PEPFAR and country-ownership: fact or fiction?

On October 27, 2009, in HIV/AIDS, PEPFAR, by Karen Grepin

The most recent issue of the JAIDS journal has a series of interesting articles on the HIV epidemic and health system. One that caught my eye was a short commentary from Mark Dybul, former US government AIDS czar, entitled “Lessons Learned From PEPFAR“.

In his abstract he argues:

“In scope, it [PEPFAR] is the first global initiative to tackle a chronic disease and was based in a new philosophical foundation centered in country ownership, a results-based accountable approach, the engagement of all sectors, and good governance.”

Did he say PEPFAR was centered on the principle of country-ownership? I can buy result-based accountable approach and engagement of all sectors and might even be sold on the idea of good governance. But I am sorry, I can’t swallow the idea that PEPFAR exemplifies the principles of country-ownership.

The concept of ownership is one of the main principles of the Paris Declaration for aid effectiveness. According to a definition from the OECD website, ownership can be defined as:

“Developing countries set their own strategies for poverty reduction, improve their institutions and tackle corruption.”

In the context of the HIV response, this would mean that countries would be responsible for developing intervention priorities, identifying implementing agencies, and being responsible for the programs. Of course country ownership does not have to be equated with government run, as it is also crucial that many stakeholders have a say and role in shaping priorities and strategies, but it does mean that governments are at least a key partner in the process.

The Center for Global Development in its report “Follow the Funding” report highlighted the lack of government involvement in PEPFAR projects as an area of weakness in the PEPFAR model. They argue that PEPFAR should “make the government a true partner in PEPFAR programs.” PEPFAR might have incorporated inputs from national plans, but it is hard to believe that it was countries themselves that developed the hallmark strategies of PEPFAR, including a heavy reliance on faith based institutions, the adoption of abstinence only messages, and strict earmarks on how monies should be spent.

Dybul points to the fact that 90% of implementing partners are local and that 80% of them are non-governmental organizations as evidence of PEPFAR’s country-ownership. I have a contract with NYU which pays me for my time as a instructor, dealing with student matters, and to support my research. But in no way does this mean that I own NYU, in fact quite the contrary given that my employer also owns the building in which I live. NYU owns me.

Even Dybul’s own successor, Dr. Eric Goosby, the guy with the exact same job Dybul had just under a year ago, has been quoted saying that PEPFAR has not achieved country-ownership and that in fact it may take years before it could ever be achieved.

I want to be clear, I think PEPFAR has changed the game in global health in many good ways, and has made important contribution to the lives of millions of people in HIV affected countries, but I have not always agreed with the way in which the program was implemented. Real country ownership is a lot more than contracting with local NGOs and informing the country about operational plans. Country ownership involves letting citizens and their elected representatives have a say in how programs are developed and implemented. PEPFAR is not doing that yet, so let’s save the praise until that is actually achieved.

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6 Responses to “PEPFAR and country-ownership: fact or fiction?”

  1. Theo Smart says:

    I think the hallmarks of PEPFAR have to include its work with groups like ICAP which developed partnerships with local organisations to rapidly scale up treatment, and not just the ones that you list (which, are in fact, it's prevention-related limitations).

    That being said, you are absolutely right that PEPFAR came in & sidelined some of the local governments/MOHs. I remember listening to Former SA Minister of Health Manto Tshabalala-Msimang complaining about this too.

    “In 2003, there was the announcement of PEPFAR,” she said at the Implementer's Mtg in 2006, “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. We didn't ask for this, we were simply ‘informed.’”

    She wanted PEPFAR to adopt the Global Fund’s country-driven approach to grant-making. This was quite funny really, given that she had previously held Global Fund monies hostage from local and provincial partners.

    Fortunately, PEPFAR worked with and strengthened local NGO and health service partners until the gov/MoH was ready to step up to the plate.

    I agree its a rather slippery slope, but I can refer you to 700,000 South Africans who are grateful PEFPAR came here.

  2. Karen Grepin says:

    Thanks for the great comment Theo.

    I could not agree more – PEPFAR has done many wonderful things that million of people benefit from every day…I just would not list country-ownership among its achievements.

    Your example perfectly illustrates the sidestepping of government which PEPFAR has done time and time again. Yes, country ownership should include involvement with many country partners, I just don't think you can really say you have country-ownership when the national government is not a true partner in the process.

  3. Anonymous says:

    Um, how can PEPFAR's strict requirements dictating percentages of funding spent on treatment, abstinence, abstinence, and well, abstinence be considered "country-driven"? Please. Requiring PEPFAR recipients to sign anti-prostitution pledges is not "country-driven". US funding was so not-country-driven that Brazil refused the money! Thank goodness Mark Dybul is no longer at PEPFAR and is free to spend his days writing revisionist history.

  4. Theo Smart says:

    That's true, Brazil did push them off. I think at the time, it was also viewed as a pharmaco-sponsored threat to their successful programme which relied on generics. That's sort of what I thought PEPFAR was and I was suspicious of it for all these same reasons.

    The ring-fencing of funding for prevention and horrible anti-prostitution pledge caused considerable difficulties for partners on the ground. I especially hate how some of the funding strengthened some particularly intolerant faith based organizations.

    But funders often set parametres on how funding should be used.

    What is interesting to me is that, initially, the funding primarily went to large US-based charities, and academic-public partnerships. The focus countries were quickly carved up into territories by ICAP, i-Tech, Project Haart, FHI, Harvard, CRS etc. It was like a land grab.

    But the fact is, at the time, local technical capacity was often severely limited. In the years since, however, the local partners have really come to the fore. This year, ICAP presented a model for how it helps provide mentorship, technical assistance and skills transfer until the local org can go it alone.

    Dybyl isn't being completely revisionist, he always paid lip service to the Monterrey Consensus and the plan always has been for PEPFAR to be a temporary engagement. But as for dealing with host governments, in the JAIDS article he states: "The final principle is an essential component of country ownership—the engagement of all sectors. A country cannot be reduced to its government." This is especially true when the national government excludes community engagement as was the case in South Africa. If it had been left up to the government, there would have been no treatment program in this country.

    My point is that, like it or not, in some cases, the choice to not give the national government complete control was what made some of PEPFAR's successes possible.

  5. Anonymous says:

    "But funders often set parametres on how funding should be used. "

    "My point is that, like it or not, in some cases, the choice to not give the national government complete control was what made some of PEPFAR's successes possible."

    But neither of these are the point that is being argued. Set all the parameters you want; claim all the success from not giving national government control, but don't also claim that PEPFAR was "country driven".

    I agree that the definition of country-driven should not be limited to "national government driven" but even in the broader understanding of country driven, you can't credit PEPFAR because of their refusal to work with sex workers, MSM (which USAID insisted on calling 'homosexuals'), or drug users to adopt effective strategies. To the extent that the country's interest was perfectly aligned with US interest (e.g., Uganda which wanted treatment and was happy to stigmatize and criminalize LGBT populations and promote abstinence) then perhaps PEPFAR was country-driven.

    I'm certainly not saying it was all bad – but let's be honest about the successes and failures and the ways in which ideologically driven approaches undermined prevention especially.

    The USAID money for Brazil was not for treatment. The Brazilians were already years ahead on that front. Most of what was planned was money for capacity building, M&E, research, policy, etc. The refusal was specifically explained as a refusal to abide by the restrictions related to the anti-prostitution pledge.

  6. Theo Smart says:

    Yes, that was what the reason the Brazilians gave for turning down the proposal. I'd actually forgotten that.

    Agree about ideologically driven approaches to prevention being destructive. Not defending it. As an MSM who spent years in evangelical schools, believe me: I don't want that foisted on anyone.

    I'm just saying that PEPFAR also including people in countries "driving" the treatment & care programmes — but that these arrangements often had to be outside of the government.

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