Country Ownership: Strategies and Challenges in Partnership Framework Countries

1. Country Ownership: Strategies and Challenges in Partnership Framework Countries William Conn, PEPFAR Regional CoordinatorLaurel Hatt, Abt Associates November 19, 2011

2. USG PEPFAR Caribbean Regional Program

3. PEPFAR II Program Components • Country Ownership • Capacity Building • Sustainability • Technical Assistance to support the National Responses • Linked to National and Regional Strategic Plans • Emphasis on strategic information • Evidence-based programs • Government to government Partnerships • Supports the Global Health Initiative (GHI) by strengthening health systems

4. Caribbean Region Signatory Country and Regional Partners (6,048,268) Six Plus Six Antigua and Barbuda (85,632) Dominica (72,660) Grenada (90,739) St. Kitts and Nevis (40,131) St. Lucia (160,267) St. Vincent and the Grenadines (104,574) Plus Two Regional Programs: PANCAP OECS/HAPU • Jamaica (2,825,928) 1.8% • Trinidad and Tobago (1,229,953) 1.5% • Suriname (524,143) 2.4% • Belize (322,100) 2.1% • Bahamas (307,552) 3% • Barbados (284,589) 1.2%

5. HIV/AIDS in the Caribbean Region • The Caribbean has the second highest adult prevalence rate of HIV/AIDS in the world after Sub-Saharan Africa. • Caribbean is the only other region outside of Africa where the proportion of women and girls living with HIV (53%) is higher than that of men and boys. • The epidemic is the leading cause of death among adults ages 25-44 years of age and has left nearly quarter of a million Caribbean children orphaned. • Unprotected sex between men and women is thought to be the main mode of transmission in the Caribbean, especially paid sex. • In 2009, approximately 12,000 Caribbean nationals died of AIDS (43% decline from 2001), and an estimated 17,000 people were newly infected with HIV (14% decline from 2001). • Highest prevalence rates among MARP groups (MSM 32% Jamaica; FSW 24% Suriname).

6. USG PEPFAR Partner Agencies • Centers for Disease Control & Prevention (CDC) • Department of Defense (DOD) • Peace Corps (OECS, Belize, Jamaica, Suriname) • Health Resources & Service Administration (HRSA) • United States Agency for International Development (USAID) Eastern Caribbean and Jamaica Missions • Regional Program based at U.S. Embassy in Barbados; State Department represented through U.S. Embassies in Bahamas, Belize, Jamaica, Suriname, Trinidad and Tobago, Grenada

7. PEPFAR Goal Areas Partnership Framework Implementation Plan MARP-Focused Goal Areas: • Prevention • Strategic Information • Laboratory Strengthening • Health Systems Strengthening

8. Caribbean Region Partnership Framework Country Ownership – Engaging Local Government and Regional Partners • Government to Government Relations • Steering Committee Members, Ministers and Ambassadors • Quarterly calls, NAP Managers take the lead • Annual Meeting, Ministers take the lead • Supporting National Strategic Plans and Regional Plans • Technical Assistance to bolster their program • CARICOM/PANCAP and OECS/HAPU, building their capacity to serve the country members in the region • RCM membership • Interagency country visits • Encouraging PPP

9. Measuring Country Ownership • Political Ownership / Stewardship • Government vision for sector support • Institutional Ownership • Local institutions own the final decisions for each stage of program development • Local institutions manage funds and have responsibility for programs • Capabilities • Country leadership have technical and management capabilities to oversee programs and make adjustments and shifts over time

10. Technical assistance for improved financial sustainability Health Systems 20/20 and SHOPS projects Laurel Hatt, Abt Associates Inc.

11. PEPFAR-funded projects working on sustainability in the Caribbean • Health Systems 20/20: USAID’s flagship health systems strengthening project • Provides expertise on health financing, governance, health systems operations, and capacity building worldwide. • Strengthening Health Outcomes through the Private Sector (SHOPS): USAID’s flagship private sector engagement project • Works to increase the role of the private sector in the sustainable provision and use of quality HIV/AIDS and other health services. • Caribbean focus: Provide technical assistance on health systems strengthening and private sector engagement, to improve financial sustainability of HIV programs

12. Why is health systems strengthening important to HIV program sustainability? • Underlying health systems weaknesses limit achievement of health and HIV/AIDS goals • Same problems seen over and over again • inadequate financing and inadequate infrastructure • shortages of staff • low worker motivation • poor quality of services • private health providers unregulated, not engaged • Need to address broader health system challenges to improve prevention and service delivery for HIV

13. Health systems strengthening and financial sustainability • Financial sustainability of HIV programs linked with overall health system financial sustainability • Need for health system financial planning: • Cost escalation? Rising out-of-pocket spending? Increasing prevalence of NCDs? Global recession? Decreased tax revenues? • Need HIV program sustainability planning, given decline in external funding: • What public and private domestic resources can be leveraged?

14. Information needs for financial sustainability planning

15. Example: HAPSAT • Flexible, user-friendly software for quantifying the financial and human resources required for a set of HIV program scenarios • Gap analysis: • Assess current funding resources • Assess financial and human resources required to maintain and scale-up HIV services • Planning resource generation/innovative financing

16. HAPSAT in Guyana • Stakeholders’ top priority for HIV program: Shortage of HRH • HAPSAT analysis quantified HRH needs • Result: Gaps are relatively small if current health workers can be utilized more efficiently • Stakeholders’ decisions: • Establish appointment system • Adjust clinic hours to better fit client needs • Review number of HIV counselors

17. HAPSAT applications to date • Conducted 11 HAPSATs since 2008, another 3 scheduled Domestic resource mobilization Sierra Leone Nigeria Cote d’Ivoire Benin Haiti Ethiopia Guyana Kenya DRCongo Vietnam HRH solutions Successful Global Fund proposal Zambia Southern Sudan Lesotho Swaziland

18. Options for increasing financial sustainability of HIV programs (1) • Resource mobilization • Increase public sector health budgets • Experiment with innovative taxes (“sin” taxes, airline levies) • Increase the proportion of health budgets allocated to HIV • Leverage additional resources from private sources • Incentivize enrollment in private health insurance plans and mandate that HIV benefits be included • Establish foundations to raise funds for HIV prevention work

19. Options for increasing financial sustainability of HIV programs (2) • Prioritization • Reallocate budgets to more cost-effective services (e.g. investments in prevention programs to reduce long-term health costs) • Contract with private providers when it is more efficient

20. Options for increasing financial sustainability of HIV programs (3) • Increase efficiency of health programs -- stretch health budgets further • Service integration (one-stop shopping) • Primary care model for routine services • Provider payment mechanisms to incentivize cost-efficient service provision • Better quality assurance to make best use of health resources

21. Next steps for technical assistance • Ongoing and future HS20/20 and SHOPS activities in the Caribbean • Comprehensive health systems and private sector assessments • Hospital costing studies • National Health Accounts estimation; HIV/AIDS subaccounts • Support for national health insurance development • Explore contracting with private providers for HIV and related services

22. Questions

23. 3 Questions • What is the current situation in your National AIDS Program as it relates to country ownership and outside funding of the program? • What are the areas of the program that you see as needing the most support and technical assistance to become sustainable? • How has the PEPFAR program helped your program and how can it help your program to become sustainable and to reach full ownership?

24. Thank you! www.pepfar.gov