The challenge of global HIV/AIDS requires sustained cooperative effort from host and donor nations, as well as international, national, and community organizations, employing their comparative strengths and resources. A key element of U.S. leadership under the President's Emergency Plan for AIDS Relief (PEPFAR/Emergency Plan) is to promote a comprehensive response by building international commitment to coordinated action to address HIV/AIDS at the country level.
Limited resources must be used efficiently to avoid duplication and achieve maximum impact. All contributors must work within the context of host country HIV/AIDS strategies, with a deliberate eye to building capacity and transferring responsibility for a sustained long-term response. This chapter focuses on Emergency Plan accomplishments in strengthening such coordinated action.
Strengthening International and Country-Level Coordination
The dramatic leadership commitment of the United States has greatly increased resources available to combat the HIV/AIDS pandemic and has brought coordination of strategies, implementation, and monitoring and evaluation to the forefront. The United States has been a partner and a facilitator of such coordination with host nations, other donors, and international partners in the fight against HIV/AIDS. The Emergency Plan has pursued initiatives to further cooperation among headquarters organizations and, even more critically, at the country level where HIV/AIDS services are being delivered.
The "Three Ones"
U.S. collaboration with key organizations includes a close partnership with the consortium of 10 United Nations agencies making up the Joint United Nations Program on HIV/AIDS (UNAIDS). The Emergency Plan has built on a long-standing effort by UNAIDS to establish principles for cooperation that make use of the comparative advantages of international partners and maximize resources by allowing for different but coordinated approaches to combat the pandemic.
In April 2004, OGAC, working with UNAIDS, the World Bank, and the U.K. Department for International Development (DfID), organized and co-chaired a major international conference in Washington for major donors and national partners to consider and adopt key principles for supporting coordinated country-driven action against HIV/AIDS. These principles became known as the "Three Ones" - one national plan, one national coordinating authority, and one national monitoring and evaluation system in each of the host countries in which organizations work. Rather than mandating that all contributors do the same things in the same ways, the Three Ones facilitate complementary and efficient action in support of host nations. Inherent in the principles is the shared recognition of the urgent need for action that supports inclusive national ownership and clear accountability.
In a historic global agreement, all major stakeholders and donors, including the Global Fund to Fight AIDS, Tuberculosis and Malaria, endorsed these principles and committed themselves to their country-level implementation. The support of the United States and the United Kingdom were instrumental in bringing the agreement about, and the respective U.S.-U.K. national efforts remain central to its implementation.
UNAIDS is working with the United States and other partners to produce regular progress reports about the implementation of the Three Ones that will highlight success stories and address those countries that have not fully put the principles into practice. The first results matrix should be completed in early 2005.
As part of U.S. implementation efforts, U.S. missions in the Emergency Plan focus countries now include progress reports on coordination efforts in all country operational plans. Field staff recognize that the Three Ones are especially relevant for those countries where the United States has substantially increased its HIV/AIDS assistance. OGAC has urged all posts to work with host governments to facilitate, where they do not already exist, the creation of inclusive national AIDS authorities and to adopt national strategies in collaboration with donors and civil society groups.
All 15 of the Emergency Plan focus countries now have such national authorities. A crucial role still remains, however, for the United States, UNAIDS, and other donors to play in contributing to a national AIDS authority's ability to set priorities and policies and in helping it monitor progress fully, inclusively, and transparently. The United States has set an example in this regard by supporting broad partnership forums where all stakeholders, including people living with AIDS, can participate in the work of the national AIDS coordinating authority.
Monitoring and evaluation is also an area where donor coordination is essential. There can be no real accountability without solid monitoring and evaluation; at the same time, multiple and duplicative reporting requirements can overburden those entities already struggling to meet HIV/AIDS service needs. The Three Ones provided renewed impetus to ongoing efforts to standardize monitoring and program evaluation activities.
Under the principle of one agreed country-level monitoring and evaluation system, the United States is committed to supporting national efforts to establish a single functional data collection and analysis system at the country level that meets the needs of both donors and program implementers. Discussed in more detail in chapter 9 ("Improving Accountability and Programming"), the United States is helping national institutions build capacity to track, monitor, and evaluate results while also working to streamline national and international indicators to improve systems for assessing progress against the HIV/AIDS pandemic and minimizing management and reporting burdens for host nations. Major accomplish- ments in 2004 included developing plans with WHO, UNAIDS, and the Global Fund for 1) the creation of joint monitoring and evaluation systems in 2005; 2) the establishment of a central technical support body for monitoring and evaluation; 3) jointly developed estimation methods and data release dates; and 4) coordinated evaluation plans.
Strengthening International Partnerships
The Global Fund to Fight AIDS, Tuberculosis and Malaria
Multilateral organizations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria play vital roles in the fight against the HIV/AIDS pandemic, organizing across countries and sectors to create innovative financing mechanisms, pool expertise, and serve special populations and needs. The United States was instrumental in the creation of the Global Fund, with President Bush making its founding pledge. Collaboration with the Fund is underlined in the Emergency Plan's strategy.
The United States leads the world in contributions to the Fund, with $1.08 billion in contributions as of January 30, 2005, and has pledged a total of $2.12 billion from the inception of the Fund through 2008 (with cumulative contributions not to exceed 33 percent of total contributions to the Fund, beginning in fiscal year 2004). The United States accounts for 35.6 percent of total pledges and 32.5 percent of contributions to the Fund as of February 2, 2005.
In January 2003, then U.S. Secretary of Health and Human Services Tommy Thompson was elected Chairman of the Fund's Board, giving the United States special leadership responsibility through April 2005. Secretary Thompson traveled throughout the world on behalf of the Fund, enlisting and engaging governments, the private sector, and nongovernmental organizations to support the Fund's efforts to combat the global pandemic.
The launch of the Emergency Plan and the congressionally mandated 33 percent cap on U.S. Global Fund contributions have been important catalysts to encourage other donors to increase financial support for the Fund. That cap requires that cumulative U.S. contributions through 2008 never exceed 33 percent of total contributions to the Fund, beginning in fiscal year 2004. As of July 31, the date set by Congress for annual "snapshots" to determine the allowable level of U.S. contributions, other donors had only contributed enough for the United States to contribute $427 million of the total $547 million appropriated for 2004. As a result, the U.S. Global AIDS Coordinator, Ambassador Randall L. Tobias, decided to extend the deadline for an additional two months, giving the Global Fund additional time to raise the resources necessary to draw down the $547 million appropriated for 2004. Together with Secretary Thompson, Ambassador Tobias contacted the Group of Eight and other donors to urge that they accelerate and increase their contributions to allow the maximum possible amount from the United States. The Fund also made direct high-level approaches to leaders such as U.K. Prime Minister Tony Blair. Even private citizens got involved, contributing nearly a million dollars, in amounts from a few dollars to many thousands.
As a result of these efforts, during this two-month grace period the Fund received additional contributions totaling $67 million, allowing a final fiscal year 2004 U.S. contribution of $459 million. Although the United States was not able to make its maximum allowable pledge, the momentum generated by this challenge generated an additional $67 million for the Global Fund from other donors, and $33 million from the United States, for a total of $100 million that the Fund might not otherwise have received.
As the Global Fund has matured, Emergency Plan support has been important in extending the reach of its projects to 130 countries and amassing billions of dollars in pledges and contributions. As with bilateral U.S. efforts under the Emergency Plan, accountability in implementing local efforts is key to the Fund's success and the foundation upon which the Fund was conceived. Much of the United States' work with the Fund in fiscal year 2004 has therefore focused on supporting the Fund in being true to this founding principle. In addition, the United States and the Fund have identified important ways to coordinate and strengthen U.S. bilateral efforts and Fund activities.
In coordination with Fund staff, the United States has continued its long-term efforts to improve the Fund's capacity to monitor program performance and results. In October 2004, Emergency Plan and Global Fund staff jointly developed a monitoring and evaluation toolkit for use by both programs, which will assist the Fund in making performance-based decisions on grant renewals. In addition, the United States helped design an early warning system to alert Fund partners, both bilateral and multilateral, when grant performance appears to be faltering. Of top priority in 2005 will be devising better means for partners to provide effective targeted assistance to improve such grants. Such program monitoring and response mechanisms will become increasingly important as the Global Fund prepares to launch a fifth round of grant proposals in March 2005, with Board approval of proposals slated for September 2005.
In June 2004, the Fund's Board approved nearly $1 billion in funding for the first two years of operations of a fourth round of Global Fund grants. As mandated by the Emergency Plan's authorizing legislation, the United States is also required to conduct a parallel technical review of Global Fund grant proposals. Fiscal year 2004 was the first year in which this provision was required, carried out through the establishment of a U.S. interagency task force comprising both headquarters and field staff from dozens of countries implementing HIV/AIDS programs. The interagency team's independent review of each Fund project resulted in the contribution of U.S. technical expertise and field knowledge to strengthen grant agreements. Numerous concerns were identified, including potential overlap of Fund and U.S. programs in several countries. Recommendations were made and submitted to the Fund's Board for approval. In many instances these suggested changes were incorporated in the final grant agreements.
Given potential overlap indicated by grants in Emergency Plan focus countries, including Tanzania, Ethiopia, and Kenya, the United States intensified efforts to identify such overlap in coordination with Fund staff and adjust grants accordingly. Coordination efforts have been improved by increasing membership and participation by U.S. personnel within the Global Fund's country coordinating mechanisms (CCMs), which coordinate and oversee the implementation of Fund projects.
The United States has also used its seat on the Global Fund's Board to maximize the participation of civil society within CCMs, in particular with the addition in 2004 of a requirement that CCMs must include representatives of people living with the diseases. In several countries where capacity is very limited, local U.S. personnel have also provided assistance to help the CCMs function more effectively.
The World Health Organization
The United States works closely with the World Health Organization (WHO) to support the implementation of evidence-based policies and sound management, including implementation within its "3 by 5" initiative. WHO provides technical leadership and has a critical role to play in establishing norms and standards for a wide range of areas within the international public health response to HIV/AIDS. As a member state with considerable expertise in HIV/AIDS, the United States has been intimately involved in formulating HIV/AIDS-related policy and guidelines, actively participating in the World Health Assembly - where Emergency Plan policy often informs the discussion -- and partnering with WHO and host countries to adapt and implement such policies.
Specific collaborations in fiscal year 2004 included developing recommendations for the expansion of HIV testing -- an important component of combating the disease with an emphasis on integrating HIV testing services into routine clinical care. Collaborations with WHO also resulted in significant advances in policy and action regarding medical transmission, including injection and blood safety. For example, the United States supported First Annual Report to Congress WHO in providing technical assistance to countries developing national blood safety plans. As a result, some countries, including Tanzania, are close to achieving a nearly 100 percent HIV-free blood supply. The United States and WHO also worked together to formulate strategies for joint TB/HIV activities at the international, national and subnational levels. In June and September 2004, the United States, WHO, and other partners sponsored TB/HIV surveillance meetings in which nine focus countries (Botswana, C�te d'Ivoire, Ethiopia, Haiti, Kenya, Mozambique, South Africa, Tanzania, and Zambia) developed plans for improved TB/HIV surveillance. The Emergency Plan now supports ongoing technical assistance for plan implementation.
Human capacity development is a major priority for both the Emergency Plan and WHO. Preliminary discussions early in fiscal year 2004 have now led to coordinated activities to provide the training and technical assistance necessary to provide sustained responses to national epidemics. In countries such as Mozambique, the Emergency Plan and WHO are jointly conducting comprehensive human capacity development assessments to identify specific strategies to address long-term human resource needs. Collaborations on building capacity in the area of strategic information have been particularly successful, making considerable progress in achieving standard definitions and reporting on HIV/AIDS-related activities.
Building on its strong international alliances in the fight against AIDS, the United States will increasingly put such cooperation to work in the rapid expansion of prevention, care, and treatment services worldwide, promoting the adoption of established best practices across all areas of bilateral and multilateral action.
Partnering with Other Bilateral Donors
The United States has partnered closely with other donor nations to pursue joint strategies on HIV/AIDS. In November 2003, President Bush and U.K. Prime Minister Blair, with Ambassador Tobias present, launched a Special Joint Task Force on HIV/AIDS to strengthen cooperative efforts in five African countries severely affected by HIV/AIDS - Ethiopia, Kenya, Uganda, Nigeria, and Zambia. The Task Force was established to focus and reinforce bilateral efforts in these countries, enlisting other donors and host governments as well. Coordinated U.S.-U.K. cooperation is targeted to expanding prevention activities, providing wide access to care and treatment, and building a skilled force of health care workers, with a focus on the comparative strengths of each nation in its international HIV/AIDS programming.
Another important donor with whom the United States collaborates on the country level is the Netherlands. In September 2003, President Bush and Dutch Prime Minister Balkenende agreed to cooperate in HIV/AIDS prevention, treatment and care in countries where both the Netherlands and United States had significant bilateral programs. These nations currently include Ghana, Zambia, Rwanda, and Ethiopia. The cooperation agreement was a first step in a joint initiative between two of the world's largest donors for HIV/AIDS and contributed to the impetus for substantial increases in the Dutch international contribution to the fight against the HIV/AIDS pandemic. U.S.-Dutch field collaboration includes working together in:
Key Challenges and Future Directions
As in its bilateral programs, the Emergency Plan has made it a priority to avoid wasteful duplication or counterproductive effort in its multilateral programs with fellow donors and international organizations. Just as accountability is a fundamental principle of Emergency Plan strategy, the world community must insist on the greatest possible degree of accountability for each dollar spent by all donors. And just as the Emergency Plan commits to supporting, strengthening and expanding the work of national governments and community organizations, the world community must continue to deepen local ownership and sustainability of programs by reinforcing national strategies.