#PEPFAR15
Maximizing Efficiency and Accountability of the Global HIV Response through
Resource Alignment
Elan Reuben, USAID and S/GAC | Michael Ruffner, S/GAC Samantha Straitz, USAID | Alexander Birikorang, The Global Fund
October 22, 2018
Global Health Mini-University
Washington, DC
2
#PEPFAR15
Presentation Outline
Setting the Stage
HIV Epidemic
Financial Picture
Efficiency Action Agenda
Tools and Approaches
HIV Resource Alignment
Vision for Future of HIV Programs
Summary
Setting the Stage
4
What is PEPFAR?
• US President's Emergency Plan for AIDS Relief (PEPFAR) was created in 2003 in response to the global HIV/AIDS epidemic.
• Represents the largest commitment by any country to address a single disease in history.
• Led and managed by the U.S. Department of State's Office of the U.S. Global AIDS Coordinator and Health Diplomacy and implemented by seven U.S. government departments and agencies, including USAID
• Originally created to assist in the delivery of ARVs → now focused on controlling the epidemic.
• Work in over 50 countries, including supporting more than 14 million people on ARVs
• There is still a significant global disease burden and need for PEPFAR to continually evolve programming and data streams
Source: pepfar.gov
PEPFAR’s Evolution From Emergency Response to Sustainable Impact for an AIDS-free Generation
PEPFAR 1.0 (2003-2009) • Emergency response • AIDS- a security issue • Rapid delivering
prevention, care, and treatment services
PEPFAR 2.0 (2009-2014) • Sustainable response • Shared responsibility &
country-driven programs • Building & strengthening
health systems to deliver HIV services
• Scaling up of prevention, care, and treatment services
PEPFAR 3.0 (2014-Present) • Epidemic control of
HIV/AIDS • End of HIV/AIDS as a public
health threat • Data, quality, oversight,
transparency & accountability for impact
• Accelerating core interventions for epidemic control
PEPFAR’s 3 Guiding Pillars
Accountability
Run cost-effective programs that
maximize the effect of every dollar
invested; actively manage programs
and partners
Transparency
Embrace high levels of transparency,
validate data, and share all levels of
program data
Impact
Save lives and avert new infections;
pursue sustained control of the
epidemic
Controlling the HIV Pandemic
8
#PEPFAR15
Overarching Thoughts
• We know more about programmatic performance and how to reach our targets than ever before
• Epidemic control is possible—and already happening in some countries
• Epidemic control is a precondition for sustainable programs and is essential for long-term national fiscal health
• Future HIV expenses in the steady state will be considerably less than they currently are
• Now is the time to plan for sustainable programs that gradually transition to domestic ownership, systems and financing
• MOFs are integral to any long-term solution—and the design of the domestic response will be far more effective when we work together
HIV Epidemic
10
What is the Global Goal for HIV?
The HIV/AIDS SDG Goal: Control the HIV Pandemic by 2030
90/90/90 by 2020 and 95/95/95 by 2025
The global strategy to achieve these objectives has been named the FAST-TRACK STRATEGY
PEPFAR’s role is to support the above as
effectively and efficiently as possible while ensuring that our achievements are sustained
11
#PEPFAR15
What Is “Epidemic Control”? And How Do We Define Success? • PEPFAR defines epidemic control in standard epidemiologic terms,
i.e., the point at which the annual number of new infections falls below the number of HIV-related deaths; some have recently discussed 1/1,000 incidence rate
• We also support UNAIDS’ 90-90-90 targets (i.e., 90% of PLHIV to be diagnosed, 90% of those diagnosed to be covered on ART, and 90% of those on ART to be virally suppressed)
• .9 x .9 x .9 = 73% of all PLHIV virally suppressed is a sound alternative way to assess progress towards epidemic control
• Near-term success is 90-90-90 across all age bands, genders, and risk groups
• Longer-term success is 95-95-95 across all age bands, genders and risk groups
12
PEPFAR PROGRAM RESULTS
Over 13.3 million women, men, and children on ART
Over 2.2 million babies born HIV-Free
Over 15.2 million voluntary medical male circumcisions
Over 6.4 million orphans, vulnerable children, and caregivers have received critical care and support
Over 65% of DREAMS districts have had a 25+% decline in new HIV infections
Source: pepfar.gov, 2018
Over 95% of all bilateral PEPFAR country funds go to partners in
Africa, Haiti, and Vietnam
Financial Picture: Acknowledging Reality
International Donor HIV Assistance Has Plateaued and Is Projected To Remain Flat or Decrease Slightly
1643 2263
2651
3700
5028 5488 5574 5440 5125
4709 4940 5220 5218 5207 1641 1041
1635
2172
2520
3000 3150 3138 3900 4707 4950 4050 4050 4050
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Global FundPEPFAR
Source: Kaiser Family Foundation *Annual budget requests in USD, millions
#PEPFAR15
17
Remarkable Expansion of PEPFAR’s results in a Flat Budget Environment
Despite Flat Budgets During the Past 4 years, GF and PEPFAR Supported Significant Increases in the Number of
PLHIV on Treatment…but How?
0
2
4
6
8
10
12
14
2013 2014 2015 2016
Millions of people supported on Treatment
PEPFAR Global Fund
Efficiency Action Agenda: Accelerating Impact Despite Flat Budgets
#PEPFAR15
20
PEPFAR Efficiency Action Agenda
The goal of the PEPFAR Efficiency Action Agenda is to increase transparency, oversight, and accountability across PEPFAR and its implementing agencies to ensure that every taxpayer dollar is optimally invested and tracked.
#PEPFAR15
21
$-
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
10,000,000
11,000,000
12,000,000
13,000,000
14,000,000
15,000,000
16,000,000
2004 2006 2008 2010 2012 2014 2016
# o
f p
eo
ple
Year Cummulative VMMC Current on HIV Treatment PEPFAR Budget (Bilateral + GF HIV)
In An Era of Flat Funding, Most Thought Continued ART Expansion Was Impossible
PE
PF
AR
Bila
tera
l Bu
dg
et, in
$M
illion
s
Expansion
through
efficiencies
Expansion through
6-7B in pipeline
22
#PEPFAR15
Main Elements of PEPFAR’s Efficiency Strategy
• Improved, streamlined delivery of services
• Lower costs of ARVs through the introduction of generics, negotiated Pooled Procurement Mechanism (PPM), quicker timeline for acceleration of TLD regimen adoption, etc.
• Physical and technical capacity building that will pay long-term dividends
• Lower viral load test costs
• Higher rates of patient adherence and retention, lower costs of pursuing patients lost to follow up
• Link resources more directly to program outcomes
PEPFAR Tools and Approaches: To Assess Current Programs and Plan for a Sustainable
Future After Epidemic Control
24
#PEPFAR15
PEPFAR Financial Landscape is Changing
• Increase reliability, usability, accountability, and timeliness of financial data to achieve program impact
• Construct common frameworks for intra- and inter-agency budgeting, monitoring, and financial reporting that build upon PEPFAR’s pillars of transparency, accountability, and impact
• Clarify linkages between COP/ROP and central funding budgets, programmatic implementation, budget execution, and financial monitoring and reporting
New PEPFAR Budgeting & Financial Monitoring Redesign: Overall Purpose
25
#PEPFAR15
We Think We Know What To Do, But These Approaches Will Help Guide the Way
• A lower cost, more efficient system is a sustainable system
• PEPFAR is focused on efficiency to continue gains against flat budgets, but also to lower overall costs
• Problem: What are our actual activities? What do those activities actually cost? What activities are correlated with outcomes?
Approaches and Innovations:
Complete:
• Fully implemented PEPFAR’s Efficiency Strategy
• Resource Alignment and Budget Data Profile work with Global Fund
• Confirmatory analyses that show the value of treatment as prevention
In Progress:
• Designed evolution of Expenditure Analysis (Budgeting and Financial Monitoring via new Expenditure Reporting classification system)
• Assuring fidelity of work plan to strategy
• Launching Activity-Based Costing and Management exercises
• Completing responsibility matrices
HIV Resource Alignment: Partner Coordination to Maximize Efficiency &
Accountability of Programs
27
#PEPFAR15
• PEPFAR and the Global Fund represent two of the largest donors in the global HIV response
• In close partnership with host national governments and other stakeholders, accomplish bilateral program results and accelerate collective impact on controlling HIV/AIDS
• Increased collaboration between PEPFAR and the Global Fund during planning and budgeting processes helps ensure investments are strategically aligned to address gaps and solutions while maximizing transparency, efficiency, and accountability of their resources
• To strengthen this partnership, and continue strategic use of funds, there is a need—more than ever—for better alignment of resources between the two entities
HIV Resource Alignment
28
#PEPFAR15
HIV Resource Alignment
• In 2017, PEPFAR, in close collaboration with partners, spearheaded an effort to align PEPFAR, Global Fund, and host country HIV/AIDS budgets
• This resource alignment provides much more comprehensive data and enables us to better understand for what program elements each entity is responsible
• This data will strengthen joint planning, avoid duplication, and inform future programming decisions
• Data will enable us to collectively maximize the impact of investments via more efficient resource allocation and help our partners plan for the future
• In April 2018, PEPFAR and the Global Fund released preliminary FY 2018 budget profiles for 21 PEPFAR partner countries based on this resource alignment collaboration.
29
#PEPFAR15
Aligning and Harmonizing Budgets Across Donors
• Each year, donors all undergo a detailed process by which to plan and budget
• Doing this independently,
however, can limit the ability to ensure budgets are aligned strategically, address gaps and solutions, and maximum benefit to the HIV program
How might we better align
budgets across donors to
improve joint and coordinated
funding?
30
#PEPFAR15
Can we Map Budgets across Donors?
PEPFAR Global Fund Domestic
Data sources FACTS Info and COP17 PBAC Funding application budget template
National strategic plan – HIV/TB funding landscape (for contribution estimates)
Level of detail - broad categories
High - grouped by PEPFAR budget code and type (site-level, above-site, commodities, etc.)
Medium - grouped by program area but not directly by type
Low - very broad program area groupings
Level of detail - activities
Medium - some activity level detail
High - activity-level budgets
None
Timeframe Oct 1, 2017 - Sept 30, 2018 Jan 1 - Dec 31, 2018 Jul 1, 2017 - Jun 30, 2018
31
#PEPFAR15
HIV Resource Alignment Initiative
Considerations for Data Review
• This profile includes budget data from PEPFAR, the Global Fund, and Domestic sources where available.
• Implementation timeframe between the three entities is usually off by one quarter i.e., PEPFAR uses US Government fiscal year (October-September), the Global Fund uses calendar year (January-December), and Domestic resources are aligned with the host country’s fiscal year.
• PEPFAR numbers may have a margin of error +/- $2M because commodities detail is being obtained from a separate tab of the budgeting tool.
• The Global Fund’s Resilient Systems Support for Health (RSSH) investments are only included where these were part of the country HIV grant.
• Domestic numbers—where available—are directly sourced from the host country’s Global Fund grant application and primarily reflect data from National Strategic Plans (NSPs) for HIV.
• Domestic numbers for Care and Treatment may include ARV drugs where disaggregation is not available.
• Program Management at Implementation-Level: a) PEPFAR- implementing partners’ program management b) Global Fund- principal recipients c) Domestic- program management and coordination
• Program Management at Donor-Level: a) PEPFAR- US Government’s management and operations b) Global Fund- no budgets appear for this category since they don't have in-country operational set-up.
32
#PEPFAR15
Budget Data Profiles: Tanzania
33
#PEPFAR15
2018 Budget Mapping for Tanzania
75%
17%
8%
FY18 Tanzania HIV Budget by Stakeholder
(Total Budget $698.2M)
PEPFAR Global Fund Domestic Govt. $-
$50
$100
$150
$200
$250
$300
$350
Programs Commodities Systems andStrategic
Information
ProgramSupport and
Management
Mill
ion
s
2018 Tanzania HIV Resource Alignment
34
#PEPFAR15
$87,946,922
$33,170,584 $28,732,924 $119,681,062
$121,802,082
$31,141,320
$13,477,525
$86,654,138
$17,720,154
$980,167
$4,416,024
$82,279,609 $5,564,104 $1,307,517
$8,470,384
$10,971,519 $10,615,776 $6,000,000 $1,530,855 $25,774,601
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Prevention Orphans andVulnerable
Children
HIV TestingServices
Care andTreatment
Commodities Systems StrategicInformation
and Data
ProgramSupport and
Management
2018 Budget Proportions by Budget Area
PEPFAR Global Fund Domestic Govt.
2018 Budget Mapping for Tanzania
42
#PEPFAR15 42
A. Costing of NSP with possibility to improve robustness • prioritize NSP costing at the country level • improve confidence in using NSP data as benchmarks • correct basic issue where funding requests tend to be better drafts vs NSP
B. Alignment of NSP costs with Ministry of Finance Chart of Account in IFMS • correct misalignment of NSP costing vs NSP funding • increase the integrity of other PFM data sources e.g. NHA • improve domestic resource utilization and tracking
C. Improve effectiveness of program management • reduce administrative / overhead costs of running programs • reprogram and reallocate requests during implementation • improve expenditure reporting and analysis
E. Possible reporting standardization for Governments and Partners • possible to generate an all-purpose report that could be further tailored.
Benefits of HIV Resource Alignment
PEPFAR’s Vision for Future of HIV Programs
44
#PEPFAR15 44
Vision for the Future: Sustainable Programs Through More Local Control and Shared Responsibilities
• Move from international to domestic IPs
• Routinize resource alignment efforts
• Support and enhance governments’ ability to manage the response
• Integrate and align functions into existing government systems
• Continue to leverage government personnel and infrastructure
• Support systems improvements for long-term sustainability
• Continue donor support for critical functions such as technical assistance, disease surveillance, and commodities
• Reduce costs and ensure long-term sustainability through, e.g., activity-based costing
45
#PEPFAR15
Current Financial Responsibilities
• The distribution of financial responsibility does not tell the full story of shared responsibility, but also underestimates country governments’ spending on the response. We need to work jointly to get an accurate assessment of country governments’ full contributions to the response.
$87,946,922
$33,170,584 $28,732,924 $119,681,062
$121,802,082
$31,141,320 $13,477,525
$86,654,138
$17,720,154
$980,167
$4,416,024 $82,279,609 $5,564,104
$1,307,517
$8,470,384
$10,971,519 $10,615,776 $6,000,000 $1,530,855 $25,774,601
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Prevention Orphans andVulnerable
Children
HIV TestingServices
Care andTreatment
Commodities Systems StrategicInformation
and Data
ProgramSupport and
Management
2018 Budget Proportions by Budget Area
PEPFAR Global Fund Domestic Govt.
46
#PEPFAR15
Estimated budgetary contributions to HIV/AIDS efforts by international donors, national governments, and other funders for Fiscal Year 2018
Source: PEPFAR Treatment Report to Congress
Country
Total (in 2017 USD)
Percent
PEPFAR
Percent
Global Fund
Percent National
Government
Percent
Other
Botswana $ 261,402,377 26.5% 2.4% 69.2% 1.9%
Burundi $ 47,558,501 37.2% 17.4% 42.4% 3.0%
Cameroon $ 166,038,604 29.6% 15.4% 29.0% 26.0%
Cote d'Ivoire $ 202,731,382 78.6% 12.4% 6.0% 3.0%
DRC $ 255,104,977 27.4% 15.2% 13.7% 43.7%
Ethiopia $ 258,896,812 59.2% 23.5% 7.8% 9.5%
Haiti $ 124,729,162 81.4% 18.6% 0.0% 0.0%
Kenya $ 719,540,603 78.6% 11.7% 3.5% 6.2%
Malawi $ 274,892,480 48.0% 40.1% 0.9% 11.1%
Mozambique $ 561,479,113 71.1% 15.0% 1.9% 12.0%
Namibia $ 161,906,500 44.9% 10.5% 41.6% 3.0%
Nigeria $ 701,872,896 54.7% 15.2% 28.2% 2.0%
South Africa $ 2,268,882,065 23.6% 4.2% 72.2% 0.0%
South Sudan $ 52,101,427 44.4% 18.6% 6.0% 31.0%
Swaziland $ 136,763,133 50.1% 2.0% 32.9% 15.0%
Tanzania $ 712,487,007 73.3% 16.9% 7.7% 2.0%
Uganda $ 610,201,495 67.0% 13.4% 10.0% 9.5%
Ukraine $ 126,704,631 29.1% 26.7% 36.8% 7.4%
Vietnam $ 110,517,160 42.0% 17.7% 37.3% 3.0%
Zambia $ 594,133,901 68.3% 20.8% 9.8% 1.1%
Zimbabwe $ 358,774,099 39.3% 41.8% 9.3% 9.5%
47
#PEPFAR15
The Reality of Current Functional Responsibilities
Functionally, countries are already leading critical areas: • Governance and policy
• Strategic management of the response
• Infrastructure and most of the manpower
• Financial contribution is underestimated and grossly underestimates importance of Domestic investment
Donor assistance supports governments through: • Commodities
• Technical assistance
• Financing surveillance
• Financing health systems strengthening
• Supporting capacity building and salary support
HIV Programs Inputs Processes Outputs Outcomes
Global Fund
Other Domestic
Functional Responsibility
Financial Responsibility
Inputs, processes, outputs, and outcomes include illustrative list and are not all inclusive
Accelerating Impact Towards Sustained HIV Epidemic Control Through Shared Responsibility
Partner
Governments
PEPFARHuman
Resources
Infrastructure
Commodities
TechnicalAssistance
Cases identified
Linked to Tx
Tx initiation
Adhering to Tx
Retained in Tx
Circumcisions
Beneficiaires served
Policy & Governance
Management of the Response
Demand Creation
Services to Beneficiaries
ARV dispensation
Training & Supervision
Quality Improvement
Monitoring & Evaluation
Surveys
Institutional Capacity
Development
Systems Development
Infections Averted
Viral
Suppression
Deaths Prevented
PreventionBiomedical and
Behavioral
Youth ProgramsOVC, AGYW
Testing ServicesFacility &
Community
Care & TreatmentClinical &
Community
Laboratory
Cross-CuttingSystems, Data,
Surveillance
49
#PEPFAR15
Responsibility Matrix Sample
50
#PEPFAR15
PEPFAR’s Broad Vision for the Future: Sustainable Programs Through Shared Responsibilities and More Local Control
50
• Increase efficiency, reduce costs, and ensure long-term sustainability through, e.g., activity-based costing and management
• Determine what it should cost not what we are spending
• Support and enhance governments’ ability to manage their response
• Integrate and align functions into existing government systems
• Continue to leverage government personnel and infrastructure
• Support systems improvements for long-term sustainability
• Continue donor support for critical functions such as disease surveillance, commodities, and technical assistance
• Routinize resource alignment efforts
• Move direct services from international to domestic IPs aligned with countries’ vision for sustainable programs
51
#PEPFAR15
PEPFAR and Other Donor Spending Will Change Over Time…
We don’t really understand how result is achieved, cost
Programming changes, transfer responsibility
End state is clear, reality is messy
Commodities will increase
VMMC will decrease over time
HTS will decrease over time
HSS will decrease over time
Training, TA and Mentoring will decrease over time
• What’s left?
• What happens if we reduce it?
52
#PEPFAR15
…But International Assistance will Continue…
Public Goods e.g. Disease Surveillance
Economies of Scale e.g. ARV, Reagents
Technical Knowledge e.g. State of the Art
Lack of Political Will e.g. Key Pops
53
#PEPFAR15
…And Eventually, a Full Domestic Response Is Possible
Better Alignment of Resources
Tapping Willingness And Ability to Pay
End State
Summary
Our work is far from done, but possible. This week:
Over 2,800 babies were infected with HIV
Over 37,000 adults were infected with HIV, of which more than 7,500 were young women
Over 19,200 adults died from HIV
Over 2,000 children died from HIV
56
#PEPFAR15
Summary
56
• We are on the right track, but we still need to accelerate our efforts
• Epidemic control is possible in every country and is essential for long-term national fiscal health
• In the face of flat and/or decreasing donor budgets, the time for strategic joint planning for sustainable programs is now
• Partner governments will be integral to this dialogue, and an effective domestic response requires their active participation and guidance
• Routinized resource alignment efforts will further accelerate efficiency and accountability of HIV programs in a budget constrained environment
