#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
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#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
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#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
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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
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
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#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
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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
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#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
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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
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
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2004 2006 2008 2010 2012 2014 2016
# o
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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
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et, in
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illion
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Expansion
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Expansion through
6-7B in pipeline
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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
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#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
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#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
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#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
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#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.
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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?
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#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
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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.
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
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#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
• 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.