From Battling One Disease to Strengthening Whole Health Systems: Three Recommendations for “Reimagining” PEPFAR

Following a long leadership vacuum, Dr. John Nkengasong is officially at the helm of PEPFAR, widely viewed as one of the most successful initiatives in the history of global health. He was on the job in time for the International AIDS Conference last week, where he discussed the need to reimagine PEPFAR in an era of multiple pandemics. Nkengasong previously led Africa’s COVID-19 response as the first director of the Africa Centers for Disease Control and Prevention.

Now, almost 20 years after its creation and as its fourth reauthorization nears—and amid calls for greater regional ownership and new pandemic threats—PEPFAR is at a turning point. Nkengasong will have to deliver a new vision for PEPFAR that fulfills dual (and ideally symbiotic) aims: advancing the unfinished HIV agenda and leveraging PEPFAR’s capabilities to keep the gas on the COVID-19 response and tackle future health threats.

PEPFAR’s new strategy—to be released in final form later this year—focuses on how to accelerate progress toward epidemic control amidst continued impacts from COVID-19, while also strengthening core health system functions as well as partnership and coordination efforts; this is precisely what the current moment requires. If the HIV response can help bolster health systems and support national governments to sustainably deliver health services (much more than it has done in the past), it has the potential to strengthen basic public health functions and consequently enhance global health security; looking ahead, further assessment will be key to understanding contributions to global health security. And as Nkengasong has emphasized, the reverse is true too: given the knock-on effects of infectious disease outbreaks on HIV services, responding to new health security risks is central to maintaining progress in the fight against HIV. 

Here are three operational priorities for PEPFAR’s new leadership in pursuit of these goals.

1. Fully harness PEPFAR’s investments for the next phase of the COVID response and to advance global health security

PEPFAR’s investments have made important contributions to the COVID-19 response in PEPFAR-supported countries. For instance, PEPFAR-funded laboratories have reportedly conducted millions of COVID-19 screenings and tests, PEPFAR-trained community health workers have been deployed in countries to ensure those in need can access testing, and PEPFAR-supported health information systems have been leveraged to collect and use data on COVID-19 cases, mortality, and vaccinations (though questions remain about the sustainability of these arrangements and their effects on program performance and COVID-19—and HIV—outcomes). As COVID-19 lingers and gaps in the response widen, fully harnessing PEPFAR’s implementing partner infrastructure to expand equitable access to the next generation of vaccines, tests, and treatments will be critical for the next phase.

As one example, PEPFAR’s capabilities and extensive reach should be applied to expanding access to COVID-19 treatments, helping to fulfill commitments made by the US at the recent Global COVID-19 Summit to deliver “pilot ‘test and treat’ strategies for the most vulnerable populations in low- and middle-income countries to help prevent hospitalizations and death from COVID-19.” PEPFAR’s existing implementing partner infrastructure can be used for country deployment programs for test-treat initiatives as a starting point to address challenges with testing and provider management of drug-drug interactions (though this will require—and could go hand in hand—with improvements to HIV test and treat interventions as well). Implementers with significant experience supporting HIV test and treat in low- and middle-income countries should be resourced to initiate COVID testing and treatment programs and provide relevant technical tools.

Zooming out, Nkengasong faces another key challenge in carving out PEPFAR’s longer-term role in the global health security architecture. This will undoubtedly require interagency coordination, alongside collaboration with multilateral institutions like the Global Fund and the World Bank. But coordination within, across, and beyond US health entities can be easy to aspire to, and hard to achieve in practice.

The exact details of how Nkengasong operationalizes PEPFAR’s role in global health security will make all the difference. Translating ambition into reality requires adequate internal structures and staffing in alignment with the new strategy’s impetus on broader health security and health system strengthening. PEPFAR’s own bilateral HIV funding has been flat at US $5.4 billion annually for the last several years, mirroring broader trends of stagnant funding in the HIV donor landscape. In the absence of much needed additional funding, a likely scenario given competing priorities beyond global health, PEPFAR would face inevitable resource tradeoffs for its health security and systems strengthening ambitions.

As a related welcome development for PEPFAR’s role in global health security, Nkengasong is already mobilizing PEPFAR’s investments to combat monkeypox. Since monkeypox is not yet widely spread in countries where PEPFAR works, PEPFAR is mainly applying its surveillance and diagnostic platforms to the monkeypox response.

2. Lead the way on localization through more direct funding and partnerships deeper than face value

In recognition of the strategic shift towards sustained HIV epidemic control, PEPFAR has sought to transition to a new model of country ownership for the last several years, but encountered roadblocks in meeting (arguably overly) ambitious direct funding targets. While PEPFAR fell short of its goal to direct 70 percent of funding to host country governments and organizations by the end of FY 2020, the initiative has continued to make meaningful progress.

Nkengasong has an opportunity to deepen PEPFAR’s commitment to channel a larger share of funding through “local” entities. But he will also need to steer PEPFAR beyond topline targets to think carefully about whom it funds and prioritize how it works in partnership with these entities. To sustain the HIV response, PEPFAR leadership must focus on the harder lift: shifting funds to governments, not just local NGO implementers. Direct government-to-government (G2G) assistance has been especially limited to date, reflecting a common trend in global health and foreign aid.

Sustainable health programs ultimately require governments to mobilize resources and channel funding through public coffers to directly manage program financing, implementation, contracting, and oversight. PEPFAR should help lay the groundwork to strengthen public financial management systems by building partner government capacity to directly contract, finance, and oversee existing and new providers. This approach would help transition to greater provision of US aid through government payers and conserve the high-quality of non-profit and private payers that PEPFAR funds, enabling both disease-specific results and cross-cutting health system strengthening.

As a starting point, PEPFAR could pilot a G2G partnership program in select countries. PEPFAR would commit to a baseline level of support for HIV treatment, while also offering financial incentives for countries to (i) allocate on-budget government resources toward HIV in countries that have identified it as a national spending priority; and/or (ii) achieve clearly defined, measurable, and verifiable outputs or outcomes (e.g., reductions in new infections), as set out by flexible fixed-amount awards. Still, shared financing commitments should be realistic given the prevailing fiscal space for health and co-financing requirements from other health donors. Demonstrating what works in a handful of pilot programs would provide important lessons on ways to ensure high-quality data on results and adequate public financial management systems are in place—in turn, building support, including from Congress, for G2G assistance.

Nkengasong also understands that PEPFAR’s localization efforts must go deeper than simply funding local implementers. As he has rightly stated, “we need to capitalize on the capacity and experience of those in the countries where we work, coming to the table with a deep respect for their perspectives and needs, and taking into account their knowledge and local expertise.” A holistic approach to localization should continue to include close collaboration with partner governments and local experts to identify shared priorities, including through greater involvement in the COP process.

To this end, PEPFAR can also apply lessons learned from previous experiences aimed at transitioning greater responsibility to partner governments. For example, initiatives such as the Partnership Framework with the government of South Africa that sought to transition PEPFAR’s role away from direct service provision underscored the need to assess and fill key gaps in public sector capacity and to establish robust monitoring systems to track patient follow-up as services shift from NGO-run to publicly managed facilities, among other lessons.

Nkengasong should also consider undertaking a systematic learning agenda about PEPFAR’s localization efforts to date. This agenda should prioritize inputs from local partners and draw on learnings across US-supported global health initiatives via collaboration with other disease-specific programs, such as the President’s Malaria Initiative.

3. Advance proactive and coherent plans for financing requirements to reach and maintain epidemic control amid COVID-induced economic shocks

While PEPFAR does not have a specific transition policy or eligibility cutoffs, programmatic transitions to enhance country ownership and responsibilities as countries progress through the process of achieving and sustaining HIV epidemic control are necessary and underway. Indeed, localization efforts reflect this reality. For example, the rollout of PEPFAR’s “acceleration” strategy—which identifies a subset of 13 priority countries—correlated with reallocations away from non-acceleration countries. Further, PEPFAR-calculated scores of a country’s ability to domestically fund, manage, and monitor its HIV response have been used to inform PEPFAR’s planning and investment decisions (e.g., in Kenya).

In light of the global financial crisis, many low- and middle-income countries are unlikely to increase—or even maintain—current levels of health spending. Accordingly, PEPFAR’s leadership should revisit its approach to programmatic transitions, carefully ensuring domestic financing asks (including for G2G programs) are realistic and coherent given each country’s evolving fiscal situation. Any drawdown decisions or co-financing incentives and requirements must be carefully planned in close collaboration with government counterparts and other development partners, particularly the Global Fund. And PEPFAR should also consider how its approach to advancing sustainable financing for HIV is coherent with other US development and global health priorities.

Such an approach will be especially important in countries where PEPFAR remains a significant source of external financing in the health sector. CGD analysis previously found that PEPFAR disbursements are extremely large relative to what governments spend on their entire health sector (40 percent in Kenya; 60 percent in Zambia; and over 100 percent in Uganda, Haiti, and Mozambique). Recent resource alignment efforts between PEPFAR and the Global Fund are a positive development in the fragmented health aid landscape, helping to avoid duplication, identify gaps, assess planned budget versus actual spend and compare against results, and provide visibility into domestic contributions.

Within and beyond PEPFAR, uncertainty around the future of development assistance for health continues to mount amid the global economic downturn and other development priorities. Formal and informal health aid transitions may still be on the horizon, even as LMIC needs for external support grow. No matter what the future holds, shifting from fragmented external spending to funding country systems is long overdue. Spending visibility and sustainability are key to assuring that high-priority public health services receive the funding they need and patients deserve.