Partnership Framework in Support of Ghana's HIV/AIDS National Response in Collaboration with all Development Partners between the Government of the United States of America and the Government of the Republic of Ghana (November 2009)

ACRONYMS

PURPOSE

The Tom Lantos and Henry J. Hyde United States Global Leadership against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act (P.L. 110-293) reauthorized the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). The law provides support for the U.S. Government to enter into Partnership Frameworks (PFs or Partnerships) with host governments as a means of promoting national ownership of sustainable HIV programs. These Partnerships seek to more closely align U.S. Government-funded HIV/AIDS efforts with national programs and the efforts of other international partners and civil society at the country level. PFs provide a 5-year joint strategic framework focused on service delivery, HIV/AIDS policy reform, and shared financial and/or in-kind commitments. After a PF is signed, a more detailed 5-year PF Implementation Plan (PFIP) is anticipated, with annual benchmarks for progress against the Partnership and a matrix detailing partner inputs to the Partnership objectives. The development of the Framework and Implementation Plan has increased collaboration and communication between the Government of Ghana and the U.S. Government and has resulted in a shared understanding of the way forward to ultimately prevent the spread of HIV/AIDS in Ghana. Through the development of the PF, both governments have strengthened their commitment to a coordinated effort in the fight against HIV/AIDS.

PARTNERS

Under the overall leadership of the Ghana AIDS Commission (GAC), the national AIDS coordination authority, the Government of Ghana (GOG) HIV/AIDS response involves partnerships with many Ministries, Departments, and Agencies, such as the Ministry of Finance, the Ministry of Health and Ghana Health Service, the Ministry of Defense, the Ministry of Women and Children Affairs, the Ministry of Employment and Social Welfare and the Ministry of Local Government, as well as decentralized bodies at the Regions and Districts, including District Assemblies. Because of the importance of HIV/AIDS to the overall stability and development of the country, the Ghana AIDS Commission reports directly to the Office of the President of Ghana. Equally important is the close relationship between the USG and the Ministry of Health, characterized by joint appearances of the U.S. Ambassador and the Minister at high-level forums. Close partnerships with non-governmental, faith based and community based organizations (NGOs, FBOs and CBOs) and the private sector are equally essential.

There are five U.S. Government agencies involved with PEPFAR activities in Ghana: the Department of State (DOS), Department of Defense (DOD), Department of Health and Human Services/Centers for Disease Control and Prevention (HHS/CDC), the United States Peace Corps (USPC) and the United States Agency for International Development (USAID). Under strong GOG leadership and oversight, these agencies should provide support to reach common goals, using a new model of coordination and collaboration among GOG, U.S. Government and other country stakeholders. The GOG and USG have had a strategic partnership since Ghana's independence and continue to have strong economic, political, and social ties at the highest levels of government as well as close collaboration at the operational level.

In addition to the U.S. Government, the GOG benefits from the support of three multilateral partners: The Joint United Nations Programme on HIV/AIDS (UNAIDS) and its co-sponsors; World Bank (WB); the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM); and five bilateral partners: the British (DfID); Danish (DANIDA); Dutch (EKN); German (GTZ); and Japanese (JICA) governments.

The GFATM is the largest external source of funding for the HIV/AIDS sector, providing performance-based grants to five Principal Recipients with the majority of the funding going to the Ministry of Health/Ghana Health Service for clinical service provision. GTZ and JICA provide project support to the HIV/AIDS sector. DfID, WB, and DANIDA pool funds through the GAC, although DANIDA earmarks its contribution for specific activities. EKN provides funding directly to the Ministry of Local Government. There are plans to move toward sector budget support (SBS) funding in future, possibly by the World Bank, DANIDA, and EKN, but no firm decisions have been made. A final significant source of funding is the District Common Fund, a fund allocated from the Ministry of Finance through the Ministry of Local Government to the District Assembly. This fund allows districts to program half a percentage of the Fund to the HIV/AIDS response, although this is not mandatory. Efforts are underway to more closely track spending from this source.

Funding details are to be provided in the implementation plan. It is important to note that future U.S. Government and the GFATM contributions combined would constitute approximately 80 percent of national level sector funding. Joint planning, led by GOG to coordinate GFATM, PEPFAR, and other donor activity is essential for the success of the Partnership. The remaining 20 percent of sector funding (such as possibly SBS and most pooled funds) are initially not linked to specific program areas. This makes financial planning by program areas of that 20 percent difficult in the context of the Partnership Framework. However, the GOG is committed to improving the targeting of resources towards achieving the common Partnership Framework goals.

An additional challenge is that a significant proportion of budget costs provided by the GOG generally support operational costs (e.g. salaries, staffing, clinics, etc.) and therefore cannot be clearly delineated by technical areas (e.g. clinical support services, prevention) at the current time due to non-exclusive technical areas of these budget items.

IMPLEMENTATION

The HIV/AIDS epidemic in Ghana is a mature, low-level, generalized epidemic with pockets of high prevalence among certain sub-populations and geographic areas. Its defining characteristic is that infection in the general population depends to great extent on continuous bridging from core high prevalence sub-populations, such as female sex workers (FSW), their clients and non-paying partners (NPP), and men who have sex with men (MSM). To address the Ghana epidemic, the goals of the Ghana National HIV & AIDS Strategic Framework (NSF II 2006-2010), built into the PF, are to reduce new infections, mitigate the health and socio-economic impact of HIV/AIDS, and promote healthy lifestyles. To achieve these goals, the NSF II seeks to strengthen the decentralized, multi-sectoral national response through evidence-based planning and programming, reducing risky sexual behavior, empowering vulnerable groups to reduce their vulnerability, reducing stigma and discrimination, mitigating the impact of the epidemic, providing appropriate treatment, strengthening strategic information systems and mobilizing adequate resources. A third iteration of the NSF is currently being developed by the GAC in consultation with Donor Partners, a process that has been informed by the work already done on the development of the Partnership Framework. To inform this strategic framework, GAC, in partnership with the U.S. Government, plans to conduct a costing study to help determine which HIV/AIDS prevention, care, and treatment strategies are most cost-efficient in Ghana. Thus, the U.S. Government and GAC are working closely to begin developing the NSF III, which is expected to be in strong accordance with the Partnership Framework and use information acquired from the costing study.

Implementation of the Partnership should scale up the response throughout the country; contribute to the achievement of universal access to HIV prevention, treatment, care, and support and the Millennium Development Goals (MDG); and better position Ghana to address the epidemic over the long term. Due to its far-reaching potential, the value of the Partnership cannot be overemphasized, especially since it builds on current interventions and fills gaps currently existing in the national AIDS response. The Partnership management strategy is structured to support the achievement of coverage targets within the timeframe of the Partnership and in a manner that promotes ownership and sustainability. The Partnership strives to increase access to quality prevention, care, treatment, and related health and community support systems.

The Partnership Framework endeavors to contribute towards the development of policies and also to their effective application based on strategic information appropriate to the Ghana HIV/AIDS epidemic. While the health policy environment is reasonably well developed, challenges remain. Currently, Ghana is undergoing a number of policy shifts with respect to health care. The National Health Insurance Scheme, established by the National Health Insurance Act of 2003, pays for curative services for enrollees. However, under the current National Health Insurance Scheme, ART is not covered. While ART costs are subsidized by the GOG, PLHIV who are receiving ART are charged a five Ghana cedi monthly user fee, which has become a barrier to access to treatment and care services for many PLHIV. One of the activities proposed under the Partnership Framework is to ensure that National Health Insurance includes ART, so that enrollees are provided ART free of charge. While Ghana is very close to meeting the suggested allocation of 15% of GOG budget (according to an independent health sector review in 2008 the medium term expenditure framework for 2008 was 14.90%) to the health sector, much of the funding is allocated towards salaries rather than services.

The Partnership Framework is fully aligned with the "Three Ones" principles. First, its goals, objectives, and strategies are consistent with those of the Ghana NSF II 2006-2010, the comprehensive national AIDS Partnership. Second, the Partnership was developed in a manner consistent with and supportive of the GAC. Third, the Partnership seeks to strengthen and use the national M&E system to collect, collate, analyze, and disseminate data using indicators that are harmonized with national indicators.

In collaboration with partners and stakeholders, an assessment of programmatic, policy, and financial gaps of the national AIDS response was undertaken. The areas of focus under the Partnership were selected based on their relative importance in supporting NSF II objectives, furthering the global PEPFAR goals and the activities of other development partners, and the relative strengths of PEPFAR's U.S. Government implementing agencies. The activities of the framework fit other USG investments in health and development, which aim to address Ghana's key development challenges by fostering a healthier, better educated, and more productive population. These areas for concentrated focus over the course of the Partnership should also strengthen GOG's increased ownership of the HIV/AIDS program and result in a declining need for U.S. Government assistance over time. If U.S. Government assistance is provided directly to the GOG under this Partnership, GOG contributions would be expected to meet host country cost sharing requirements under U.S. foreign assistance programs. Details regarding the GOG's financial and/or in-kind contributions to programs under this Partnership are to be provided in the Partnership Framework Implementation Plan (PFIP).

The Ghanaian Partnership was developed with the full collaboration and participation of the GOG Partnership Framework Oversight Committee comprised of local experts and leaders, representatives of civil society and the private sector, and multi- and bi-lateral development partners. This committee, led by the Director General of the GAC, met periodically to discuss key issues and attain consensus on the goals of the partnership framework. Members agreed on the goals and identified gaps within Ghana's current HIV/AIDS efforts and were involved in drafting the concept paper that laid out the Partnership Framework. Throughout the process, Ghana government and other bilateral, multilateral, and UN agency partners have both crafted and given feedback to documents.

The Partnership promotes national ownership in that it is led by national authorities with the full participation of all partners, it places an equal emphasis on policies, results, and capacity building of national institutions, investments are made with the understanding that the GOG intends to progressively take more responsibility for the financing of Ghana's HIV/AIDS response, and that HIV/AIDS interventions should progressively enter the mainstream of public health programs and be more fully integrated with other services.

The Partnership promotes full inclusion of and expanded roles for the private sector as well as civil society in the national response. This inclusive approach may entail the development of Public Private Partnerships (PPP) and Global Development Alliances (GDA) as a means of ensuring longer term sustainability.

The Partnership lays the foundation for the development of a PFIP. The PFIP details the annual activities that may be undertaken by the U.S. Government in support of the GOG and other development partners in order to achieve the common goals and objectives identified in the Partnership.

PRINCIPLES

In implementing this Partnership, the U.S. Government and the GOG intend the Partnership to be governed by the following guiding principles:

• High-level government commitment, national leadership, and continued ownership of the response by the government and people of Ghana;
• The principles of the "Three Ones": One national strategy, the NSF II; one national authority, the GAC; and one national monitoring and evaluation system. In doing so, the Partnership intends to operate under independent financing arrangements for U.S. government foreign assistance;
• Greater transparency and joint decision-making in program implementation and resource allocation for the national response, including reporting PEPFAR budgets, expenditures, and results within the GOG mechanisms for reporting the achievements of the overall national response;
• Good stewardship of GOG, U.S. Government and pooled funds;
• Recognition that U.S. Government and GOG resources are limited and investments are subject to the availability of funds;
• Strong alignment with the support provided by the GFATM grants;
• Strong alignment with the comparative strengths of PEPFAR's U.S. Government agencies, including direct technical support and service delivery through their respective implementing partners;
• Increased fiscal accountability for programs
• Increased results for programs based on scientific evidence and best practices implemented in the highest quality and most cost effective manner achievable;
• Clearly defined roles and commitments of all partners;
• Maximized public-private partnerships (PPP) to enhance sustainability, coordination, and sharing of best practices between development partners and implementers;
• Meaningful involvement of people living with HIV/AIDS (PLHIV) in program development, implementation, and evaluation; and
• Recognition that achievement of the partnership goals requires resource flows beyond the ability of any one partner, and that unanticipated constraints on availability of funding from either signatory or from other key partners could lead to a review and realignment of goals.

FIVE-YEAR STRATEGIC OVERVIEW

This Partnership represents an enhanced engagement by the GOG and is built in support of the GOG's NSF II and the National Poverty Reduction Strategy (NPRS). After a thorough review of gaps and opportunities, several critical areas for productive collaboration were identified. These areas were selected in close collaboration with all development partners. Collectively, working in these areas should serve to support the achievement of the NSF II and PEPFAR targets and ensure greater sustainability and GOG ownership over time. The Partnership seeks to reduce the number of new infections, expand and improve the care and treatment of PLHIV, strengthen the policy environment, and strengthen health systems at both the national and community levels.

The HIV/AIDS epidemic in Ghana is a mature, low-level generalized epidemic with pockets of high prevalence among certain sub-populations and geographic areas. The adult HIV prevalence is estimated to be 1.7% in 2008 (UNAIDS, 2009). While prevalence appears to be declining, as seen among pregnant women (with a peak of 3.6% in 2003 to 2.2% in 2008), estimates of HIV prevalence among FSW range from 30-45%. Among MSM, HIV prevalence is approximately 26%. Women who identify themselves as sex workers are estimated at around 34,000; but it is unknown how many FSW and MSM are involved in informal, transactional sex. Size estimations for other populations including MSM, NPP, clients of FSW, and IDU are currently lacking.

There are approximately 236,000 people living with HIV/AIDS (PLHIV) nationwide in 2009. While approximately 70% of adult PLHIV are in discordant relationships with regular partners, very few PLHIV have disclosed their status to these partners, suggesting that PLHIV and their regular partners are another group requiring targeted prevention interventions; in approximately half of the discordant couples the female partner is sero-positive. Stigma related to HIV infection is high in Ghana and serves as a significant obstacle to reaching those already infected as well as populations that are most-at-risk.

To address the epidemic in Ghana, the Partnership Framework is focused on five goals:

1. Reduce the number of new infections by 30 percent (6,000) by 2013¹
2. Increase ART coverage from 30 percent to 60 percent (45,000) by 2013;
3. Increase the number of persons receiving care (excluding ART) by 200 percent to 130,000 by 2013²;
4. Strengthen Health Management Systems needed to achieve the prevention, treatment and care goals;
5. Strengthen capacity of CBOs to provide information and services to most-at-risk populations (MARP) and PLHIV.

The overall accomplishments to be achieved by the government and people of Ghana in collaboration with all development partners toward each of these five goals, as well as policy issues to be addressed during the course of the Partnership and overall strategies for achieving these goals, are described below.

1. Prevention

Goal: Reduce the annual number of new infections by 30 percent (6,000) by 2013

The U.S. Government, along with all other development partners, intends to work together with the GOG in support of the NSF II and the forthcoming NSF III objective to reduce the number of new infections. By strategically targeting MARP, HIV-positive pregnant women, and PLHIV, the Partnership can effectively contribute to a reduction in the number of new cases over the course of the Partnership's timeframe.

While all partners have supported prevention activities and target MARP to some extent, the GFATM Round 8 Grant is particularly significant in that unlike Round 5, which concentrated on care and treatment, the Round 8 Grant includes significant levels of funding for prevention activities, including attention to MARP. Three out of five PRs are from civil society. The U.S. Government intends to participate closely with all partners to coordinate activities and ensure that available resources are used effectively (more detail is provided in the management section).

Strategies to reduce the number of new cases are:

Expand communications and services for MARP

Prevention activities under this Partnership concentrate on MARP and the critical bridge populations surrounding these high-risk groups. The Partnership supports making information counseling and services available to FSW and their clients and partners as well as to MSM and their female partners, closely coordinating with initiatives supported by other donor partners. The Partnership intends to define a core package of prevention services for MARP and establish a network of MARP-friendly facilities to ensure that MARP access care and prevention services. The participants intend to remain vigilant and seek out and develop programs to address the problems of potentially new MARP, e.g. prisoners, injecting drug users (IDUs), and youth engaging in high-risk behaviors. In addition, the Partnership plans to evaluate new and existing behavior change strategies to ensure that the prevention package provides maximal impact.

Ensure PMTCT coverage

The Partnership seeks to ensure eighty percent coverage of the prevention of mother-to-child transmission, concentrating on improving the quality of care, counseling, and communication at ante-natal care (ANC) services. The Partnership also intends to integrate HIV/AIDS prevention with other reproductive health services and bring PMTCT to the community level, to the extent possible, leveraging U.S. Government and GFATM.

Expand programs for PLHIV

To ensure that PLHIV do not inadvertently infect others, the Partnership endeavors to strengthen the country's Prevention with Positives (PWP) program. The partnership seeks to define a model package, endorsed by all national implementers, of prevention services and supplies for distribution to PLHIV, primarily through support groups.

Accomplishments to Date

• Developed MARP and PLHIV behavior change communication best practices and tools
• Established approximately 30 MARP-friendly facilities
• Implemented prevention of mother-to-child transmission (PMTCT) in over 400 health facilities nationwide
• Established approximately 300 hundred PLHIV support groups, of which half are assisted by umbrella civil society organizations
• Awarded GFATM Round 8 Grant with emphasis on prevention and implementation through three civil society Principal Recipients (PRs)

Key Enabling Activities

• Develop and institutionalize policies and guidelines on MARP
• Negotiate a memorandum of understanding (MOU) between service providers, MARP, judiciary, and law enforcement agencies
• Decentralize PMTCT to the community level
• Develop evidence-based national standards for PLHIV support groups

2 & 3. Treatment, Care and Support

Goals: Increase ART coverage from 30 to 60 percent (45,000) by 2013; Increase the number of persons receiving care (excluding ART) by 200 percent to 130,000 by 2013

The Partnership recognizes the importance of collective efforts of all partners to provide responsive clinical services, with emphasis on those supported by the GFATM, through a participatory process that engages the community, particularly PLHIV groups.

Strategies to increase the number of PLHIV receiving care and treatment are:

Strengthen case identification, facilitate care seeking, and improve quality of care for PLHIV

Through this participatory process, the Partnership endeavors to support existing and future clinical services by improving the quality of services, ensuring linkages between the service delivery at health facilities and the community, and expanding outreach activities to strengthen case-finding and care-seeking of treatment-eligible persons. Addressing stigma and discrimination issues among health care providers and PLHIV themselves is another key aspect of supporting GFATM implementation. At the facility level, efforts should be directed to promote greater integration of STI, TB, FP and ANC services with HIV-related care, again supplementing work done under GFATM grants.

Provide therapeutic nutritional supplementation

Ghana has made excellent progress in achieving the Millennium Development Goal of eliminating hunger, to the extent that the USG Food for Peace program is being phased out. While chronic issues of food security are not prominent in Ghana, it is important to ensure that those who are suffering from HIV-related malnutrition are able to access nutritional supplementation, especially if they are beginning ART treatment. Thus, the Partnership plans to ensure that ART patients whose nutritional status is inadequate benefit from therapeutic supplementation for the first six months of their treatment. Further, the Partnership seeks to promote and establish the local production of therapeutic food packages within the context of a Global Development Alliance (GDA). In general, the strong economic progress that Ghana has experienced is expected to continue to provide opportunities for ART patients who have recovered from severe illness to be able to earn income sufficient for their food needs.

Strengthen PLHIV support groups

Ghana already benefits from the existence of several hundred PLHIV support groups supported by a host of financial donors. The potential contribution of these groups to individual members and the national program is considerable and under-utilized. For example, the promotion of PLHIV support group members to serve as trusted adherence counselors ("Models of Hope") could enhance treatment programs as they scale-up with GFATM support. The Partnership plans to strengthen and improve the quality of PLHIV support groups, scale up PWP activities, and actively involve PLHIV in case-finding of hidden AIDS cases.

Support implementation of the National OVC Action Plan

The Partnership and others players such as UNICEF recognize that support to orphans and vulnerable children (OVC) in Ghana is fragmented and that implementing the National Action Plan to support the existing OVC policy's application could achieve significant results.

Accomplishments to Date

• Established programs for the provision of ART through more than 100 hospitals and health centers
• Achieved 30 percent treatment coverage for the estimated 70,000 anti-retroviral treatment (ART)-eligible PLHIV
• Provided care for 42,000 of the 180,000 eligible PLHIV
• Enacted the National Policy Guidelines on Orphans and Other Children made Vulnerable by HIV/AIDS in January 2005

Key Enabling Activities

• Integrate sexually transmitted infection (STI), ANC, family planning (FP), malaria, and tuberculosis (TB) services into HIV/AIDS-related services
• Integrate HIV/AIDS into pre-service training curricula
• Explore opportunities for task shifting
• Increase involvement of civil society and the private sector
• Implement the existing National Action Plan to support implementation of the National Policy Guidelines on Orphans and Other Children made Vulnerable by HIV/AIDS
• Finance the national response via user fees and social financing arrangements such as the National Health Insurance Scheme (NHIS) Strategy

4. Health Systems Strengthening

Goal: Strengthen Health Management Systems needed to achieve the prevention, treatment, and care goals as indicated by:

• ARVs included under national health insurance
• 100% of the major reference labs in Ghana accredited according international (WHO) standards³
• Appropriate routine surveillance, HMIS, and M&E conducted according to international guidance to allow reporting and use of National, UNGASS, and PEPFAR indicators included in the PF implementation plan

Strategies to strengthen health management systems are:

Strengthen policy dialogue

Policy development, advocacy, and implementation are essential areas of collaboration that the Partnership intends to support. GAC serves as the nation's highest level coordination, policy dialogue, and advocacy forum. The U.S. Government and all development partners share a desire to support the strengthening of the GAC's coordination, policy dialogue and advocacy activities, including the development of the NSF III and its costing. All of Ghana's partners support a strong GAC and recognize the importance of policy issues in the national response.

The policy dialogue agenda of the Partnership addresses seven key policy areas: human resources for health, integration of services, expanding the involvement of civil society and the private sector in the national response, OVC, financing the national response, MARP, and stigma and discrimination. A key component of furthering Ghana's policies with respect to HIV/AIDS is ensuring that people on ART are able to receive drugs free of charge through the National Health Insurance scheme. Other illustrative policy issues to be addressed during the Partnership are identified in each goal's Key Enabling Activities.

Improve human and financial resource management

The Partnership seeks to strengthen Ghana's financial and human resource management systems by analyzing gaps in human resources and increasing funding levels for HIV/AIDS. The Partnership efforts center on key policy issues in order to facilitate the training and utilization of workers from the public and private sectors, including civil society partners. In collaboration with all relevant agencies, the Partnership seeks to support the National AIDS Spending Assessment, as it is a critical tool to monitor the HIV/AIDS spending and assist the GAC for future budgeting. These efforts should result in better integration of HIV/AIDS into the training of medical professionals and community health workers, as well as expand the contributions to the national effort made by both private providers and civil society organizations. Long-term financing and the financial management of the national response is another critical area for Partnership collaboration.

Provide assistance to strengthen laboratory capacity

The Partnership seeks to work with the Ghana public health and diagnostic laboratories and other key specialized national laboratories to assist with improving facilities and training personnel to meet WHO international accreditation standards. Further, the Partnership will assist in the development of comprehensive national laboratory policies and formulate national strategic plans. These efforts should lead to establishing comprehensive laboratory quality management systems for HIV, TB, malaria, and logistics systems, including rapid testing services, to ensure adequate supplies and distribution of reagents and consumables, leveraging Presidential Malaria Initiative efforts.

All these activities are being supported by various training programs and technical support. The Partnership also hopes to focus on advanced laboratory testing (HIV genotype/phenotype testing and TB resistance testing at Public Health National Research Laboratory and/or the Noguchi Memorial Institute for Medical Research) and additional laboratory technical assistance for surveillance activities and research projects, strengthening the existing U.S. Government programs.

Ensure national response program uses data effectively

Strategic Information (SI) is the cornerstone of evidence-based planning and decision-making. The Partnership intends to work within the context of existing and developing national systems implemented by the Ghana Health Services (GHS) National AIDS Control Program (NACP) and the GAC to ensure that the monitoring and information systems and routine surveillance and evaluation activities are comprehensive and sustainable. This effort builds on the substantial existing national SI capacity at the NACP and GAC to more fully monitor and evaluate the epidemic and the national response to HIV/AIDS, complementing work of several Development Partners such as the GFATM and British and German governments.

These activities support the continued development of PEPFAR comprehensive Second Generation HIV Surveillance, including training and technical support for surveillance regarding prevalence, new infections, behaviors, and drug resistance. The Partnership could also work to strengthen the capacity and harmonization of the national M&E system, as well as specific implementing partners, to better monitor and evaluate specific programs and the response to the HIV/AIDS epidemic. A critical component of SI is to identify opportunities to strengthen GHS's ability to manage health information technology within HIV as well as its linkage to other service areas such as TB, maternal, child, and reproductive health (MCH/RH), laboratory, logistics, and supply chain management. A final area of focus is to enhance opportunities to disseminate information so that data from SI efforts can be incorporated into program planning and policy making processes.

Accomplishments to Date

• Established GAC with a clear policy and advocacy mandate and with the support of all participants
• Provided financial resources through GOG's and Donor Partners' sector budget support and direct project funding
• Established GFATM support for clinical and drug supply
• Mandated District Assemblies to lead the national response locally
• Funded District Assemblies' efforts through the District Common Fund

Key Enabling Activities

• Strengthen the GAC as a focal point for policy dialogue and advocacy
• Create an AIDS account within the national budget
• Support the development of the NSF-III
• Cost the national HIV/AIDS strategy: the National Strategic Framework III
• Integrate HIV/AIDS within pre-service training curricula
• Strengthen District Assemblies and their ability to effectively program Common Fund resources
• Strengthen the national M&E system
• Develop and institutionalize a National Strategic Laboratory Plan
• Strengthen comprehensive HIV surveillance

5. Community Systems Strengthening

Goal: Strengthen Civil Society Organizations' (CSO's) capacity to provide information and services to MARP, PLHIV, and other vulnerable groups, as indicated by:

• 250 CSO with completed assessments and capacity building plans implemented
• 25% of the general population with accepting attitudes toward PLHIV⁴

Strategies to strengthen community systems are:

Build capacity of CSO

The Partnership seeks to contribute to the development and strengthening of CSO that provide essential support services to members of the community most at risk of HIV infection as well as PLHIV. These efforts endeavor to provide information and HIV counseling and testing and facilitate the linkages between care providers and those most in need of care. The Partnership plans to build the capacity of CSOs to effectively plan and implement HIV/AIDS programs while strengthening communications and coordination of efforts at the community level and improving implementation efforts supported by other Development Partners.

Ensure coordination

The participants share a desire to decentralize the national response and weave support around District Assemblies and Regional Coordinating Councils who have responsibility to coordinate and monitor the national response at the local level. A key component to ensuring coordination is to document Development Partners' current activities, as well as projected activities in CSO and government capacity building over the partnership framework period. This may involve increased personnel at the District and Regional levels as well as comprehensive training and assistance to assist authorities' ability to promote a coordinated and data-driven local response.

Decrease stigma and discrimination

While stigma and discrimination reduction nationwide is an important goal of the NSF and shared by all development partners, the Partnership intends to focus its common efforts toward resolving the stigma and discrimination issues surrounding health care workers, uniformed personnel, and PLHIV, FSW, and MSM themselves, collaborating closely with the Anti-stigma Campaign Coordination Group.

Accomplishments to Date

• Established networks of HIV/AIDS NGOs and PLHIV organizations
• Established a national HIV/AIDS NGO network
• Reinforced the local system for community-based HIV/AIDS service delivery by strengthening FBOs and CBOs
• Enacted underlying laws and legislation for the rights and protection of PLHIV

Key Enabling Activities

• Continue to reinforce civil society's contribution to the HIV/AIDS response through individual organizations, umbrella groups, and networks
• Strengthen linkages between civil society, clinical service outlets, local authorities, and PLHIV
• Develop policies and guidelines on stigma and discrimination
• Strengthen constitutional and human capacity of District Assemblies and Regional Coordinating Councils

ROLES AND COMMITMENTS

The table below broadly describes the Partnership goals, objectives and the expected activities of the GOG, the U.S. Government and other development partners. Further details about the financing and areas of concentration of other partners will be provided within the PFIP.

1. Reduce the number of new infections by 30 percent (6,500) by 2013

2. Increase ART coverage from 30 percent to 60 percent (45,000) by 2013

3. Increase the number of persons receiving care (excluding ART) by 200 percent to 130,000 by 2013

4. Strengthen Health Management Systems to achieve HIV/AIDS prevention, treatment and care goals, as indicated by:

• ARVs included under national health insurance by 2013
• 100% of the major reference labs in Ghana accredited according international (WHO) standards by 2013⁵
• Appropriate routine surveillance, HMIS, and M&E conducted according to international guidance to allow reporting and use of National, UNGASS, and PEPFAR indicators included in the PF implementation plan

5. Goal: Strengthen CSO capacity to provide information and services to MARP, PLHIV, and other vulnerable groups, as indicated by:

• 200 CSOs with completed assessments and capacity building plans implemented by 2013
• 25% of the general population with accepting attitudes toward PLHIV by 2013

^*As noted in the narrative, a key component to ensuring coordination is to document what activities Development Partners are currently engaged in, as well as projected activities in CBO and government capacity building over the partnership framework period

MANAGEMENT AND COMMUNICATIONS

GAC is the mandated and appropriate forum for coordinating the Partnership on behalf of the GOG.

GAC organizes the National HIV/AIDS Partnership Forum twice yearly to bring together all stakeholders and discuss sector-wide topics. At the December meeting, a national Annual Program of Work (APOW) is finalized that serves to direct and coordinate the work of all parties assisting with the national response. The Partnership should be thoroughly integrated within the larger, national APOW.

There are several Technical Working Groups (TWG), one meeting monthly to coordinate sector issues in between the National Partnership Forum, and several more specific TWG, e.g. for ART, MARP, and SI. These are expected to play an essential role in in-depth coordination of the sector.

To ensure the transparent and participatory development of the Partnership, the GAC established a Partnership Framework Oversight Committee. This Oversight Committee may continue to play the central role to ensure proper management and communications of and around the Partnership within the larger National Partnership Forum structure. The committee is chaired by the GAC Director General. At present, the Oversight Committee is comprised of five members in addition to GAC⁶ and the U.S. Government: UNAIDS, NACP (as the representative of the MOH), NAP+ (a PLHIV umbrella association), GHANET (a network of NGOs working in HIV/AIDS), and the Ghana Business Coalition Against HIV & AIDS. To ensure greater coordination with GFATM activities, all GF Principal Recipients could become members of the Partnership Framework Oversight Committee. Additionally, the GOG intends to nominate a representative from the Ministry of Finance to serve on the Oversight Committee.

The Committee may meet on a quarterly basis to monitor progress and propose any mid-course adjustments that might prove beneficial to resolving implementation bottlenecks. Modifications to this Partnership may be made in writing with the full consent of both signatories.

In addition, specific TWG with all relevant stakeholders should be formed, and some of the GAC subcommittees (such as the already functional MARP subcommittee) can be used for additional coordination of activities.

PFIP DEVELOPMENT

The PFIP should be based on the approved Partnership and developed within the auspices of the Partnership Framework Oversight Committee.

¹ The relative importance of this goal for the sustainability of the national HIV/AIDS response requires allocating 50 percent of overall US Government funding to it.
² There are discussions ongoing with the National AIDS Control Program on phrasing this goal in terms of coverage.
³ This includes 1 national lab, and 4 public health reference labs
⁴ The 2008 DHS found that 11% of women and 19% of men expressed accepting attitudes towards those living with HIV/AIDS; thus, 25% would represent a doubling of accepting attitudes towards PLHIV in the general population
⁵ This includes 1 national lab, and 4 public health reference labs
⁶ The Ghana AIDS Commission is the national AIDS coordination authority. Rather than including representatives from different ministries, it is a supra-ministerial body that reports directly to the President of Ghana.