saving lives, strengthening...

Saving Lives, Strengthening Systems

FY 2011 Senior Review

August 5, 2009

This whole-of-government strategy is still being developed.

Programs, implementation strategies and budgets will change.

“Our investment in programs to combat HIV/AIDS, malaria, TB, and other preventable diseases save millions of lives, reduce maternal and child mortality, and reflect our nation’s leadership as a positive force for progress around the world.” —Secretary Clinton, May 5, 2009

The U.S. is the global leader in addressing global health needs, investing $8.2 billion in FY 2009 and $45 billion over the last decade. While progress has been made, urgent health challenges remain.

• HIV/AIDS: 33 million people live with HIV/AIDS globally; in 2007, 2 million people died of HIV/AIDS and 2.7 million were newly infected

• Child Mortality: 9.2 million children die in the developing world every year; approximately 2/3 of these deaths are from preventable disease and malnutrition

• Maternal mortality: 530,000 mothers die in the developing world each year; every minute, a woman dies from complications related to pregnancy or childbirth and 20 more suffer injury, infection or disease

• Tuberculosis: 1.7 million people die from TB and 9.2 million people are newly affected each year, of which 500,000 TB cases are multi-drug resistant

• Malaria: 900,000 people die of malaria and 300 million people are newly infected annually

• Tropical Disease: 400,000 people die from Neglected Tropical Diseases every year, 1 billion suffer from one or more tropical disease, causing severe disability and hindering cognitive development

• Unintended Pregnancy: 52 million women experience unintended pregnancies and 22 million women obtain abortions annually

• Undernourishment: More than 150 million children under the age of five, and 1 out of 3 women in the developing world are undernourished

The Problem: Despite Major Investment, Urgent Global Health Needs

2

The U.S. Government Response: History of Specific Programs & Successes

Program Results

Family Planning (since 1960s) Contraceptive use among women of reproductive age has increased from less than 10% in the 1960s to over 43% today.

Child Survival and Maternal Health (since 1980s)

Deaths of children under five decreased from >15 million in the 1980s to 9 million now (saving 6-7 million children’s lives each year.) Maternal mortality declined by 20-50% in more than 10 countries.

Tuberculosis through the Infectious Diseases Strategy and the Global Fund (since 2001)

Over 1.2 million people successfully treated for TB in 2007, saving more than 600,000 lives.

HIV/AIDS through PEPFAR & the Global Fund (since 2004) with additional results attributable to the Global Fund

More than 2.1 million individuals receiving anti-retroviral therapy; nearly 1.2 million pregnant women received PMTCT, preventing nearly 240,000 newborn HIV infections.

Malaria through the President’s Malaria Initiative & the Global Fund (since 2005)

Over 32 million people reached with malaria prevention or treatment interventions in 2008 through the President’s Malaria Initiative.

Neglected Tropical Diseases (since 2006) More than 132 million treatments for NTDs have been delivered to more than 38 million people.

The U.S. Government response to the global health problem is characterized by a number of primarily disease-specific programs that have achieved laudable results worldwide. The challenge of the Global Health Initiative is to transform these existing programs into an integrated whole, which together delivers more than the sum of its parts.

3

Significant global health resources have been dedicated across multiple sectors and agencies, with insufficient coordination and integration.

By USG Department & Agency, FY 2008

Total = $9.6 billion

Note: This chart includes combined bilateral and multilateral funding for all U.S. global health sub-sectors. “Other” represents funding at HHS Office of Global Health Affairs, EPA, and DHS. “State OGAC “ includes PEPFAR Global HIV/AIDS Account and part of the Global Fund appropriation. The majority of State OGAC funding is transferred to the agencies that implement programs on the ground (e.g., USAID, HHS, DoD and Peace Corps). “NIH “ includes part of the Global Fund Appropriation.

Total = $9.6 billion

By Major Sub-Sector and for the Global Fund FY 2008

Note: The funding for the U.S. contribution to the Global Fund is appropriated to PEPFAR, and is provided to the Global Fund without a specified disease allocation. As such, it is included above as a stand-alone category. The Global Fund pools U.S. government and other donor contributions and provides grants to low- and middle-income countries for HIV, TB, and/or malaria activities. To date, the Global Fund reports distributing 62% of funding to HIV programs, 25% to malaria, and 14% to TB.

Source: Kaiser Family Foundation USG published reports, SF-133 Reports, OMB Budget Database and OMB direct data request.

The Problem: Persistent Management and Implementation Challenges Remain

4

The Global Health Initiative: The Way Forward

“We will not be successful in our efforts to end deaths from AIDS, malaria, and tuberculosis unless we do more to improve health systems around the world, focus our efforts on child and maternal health, and

ensure that best practices drive the funding for these programs.”—President Obama, May 5, 2009

In May, President Obama announced a $63 billion commitment to global health to address some of the most serious health problems facing the world’s poorest people. The Initiative, as announced, aims at focusing attention on broader global health challenges, including child and maternal health, family planning, and neglected tropical diseases, while maintaining our robust funding and strong commitment to the fight against HIV/AIDS. It also emphasizes the need to adopt a more integrated approach to improving health and strengthening health systems.

GLOBAL HEALTH FUNDING (FY2009-FY2014, in billions)

FY2009

Enacted

FY2010

Budget

Change FY10

from FY09

6 Year Total

(FY09-FY14)

Global HIV/AIDS & TB 6.638 6.655 0.165

Malaria 0.561 0.762 0.201

HIV/AIDS, TB & Malaria Subtotal 7.199 7.417 0.366 51.000

Global Health Priorities Subtotal 1.135 1.228 0.093 12.000

GLOBAL HEALTH INITIATIVE TOTAL 8.334 8.645 0.459 63.000

5

The Global Health Initiative: Requirements of a New Approach

Improved Metrics, Monitoring & Evaluation

Country Ownership

Strategic Integration and Coordination

Women-Centered Programming

Problems with the Traditional ApproachRequirements of a

New Approach

Donor-driven priorities, which characterize many health interventions, have stifled host-country commitment and willingness to lead and manage their own health programs.

Limited measurement of impact, including lack of ability to measure the strengthening of health systems and efficiencies gained from integration.

Failure to comprehensively address health challenges due to limited coordination within the USG and across disease-specific programs. Failure to mobilize and leverage additional global resources and align them behind a common agenda.

Women do not have equal access to health care, have been underserved by current health interventions; maternal mortality has not declined globally

Sustainability and Health Systems Strengthening

The disease focus and emergency nature of donor programs have contributed to underinvestment in the development of sustainable local health systems.

6

Requirements of a New Approach: Women-Centered Programming

Women must be at the center of any global health strategy. Research shows that where women are valued, protected, educated, and healthy, there are long-term benefits for their families and communities, including increased child survival, decreased health care costs, expanded access to health care for their families, and improved productivity and household incomes.

Integrate women-focused interventions among our health programs, linking maternal health services with family planning, prevention of mother-to-child transmission of HIV, and other services.

Include specific program requirements that will improve outcomes for women, including:

Provision of community-based care

Sex-disaggregated data collection and analysis

Multi-sectoral approaches/linkages

Country-level policy reform and government capacity strengthening

Promotion of women as health providers and training providers in women-centered care

Establish review mechanisms to ensure that women’s issues are incorporated into every stage of the GHI, including:

Policy considerations: Identify how each health program will integrate women’s issues at the policy development stage

Procurement: Include gender considerations in procurement documents and evaluation criteria for program awards

Metrics and evaluation: Develop indicators to track progress of a gender-integrated approach and institute a reporting requirement on gender for each health program





Country Ownership

7

Insufficient Coverage of HIV Counseling and Testing among Pregnant Women

Numerator : PEPFAR 2007 and 2008 APR; Denominator: US Census Bureau, 2008.

Requirements of a New Approach: Women-Centered Programming, cont.

Lifetime Risk of Maternal Death in Many Regions

Industrialized

countries:

1 in 8,000

Sub-

Saharan

Africa:

1 in 22

LA/C:

1 in 280

South

Asia:

1 in 59

The map on the left shows the dire problem of maternal mortality and morbidity in many regions around the globe. The graph on the right shows insufficient coverage of HIV counseling and testing of pregnant women. Both depict the striking and persistent inability of women to access the health care they need. A fundamental part of the GHI will be to place women at the center of care both to reduce the inequities that women face when trying to access care for their own health needs, and serve as a gateway for their families to get the care they need.

Source: WHO/UNICEF/UNFPA/World Bank: Maternal Mortality Estimates 2005, App 8, pub 2007

8

Requirements of a New Approach: Strategic Integration and Coordination

The GHI must ensure integration and coordination, including integration among USG health programs, integration with other USG initiatives outside of health, such as food security, water supply and sanitation, and economic growth, and collaboration with other donors and multilateral organizations.

Across USG health programs, we must:

Evaluate health elements against their contribution to health systems building blocks

Identify synergies when evaluating health needs; planning and implementing health strategies and responses.

Establish Country Health Teams, with representation from every USG agency with health programs in-country, to conduct overall planning and program reviews for integrating USG health programs around partner country priorities.

Across USG development programs, we must:

Assess opportunities to address contributing factors to poor health, including poverty and the lack of access to clean water, adequate nutrition, and education.

Coordinate programs to build a comprehensive and sustainable response, including economic growth and good governance.

Together with other donors and multilateral partners, we must:

Identify and leverage comparative advantages, reduce duplication, and maximize coverage.

Incorporate and leverage, where possible, standardized policy and regulatory requirements.




Country Ownership


9

Requirements of a New Approach: Strategic Integration and Coordination Across USG Health Programs

We must evaluate health elements through the lens of their contribution to the six health systems building blocks:

1. Health Finance, including fundraising, forecasting and appropriate expenditure

2. Information Systems, including production, analysis, dissemination, and use of reliable and timely health information

3. Human Resources, including recruitment, training and retention of health workers

4. Service Delivery, including provision of effective, safe, and high-quality health services and interventions

5. Commodities/Procurement, including supply chains and rational use of high quality, safe, effective drugs and technologies

6. Leadership/Governance, including laws and policies; oversight, regulation, and accountability; and attention to equity, coverage, access, and quality

We must identify synergies when:

1. Assessing partner country health needs

2. Developing operational strategies, including USG human resource needs

3. Designing procurement options

4. Reporting on results and conducting portfolio reviews




Country Ownership


10

Requirements of a New Approach: Strategic Integration and Coordination Across USG Health Programs, cont.Supporting country-level planning. Coordinated and strategic country-level planning is at the heart of the Global Health Initiative. Developing tools for the field, such as the health systems planning matrix below (with illustrative data from Uganda), will allow country health teams to develop comprehensive, strategic, and integrated plans that reduce duplication, maximize efficiency, and support partner country strategies and needs.

HIV/AIDS Activities

TB Activities

MCH Activities

Malaria Activities

FP Activities

Health Finance - - - - -

Information Systems

Support of the Three Ones; HMIS Improvement; Surveillance of HIV Drug Resistance; Improvement of M&E practices/systems

$8.7 million

Expansion of DOTS/TB information systems

$50,000

- MIS, strengthen Sentinel sites, TA to NMCP for tracking malaria interventions

$1 million

Strengthen FP HMIS in the public sector

$312,000

Human Resources

National HRH Strategic Plan; HRIS linked to MOH Planning; Leadership Training; Fellowship Program; Internship program for entry-level health workers; In-Service Training; Development of MOH training curricula; Task Shifting; Accreditation of in-service training and continuing professional development

$.25 million

- Training in skilled delivery and obstetric care

$320,000

Leadership training, support for interns, healthcare worker retention

$115,000

Training of FP service providers at facilities/ health workers in communities

$400,000

Service Delivery

Development of MOH standards and technical guidelines; Involving PLHA networks in referrals and provision of services; Strengthening collaboration of service provider networks; Accreditation of private sector treatment facilities;

$39.3 million

Increase availability of TB diagnostics, improved lab capacity

$1.85 million

Improve comprehensive/ integrated ANC services. Support for MCH including immunization, nutrition, hygiene

$3.83 million

Malaria-related BCC, education to mothers at ANC, supportive supervision to healthcare workers

$ 11.2 million

Expand contraceptive mix, including long-term methods. Improving FP providers’ skills. Behavior change interventions to encourage constructive engagement of men.

$6.3 million

Commodities/ Procurement

Procurement coordination for ARVs; Technical assistance for national forecasting and strategic planning; District and health center level strengthening of logistics management capacity

$12.8 million

Improve logistics/drug management

$100,000

- IRS Chemicals, ITNs $8.9 million

Improve contraceptive supplies, improve national systems to manage and deliver contraceptives

$4.5 million

Leadership/ Governance

Development of MOH policies; Support for the roll-out of HIV workplace policy in private sector

$525,000

Support District level leadership in TB; national coordination of TB partners

$200,000

Support the GOU in strengthening maternal health services that target children under 5 and pregnant women

$1.3 million

TA to decision makers regarding transparent supply chain management

$400,000

Engaging decision makers and Parliamentarians to support family planning/ overcome policy barriers

$550,000

11

Previous Situation: One public sector supply chain for basic medicines and separate vertical supply chains for HIV, malaria, family planning, and other donor-funded health programs. The Government of Tanzania decided to integrate some supply chain functions to reduce management burdens, improve visibility, and increase accountability.

Current Situation: In 2005 Tanzania began to roll out a redesigned logistics system with integrated warehousing, distribution, information and procurement. It continues to be rolled out, currently operating in 16 of 21 regions. HIV commodities are not yet included, but will be in the future.

Benefits:

• Improved availability of medicines at service delivery points

• Improved data on commodity availability

• Presumably improved system efficiency

Challenges:

• Creates large burden on limited human resources

• Fragmentation of financing means that some commodities remain vertical

• Slow roll-out created multiple supply chains that needed to be designed concurrently.(i.e., after 4 years of implementation, vertical supply chains still operate in 5 regions)

Lessons:

• Success requires a prudent design; some aspects of supply chain operate best vertically

• Integration must accommodate special needs of distinct products (e.g., cold chain, bulkiness, value)

• Strong political commitment and significant financing for roll-out is required

Requirements of a New Approach: Strategic Integration and Coordination Across USG Health Programs, cont.

Supply Chain Reform in Tanzania. As part of the Global Health Initiative, a dedicated working group is examining the health procurement system and tasked with making recommendations related to supply chain reform. Tanzania provides a case study in how me might approach this issue.

12

Requirements of a New Approach: Strategic Integration and Coordination Across USG Development ProgramsStrategically integrating across health programs and coordinating between health and other development sectors are key to improving the efficient use of USG resources. The table below offers a snapshot of coordination opportunities across health, food security, water, education, governance, and economic growth programs.

USAID and State Health Programs Other USG Development Programs

Country MCH FP/RH PMI PEPFAR TBFood

SecurityWater for the Poor

Basic Education DG EG MCC

Afghanistan ■■ ■■ ■■ ■■ ■■ ■ ■ ■

Bangladesh ■■ ■■ ■■ ■■ ■■ ■ ■ ■

Burundi ■ ■ ■ ■ ■

DR Congo ■■ ■■ ■ ■ ■■ ■■ ■■ ■ ■ ■

Ethiopia ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■ ■ ■

Ghana ■■ ■■ ■■ ■ ■ ■■ ■■ ■ ■ ■

India ■■ ■■ ■ ■■ ■■ ■■ ■ ■

Kenya ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■ ■ ■ ■

Madagascar ■■ ■■ ■■ ■■ ■

Malawi ■■ ■■ ■■ ■ ■ ■■ ■ ■ ■

Mozambique ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■ ■ ■

Nigeria ■■ ■■ ■ ■■ ■■ ■■ ■■ ■ ■ ■

Pakistan ■■ ■■ ■■ ■■ ■■ ■ ■ ■

Rwanda ■■ ■■ ■■ ■■ ■■ ■ ■ ■

Sudan ■■ ■ ■ ■ ■ ■■ ■ ■ ■

Tanzania ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■ ■ ■

Uganda ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■ ■ ■ ■

Zambia ■■ ■■ ■■ ■■ ■ ■■ ■■ ■ ■ ■

■■= Intensive Focus (or Original Focus Countries, for PEPFAR) Country Program ■= Country Program 13

Requirements of a New Approach: Strategic Integration and Coordination With Other Donors and Multilaterals

Working with the Global Fund. The partnership between the USG and the Global Fund is an important part of the global HIV/AIDS response, with USG leadership helping to establish the Global Fund, mobilize donors, and promote policy coherence. Through Global Fund grants, the USG has helped to expand reach, build country ownership, and establish indigenous and external oversight mechanisms.

Current Integration: PEPFAR is engaging in joint country assessments with the Global Fund around their National Strategy Applications (NSAs), which will use national disease strategies as the basis of funding; PEPFAR plans to coordinate with NSAs as part of the Partnership Framework process.

PEPFAR country teams work closely with the Global Fund grant programs in partner countries, USG representatives sit on Global Fund Country Coordinating Mechanisms in 94 % of PEPFAR countries, the vast majority of which support Global Fund proposal development.

Lessons Learned: For donors with resources too limited to support bilateral programs, the Fund provides a means to contribute. It has also been an important factor in building country ownership and capacity. However, in its early years, disbursements were slow as countries built internal management capacity, and some countries continue to have large pipelines of approved funding. In order to maximize impact, we need on-the-ground collaboration between USG and Global Fund grants.

The U.S. is the largest donor to the Global Fund, having contributed $3.5 billion since 2001.

14

Sustainability cannot be attained unless the governments of partner countries have the capacity and political will to manage and operate their health programs. Through the GHI, the USG will work to identify partner priorities and establish the contributions that both the USG and partner countries can bring to health sector activities.

Country ownership happens when we:

Ensure that partner country governments are at the center of development, implementation, decision-making, and leadership of health programs.

Establish and build country capacity to allow, over time, transition of financing, management, and operation of programs, with necessary technical assistance.

Include local NGOs and the private sector in delivery and support of health services.

Engage communities to enable individuals to make informed decisions regarding their health.

How we can do it:

Under the leadership of partner countries, participate with other donors and stakeholders in developing country-led national plans and strategies.

Assist and support partner country governments in assessments, analyses, and reviews of state-of-the-art and best practices, to inform national plans and strategies.

Plan USG assistance and investments within the context of these national plans, identifying best use of our resources and comparative advantages.

Participate in collaborative, country-led monitoring, evaluation, and regular periodic reviews of progress.

Increase technical assistance and mentoring for civil servants, local NGOs, and private sector partners to build country-level capacity.


Country Ownership




Requirements of a New Approach: Country Ownership

15

Requirements of a New Approach: Country Ownership PEPFAR Partnership Frameworks as a Case Study

PEPFAR is currently engaged in negotiations with governments in many of the countries in which it works to develop a country-driven long-range planning mechanism, called Partnership Frameworks (PFs).

PFs provide a five-year joint strategic framework for cooperation between the U.S. Government, the partner government, and other partners to combat HIV/AIDS through service delivery, policy reform, and coordinated financial commitments.

PFs support and strengthen national HIV/AIDS strategies and focus on building strategic partnerships within countries to secure long-term sustainability of HIV/AIDS programs.

To date, two countries have signed PFs, and more than twenty countries and regions are in the process of developing frameworks.

16

Background: The multiplicity of donors can present tremendous management challenges for capacity-constrained partner governments. To quote one health minister, “My greatest asset is the large number of donors here to assist. My greatest challenge is the large number of donors here to assist.” The diversity of donor-led programs, policy prescriptions, monitoring and evaluation and reporting requirements presents barriers to coordination; diverts overburdened health ministries from health program planning, implementation, and oversight to donor management and response; and ultimately undermines country ownership. In response, in 2004, the U.S., U.K. and UNAIDS launched an initiative to promote the use of “three ones” for country-level HIV/AIDS programs. Donors were encouraged to work under one agreed HIV/AIDS Action Framework, one National AIDS Coordinating Authority, and one agreed country-level Monitoring and Evaluation System. A similar approach has been successfully used for malaria and TB.

Proposal: The USG would lead the development and launch of a “Three Ones for Global Health.” The USG will leverage its status as the largest donor in global health to:

Partner with and help build the capacity of countries to develop ONE comprehensive health plan and strategy, including systems needs, that will provide the basis for coordinating the work of all partners;

Partner with and help build the capacity of countries to establish ONE country-level, country-led coordinating mechanism to coordinate across all health programs and partners;

Partner with and help build the capacity of countries to design and implement ONE monitoring and evaluation framework, to provide the basis for program management and results reporting across all partners; and

Convene, connect, and mobilize all donors to participate in the “Three Ones for Global Health” framework.


Country Ownership




Requirements of a New Approach: Country Ownership Proposal for a GHI Leadership Initiative

17


Country Ownership




Requirements of a New Approach: Sustainability and Health Systems Strengthening

Sustainability encompasses both building and strengthening health systems and supporting, over time, the transition from USG to country management and operation.

Health Systems Strengthening (HSS) is key to achieving sustainable improvements in health and requires:

Deliberate focus of USG assistance, not merely a by-product of disease-specific, MCH/FP, or other health and development work

Sustained financial commitment to develop durable health systems

Establishment of indicators and measurement of impact

Support in developing local capacity for: service delivery, financing, leadership and governance; human resources, information systems; and commodities procurement

Health Systems Strengthening must be incorporated into the planning, implementation, and budgeting stages of country health strategies to identify areas where investments will yield greatest outcomes:

Design tailored package of HSS interventions critical to USG’s and partner country health objectives

Set qualitative/quantitative baselines, benchmarks, targets for HSS activities

Establish costs of these HSS activities

Determine how each health element would contribute to HSS targets

18

Pie Chart

FY 2009 – Challenges with Current Approach

• PEPFAR funds health systems strengthening (HSS) at $1.1 billion. This figure includes lab and infrastructure, logistics and commodities, strategic information (i.e. national M&E system), human capacity development, and HSS (i.e. policy work and financial systems.)

• However, investments are not systematic. There are no clear definitions of program areas, and activities are not organized around a strategic a framework.

Goals for FY 2010 and Beyond

• Increase investment in health systems as programs shift to reflect country priorities and expand government capacity.

• Develop and disseminate a strategic framework, definitions, and indicators to assist planning and implementation of priority HSS activities, through consensus with international partners.

• Identify existing programmatic work that is HSS (i.e. quality improvement of service delivery.)

• Create and disseminate guidance and matrices to assist field teams in establishing logical connections among components of health systems, outlining sequences of activities, and aligning with country-specific priorities.

NOTE: Future investments for FY 2010 and beyond will be determined in collaboration with the field.

FY 2009 Health System Strengthening-Related Funding, By Focus Area

Requirements of a New Approach: Sustainability and Health Systems Strengthening—PEPFAR Example

19


Country Ownership




Requirements of a New Approach: Improved Metrics, Monitoringand Evaluation

The Global Health Initiative must be continually and effectively monitored and evaluated to ensure measurable results.

Current M&E Activities

DHS: Demographic and Health Surveys (DHS) measure health outcomes and impact of health programming every 3-5 years with large sample sizes that allow for comparisons over time

Project monitoring: USG health programs employ routine project monitoring for interim indicators; for example, PEPFAR annual performance review (APR) data determines progress toward Congressionally-mandated targets.

Limitations of Existing M & E Activities

Integration: Lack of knowledge for measuring and evaluating costs and efficiencies from integrating USG health and development programs and with multilateral partners.

Sustainability: There are no internationally agreed-upon indicators to measure key sustainability outcomes, such as health systems strengthening.

GHI Performance Measurement Program. The GHI will develop metrics that evaluate the impact of integrating our health programs and measure how well these programs develop long-term capacity and create enduring change at the country level. The GHI M & E program will include the following components:

Increase M & E resources: USAID will increase the proportion of their budget dedicated to M&E; PEPFAR will focus on achieving results for better performance delivery.

Develop sustainability metrics: Research, test, and promote international consensus on indicators (both quantitative and qualitative) to measure sustainability, including health system strengthening, at the country level.

Develop integration metrics: Work to develop indicators (both quantitative and qualitative) to evaluate the impact of integration on improved program impact and efficiency.

Increase transparency: Increase publication of data associated with programming to facilitate research and analysis of new metrics and indicators.

20

In its next 5 years, PEPFAR will:• Scale up proven interventions with accountability and measurable results, to meet Congressionally-mandated targets for prevention, care and treatment; • Increase country ownership, with expanded programmatic investments jointly planned with countries; • Begin transition from service delivery to increased emphasis on technical support in the 31 countries with significant investments; and• Engage in more robust monitoring and evaluation, including building capacity for evaluation.

Resources to Achieve Goals: The Next Phase of PEPFAR

Scale up proven interventions

Identification of efficiencies; reliance on "toolkit" of

proven practices

Meeting Congressionally-mandated targets with

reductions in cost of delivery

Increase country ownership

Partnership Framework negotiations and signings; better coordination with multilateral

partners

Meeting benchmarks from Partnership Framework

implementation plans; increased donor harmonization in support

of national strategies.

Transition to increased emphasis on technical

support

Increased partnerships with government; new mentorship

and training of country civil service

Improved ability of governments to expand

management and operation of health programming

Robust national monitoring and evaluation

system

Establish metrics to support accountability and development of

evidence-base; generate more useful outcome and impact data to

support strategic and programmatic decision-making

Better information about programs and their

effectiveness; increased publication of data

Goal Implementation What we will achieve

23

Estimated reduction per person: $188

Review of treatment program and patient characteristics and scale-up expectations led to revision of some model inputs

Changes in Modeling Assumptions of PEPFAR Treatment Program:

Drug Regimenso Assumes a slower uptake of more expensive first-line ARV regimens that contain Tenofovir, a less toxic but more

expensive drug: 45% (previously 50%)o Mark-up for internal supply-chain management: 15% (previously 20%)o Proportion of branded drugs purchased by PEPFAR: 15% (previously 20%)

Current Distribution of Patients o Model is premised on 25% (previously 30%) of patients newly initiating therapy for the first time, and 5% (previously

7%) of those patients are second line therapieso Additional costs for buffer stock of drugs associated with patients initiating therapy

Patient Characteristicso Assumes a slower rate of transition to second-line therapy: 4% (previously 5%)o Proportion of new treatment slots allocated to pediatric patients: 12.5% (previously 20%)

Non-ARV Costs Associated with Patient Care (lab, non ARV drugs, and human resources)o Costs associated with care of second-line patients compared to first-line: costs are equal/100% (previously 150% )o Costs associated with care of pediatric patients as compared with adults: 110% (previously 150%)o Additional mark-up for technical assistance, operations/overhead above site level: 40% (previously 30%)

$743 per person$931 per person

Next Step: PEPFAR will engage in prevention and cost modeling to inform future budget decisions.

Resources to Achieve Goals: The Next Phase of PEPFAR, cont. Changes in Treatment Cost Modeling

24

The Global Fund: 2001-2008 Grant Disbursements by Region and Disease

Resources to Achieve Goals: The Next Phase of PEPFAR, cont. Partnership with the Global Fund

BackgroundThe Global Fund brings together diverse stakeholders to mobilize, manage, and disburse resources for combating HIV/AIDS, TB, and malaria. To date, 579 grants have gone to 140 countries. The U.S. is the largest donor to the Global Fund, having contributed $3.5 billion through FY09.

Issues• The Global Fund faces significant shortfalls in financing. In its latestround, only $900 million is expected to be available for new grants, yet demand for new grants is expected to exceed $3 billion.

• The Global Fund has historically approved all technically sound grants, but is currently examining this policy due to limited resources.

• Some countries have large pipelines of approved funding from the Global Fund, but continue to submit new proposals in each successive grant round.

• PEPFAR, PMI, and the USG TB programs are exploring opportunities to strengthen collaboration with the Global Fund to encourage increased grant impact.

In FY 2011, the U.S. is requesting a $1 billion contribution to the Fund, which is a straightline request from FY 2009 actuals , due to increase in Global Fund financing from FY 2009 supplemental appropriations.

25

Resources to Achieve Goals: The Next Phase of PEPFAR, cont. PEPFAR Country Level Budget Requests (Notional)

The map above depicts the former PEPFAR focus countries in blue, and the other PEPFAR Operational Plan

countries in green. Please note that country level allocations are

notional and will likely change, as per footnote below.

As part of our move to sustainability, PEPFAR is examining country

budgets and working to distribute resources based upon need aligned with our new strategic focus. We

are also working to encourage increased country financing where

possible.

The transition to sustainability is gradual, but is occurring.

* Funding levels for all years include direct field allocations and Partnership Frameworks. Levels do not include support for the Global Fund grants in-country or PEPFAR central funding. Please note that the optics of increased funding for FY10 over FY11 is due to the allocation of Track 1 funding from central to field mechanisms. At this time, Track 1 central allocations are not yet completed for FY 2011. All levels are planned and subject to change.

FY09 FY10 FY11

Botswana 88.2 88.6 88.2

Cote d’Ivoire 136.5 138.5 136.5

Ethiopia 339.5 343.0 339.5

Guyana 18.8 19.7 18.8

Haiti 117.5 123.2 117.5

Kenya 559.0 566.9 559

Mozambique 239.6 244.3 239.6

Namibia 106.4 107.3 106.4

Nigeria 470.2 474.3 470.2

Rwanda 135.1 140.2 135.1

South Africa 527.9 535.0 524.8

Tanzania 333.8 340.0 333.8

Uganda 315.6 322.1 315.6

Vietnam 103.1 102.8 103.1

Zambia 265.9 271.6 265.9

Total 3,757.1 3,817.5 3,754.0

PEPFAR Planned Funding for

Former Focus Countries *($ in millions)

FY09 FY10 FY11

Angola 17.0 17.7 17.0

Cambodia 18.0 18.5 18.0

China 10.3 10.0 10.3

Dominican

Republic 17.3 17.5 17.3

DRC 29.7 31.3 29.7

Ghana 17.5 18.0 17.5

India 33.0 33.0 33.0

Indonesia 13.0 13.0 13.0

Lesotho 26.7 29.4 26.7

Malawi 43.2 45.0 43.2

Russia 8.0 4.0 2.0

Sudan 8.8 9.5 9.5

Swaziland 27.8 28.8 27.8

Thailand 5.5 5.5 5.5

Ukraine 16.7 17.2 16.7

Zimbabwe 46.5 47.5 26.5

Total 339.0 345.9 313.7

PEPFAR Planned Funding for

Other COP Countries *($ in millions)

26

Resources to Achieve Goals: The Next Phase of PEPFAR, cont. PEPFAR Allocations by Program Area

FY 2011 Budget Request by Program Area

PEPFAR’s total FY 2011 budget request: For GHCS/State the total request is $5,780 million. When including all Foreign Operations appropriations the total request is $6,130 million, which includes $1 billion for the Global Fund (including $300 million from HHS/NIH) and $45 million for UNAIDS.The request is based on maximizing program dollars within existing prevention, care and treatment models, geared toward meeting Congressionally mandated goals while seeking efficiencies in programs to do more with existing funding. On that principle, the FY 2011 request reduces administrative costs overall by 1%

Beginning in FY 2010 and continuing into FY 2011, PEPFAR will examine existing programs and reconfigure activities and contracts to more efficiently use resources, better target most at-risk populations, and scale up health worker training within its budget.

Graph reflects FY 2011 bilateral funding request of $5.5 billion across all accounts, an increase of $411 million from the FY 2010 request

Prevention$1.60B

Treatment$2.3B

Care$1.2B

($514M is for OVCs)

AdminCosts$360M

Historical Allocations by Program Area

Original Focus Country Budget Allocations

From FYs 2004-2008, in the original focus countries, 42% of funds were dedicated to treatment, 19% to care, 27% to prevention, and 13% to other. The total budget was $9.9 billion. In In FY 2009, 38% of funds are directed to treatment, 21% to care, 25% to prevention,

and 15% to other. The total budget is $3.6 billion.

27

Initiative Goals:

Eliminate malaria as a major health problem in Africa by reducing malaria cases and deaths by approximately 50% across the 450 million people who account for 70% of the at-risk population in Africa

Reach 80% coverage of this population with current package of four highly effective malaria prevention and treatment measures

Focus malaria interventions to reach women of child-bearing age, pregnant women, and children under 5 years of age

With maternal and child health and family planning programs, develop 150,000 community health workers

New Focused Approach: On Nigeria and DR Congo, which together

account for nearly 50% of all malaria in Africa

New, national level programs in up to 5 additional African countries

Scaled up integration of community-based programs with MCH/FP

Integration with HIV/AIDS and child health, including antenatal and well-baby care

Intensified host country capacity building in: pharmaceutical management; program monitoring & evaluation; use of data for decision making; disease surveillance and reporting; and laboratory diagnostic service

Health ProblemApproximately 900,000 annual deaths and 300 million cases. In high transmission areas, malaria contributes to 3-5% of maternal anemia, which can lead to maternal death and is particularly harmful in women co-infected with HIV.

Budget Resources Enacted/Needed

Resources to Achieve Goals: Malaria

Enacted Request Over Time Total

Resources Required (millions) FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2009-2014

Malaria $385 $585 $800 $1,000 $1,000 $1,000 $4.770

28

Initiative Goals:

Contribute to the Global Plan to STOP TB targets, by reducing TB prevalence and deaths by 50% in 20 high burden countries by 2015 (relative to the 1990 baseline.) Reaching these goals would enable the elimination of TB by 2050

Increase access to TB testing

Reduce TB transmission in health facilities and the risk to health workers and patients

Increase awareness of the danger of TB and engage a larger donor group

Improve data resources to better inform decisions

Increase integration with other elements of GHI through primary health services

New Focused Approach: Accelerate TB case finding through various

methods, including screening in HIV testing sites

Scale up services for MDR TB, including rapid diagnostic tests

Scale up infection control measures for airborne disease transmission

Improve bio-safety in laboratories

Scale up fully functioning laboratory networks

Engage private sector providers more actively

Integrate commodity management systems

Strengthen information systems and data analysis

Health ProblemEach year Tuberculosis accounts for 1.7 million deaths and 9.2 million new cases of TB are diagnosed. 500,000 of those cases are multi-drug resistant (MDR).


Resources to Achieve Goals: Tuberculosis

Enacted Request Over Time TotalResources Required(millions) FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2009-FY2014

TB $176.6 $191.4 $330.0 $650.0 $800.0 $843.4 $2991.429

Initiative Goals:

Save the lives of 3 million children across 24 focus countries, putting countries on track to reach the 2015 MDG 4 target

Enhance integration with PMI and PEPFAR

With maternal health, family planning and malaria programs, train 150,000 new community health workers

Integrate aspects of the supply and delivery chain of care and commodities to maximize efficiency and reach

Ensure girls receive the attention they need and deserve

New Focused Approach: Work with the Food Security Initiative to

reduce malnutrition

Integrate family planning with mother and child care

Work across diseases to maximize access to goods and services, expanding the reach of high impact interventions

Emphasize primary and community-based prevention and treatment approaches

Increase use of behavior change, social marketing, and information technology

Pay special attention to girls in regions where they have historically received less care

Health ProblemMore than 9 million children die each year before their fifth birthday. Children are the most vulnerable to disease and the least able to fight it.


Resources to Achieve Goals: Child Health

Enacted Request Over Time TotalResources Required (millions) FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2009-FY2014

Child Health $ 395.0 $ 410.0 $ 600.0 $ 670.0 $ 700.0 $ 730.0 $ 3,505.0

30

Initiative Goals: Save the lives of approximately 500,000

mothers by 2015 in 24 countries

Prevent one in five maternal deaths in the year 2015

Create an integrated approach to maternal health

Strengthen care and commodity delivery systems, including (with child health, family planning, and malaria) supporting 150,000 new community health workers and training 50,000 skilled birth attendants in high impact interventions

New Focused Approach: Create a “Maternal Survival Initiative” Increased funding for maternal health. Fifty-

two percent of the new GHI MCH funding will be dedicated to maternal health interventions.

Strategic change in programming focus. Dual-track approach: (1) Accelerated scale-up of high

impact interventions,; and (2) Health systems strengthening (e.g., increased human resources and institutional capacity for comprehensive obstetric care)

Integration: Fully integrate MCH and FP; integrate with PMI in malaria-endemic countries and with PMTCT in countries with generalized HIV epidemics

Donor coordination: Work with other bilateral and multilateral organizations and NGOs to coordinate programs and leverage increased commitment to maternal health

Policy reform: Advocate for increased political commitment and removal of barriers to women’s care

Health ProblemEach year there are 530,000 maternal deaths. Almost all of these deaths are preventable.


Resources to Achieve Goals: Maternal Health


Maternal Health $ 100 $ 115 $ 315 $ 390 $ 430 $ 460 $ 1,810

31

Initiative Goals:

Reduce the total number of malnourished children by 7 million, saving 200,000 lives.

Reduce the occurrences of anemia in women by 25% in high burden countries.

Provide access to the latest scientific innovations.

Increase the number of health workers.

New Focused Approach: Work with the Food Security Initiative to

best help mothers and children

Scale-up community management of acute malnutrition and integrate into national and routine health systems, such as MCH/FP and HIV

Track and introduce innovative products like micronutrient powders and nutrient supplements

Increase capacity of primary and community health workers to treat and prevent malnutrition

Focus on girls in the implementation of nutrition interventions.

Health ProblemMore than 150 million children under the age of 5 are malnourished. Malnutrition is the principal underlying cause of more than 3 million child deaths each year. Anemia is an underlying cause of 20% of maternal death.

Budget Resources Enacted/Needed (linked to Food Security Initiative):

Resources to Achieve Goals: Nutrition


Nutrition $ 230.0 $ 265.0 $ 245.0 $ 160.0 $ 900.0

32

Initiative Goals: Prevent 49 million unintended pregnancies

and 20 million abortions

Reduce one-quarter of all unintended pregnancies

Scale-up integration with other parts of the GHI strategy

Increase access to family planning and improve birth spacing

With maternal and child health and malaria programs, develop 150,000 community health workers

New Focused Approach: Integrate family planning with HIV prevention-

of-mother-to-child transmission and other HIV/AIDS programs

Strengthen commodity supply and logistics systems that reach communities

Increase the number of trained and equipped community-based providers

Integrate FP with post-partum and post-abortion care

Co-locate services and combine in-service training of providers with MCH and other health interventions

Engage in high level diplomatic advocacy for family planning

Health ProblemMore than 200 million are unable to get the family planning information and services they want and need each year. This results in 52 million unintended pregnancies, 22 million abortions and 142,000 maternal deaths.


Resources to Achieve Goals: Family Planning and Reproductive Health


Resources Required (millions) FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2009-FY2014

Family Planning $ 455.0 $ 475.0 $ 650.0 $ 750.0 $ 820.0 $ 850.0 $ 4,000.0

33

Initiative Goals:

Establish an integrated and cost-effective mass drug administration strategy

Provide 1.3 billion NTD treatments in 30 high burden countries, targeting 7 priority NTDs

Eliminate lymphatic filariasis worldwide by 2016

Eliminate onchocerciasis in the Americas by 2016

Train at least 250,000 new community volunteers

New Focused Approach: Global scale-up of integrated approach as

the key platform to eliminate NTDs

Focus on elimination of at least two NTDs

Integration with child health and HIV/AIDS services, education, and water and sanitation

Enhanced technical strategy to achieve elimination, including vector control and use of new drug combinations

Establish baseline prevalence in 40 countries and introduce systems to monitor progress of integrated approach

Health Problem1.2 billion people suffer from at least one NTD and 400,000 people die from NTDs each year. These diseases can cause severe disability, childhood malnutrition, delayed cognitive development, disfigurement and blindness.


Resources to Achieve Goals: Neglected Tropical Diseases (NTDs)



Neglected Tropical Diseases $ 25.0 $ 70.0 $ 200.0 $ 240.0 $ 244.0 $ 247.0 $ 1,026.0

34


Resources to Achieve Goals: Other Health Areas

Avian and Pandemic Influenza

Build a systematic global effort to monitor for pathogens, such as the H1N1 and H5N1 viruses, emerging from animals to humans.

Focus on pre-empting or combating these diseases at their source. The first stages of zoonotic diseases pose a significant threat to public health.

Vulnerable Children

Develop integrated child protection systems in at least 8 countries with host country governments and UNICEF.

Strengthen national systems to prevent and respond to abuse, neglect, exploitation, or violence affecting children.

Increase household income and assets of vulnerable families.

Other Public Health Threats

Enhance surveillance capacity in 25 priority countries using an expanded field epidemiology training/mentoring program and regional centers of excellence.

Introduce national-level drug regulatory committees to oversee drug quality and anti-microbial resistance monitoring 20 countries.



Avian and Other Pandemic Influenza $ 140.0 $ 125.0 $ 125.0 $ 125.0 $ 125.0 $ 125.0 $ 765.0

Other Public Health Threats (Surv/AMR) $ 5.0 $ 18.0 $ 20.0 $ 20.0 $ 20.0 $ 20.0 $ 103.0

Vulnerable Children $ 15.0 $ 15.0 $ 15.0 $ 15.0 $ 15.0 $ 15.0 $ 90.0

35

Budget Resources Enacted/Needed*

Resources to Achieve Goals: Other Health AreasWater Supply and Sanitation

Strategic Objectives

In accordance with the Paul Simon Water for the Poor Act of 2005, to “provide affordable and equitable access to safe water and sanitation in developing Countries” by:

• Increasing access to water supply and sanitation, and promoting better hygiene;

• Improving water resources management; and

• Increasing water productivity.

Results and Future Targets

• In FY08 USAID efforts led to more than 7.7 million people receiving improved access to safe drinking water and 6.3 million received improved access to sanitation.

• Of these, more than 4.6 million received first-time access to an improved drinking water source and more than 2.1 million to improved sanitation.

• As of 2008, forecasts show that an additional 784 million people worldwide will need to gain access to improved drinking water sources to meet the MDG target.

Develop integrated child protection systems in at least 8 countries with host country governments and UNICEF.

Strengthen national systems to prevent and respond to abuse, neglect, exploitation, or violence affecting children.

Activities

• Established interagency team (more than 20 agencies and departments)

• Developed a USG strategy –priority countries, overall goals, objectives, and approach for USG efforts on water and sanitation

• Developed country specific plans in 14 of 31 priority countries with indicators for measuring and tracking progress

• Obligated $815 million in FY08 to improve access to safe drinking water and sanitation and promote hygiene in 95 countries worldwide.

Enacted Request Over Time TotalResources Required (millions) FY2009 FY2010** FY2011 FY2012 FY2013 FY2014 FY2009-FY2014

Water Supply and Sanitation $ 278.8$ 166.1

(300) $ 300 $ 300 $ 300 $ 300 $ 1778.8

* USAID only. MCC also makes significant investments in the water and sanitation sector, including $546.9 million in FY08.** A $300 million or more congressional earmark for USAID drinking water and sanitation projects is expected in FY010.

Future requests assume a continuation of the earmark.

36

Integration and coordination. A foundation of the GHI and key to achieving our goals is strategic integration and coordination of USG health programs. Currently, however, we lack the management and incentive structures to ensure such coordination, with a health portfolio characterized by vertical, disease-specific programs, many with separate coordinating authorities. We further lack the metrics to assess the costs, efficiencies, and impact we will incur and derive from integration. In this environment, how can we incentivize and ensure effective integration? What governance structure is needed both at the policymaking and program level to ensure cooperation within and across USG health programs and agencies? What are the right structures and mechanisms to incentivize coordination and integration in the field?

Achieving disease targets versus health systems strengthening. We know intuitively that country ownership and strong indigenous capacity to lead, manage, and implement comprehensive health programs will save millions of lives. But the outcome and impact indicators do not yet exist to capture such effects of health systems strengthening and capacity building. Traditionally, then, our health programs have focused on service-delivery approaches for which disease targets can be identified and measured—numbers of people treated, infections averted, lives saved. In a resource-constrained environment of unlimited need, service delivery and health systems strengthening has often been viewed as a choice between saving lives now versus uncertain impact later. With these tensions in mind, how can we build and sustain a commitment to health systems strengthening and country ownership?

The Global Health Initiative: Challenges & Strategic Trade-OffsPromoting and supporting country ownership. Here, again, tensions exist between the hard, long work of promoting and enabling country ownership and the ability to save lives now. Moreover, partner country priorities and interventions may not always match our own judgment. How do we support partner-country priorities while ensuring that we meet our program (and often congressionally-mandated) goals? And where we face reluctant governments, what incentives, financial or otherwise, can increase the sense of ownership and responsibility among partner countries for health outcomes?

Resource allocation and focus. Disease-specific programs have heretofore been targeted primarily in countries with the greatest disease prevalence. Similarly, the greatest numbers of lives saved can often be achieved by gathering the low-hanging fruit across a broad swath of countries. Given the objectives set by the Global Health Initiative, including fostering integration and sustainability, how should we allocate Initiative resources? Should we set out to accomplish our new goals with the increase in funding offered by the Initiative or should we consider rebalancing the existing distribution between and among health programs? Should we focus comprehensively in a small set of countries or maintain a broad presence in many? What are the moral and ethical obligations attendant to scaling down existing health programs in areas with continued need?

Human Resources. Current human resources are geared toward disease-specific interventions. A commitment to integration and sustainability means recruiting and cross-training a cadre of professionals with broad expertise in health, development, governance, and systems strengthening.

37

saving lives, strengthening...

Documents