PEPFAR's Role in the Global Health Initiative

Children perform during the arrival of Secretary of State Hillary Rodham Clinton at the PEPFAR-supported Cullinan Clinic in Johannesburg, South Africa. In August 2009, Secretary Clinton traveled to seven African countries to speak about the United States? continued commitment to Africa. Throughout her trip, Secretary Clinton highlighted the fight against global AIDS as a central piece of the foreign policy and global health agenda outlined by the Obama administration. State Department Image

Earlier this year, President Barack Obama announced the launch of the Global Health Initiative (GHI), a six-year, $63 billion interagency effort of the U.S. Government (USG) to support partner countries in improving and expanding access to health services. As the largest bilateral health assistance program of the USG, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) will be a central part of the GHI.

The GHI is designed to build upon the impressive results and momentum of PEPFAR and other USG health programs. It will leverage the full range of USG assets in supporting a long-term strategic approach to global health. It will carry forward existing commitments, enabling partner countries to improve health in communities impacted by HIV and other diseases. As part of the GHI, PEPFAR will support countries in providing more efficient, integrated and sustainable health programs and serve as a foundation upon which to link and integrate systems of care.

PEPFAR will contribute to the GHI in the following ways:

Adopt a Woman and Girl-Centered Approach to Health and Gender Equity. Evidence has repeatedly shown that women are the gateway to healthy families and key to achieving long-term development goals. Central to the GHI are long-term, systemic changes in the way health programs respond to and incorporate the needs, perspectives, and abilities of women and girls. A woman-centered approach takes into account the realities of women's and girls' lives as shaped by gender norms, service availability, and larger structural factors. Working with men and boys will be important to achieving these goals.

The current data around the AIDS epidemic emphasizes the need to place women and girls at the center of PEPFAR's prevention, care, and treatment work with countries. The World Health Organization (WHO) reports that worldwide, AIDS is the leading cause of death and disease among women of reproductive age.1 Women currently account for nearly 60% of HIV infections in sub-Saharan Africa.2 In many PEPFAR countries, larger structural conditions - social, economic, and cultural factors - often place women and girls at increased risk for infection.

To date, PEPFAR has worked to integrate gender into all aspects of its programming and has developed five key areas of cross-cutting gender focus for its field programs. During the next phase of the program, PEPFAR is working to better implement its gender principles, with a particular focus on addressing the linkages between HIV and gender-based violence. In addition, as part of its prevention portfolio, PEPFAR is increasing investments in prevention of mother-to-child HIV transmission (PMTCT) to ensure that HIV-positive women are identified and referred to treatment and care. Finally, PEPFAR is working to expand the linkages between reproductive health and HIV care and treatment services. Doing so enables women seeking reproductive health care to receive HIV education and services, and women living with HIV to receive quality reproductive health and family planning services.

Increase Impact through Strategic Integration and Coordination. The USG has achieved significant success with both PEPFAR and other disease- and issue-specific initiatives and programs. To build on this success, the GHI will support holistic planning, and programming among health and development programs and will foster integration, where effective and efficient. It will also improve coordination among existing USG health and development programs.

PEPFAR has worked to foster integration between HIV and other health and development programming. It has linked care programs to food, nutrition and safe water initiatives. PEPFAR's prevention programs are linked to education and economic growth efforts, and its treatment programs are linked to tuberculosis (TB) care.

Through Partnership Frameworks, PEPFAR is supporting its partner countries to expand donor coordination at the local level, avoiding duplication of efforts and supporting leveraged investments.

Strengthen and Leverage Key Multilateral Institutions. The USG will expand engagement with key multilateral institutions and global health partnerships to develop a comprehensive approach to achieving the Millennium Development Goals (MDGs), and other core objectives.

Both bilateral and multilateral efforts are essential in achieving durable success in the fight against AIDS. In particular, PEPFAR is working with the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and its grantees to expand collaboration and ensure consistency and efficiency of programming. PEPFAR is also supporting regional organizations in collaborative efforts to combat HIV/AIDS, and strengthening engagement with the Global Fund, WHO, and the Joint United Nations Programme on HIV/AIDS (UNAIDS).

Encourage Country Ownership and Invest in Country-led Plans. USG partnerships will work to place countries at the center of development, implementation, management, decision-making, and leadership of programs. GHI programs and activities will support country-led health and development plans. Working with other donors and multilateral organizations, the GHI will support long-term partner country capacity to provide essential health services, with particular attention to the poor and underserved.

PEPFAR has already started to implement this principle through its Partnership Framework process. It is expanding these efforts by supporting countries in efforts to reassess and prioritize needs, as well as oversee and coordinate the response of donors and implementers.

Build Sustainability through Health Systems Strengthening. The USG recognizes that achieving sustainable health impact requires country commitment to health systems that extend access, increase equity, and ensure quality health services. The GHI will support countries to make measurable improvements in the WHO's six building blocks of health systems functions - service delivery; health workforce; information; medical products, vaccines and technologies; managing and financing; and leadership and governance - in order to improve the overall quality of their health services. As part of the GHI, the USG will also build the capacity of countries to plan, manage, and sustainably finance their health systems.

PEPFAR's major goal in its next phase is to support the transition from an emergency response to a sustainable program by increasing engagement and technical support for partner countries. In most countries full transition will likely not be completed over the next five years. However, it is essential for PEPFAR to lay the groundwork now for that transition by supporting countries in building capacity to manage and operate programming for infected and affected communities. A significant part of creating sustainability involves building and strengthening health systems, a heightened emphasis in PEPFAR's next phase.

Improve Metrics, Monitoring and Evaluation. Programs must be continually and effectively monitored and evaluated to ensure accountability and measurable results. The GHI will support harmonized metrics that evaluate the impact of integrating health programs and strengthening health systems. It will also work to measure development of long-term capacity and enduring change at the country level.

PEPFAR will contribute to this effort by using its already-amassed and future collected data to determine best practices and program efficiencies. It is continuing efforts to reduce the administrative burden on the field. In addition, PEPFAR is contributing to the creation of harmonized indicators, and internationally accepted measures of impact.

Promote Research, Development and Innovation. In addition to expanding the evaluation of programs, the GHI will increase focus on research, development, science and technology. Through work with academic institutions and the private sector, the GHI can identify and promote innovations and promising practices in global health.

PEPFAR was designed as an innovative mechanism for responding to a global crisis. It has worked throughout its history to support promising practices and innovation as part of its prevention, care, and treatment programming. In the next phase, PEPFAR is working to train individuals who can engage in identification and evaluation of new interventions at the country level. In addition, the program is continuing to develop public-private partnerships to support initiatives that utilize the technology and skills of the private sector. Finally, through its multilateral engagement, PEPFAR will work to explore creative mechanisms to finance the global AIDS response.

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