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.Share on Facebook