Is PEPFAR competing or cooperating in treatment scale-up?

Given the political climate in which the PEPFAR Implementers meeting and the UN High Level meeting took place, it would be only natural for some working in the respective funding organisations to become a bit competitive — and yet publicly at least both appear to be striving for closer cooperation.

Given the fact that both organisations are funding similar work in the same areas, without close communication there is a capacity for overlap and creating redundant, parallel systems. In some cases, duplications of effort have led to competition for the same patients. In one case, a free PEPFAR ART site was established near an established fee-for service Global Fund site, and inadvertently siphoned patients away — contributing to the failure of one country [Nigeria] to have the second phase of its first round Global Fund grant renewed.

According to Ms. Helen Evans, Deputy Executive Director of the Global Fund, such poor coordination ultimately led to a meeting in January 2006, between PEPFAR, the Global Fund and the World Bank to improve communications amongst country teams and to identify challenges to successful implementation as well as come up with concrete actions to tackle those challenges. “But meetings to do this can only be justified if they produce identifiable positive improvements in service delivery leading to better outcomes for people,” she said. However, she believes that the Implementers meeting contained many examples of PEPFAR and the Global Fund working together.

“We are indeed close and complementary partners. We need each other... The success of one depends upon the other,” she said.

In her address at the start of the Implementers meeting, she asked participants to focus on closer cooperation, insisting that it is in both organisations’ best interests to “convince tax payers and law makers that this effort is worth increased effort, predictable and long term investments in order to sustain and further scale up our work.”

“How do we strengthen health systems to allow the scale-up to occur and to ensure that the scale-up is sustainable?” she said. “One of the obstacles to increasing access to treatment is the frailty of basic health systems in many countries.”

In this regard, the Global Fund has certain advantages over PEPFAR because the Global Fund favours a country-driven approach which brings the key stakeholders (governmental and non-governmental organisations) in a country together to flesh out what they believe the country should ask for in its grant (and hammer out what they believe they can deliver). With all the stakeholders together, there is less chance for a duplication of efforts or development of parallel systems within the country — and the process forces different places to gradually stitch their efforts together into a stronger national healthcare infrastructure.

Good examples of this process were presented from Kenya and Tanzania, where two different approaches to coordination have been followed.

In Kenya, coordination of donor activities takes place at the provincial level, where the word of the provincial ART officer is final. Lennah Nyabiage of the Kenyan Ministry of Health explained her role: coordinating all donor activities, including PEPFAR-funded programmes in Nyanza province.

“Partners often want to go to particular districts, but the Ministry of Health has to tell them to go to places without ART coverage. The provincial officer has to try to get partners to direct money where it is needed, rather than according to the preferences of partners.”

Ms. Nyabiage has a lot of partners to coordinate in Nyanza province: the US Centers for Disease Control, Mildmay International, MSF, Catholic Relief Services and the German development agency GTZ are all directly supporting antiretroviral treatment in Nyaza province, largely through PEPFAR grants. Other donors are supporting other parts of the effort; the UK medical emergency charity Merlin is covering the cost of courier services to take blood samples to laboratories as part of a prevention and care project targeting mobile fishing populations on Lake Victoria.

In Tanzania on the other hand, the division of labour has been coordinated at the national level, with provinces allocated to different consortia of organisations, even though most of the programmes are funded by PEPFAR. These consortia are responsible for all aspects of scale-up in a particular province.

In Zambia national treatment scale-up has been funded through a mixture of Global Fund and PEPFAR money, with Global Fund money buying generic antiretrovirals in some parts of the country and PEPFAR money buying branded antiretrovirals in other parts. This reduces the total treatment cost to the government without infringing the US Congressional requirement that PEPFAR money only be spent on FDA-approved products.

But coordination doesn`t always work — at least not as quickly as people living with HIV really need. Governments often drag their feet, lack competent leadership or are corrupt. Local stakeholder representation may be inequitable (with some groups being completely shut out) or negotiations between stakeholders can be influenced by politics or simply inefficient. As a result, the proposals the Global Fund receives, or the implementation of the funds on the ground, are not always as good as they could be.

It is in these situations where PEPFAR is particularly useful — whenever Global Fund efforts meet an impasse which PEPFAR-funded programmes, by virtue of feeling less obliged to work through local government-led coordinating bodies, can more rapidly address. One advantage PEPFAR has is its ability to bypass government coordinating bodies, red-tape and logjams to direct funding to groups, community-based or otherwise, that can rapidly mobilise and get the work done. But this works especially well when PEPFAR and Global Fund keep each other informed of each others efforts and challenges in implementation.

PEPFAR’s efforts are not always appreciated by local government, but in some cases, this in and of itself could be seen as evidence of just how necessary PEPFAR’s work is.

In her opening address at the Implementers meeting, Minister Tshabalala-Msimang made many valid points about the need for local governments to build and maintain self-sufficient health systems — and indeed South Africa is contributing substantial resources to strengthening its own health system. However, given South Africa’s history on the issue, without pressure from PEPFAR, it is not clear how far those efforts would have favoured the roll-out of ART.

The minister said that South Africa hadn’t asked for PEPFAR’s assistance. “In 2003, there was the announcement of PEPFAR,” she said, “which included South Africa amongst several focus countries for this programme. The announcement was followed by discussions on a number of issues including lack of clarity on the criteria for selecting these focus countries.” As for South Africa’s inclusion, she complained that “We were simply ‘informed’ .”

“The other issue was direct access by “principal partners” to PEPFAR funding which posed a serious coordination and harmonisation challenge,” she claimed. The Minister stressed “our view is that external funding must be coordinated through government systems...’ and that this would achieve “better outcomes.”

But simply because PEPFAR funds some principal partners directly does not mean that these efforts cannot be made complementary or later be integrated into government systems. At the Implementers meeting, it was clear that PEPFAR has catalysed novel pilot projects in South Africa, such as successfully providing ART at the primary health level, which have moved ahead equitable access to ART much faster than the government ever would have on its own.

But ultimately, even though she did not initially ask for PEPFAR’s help, even Minister Tshabalala-Msimang was worried about PEPFAR’s future funding.

“We hope that this meeting will also begin to shed some light on the future of PEPFAR as we are into the second half of this five-year initiative. Discussions on this issue will assist in ensuring certainty in the future of programmes supported by PEPFAR and assist focus countries to plan accordingly,” she said.

Other focus countries are even more concerned, while others which are not currently included as focus countries, such as Malawi and Zimbabwe, are desperate to be included in the mix.

According to Dr. Alex Coutinho of TASO in Uganda, it is all well and good that South Africa can fund 90% of its health system needs through its own resources. “We admire SA for being able to do that,” he said. “But we are not in the enviable position of South Africa. For Uganda and for many other of the fourteen [PEPFAR] countries, it is not a five year or even a ten year [partnership that is needed].

“Countries are very frightened that they won’t have sustainable funding,” said Ambassador Lewis at the UN meeting. “They just don’t know what’s going to happen down the road, in 2008, 2009, 2010. People are on treatment. People are being kept alive because of the money. If the money does not flow and the drugs are interrupted, people die. That’s simply an unthinkable proposition. This is simply a matter of life or death.”

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