analysisBy David Garmaise
In some countries, PEPFAR and the Global Fund provide 90% of total funding for responses to HIV, yet the planning and implementation processes of the two donors are not always aligned. This is one of the findings of an evaluation of the US President's Emergency Program for AIDS Relief (PEPFAR) conducted by the US Institute of Medicine.
However, the evaluation also found that, recently, PEPFAR has started planning country programmes in greater coordination with the Global Fund. The evaluation quoted Ambassador Eric Goosby, the US Global AIDS Coordinator and head of PEPFAR, as saying that he foresees significant cost savings as the two donors become more aligned.
Coordination and collaboration
The evaluation documents existing efforts to coordinate the work of PEPFAR and the Global Fund. In some countries, the two entities have avoided duplication of effort by signing a memorandum of understanding between the two donors and the government. In Angola and South Sudan, the Global Fund finances procurement of antiretrovirals (ARVs) and PEPFAR supports the delivery of ARVs to patients and also supports health worker training. In Malawi, PEPFAR funding is targeted to urban areas while Global Fund financing supports rural communities.
In one country, not named in the evaluation report, PEPFAR supports the salary of a Global Fund coordinator who works with various departments in the Ministry of Health (MOH) that implement Global Fund-supported projects. The coordinator ensures that everyone stays on schedule and that reporting deadlines are met. In another country, also not named, a PEPFAR partner helped the MOH set up a Global Fund Management Unit to support the financial management, M&E, and supply chain management of Global Fund grants.
PEPFAR has also been working with the Global Fund to provide country information to facilitate decision making (because PEPFAR has a greater presence on the ground in countries).
The evaluation report said that PEPFAR's efforts to strengthen partner country supply chains have benefited Global Fund programmes.
According to the evaluation report, in 2011 the US established a Country Collaboration Initiative, through which additional funding was made available to PEPFAR country teams to increase coordination and collaboration with Global Fund-supported activities within countries and "to optimize Global Fund grant performance."
(See also GFO article on collaboration between PEPFAR and the Global Fund in Tanzania.)
The evaluation report identified some of the challenges involved in the two entities working together at the global level. These include a lack of discussion around strategic planning, and failure to identify synergies between the two programmes. However, the evaluation says, the recent introduction of a PEPFAR liaison to the Global Fund, based in Geneva, is having a positive effect on dialogue between the two entities.
In many countries, the vast majority of treatment for HIV is funded by either PEPFAR or the Global Fund, or some combination of the two. The evaluation report said that this creates fragility, especially given the ongoing uncertainty related to future HIV funding levels due to the global economic recession. The report said that this fragility was exemplified on several country visits when a Global Fund proposal had been rejected or a round had been cancelled. "As one interviewee put it, 'Now that the Global Fund is out, there's no other back-up plan.' "
The report said that some of the people interviewed for the evaluation described PEPFAR as a "safety net" for the government and gave examples of where PEPFAR has provided buffer stocks or emergency procurement to address shortages or stockouts.
The evaluation report discusses the challenges of implementing a culture of country ownership within PEPFAR. "Concerns of financial stewardship of US taxpayer dollars and quality of services provided to beneficiaries by implementing partners, coupled with a strong sense of ownership of the program by US Government staff and implementing partners," the report said, "may have contributed to the perception that country counterparts might not approach the stewardship the same way, with the same intensity, or with the same results for quality of services."
The evaluation report quoted one interviewee as follows:
"The culture of our institutions is still [that] we are in control, we are the donors; as much as we try to say we're not, that's not the culture and it's not the structure. The Global Fund is the only institution in a multilateral sense that was created to respond to those principles of fully country-owned. No other institution was, and the Global Fund hasn't succeeded at it."