Sustaining Hard-Fought Gains
Despite the remarkable progress in the past
decade as a result of U.S. government investment along with contributions from international
donors and partner countries themselves, substantial
unmet needs remain across HIV services.
For future progress, PEPFAR will need to work
effectively with partner countries and global
stakeholders to ensure that hard-fought gains are
not lost and to achieve sustainable management of
HIV programs, equitable access to services for the
populations that are most in need, and sustainable
control of the HIV epidemic.
Success will rely on an unrelenting focus on
strengthening the capacity for service delivery
through local public and private health systems
in PEPFAR partner countries. Already, PEPFAR
has improved the function of health systems. It
has strengthened laboratories; bolstered the reliability
of supplies of essential medicines and HIVrelated
health commodities, such as condoms and
test kits; and strengthened the health workforce
by training hundreds of thousands of health care
providers and others involved in implementing
HIV programs. As PEPFAR matures, it will
continue to transition away from the emergency
response mode that defined its early existence.
In recent years, PEPFAR has provided
increasing support for partner country planning
and the development of national frameworks,
policies, and strategic plans, which are critical
for a sustainable HIV response led by individual
countries. PEPFAR is gradually shifting funding
away from providing services directly to providing
technical assistance, building capacity, and strengthening systems. As PEPFAR intensifies its
focus on fostering the ability of countries to take
on greater responsibility for long-term efforts to
respond to HIV, ambitious aims may not lead to
results as rapidly or dramatically as in the past.
During the transition period, the level and quality
of services and programs available in partner
countries may be diminished. At the same time,
the transition can be an opportunity to better integrate
HIV services with other health services, to
achieve efficiencies and to improve overall health.
Today, the ability of many countries to respond
to HIV relies heavily, and sometimes exclusively,
on external funding. There has been a growing
recognition by all stakeholders that partner countries
will need to take ownership of HIV programs
that respond to their particular epidemics, by
defining goals and priorities, providing more services,
shouldering increasing funding responsibility,
and making strategic, albeit difficult, decisions
about the efficient use of finite resources.
Comprehensive plans for future U.S. support
should concentrate on long-term development
of infrastructure and improving the capacity of
partner countries to establish and implement
effective processes and systems for planning and
implementing HIV programs. The essential pillars
of capacity building will include not only the
facilities and service providers that have been the
focus in the past, but also a stronger emphasis on
financial and program management.
PEPFAR has been globally transformative. Across
partner countries, PEPFAR was described as a
lifeline, and people credit PEPFAR for restoring
hope. The initiative’s future contributions will be
informed by its past achievements, but, by necessity,
will take a new direction. PEPFAR will gradually
cede control, as partner countries take on more
central roles in accountability and setting strategic
priorities for investment in their HIV response.
The pace of transition will vary by nation, but such
an evolution in PEPFAR’s mission is vital.
The IOM committee is hopeful that its comprehensive
evaluation will help PEPFAR achieve its
aims for this new era, and it encourages the initiative
to remain bold in its vision and global leadership.
PEPFAR has the opportunity and the potential
to once again transform the way global assistance
for health is envisioned and implemented.