop the scientific expertise needed for research and innovation. PEPFAR partners with National Institutes of Health on the Medical Education Partnership Initiative and with Health Resources and Services Administration on the Nursing Education Partnership Initiative. These initiatives seek to alleviate Africa's critical shortage of trained health care professionals and paraprofessionals, while developing sustainable local capacity to produce skilled doctors, nurses, and midwives for generations to come. PEPFAR makes grants directly to leaders of African medical institutions, reinforcing these institutions to advance educational excellence, improve standards of practice, and build country ownership of health workforce training. Through Nursing Education Partnership Initiative, PEPFAR is directly engaged with national human resources for health strategies developed by the Ministries of Health and tailoring support to nursing schools to increase the number and quality of training of new nurses to meet the countries' needs.
Laboratories and trained laboratory specialists are needed to improve the ability of clinicians to deliver quality HIV clinical care and provide the empirical data needed to track the status of the epidemic through surveillance. With Centers for Disease Control and Prevention and National Institutes of Health assistance, PEPFAR supports the newly established African Society for Laboratory Medicine (ASLM). ASLM is a pan-African professional body that is advancing professional laboratory medicine practices, science, systems, and networks in Africa. Its activities range from workforce development to technical assistance, with a focus on accreditation and quality management of the laboratory. ASLM is working to connect and inform laboratory scientists through the creation of a peer-reviewed journal, which fosters local South–South technical assistance and serves as a forum for sharing research, training, academic, and industry news.
Building Country Capacity to Lead
As PEPFAR's role moves from being primarily an implementer to a technical assistance resource for partner countries, the focus increasingly becomes supporting and enhancing country capacity to plan, manage, oversee, and ultimately finance their national responses for the long term. Long-term sustainable responses to HIV and other global health challenges require technical, managerial, and budgetary expertise at multiple levels of government and within the health sector, including that needed to lead planning, donor coordination, program management, and evaluation. At the program level, experience gained in transitioning the work of PEPFAR's first round of treatment partners, collectively called Track-1 partners, to partner governments and indigenous institutions has demonstrated how complex these transitions can be. All Track-1 treatment programs in 15 countries have now been fully transferred from United States to local partners. The experience of Rwanda also demonstrates how successful capacity-building has allowed PEPFAR's role to evolve from implementer to technical resource, with strong government leadership achieving impressive results in both HIV indicators and broader health outcomes.
Although financing is only one dimension of country capacity and ownership, it is an important dimension in an era of constrained global resources. As economies grow, many countries are stepping up and increasingly taking on services that PEPFAR once provided. For example, in South Africa, the government has more than doubled its commitment on HIV in recent years to more than $1.3 billion per year. A special 2-year “bridge funding” commitment by PEPFAR to provide antiretroviral (ARV) drugs in South Africa, with aggressively negotiated generic drug pricing, helped enable the government to launch its own increased purchasing of ARV drugs, with the newly negotiated low prices. The government of South Africa is now approaching the goal of providing all ARV drugs needed in country, with support from the Global Fund. This allows PEPFAR to continue to transition from a role dominated by direct service delivery toward one focused on technical support. Other countries have also increased their investments, putting country ownership and shared responsibility into action.
Partnering With the Global Fund
The Global Fund provides a large-scale funding mechanism for combating AIDS, tuberculosis, and malaria and is particularly important for donor countries that do not have large bilateral programs such as PEPFAR, the President's Malaria Initiative, and the large US bilateral maternal and child health programs. The United States contributions to the Global Fund leverage resources from other donors, multiplying impact beyond what US dollars could do alone. In recent months, since the United States demonstrated its increased commitment to the Fund, both new and old donors, including Saudi Arabia, Japan, Germany, and the Bill and Melinda Gates Foundation, have stepped up their contributions. The United States has also been a leader in supporting the Fund's efforts to reform and transform its operations at both the country and headquarters levels to maximize the impact of its investments. This will encourage additional investments, providing assurance that contributions will be spent efficiently and effectively to save as many lives as possible.
To support country-owned programs, PEPFAR and the Global Fund are increasingly engaging in joint planning. PEPFAR and the Fund now cofinance some components of country AIDS responses and are exploring new ways of doing business to maximize the impact of their collective investment in country-led programs. For example, Global Fund resources in a country may fund all required drugs, whereas PEPFAR focuses on technical assistance, capacity building, monitoring and evaluation, and voluntary counseling and testing. This division of labor is overseen by the country government and with participation of civil society, making the arrangement an example of both country ownership and shared responsibility in action, with an impact greater than the sum of the parts.
Moving Forward With New Paradigms for PEPFAR and Global Health
Under the leadership of the Obama Administration and with strong bipartisan support from the U.S. Congress, it is clear that the United States is committed to continue to lead the global AIDS fight. Supporting country ownership at every opportunity will strengthen national leadership and build the bridge to a sustainable AIDS response, leveraging the PEPFAR platform to deliver improved broader health outcomes for the populations served. Shared responsibility will require diplomatic and other efforts to ensure that all partners join in shouldering the burden. The world can no longer afford to have bilateral, multilateral, and global technical agencies acting in isolation, when countries urgently need the talents and support of all for real and lasting progress.
The people of the United States have contributed to unprecedented progress toward the goal of an AIDS-free generation over the last decade. As the global community pursues a vision based on country ownership and shared responsibility for global health at large, American leadership will continue to play a central role in realizing that vision. As we pursue this vision, few achievements will be more valuable than realizing the goal of ending the world's chapter on AIDS forever.
