In July 2008, as part of its reauthorization, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) was encouraged to negotiate framework documents with partner countries. By establishing these partnerships, PEPFAR is promoting and developing a more sustainable approach to the fight against HIV/AIDS at the country level. These Partnership Frameworks are characterized by strengthened country capacity, ownership, and leadership, and represent a substantially new focus for PEPFAR.
Partnership Frameworks pave the way for approaches to foreign assistance based upon collaboration on principles that are common to U.S. Government (USG) objectives and partner country plans and activities. Partnership Frameworks provide a joint five-year strategy for cooperation between the USG and the partner government, with the participation of other partners. In some instances, PEPFAR is also negotiating Partnership Frameworks at the regional level. Each Framework clearly establishes plans for provision of technical assistance and support for service delivery, policy development, and coordinated financial commitments. At the end of the five-year timeframe, in addition to gains around HIV prevention, care, and treatment, country governments will be better positioned to assume responsibility for their national responses to the epidemic.
Like other aspects of PEPFAR, the development of Partnership Frameworks is an interagency effort. It is carried out under the authority of the U.S. Global AIDS Coordinator at the Department of State, and led by the U.S. Ambassador in-country with support from the interagency PEPFAR country team. The process of negotiating these partnerships also involves the active participation of other key partners from civil society.
The primary lessons learned to date include the following, which PEPFAR will use to guide the process moving forward:
- It is critical to involve high-level, broad representation from multiple ministries in the partner government from the very beginning;
- Where applicable, Partnership Frameworks should build upon existing national strategies;
- While the central dialogue in a Framework is between the USG and the partner government, multisectoral involvement ensures buy-in from all involved parties across government and civil society, including people living with HIV/AIDS (PLWHA);
- Continuous, ongoing dialogue allows all voices to be heard and issues to be rapidly resolved as they arise; and
- The process of negotiating these documents provides a new and welcome platform for leveraging policy reforms.
The principles used to guide the development of these partnerships include the following:
- Country ownership: Governments must be at the center of decision-making, leadership, and management of their national HIV/AIDS programs and health systems. Over the period defined in the Partnership Framework, as appropriate in the respective country, PEPFAR-supported programs will take steps to progressively shift supported activities from direct implementation to technical assistance. These efforts will build government and local capacity to plan, oversee, and manage programs, deliver services, and coordinate assistance from multiple donors. Discussions regarding country ownership should involve Ministries of Health and all appropriate ministries and high level elected officials that impact HIV/AIDS programming. As noted above, local civil society is also a key component in multisectoral discussions. By including the contributions of multiple donors as part of the Framework, PEPFAR will help countries take a position of leadership in coordinating among funders.
- Sustainability: Partnership Frameworks should be crafted to help ensure that the national response to the HIV/AIDS epidemic is moving toward sustainability while improving quality of programming. Efforts to create sustainability must support the country government in developing the capacity to manage all relevant components of a multisector health system. Donor funding should supplement, not supplant, existing country work around HIV/AIDS, and Frameworks should account for the contributions of public, private, and civil society organizations.
- Flexibility: Different approaches to Partnership Frameworks are appropriate for different settings. Country context must drive Framework objectives and approaches. Thus, the appropriate mix of direct services, health systems strengthening, and technical assistance will vary by country within the context of national strategies and plans. In addition, the policy areas addressed by Partnership Frameworks should reflect the specific policy development needs of the relevant country.
- Progress toward policy reform and increased management and financial accountability: Partnership Frameworks emphasize key policies that promote effective, sustainable, and quality HIV/AIDS programs. They also offer an important new opportunity to engage government partners in commitments. Through these Frameworks, PEPFAR and government partners emphasize overall accountability for resources and appropriate budgeting in HIV/AIDS programs.
- Integration of HIV/AIDS into strengthened health systems and a broader health and development agenda: Partnership Frameworks contribute to strengthened HIV/AIDS services within the context of the broader health system. In an environment with diverse development needs, they promote integration of services to maximize impact and efficiency.
- Monitoring and evaluation (M&E): Partnership Frameworks set measurable goals, objectives, and concrete commitments for PEPFAR, the government, and all partners in the Partnership Framework. The Partnership Framework identifies indicators to assess progress toward achieving these goals and objectives, and meeting national commitments.
- "Do no harm": Partnership Frameworks promote sustainability and country ownership through capacity-building of governments and local partners. Existing service systems supported by PEPFAR and partner governments are continuing to deliver quality prevention, treatment, and care services while the transition to country ownership occurs over time.