In July 2008, US legislation (Public Law 110-293) reauthorized US Government (USG) global efforts to combat HIV/AIDS, tuberculosis and malaria for 2009-2013. The law authorized the USG to establish compacts or framework documents with partner countries to promote a more sustainable approach, characterized by strengthened country capacity, ownership, and leadership. This approach represents a substantially new focus for PEPFAR.
This document serves as an adjunct to earlier guidance on Partnership Frameworks (PFs) (primarily the "Framework for Development of Partnership Compacts in PEPFAR") and is meant to further detail the process and content of Partnership Frameworks. In general, this document refers to national governments, but, where needed, this guidance can be adapted to regional structures and contexts.
In this guidance, the term "Partnership Framework" replaces "Partnership Compact" to distinguish it from a legally binding agreement. In addition, this document incorporates a two-step process of developing a broad initial Partnership Framework and a subsequent more detailed Partnership Framework Implementation Plan (PFIP).
This is "Version 2" of this guidance, updated following its first phase of use and further refinement of the direction of PEPFAR under reauthorization.
The purpose of a Partnership Framework is to provide a 5-year joint strategic framework for cooperation between the USG, the partner government, and other partners to combat HIV/AIDS in the country through technical assistance and support for service delivery, policy reform, and coordinated financial commitments. At the end of the five year time-frame, the expectation is that, in addition to results in the prevention, care and treatment of HIV/AIDS, country governments will be better positioned to assume primary responsibility for the national responses to HIV/AIDS in terms of management, strategic direction, performance monitoring, decision-making, coordination, and, where possible, financial support and service delivery. The Partnership Framework should be established with transparency, accountability, and, in addition to the partner government, the active participation of other key partners from civil society (e.g. associations of people living with HIV/AIDS, non-governmental organizations [NGOs], private voluntary organizations [PVOs], community-based and faith-based organizations [CBOs, FBOs]), the private sector (for-profit organizations and companies, non-profit organizations, business coalitions, chambers of commerce, etc.), other bilateral and multilateral partners (e.g., the Global Fund to Fight AIDS, TB and Malaria [GFATM]), and international organizations (e.g. UNAIDS), bringing together all actors to support and strengthen the capacity of governments to plan, oversee, manage, and ultimately finance their national HIV/AIDS strategies.
B. GUIDING PRINCIPLES
All Partnership Frameworks should embrace the following principles:
Country ownership: A key objective of the Partnership Framework is to ensure that programs reflect country ownership - that is, that governments are at the center of decision-making, leadership, and management of their national HIV/AIDS programs and ultimately their national health systems, and that their efforts embrace the contributions of civil society. Partnership Frameworks present an opportunity to support country ownership by accelerating a transition of PEPFAR support from direct service provision to increased provision of technical assistance to governments, with the goal of expanding government capacity to plan, oversee, manage, deliver, and eventually finance national HIV/AIDS programs. This focus will support government coordination of different funding streams under the framework of a national strategy to ensure consistency of interventions and priorities, to improve overall health systems, and to engage with indigenous partners in the private for-profit and not-for-profit sectors to provide quality services. For many countries, the non-governmental sector is an important implementer of services as part of the national response to the epidemic, led by an engaged and active government, and the Partnership Framework should reflect this. To strengthen the government response, PEPFAR should work with governments to develop their capacity to manage, develop appropriate policies for, and regulate the services delivered by the non-governmental sector, as well as their capacity to oversee and coordinate with the provincial, district, and village levels.
PEPFAR should facilitate governments' leadership role in their HIV/AIDS programs by: 1) providing technical assistance to expand government capacity to plan, develop and implement policies, and to oversee, manage, deliver, monitor, and finance programs; 2) supporting a robust policy reform agenda; and 3) integrating existing parallel service delivery systems with the government-coordinated and managed health system. Over the five year period of the Partnership Framework, as appropriate in the country, PEPFAR-supported programs will in most cases take steps to progressively shift from directly implementing programs and services, predominantly through external partners, to providing technical assistance and support that build government and local capacity to plan, oversee and manage programs, deliver quality services and deploy local capacity to implement services. Country context will dictate the speed at which this transition will take place, the institutions that will be the focus of technical assistance, and the content and form of the PEPFAR-supported technical assistance. Also central to country ownership is government leadership to convene the range of country actors (including all donors) to ensure that their contributions support the national strategy; PEPFAR should support governments' efforts to play this role.
Sustainability: For purposes of Partnership Frameworks, promoting sustainability means supporting the partner government in growing its capacity to lead, manage, and ultimately finance its health system with indigenous resources (including its civil society sector), rather than external resources, to the greatest extent possible. Every country is at a different point on the continuum of sustainability. Partnership Frameworks should be crafted to help ensure that the national response to the HIV/AIDS epidemic is moving toward sustainability while sustaining or improving quality, with the country government developing the capacity to support all relevant components (e.g., service delivery, workforce, products and technologies, financing, information, and governance) of a multi-sector health system, which may include public, private for- and not-for profit, civil society, and community organizations. Partnership Frameworks should support the national system's progress, commensurate with the country's need and available resources, toward maintaining a level of effective and quality programs. Because of limited resource availability, PEPFAR partner countries will continue to use donor resources and assistance to develop and maintain their health systems. Partnership Frameworks should help strengthen government capacity to coordinate the multiple sources of financial and technical assistance.
Support for country coordination of resources: As in the first phase of PEPFAR, in keeping with donor harmonization and alignment efforts, and to emphasize the principle of country ownership, Partnership Frameworks should be fully in line with the national HIV/AIDS plan of the country, and should emphasize sustainable programs with increased country decision-making authority and leadership. Framework documents should be aligned with the "Three Ones" principles (one HIV/AIDS action framework, one national AIDS coordinating authority, and one country-level monitoring and evaluation system), as well as the principles of the Monterrey Accords and Paris Declaration (see Annex IV). In addition, all Partnership Frameworks should further PEPFAR's program scale-up goals of supporting treatment for 3 million people, prevention of 12 million infections, and care for 12 million, including 5 million orphans and vulnerable children, within the context of improving broader country health policy, financing and management capacity. As part of the USG's Global Health Initiative, Partnership Frameworks should relate to broader development reform efforts that may be taking place in a country (such as the International Health Partnership [IHP+] and the architectural reforms of the GFATM, including the National Strategy Application [NSA] process) as indicated by the country, articulating the relationship between the PEPFAR Partnership Framework and these other efforts.
USG interagency collaboration: Like other aspects of PEPFAR, the development of Partnership Frameworks should be an interagency effort carried out under the authority of the U.S. Global AIDS Coordinator at the Department of State, and led by the U.S. Chief of Mission or his/her designee1 at the Embassy with support from the USG agencies on the interagency PEPFAR country team.
Engagement and participation: Successes in the fight against AIDS have been achieved, in part, because of a strong multi-sectoral approach. In developing Partnership Frameworks, all relevant parties should be engaged, with the partner government taking the lead in deciding who to include, and when to include the participation of civil society and other sectors. The national government (e.g., Ministry of Health, Ministry of Finance, National AIDS Coordinating Authority and other government entities as appropriate) should be the country signatory, but if the government deems it appropriate, Partnership Framework development, implementation, and monitoring may also include a multi-sectoral partnership, highlighting the role of civil society (e.g. NGOs, faith-based organizations, groups or associations of people living with HIV/AIDS [PLWA], community groups, women's groups), international partners (e.g. GFATM, World Health Organization [WHO], World Bank, Joint United Nations Programme on HIV/AIDS [UNAIDS]), other bilateral donors working in country, private foundations, and the private sector (e.g. local Business Coalition on HIV/AIDS, Chamber of Commerce, actively engaged companies). As deemed appropriate by the government, cross-border collaboration should also be considered, as should engagement of organizations from sectors that may be outside the direct purview of public health but have a strong influence on public health, such as education or economic strengthening. Where there are effective pre-existing coordinating bodies, for example the GFATM Country Coordinating Mechanism (CCM) or mechanisms through IHP+, consideration should be given to their potential leadership role, if the partner government so chooses. The intent is not to create a new management body, but to support the country's leadership in engaging all sectors.
Strategic framework: Partnership Frameworks are 5-year strategic frameworks for the USG's collaborations with partner countries on HIV/AIDS. Thus:
Flexibility: Different approaches to Partnership Frameworks are appropriate for different settings and thus country context must drive Framework objectives and approaches. For example, in some countries, the USG is providing substantial funding and support for service delivery and strengthening health systems, while in others, USG support is primarily limited to providing technical assistance. Similarly, countries with generalized epidemics have different areas of programmatic emphasis compared with countries with concentrated epidemics. Thus, the appropriate mix of direct services, health system strengthening, and technical assistance will vary by country and will be dynamic in order to address country needs, within the context of national strategies. In addition, the policy areas addressed by Partnership Frameworks should reflect the specific policy reform needs of the relevant country.
Progress towards policy reform and increased financial accountability: Partnership Frameworks should emphasize key policies that promote effective and sustainable quality HIV/AIDS programs and offer an important new opportunity to engage government partners in these areas (see Annex I). The expectation is that Partnership Frameworks will explicitly address each of these key policy issues and demonstrate PEPFAR and government commitments to achieve progress. Partnership Frameworks should also emphasize overall accountability for resources and appropriate budgeting in HIV/AIDS programs. Based on the country's level of resources, a goal should be increased country financial contributions to the program over time, which could include increased reliance on GFATM financing as well as increased funding from national budgets. Partnership Frameworks also provide an opportunity for the USG to work with governments to improve transparency and more closely track HIV/AIDS and overall health financing through National Health Accounts (NHAs), National AIDS Spending Assessments (NASAs), and other financial monitoring and reporting systems. Working towards a costed national HIV/AIDS strategy should be an important priority for the Partnership. Principles of cost efficiency and cost effectiveness should be incorporated into the Partnership Framework.
Integration of HIV/AIDS into strengthened health systems and a broader health and development agenda: Partnership Frameworks should contribute to strengthened HIV/AIDS services within the context of the broader health system in an environment with diverse development needs, and should be aligned with the Global Health Initiative (GHI) approach of integrating services to maximize impact and efficiency. Partnership Frameworks should link and achieve synergies with other relevant development efforts, in particular working towards the Millennium Development Goals (MDGs) and other USG development efforts such as the President's Malaria Initiative (PMI), tuberculosis, maternal child health, education, food and nutrition, economic strengthening, Millennium Challenge Corporation (MCC), and other programs as appropriate. Where parallel service delivery systems have been created, the USG should support government efforts to integrate these into the government-coordinated public health system wherever possible.
Monitoring and evaluation (M&E): Partnership Frameworks should set measurable goals, objectives, and concrete commitments, not only for the USG but for all partners in the Partnership Framework. The Partnership Framework should identify indicators to assess partners' progress towards achieving these goals and objectives, and meeting these commitments. In general, the scope of the targets should be national and not limited to PEPFAR-supported accomplishments. The Partnership process should emphasize national target-setting and transitioning PEPFAR-specific reporting systems to national, country-owned systems in full support of the "Third One." As a multi-party partnership, the reporting needs of all parties (including the government and PEPFAR) should be considered, as should the need for international harmonization of indicators used to monitor the program carried out under the Partnership.
Collaborative but not contractual: Partnership Frameworks are not legally binding agreements, but non-binding joint strategic planning documents that outline the goals and objectives to be achieved and the commitments and contributions expected of all participating Framework members. Partnership Frameworks are intended to facilitate communication and collaboration among partners, including ensuring through action that programs become more sustainable and integrated over the five-year time frame. Partnership Frameworks do not alter existing arrangements such as cooperative agreements or contracts.
Transparency: To inform key stakeholders, every Partnership Framework will be submitted to the U.S. Congress, published in the U.S. Federal Register, posted on PEPFAR's public internet website, and should likewise be widely disseminated and made publicly available in countries.
"Do no harm": Partnership Frameworks should promote sustainability and country ownership through aggressive capacity-building of governments and local partners, but existing service systems implemented by external partners should continue to deliver quality prevention, treatment, and care services while the transition to greater sustainability and country ownership occurs over time. For example, continued access must be ensured for persons started on antiretroviral treatment or in OVC programs with PEPFAR support.
C. PROCESS AND CONTENT
As detailed in Parts II and III of this guidance document, Partnership Framework documents consist of two inter-related sections developed in two stages - the Partnership Framework and the Partnership Framework Implementation Plan
Development of the first section of a Partnership Framework focuses on establishing a collaborative relationship, negotiating the overarching 5-year goals of the Framework and the commitments of each party, and setting forth these agreements in a concise signed document called the "Partnership Framework."
The second, more detailed section, the Partnership Framework Implementation Plan, flows from the Framework. It includes a description of the approach to supporting increased country ownership, baseline data, specific strategies for achieving the 5-year goals and objectives, and a monitoring and evaluation plan.
Both sections of the Partnership Framework will need to be reviewed, negotiated and signed. Part IV of this guidance document discusses those processes.
Over the life of the Partnership Framework, PEPFAR and the government, with the participation of other partners, will jointly:
Questions concerning this guidance and its application should be directed to PEPFAR headquarters Country Support Teams. Technical assistance (TA) for development of the Partnership Framework Implementation Plan may be required, particularly in areas such as finance and policy. Country partners developing the Framework should identify such needs and engage appropriate TA from resources in the country, headquarters, or regional technical experts.
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