III. Partnership Framework Implementation Plans

A. PROCESS FOR DEVELOPMENT

The Partnership Framework Implementation Plan spells out in more detail the objectives, commitments and targets for the Partnership Framework. As a more specific document than the Partnership Framework, the Implementation Plan can be updated as needed to reflect changing conditions or priorities without altering the Partnership Framework. While signatories to the Partnership Framework should be aware of the content of the Implementation Plan, the Implementation Plan itself may be signed by lower-level signatories or by multiple partners, as in the case of Regional Frameworks.

1. Establishing baselines

Given the need for strong evidence-based strategies, either actual baseline data or a timeline and plan for conducting situation assessments and establishing baselines should be included in the Partnership Framework Implementation Plan. Partnership Framework design teams need not start from square one in conducting situation assessments. Existing assessments should be utilized, when available, to save time and strengthen harmonization. These can be complemented with new situation assessments as needed.

HIV/AIDS epidemic and response situation assessment: In many cases, recent national planning may have included an assessment of the HIV/AIDS epidemic and response, which can be used as a baseline. If this is not the case, design teams will need to develop a baseline situation assessment of the current state of the epidemic and the response by all partners. In conducting an HIV/AIDS situation assessment, consider reviewing national monitoring indicators, including United Nations General Assembly Special Session on HIV/AIDS (UNGASS) National Program Indicators; recent survey and surveillance, program evaluation, data triangulation, and/or cohort study information; and results from other host country partners. The HIV situation assessment should be informed by consultations with key stakeholders, including the host government, civil society, non-governmental organizations, other donors, international organizations, and the private sector. The assessment should include a discussion of the overall strengths and weaknesses of the health system as they affect prospects for achieving PEPFAR prevention care and treatment objectives, including, for example, analysis of service delivery or health workforce. The assessment should identify areas for potential emphasis in the Implementation Plan. See Annex V for additional suggestions for assessing health system strengths and weaknesses.

HIV/AIDS policy reform situation assessment: A policy reform situation assessment can be a stand-alone exercise or can be integrated into the HIV/AIDS situation assessment described above. In either case, all policy areas from Annex I - “List of Policy Areas to be addressed in the Partnership Framework” should be considered. While it may not be appropriate or necessary to work in all areas, analysis of all areas and their implementation should be completed.

Policy reform ensures that evidence-based policies are in place and implemented at the provincial/state, district, and local levels. It includes training of health care workers or others important to policy enforcement (e.g., police on gender-based violence, judiciary on non-discrimination of PLHAs), and other activities that can improve compliance and narrow the gap between policy and practice. Consider reviewing the UNAIDS National Composite Policy Index data available in 2008 UNGASS country reports to note policy areas identified by host government and civil society as requiring increased attention. Also, evaluate the degree to which an enabling policy framework exists in the host country, assessing governance and policy-making processes such as: (a) relevant Constitutional provisions; (b) important influences on policy processes; and (c) effectiveness of tools to implement policies.

Building on or in conjunction with consultations carried out to identify 5-year goals, the design team should consider convening one or more workshops or meetings involving critical stakeholders. Objectives could include: (1) brainstorming existing policies that impact HIV/AIDS and health systems and briefly describing their suspected impact, (2) brainstorming policy gaps that could be filled by new or amended policies, (3) considering whether any policies should be repealed, (4) identifying policy bottlenecks to achievement of program goals, and (5) discussing ways in which existing policies could be better implemented.

There may be differences of opinion between the USG and the host government on certain policies. In such cases, the Partnership Framework may work toward a reform agenda around that policy and/or focus on other policy reform areas where consensus exists.

HIV/AIDS financing situation assessment: The purpose of this assessment is to better understand program costs, available resources and projected gaps and trends over time. Again the ideal is to use existing data sources where-ever possible. Design teams should review trends of financial commitments to health, taking advantage of resources such as National Health Accounts bi-annual data available online at https://www.who.int/nha/ and at http://www.unaids.org/en/KnowledgeCentre/HIVData/CountryProgress/Default.asp, including percentage of total government expenditure budgeted to health as well as National AIDS Spending Assessment data, if available. Evaluation of data from GFATM’s enhanced financial reporting system may also be useful, along with other data produced from other financial monitoring and reporting systems. Data on program costs and financing may also exist from completed evaluations.

A financing baseline that identifies gaps and a strategy should be developed with a participatory process involving key stakeholders (e.g., Ministry of Finance) through workshops or meetings. PEPFAR and host government representatives with authority to do so should make planned financial commitments with annual and 5-year targets, while acknowledging uncertainty given annual budgeting.

In many countries, data is limited. In such cases, it is possible that establishing systems to obtain quality data may be one of the Partnership Framework objectives.

2. Setting targets, monitoring, and evaluation

The USG, host government, and other parties involved in the Partnership should consider program response to date, available resources, unmet needs, priorities of the national HIV/AIDS control plan, and other factors, to determine the scope of the activities to be carried out through the Partnership Framework to meet the 5-year goals of the Framework. This scope should include program areas (e.g., PMTCT service provision, OVC support, lab strengthening, healthcare worker training, etc.) and policy reforms (e.g., task shifting, opt-out testing, etc.) that will be addressed through the Partnership and cover all PEPFAR-supported HIV/AIDS activities in the country. Objectives for each program area should be defined.

Once the scope of activities and objectives are agreed on, the Partnership should select indicators that will be used to set 5-year targets and monitor progress on the goals and objectives. Indicators for goals should be higher level, typically measured by means of outcome and impact indicators. Key indicators for objectives will measure services provided, coverage of services, status of health systems and infrastructure, and other parameters. All indicators used for monitoring Partnership Framework progress should be the result of a country harmonization process with the national government and other major donors, including the GFATM. In general, indicators should have a national perspective (e.g., percent of pregnant women who were tested for HIV and who know their results), supplemented by a PEPFAR-specific perspective (e.g., number of new healthcare workers who graduated from a pre-service training institute with PEPFAR support) only as needed for USG-specific reporting. Other Framework partners may also have specific requirements for indicators that should be considered.

The Partnership should then set 5-year targets, to be measured using these indicators. These targets should be based on baseline data, status of the program, available resources (assuming availability of funds), and other factors. In general, these targets should also have a national perspective and account for all accomplishments in the country by all contributors to the response. Reporting against these targets will take place through PEPFAR’s APR process.

Based on these targets, the Partnership should agree on specific commitments by the USG, host country, and other partners during the 5 years of the Partnership. These commitments will be financial (i.e., anticipated funding to be provided to the program) and programmatic (e.g., carrying out specific activities in support of blood safety, implementing policy change in gender, etc.). These commitments should evolve over the course of the Partnership such that the programs are increasingly carried out by, managed by, and, where feasible, funded by the host government and civil society.

Finally, the Partnership should establish a plan for monitoring progress towards achieving the Partnership’s targets, meeting its specific commitments, and measuring its impact.

B. RECOMMENDED CONTENT OF THE PARTNERSHIP FRAMEWORK IMPLEMENTATION PLAN [~20 PAGES]

The Partnership Framework Implementation Plan will be developed at the same time as or subsequent to the signing of the Partnership Framework, as agreed by the PEPFAR country team in consultation with other partners. Together with the more succinct signed Partnership Framework document, it represents the 5-year strategic framework for USG PEPFAR collaboration with the host government and other partners. Therefore, once signed, it is the basis for COP development, and COP activities should all follow from this strategy. PEPFAR country teams may renegotiate the Implementation Plan periodically as circumstances change.

1. Introduction

Relate the Implementation Plan to the Partnership Framework. Describe how the Partnership Framework strengthens the ability of the host country to manage and finance HIV/AIDS programs by emphasizing capacity building and support of country-driven efforts which are, in turn, supported by funds from other donors and the government itself. Address how over the course of the 5 years the responsibility for decision-making and management of programs will be increasingly transitioned to the host country partners.

2. Country HIV/AIDS profile and baselines

Succinctly provide relevant background data for the host country HIV/AIDS profile, the service delivery (including health systems) baseline, the policy reform baseline, and the financial commitment baseline.

Country HIV/AIDS Profile

• Trends in HIV prevalence, incidence, and other characteristics of the country’s epidemic (demographic, geographic, social, etc.)
• Health sector characteristics that influence the spread and control of HIV

Baseline information

• Service delivery: Current national response, including respective roles and contributions of host government (including status and timeframe of national strategy and whether it contains cost information, as well as information on health systems and gender), NGOs, private sector, other civil society organizations, international organizations, PEPFAR, and other donors; brief overview of the strengths and weaknesses of the health system as it relates to HIV/AIDS, including critical constraints.
• Policy reform
  • Brief overview of the policy framework including relevant policy-making bodies (e.g., Ministries), authorities, and procedures.
  • Table listing key policies in existence to support HIV/AIDS prevention, care, and treatment, including those addressing issues related to health workforce and human capacity development to address the HIV/AIDS epidemic. Consider all policy areas in Annex I, including the existence of policies and the degree to which they are implemented. However, the baseline need only include those deemed most relevant by the Partnership Framework partners and participating stakeholders.
• Financial accountability
  • Tabulate host government, USG, and other funding on HIV/AIDS and health (data available at http://www.who.int/nha/what/en) over recent years.

3. Strategy and commitments

Describe the overall strategy employed for the Partnership, detailing goals, objectives and commitments.

National Strategy: Summarize the programmatic approaches as represented in the National Strategic Plan on HIV/AIDS in the country, addressing HIV prevention, care, and treatment through service delivery, health systems strengthening, policy reform, and financial commitment.

Partnership Framework Strategy: Service Delivery and Policy Reform Commitments: Describe how the Partnership Framework’s 5-year goals, objectives and commitments complement those of other donors and contribute to the realization of the country’s National Strategic Plan on HIV/AIDS. Describe how the commitments to various components of the HIV/AIDS response reflect the comparative advantage of the host country, USG, and other partners to achieve maximum impact. Include, in tabular form, (see illustrative Table 2) the specific goals, objectives and commitments for your Partnership, including policy reform commitments for each relevant objective. This table should build on the table developed for the Partnership Framework, providing more specific detail and information.

Financial Accountability: Describe the host government’s ability to: provide and make publicly available timely and accurate cost and financing information; increase (to the extent feasible) public financing for HIV/AIDS and health (e.g., meeting Abuja Declaration target of 15% national budget to health). Under the PEPFAR reauthorization legislation, Partnership Frameworks must include "cost sharing assurances" from the partner government that demonstrate a 25% contribution (in cash or in kind) to programs in which the USG directly funds the partner government (i.e., assurances meeting the requirements of section 110 of the Foreign Assistance Act). Describe expected commitments and timing of other donors, including the GFATM and the IHP+ as applicable. Describe how cost-efficiencies will be increased over the course of the Partnership, through coordinated financing and other strategies. Describe how the availability of PEPFAR funds and possibly those of the host government and other donors will be based on a review of the Partnership Framework performance against the annual targets and on the availability of funds.

Complete, in tabular form (see illustrative Table 3) the projected funding for the HIV/AIDS response in the country by various funding sources. This table should include all funding sources, not just those of signatories to this Partnership. These projections will be used to track financial commitments of the signatories over the course of the Partnership.

4. Monitoring and evaluation

Describe how the Partnership Framework Implementation Plan will be monitored, and how such monitoring will support national data collection systems, moving away from PEPFAR-specific reporting systems. In this description, include how the partners plan to jointly monitor the Framework, including an annual joint review that assesses progress towards targets, meeting of commitments, achieving cost efficiencies through coordinated financing, increasing program ownership by host country, and steps to allow for mid-course corrections, as needed, to ensure achievement of goals. The following suggests a framework for this joint monitoring.

Describe plans to collect data to monitor Framework goals. These data should derive from surveillance, population-based surveys, facility surveys, program evaluation, public health evaluation, and other means to describe the impact of the program on key measures of HIV prevalence and incidence, behaviors, morbidity, mortality, population well-being, and health system strengthening. These surveys and surveillance activities do not occur annually, so planning should identify when this work is scheduled and when results will be available for reporting.

Describe plans to monitor progress toward Partnership objectives in scaling up services, advancing enabling policies, and meeting financial and activity commitments. Below are two example table templates that can be used for this description. The first (illustrative Table 4) includes programmatic objectives, indicators, baseline, and 5-year targets, while the second (illustrative Table 5) includes objectives, commitments and commitment indicators.

The programmatic table should include all of the indicators and targets that will be tracked through the Partnership, including all those required by PEPFAR (see forthcoming draft indicator annex) and any others agreed upon as part of the Partnership. These indicators will be used to track the progress of the Partnership in achieving its goals. Indicators are not needed for program areas not addressed through the Partnership Framework and COP.

Annual reporting on these indicators will be through the PEPFAR semi-annual and annual reporting process. In the Partnership Framework, PEPFAR ‘downstream’ and ‘upstream’ targets and results will be replaced by ‘direct’ (USG direct delivery of services) and ‘national’ counts. Therefore, measurement of the 5-year targets should be based on national-level and PEPFAR direct results. Specific guidance for appropriate PEPFAR accounting in program areas lacking ‘direct’ support is forthcoming. Financial commitments will be monitored on the basis of National AIDS Spending Assessments and National Health Accounts (see Annex III); reporting will occur bi-annually.

Measuring policy reform will be kept relatively simple and follow a standard template. Details of the template are forthcoming as a component of the indicator annex for the Framework Guidance document. The baseline stage of policy reform and the target stage for the 5-year Partnership will need to be highlighted for all policy areas targeted for the Partnership. These targets will be used to track the progress of the Partnership in achieving its goals of policy reform.

Monitoring specific activity commitments will be based on narrative reporting among the Partnership members. Simple, nominal categories will be used, along with additional explanatory text appropriate to the discussion. Commitments will not be monitored individually, but rather as clusters associated with the objectives. Table 5 provides an illustration of how this matrix might appear. A version of this table will be used by the partners and other stakeholders to track the progress of the partnership in achieving its goals of coordinating activities and transitioning programs to local ownership. These results will be reported annually to headquarters.

IV. Negotiating, Reviewing and Signing the Partnership Framework

A. NEGOTIATION

For the USG, the USG Chief of Mission or his/her designee should lead the team negotiating the Partnership Framework. Negotiation teams should represent all USG agencies supporting HIV/AIDS activities in the host country. Negotiation support may be made available from Department of State and other PEPFAR agency headquarters, if requested. On the host country side, Partnership Frameworks should be negotiated by the highest level of government feasible.

B. CLEARANCE AND REVIEW

1. Optional joint review

While it is anticipated that both the USG and host government will conduct internal reviews of draft Partnership Frameworks, in order to ensure transparency and buy-in, countries may wish to consider conducting a joint review that involves key stakeholders involved in development and implementation of the Partnership Framework. It is anticipated that those participating in such a review would be of a higher level within their organization than those on the design team. If opting to carry out a joint review, inclusive in the plan and timeline for Framework development, as described in Section II.A.1, above, Partnership Framework design teams should define the joint review process, including review criteria, participants, and timing.

2. USG clearance and review process

The USG will follow the process outlined below to review and clear Partnership Framework documents.

STEP 1A: Preliminary review of Partnership Framework

As the elements of the Partnership Framework and Implementation Plan take shape, USG teams are encouraged to informally share annotated outlines or first drafts with their Country Support Team at headquarters for early and iterative feedback. Once a complete draft of the Partnership Framework is completed, but before a joint review, it should be shared with the Country Support Team for a “preliminary review.” An interagency team, chaired by the Deputy Principals, will review the draft against the following “big picture” review criteria and provide the design team with feedback/guidance:

• Demonstrates a strong strategic vision for the Partnership on HIV/AIDS over five years;
• Sets ambitious but feasible goals for scale-up of delivery of prevention, care and treatment services;
• Goals and objectives support the National HIV Strategy;
• Framework objectives will lead to achievement of goals;
• Builds on national plans and describes an effective joint governance structure for the Partnership using existing coordination mechanisms where possible;
• Demonstrates reasonable expectations and accountability of partners (host government, USG and others) to achieve goals;
• Reflects a strong consultative process;
• Reflects joint, coordinated programming among all partners;
• Follows PEPFAR and host country policy.

A concurrent preliminary legal and USG policy review will take place. After receiving comments from headquarters, country teams should complete negotiations and finalize the Partnership Framework. They should then move forward with completing the more detailed Partnership Framework Implementation Plan.

STEP 1B: Review of Partnership Framework Implementation Plan

As with the Partnership Framework, USG teams are encouraged to share drafts of the Partnership Framework Implementation Plan with their Country Support Team for ongoing feedback. Once a first draft of the Partnership Framework Implementation Plan is completed, country teams should submit the draft to their Country Support Team for review by an interagency team chaired by the Deputy Principals, against the following criteria:

• Implementation Plan supports the Partnership Framework;
• Baseline information provides good understanding of current state of service delivery, health systems, policy development, and HIV funding;
• Identifies and addresses key policy barriers to adequately address the HIV/AIDS epidemic over the long-term;
• Addresses healthcare workforce issues;
• Demonstrates coordinated financing that moves, where possible, toward greater host country (government and private) support;
• Contributes to strengthened health systems in areas needed for the greatest direct impact on the HIV epidemic;
• Reflects aggressive but feasible plan for increasingly transitioning programs to local ownership over time;
• Appropriate commitments are made by all parties;
• Includes well-designed monitoring plan to measure progress, financing and impact, including Framework partners’ reporting and accountability structures;
• Describes a strong management plan and partner communication and management framework;
• Strengthens national data systems.

After receiving comments from HQ, country teams should work with their partners to address any issues raised and finalize the Partnership Framework Implementation Plan.

STEP 2 (A&B): Final clearance and review for Partnership Framework and Partnership Framework Implementation Plan

Once internal (host country and USG) clearances are complete, the proposed Partnership Framework and Partnership Framework Implementation Plan should be submitted to headquarters through the country’s Country Support Team lead for final legal review and clearance.

Depending on whether the country team has opted to complete the Partnership Framework and Partnership Framework Implementation Plan simultaneously or sequentially, this final review and clearance can also take place simultaneously or sequentially.

C. SIGNING AND DISTRIBUTING THE PARTNERSHIP FRAMEWORK

After the final review and once all necessary clearances have been obtained, the Chief of Mission or his/her designee, the host government representative(s), and other signatories should sign the document. A copy of the signed document should be provided to all signatories as well as to OGAC and other agency headquarters. USG legislation requires that the Global AIDS Coordinator submit the final Partnership Frameworks to Congress, publish them in the Federal Register, and post them on the OGAC Internet website within 10 days of signing. The final signed Partnership Framework should also be translated as appropriate, made publicly available, and widely distributed to other stakeholders representing civil society, NGOs, other donors, international organizations, and the private sector to facilitate implementation and monitoring in the host country.

1. Considerations regarding signatories

Partnership Frameworks should be signed by representatives of the USG and host government (or multiple participating governments or regional partnerships in the case of regional frameworks). The host government, in dialogue with the USG, should be the final determinant of whether formal signatory roles should be assigned to entities other than itself and the USG. In the case of regional programs, special considerations will need to be applied when determining negotiation and signatory practices.

General considerations in determining how many signatures are needed and who should sign include:

US Government: The Chief of Mission or his/her designee should sign on behalf of the USG.

Host Government (National Level): Signatories should be able to exercise some control over the allocation of resources planned in the Partnership Framework and influence over those implementing the actions outlined in the Framework. The host government signatory should coordinate with all relevant ministries to ensure effective implementation. For these reasons, signature on behalf of the host government should generally be sought at the Ministerial level or above. If success of the Partnership Framework depends on buy-in from a specific Ministry or host government office, the signature of a representative from that Ministry or office should be considered.

Host Country Government (Sub-National Level): Sub-national signatories may be appropriate if the national government approves and critical activities in the Partnership Framework require involvement of lower levels of government. Signature of national level government is still essential.

International Organizations: In some cases, it may be appropriate to have the GFATM, UNAIDS, or another international organization as a signatory. In the case of the GFATM it is likely that this will occur at either the Country Coordinating Mechanism or Principal Recipient level.

Civil Society and Private Sector: If included, signatories should broadly represent civil society and the private sector; consideration should be given to entities such as umbrella groups, PLWA groups, etc. Groups and their representatives should be acceptable as signatories to both the host country government and the USG.