"New resources are not enough. We need new thinking by all nations. Our greatest challenge is to get beyond empty symbolism and discredited policies, and match our good intentions with good results."
-- President George W. Bush June 30, 2005
The fight against HIV/AIDS must be sustained, and ultimately won, at the community and national levels. At this stage of the fight, the support of international partners is of vital importance in many places, and they must ensure that their support helps communities develop their own capacity to create and sustain their leadership in the fight.
The "stovepiping" that often occurs when international partners make contributions poses risks of duplication and waste while failing to help develop indigenous capacity. The onus rests on us: in addition to implementing high-quality, sustainable programs that deliver results, we must work together to ensure coordinated action in support of host countries' national strategies.
PEPFAR is increasingly seen by others involved in the fight against HIV/AIDS as a leader - not only at the aggregate level of total resources, but at the country level for its commitment to local capacity-building. PEPFAR is working to ensure that effectiveness and sustainability are core values upheld by all partners in the fight.
Strengthening Multilateral Action
Strengthening Multilateral Action at the Country Level
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
The United States, as a founding member of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and its first and largest donor, continues to play a leadership role in ensuring the success of this essential international effort. The Global Fund is based on a unique model that encourages and relies on partnerships among governments; civil society, including community- and faithbased organizations; international organizations; bilateral and multilateral donors; the private sector; and affected communities in the fight against HIV/AIDS, tuberculosis (TB), and malaria.
U.S. financial support
Founded in January 2002, the Global Fund operates as a financing instrument — not as an implementing entity — to attract and disburse additional resources to prevent and treat these three deadly diseases. As a partnership among governments, civil society, the private sector and affected communities, the Global Fund acts as a coordinated, multilateral financing mechanism, which enables a variety of international partners — especially those which may not have bilateral programs but still wish to contribute to the fight against HIV/AIDS — to pool their resources and finance essential programs in resource-limited settings.
The U.S. contribution to the Fund is particularly impressive because it is in addition to massive bilateral efforts. In contrast to some nations, for which the Global Fund may be the most viable mechanism for matching HIV/AIDS resources to needs in the developing world, the U.S. contribution to the Global Fund is just one part of a diverse portfolio of United States investments in HIV/AIDS. The five-year, $15 billion commitment of the President's Emergency Plan for AIDS Relief includes bilateral and regional funding to 123 countries, international HIV/AIDS research, and contributions to multilateral efforts like the Global Fund.
As the world's largest donor to combating HIV/AIDS, TB, and malaria internationally, the United States views its contribution to the Global Fund as both an invitation and a challenge to the rest of the international community to join in its commitment to fighting these diseases. While many countries have become generous contributors to the Global Fund and the resources mobilized to date have been impressive, there have been few new donors recently. For the long-term viability of the Global Fund, the Board of the Fund must seek and engage new public and private sector donors and turn them into sustained and committed contributors.
As mandated by Congress, the United States' contribution to the Global Fund cannot exceed 33 percent of all contributions to the Fund. The United States has clarified for the Global Fund Secretariat, Board and others that the cap on U.S. contributions is a maximum limit, not an annual obligation. At the same time, given that the Global Fund must raise sufficient funds to access the full United States contribution, the 33 percent limit provides other donors with added incentive to contribute to the Fund.
The United States has already contributed nearly 50 percent more to the Global Fund in just three years than President Bush's pledge of $1 billion over five years, made in 2003. The United States pledged an additional $600 million for 2006 and 2007 at the First Voluntary Replenishment conference in September 2005, bringing the total U.S. pledge to the Global Fund to more than double the President's $1 billion commitment.
Because of the terrible and immediate effects of HIV/AIDS - 14,000 new infections and 8,000 deaths every day - each country must assess how it can respond most urgently and effectively. Although it is important that the U.S. Government (USG) continue resources for the Global Fund, for the USG the most effective use of resources in the near term is through bilateral programs. Each nation must make its own decision about how to allocate its contributions between its bilateral programs (for nations that have them) and multilateral initiatives such as the Global Fund. As shown in Figure 8.1 for 2004, some other countries with significant bilateral programs have a higher bilateral ratio, as a share of all global
HIV/AIDS funding, than the U.S., and many other nations have ratios comparable to that of the U.S.
The Emergency Plan consistently encourages other developed countries to increase their own financial commitments to the global HIV/AIDS fight. Particularly for nations without strong bilateral programs, the Global Fund provides a vital mechanism to increase their financial commitment.
U.S. country-level support for grant management and coordination
It is in the interest of the United States, as well as in the interest of all people who are affected by HIV/AIDS, TB and malaria, to ensure the Global Fund is an effective, efficient and successful partner on the ground. The USG thus contributes significantly to enhancing the performance of Global Fund grants on the ground, while also working to coordinate its bilateral programs with those of the Fund.
With bilateral programs in 123 countries worldwide, established partners and two decades of experience combating HIV/AIDS internationally, the United States is uniquely positioned to assist Global Fund grantees to help ensure grant impact. In the focus countries, where the USG has committed resources intended to bring prevention, care and treatment programs up to national scale, collaboration based on comparative advantages contributes to consistent and comprehensive service provision. Outside the focus countries, U.S. bilateral support and technical assistance leverages Global Fund financing and helps to bring prevention, care and treatment programs up to full national scale.
In many nations outside the 15 focus countries, Global Fund financing will play a leading role in bringing national programs of prevention, treatment, and care to full national scale. In such countries, U.S. funding aims to improve the effectiveness of Global Fund dollars. Through coordination and the provision of technical assistance, U.S. bilateral support is working to ensure that Global Fund dollars are used to maximum advantage.
Recognizing the importance of U.S. technical assistance to the success of the Global Fund, Congress authorized the U.S. Global AIDS Coordinator to employ up to 5 percent of the U.S. contribution for fiscal year 2005 for technical assistance to Global Fund grantees through U.S. bilateral mechanisms. Approximately $14 million is being directed to partners in the field worldwide to provide technical assistance to Fund grantees, including approximately $12 million in fiscal year 2005 funds. These funds will fill a critical need expressed by many Fund grantees, and will allow them to expand access to services and support the success of their grants.
This technical assistance is being used as a catalyst, focused on alleviating bottlenecks and resolving the major issues which can cause these grants to falter. It seeks to address a range of issues, including:
These funds will enable timely responses to requests from the field for technical assistance. Requests may come from grantees, the Global Fund's newly-developed Early Alert and Response System (EARS), or other in-country international partners such as UNAIDS and the World Health Organization (WHO).
U.S. Global Fund financial support, bilateral programs, and technical assistance all provide important opportunities to help Fund grants succeed. Also crucial are the unparalleled relationships the United States has in these host nations, thanks to the dedicated USG teams in country. U.S. field personnel represent the United States on local Country Coordinating Mechanism (CCMs), contributing to the decisions of these critical bodies in the development and selection of proposals to recommend for Global Fund Secretariat and Board approval, and playing a role in the oversight of program implementation. During the second Round of grant proposal submission (January 2003), U.S. Government representatives had seats on more than 26 percent of the Global Fund CCMs around the world. By the third Round (October, 2003), USG membership in CCMs had risen to 42 percent, and by the fourth Round (June 2004) to 47 percent.
To promote coordination, the U.S. has entered into Memoranda of Understanding (MOUs) in a number of countries. These documents bring together Ministries of Health, PEPFAR, and the Global Fund to clarify collaboration and partnership activities. Such MOUs have been entered into in Tanzania and Ethiopia, and will help to ensure a coordinated approach in such areas as antiretroviral treatment (ART) provision.
To strengthen coordination, PEPFAR held bilateral meetings with WHO, the Global Fund, and UNAIDS to better understand management practices and priorities at the individual country level. These discussions in Washington in February and March 2005 strengthened understanding and collaboration among international partners in the field. This work has led, for example, to joint visits to resolve antiretroviral drug (ARV) procurement issues in Haiti, Guyana and Malawi, and to the launch of a collaborative effort with WHO to strengthen TB/HIV programs in three countries.
Rwanda: Coordination paves road to treatment success
In October 2004, the Rwandan Ministry of Health issued a Ministerial Order requiring that all ARVs be procured through CAMERWA, the national pharmaceutical procurement agency, in order to maximize purchasing power. The Ministerial Order requires providers to prescribe ARVs according to World Health Organization (WHO) guidelines, use generic drugs as first line treatment, and limit the use of brand-name ARVs to patients requiring second-line ARVs due to complications with the first line treatment.
In December 2004, the first coordinated procurement took place, with international partners purchasing portions of Rwanda's overall ARV needs according to their individual procurement parameters. Emergency Plan funds were used to buy HHS/FDA-approved ARVs for second-line treatment, while the Global Fund, World Bank and others purchased other WHO-prequalified drugs for first-line treatment. As a result of this new system, CAMERWA now distributes ARVs to pharmacies according to their patients' needs, regardless of which donor supports the site. Now, as more generic drugs gain HHS/FDA approval and tentative approval, the Emergency Plan is also supporting procurement of some generic drugs used in first-line treatment.
There are several benefits associated with the combined procurement. Rwanda is getting a better price for the ARVs due to the larger quantities being ordered, and money is also saved through lower management costs and reduced transportation costs. The coordination also has a clinical benefit: different drugs can be packaged differently with different shapes, quantities and inscriptions, leading to confusion and potential non-adherence, but coordinated procurement reduces the risk of confusion. In light of Rwanda's success, other African countries may well adopt similar approaches.
The system is also helping to build a strong system for monitoring, tracking, reporting and auditing ARV consumption and supply. CAMERWA maintains statistics on the number of patients receiving ARVs, the current stock of each pharmacy, and the consumption rate, making projections for future procurements more accurate.
The spirit of cooperation among the Government of Rwanda, implementing partners, and international partners such as PEPFAR, the Global Fund, and the World Bank, is making an essential contribution on the ground in Rwanda - and lives are being saved as a result.
U.S. policy and strategy support
The United States was privileged to be the leading participant in launching the Global Fund, and remains committed to supporting the Global Fund to overcome the inevitable hurdles it faces as it continues to grow and develop. Through membership on the Global Fund's Board of Directors and its Committees, and through both formal representations and informal discussions with the Fund's Executive Director and Secretariat staff, the United States is working to ensure that the Global Fund:
The U.S. Global AIDS Coordinator, Ambassador Randall Tobias, has succeeded former Secretary of Health and Human Services Tommy G. Thompson as the United States representative on the Board. In June 2005, the new Board Chair and Vice Chair confirmed Ambassador Tobias to lead the newly formed Policy and Strategy Committee (PSC). The PSC is leading the development of a five-year strategy for the Fund, scheduled for adoption by the Board in mid-2006. With the assistance of U.S. field staff and an interagency headquarters core team, the United States actively contributes to discussions on Global Fund policies and procedures in Geneva.
The United States continues to work with the Global Fund Secretariat and its Board of Directors to establish a set of performance measures for all grants to maintain the consistent application of the Global Fund's principle of "performance-based" funding. The United States has also shared with the Global Fund Secretariat the performance measures used to evaluate the performance of all U.S. contributions to the Fund, and has encouraged the Fund to use this list or a similar list of indicators within the Secretariat to evaluate grant effectiveness.
An area of special concern is the Fund's current inability to track the results of specific prevention, care and treatment spending within each grant. However, the Office of the U.S. Global AIDS Coordinator has worked closely with the Global Fund Secretariat and other international donors over the past year to help develop a standardized set of progress indicators for each disease. The Global Fund Secretariat is currently retro-fitting these indicators into each of its existing grants, so that it will be able to compile this data in the future. The Global Fund will be reporting in mid-2006 on the impact of Global Fund grants on health systems in recipient countries. Other impact analyses will be done later as the portfolio of grants matures.
The Global Fund has been fully operational since January 2002, and in less than four years the institution has made remarkable progress. As the organization develops, the United States will pay special attention to helping the Fund coordinate with PEPFAR and bilateral and multilateral organizations. The USG will remain alert to the common need to monitor absorptive capacity in developing countries, and fiduciary oversight and accountability.
The USG remains deeply committed to ensuring that the Global Fund succeeds in its mission to help in the global fight to combat HIV/AIDS, TB and malaria. Through its seat on the Board of Directors and its Chairmanship of the critical PSC; through formal and informal discussions with Global Fund Secretariat staff, CCMs and local fund agents; and through active engagement with both private- and public-sector stakeholders in affected countries, the USG will stay fully engaged with the Global Fund to ensure its ultimate success.
UNAIDS, the "Three Ones" and the Global Task Team
In 2004, the United States co-sponsored the "Three Ones" agreement under the auspices of UNAIDS. The Three Ones represent a commitment on the part of the major international HIV/AIDS partners, including the USG, to support one national HIV/AIDS framework, one national coordinating authority, and one country-level monitoring and evaluation system in each nation.
PEPFAR has assumed a leadership role in making the Three Ones a reality on the ground, reaching out to host governments, other donors, and international partners to further the coordination sought by the Three Ones. In both the focus countries and other countries with USG bilateral programs, the central operating principle of PEPFAR assistance is the Three Ones.
The Global Task Team on Improving AIDS Coordination Among Multilateral Institutions and International Donors (GTT) was created after a March 2005 UNAIDS conference aimed at identifying strategies to implement
the Three Ones. The GTT has made recommendations for further coordination, particularly within the multilateral system, to resolve areas of duplication and gaps in the global response to AIDS. The recommendations include options for how the multilateral system can streamline, simplify and harmonize AIDS procedures and practices.
As a leader in both the adoption of the Three Ones and the development of the GTT recommendations, the U.S. commends the GTT recommendations for identifying specific strategies for furthering international collaboration and coordination in the fight against HIV/AIDS. However, the U.S. emphasizes that implementation of the GTT recommendations must be within the framework of national laws and policies, as well as regulations and policies of the governing bodies of multilateral organizations and international institutions.
The GTT recommendations provide a means for partners to work together to ensure that programs reflect the values of accountability and program effectiveness, as well as the realities and priorities of governments and civil society in recipient countries.
PEPFAR's strategic information team has worked intensively with UNAIDS and other international partners to implement the GTT's recommendations in the monitoring and evaluation area, and one result has been the development of a Global Fund assessment tool, discussed further in the chapter on Improving Accountability and Programming. This tool will allow improved accountability for the effectiveness of Fund grants.
Lesotho and Swaziland: Collaboration to ensure successful Global Fund grants
World Health Organization
The United States works closely with the WHO to support the implementation of evidence-based policies and sound management. WHO provides technical leadership as well as 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.
PEPFAR and WHO have worked to clear barriers to scale-up of ART programs (discussed further in the chapter on Treatment). In order to ensure that such medicines are available for purchase by Emergency Plan implementing partners in-country, HHS/FDA and the WHO Secretariat have signed a confidentiality agreement to share information on their reviews and inspections. As a result, HHS/FDA fully and tentatively approved ARVs have begun to be added to the WHO prequalification list. The USG also participated in the WHO/UNICEF high-level meeting to enhance and accelerate prevention of mother-to-child HIV transmission and provided funding to WHO for HIV/TB and safe blood programs.
Collaborations on building capacity in the area of strategic information, discussed further in the chapter on
Improving Accountability and Programming, have been particularly successful, making considerable progress in achieving standard definitions and reporting on HIV/AIDS-related activities. Working to ensure data quality, PEPFAR has worked with WHO and others to issue standards for data storage and reporting. PEPFAR has provided support for the WHO's Service Availability Mapping (SAM) project, and has worked with WHO to organize regional strategic information training meetings in Africa. PEPFAR funds also supported the development of a USG/WHO/UNAIDS standard for ART patient tracking at the clinic level, currently being scaled up in several countries.
Key Challenges and Future Directions
PEPFAR will continue to make coordination of international partner responses an intensive focus going forward. The Emergency Plan will continue to be a leader in working with international organizations and other partners to put accessibility, quality and sustainability at the center of all HIV/AIDS work. These cannot be achieved without accountability, and PEPFAR is working to disseminate best practices for accountability as bilateral programs scale up.
Given the importance of the Global Fund to the overall PEPFAR initiative, the U.S. will continue to work with the Fund, as well as the World Bank, to address grant management and implementation issues, coordination challenges on the ground, and larger issues around financing, policy and strategy.