2016 Calls for a different kind of PEPFAR response—less technical assistance and mentoring and more front-line interventions to implement Test & Start this year

What portion of funds from the President’s Emergency Plan for AIDS Relief for “treatment” goes to address the major front-line barriers keeping people living with HIV from getting on treatment and achieving viral suppression?  In most countries major investments are made in ARVs and other drugs, front line health workers, and core costs to keep facilities going. In some countries significant investment is also made outside the clinic in community-based health workers and systems to support the ART program—and here and there some funding goes to accountability work. In Malawi and Zimbabwe, however, more focus is needed on front-line needs—more of the funding needs to directly reach people living with HIV. The countries have different needs, yet there are some similarities in the PEPFAR programs that should be addressed for 2016.

PEPFAR is currently finalizing its 2016 Country Operational Plans (COPs) for these countries. To their strong credit, the process this year is more open than it has ever been to input from civil society about how PEPFAR should spend its funding—though the process still has a long way to go.  You can read some of what Civil Society has to say about the draft 2016 PEPFAR plans here—calling for a significant shift in funding. There is some clear evidence PEPFAR teams are paying attention.  Looking at the publicly available plans from last year—COP2015—suggests that there is work to do for COP16. Tens of millions of dollars have been focused on training, technical assistance, and mentoring projects while some critical front-line needs in communities and clinics have gone without resources.

With the move to immediate treatment for all in 2016 – or “test and start” - it is time to repurpose funds into programming to directly enable people living with HIV to achieve viral suppression.
 

PEPFAR is a Major Funder in Malawi and Zimbabwe 

For a variety of historical and political reasons, PEPFAR funding in Malawi and Zimbabwe was originally small. Despite massive epidemics, neither was among the 15 “focus countries” announced by President Bush. When funding eventually came it started slowly and focused not on providing treatment or supporting staffing, but on “technical assistance” (TA).  Since then, the programs have grown substantially and both countries are no longer classified as TA countries and instead are identified as countries where PEPFAR is focused on direct service delivery. In the next fiscal year Malawi is set to receive nearly $100 million and Zimbabwe $95 million.  This means that PEPFAR is:

• 30% of total AIDS spending in Zimbabwe
• Over 40% of total AIDS spending in Malawi

PEPFAR has historically focused on what a smaller amount of funding could do in each country on top of the Global Fund and national response—addressing some key technical barriers. But PEPFAR is no longer a small player in the AIDS response in either country and has a responsibility to re-orient its funding to ensure it is addressing the most urgent issues holding back access and rapid scale up of treatment and prevention efforts.

Technical Assistance, Training, and Mentoring Dominates

In both countries, PEPFAR programs in 2015 showed significant vestiges of policy decisions made in past years when the funding plan was quite different. As a result, much of what PEPFAR funds both at “above site level” and in front-line facilities and communities remains focused on what most of us would consider technical assistance.

A review of the activities for last year in the Country Operational Plan shows that in all three countries the majority of activities planned under the adult treatment budget-line focused on “technical assistance,” “training,” “mentoring,” “quality improvement,” “capacity building,” and other terms that indicated the major activity was not directly providing treatment and clinical care to people living with HIV. This model provides a “light touch” in terms of presence in clinics—focused on visiting not working in clinics and communities—and is comparatively expensive for what it provides.  In an era of test and start, this higher cost, light touch model needs to be reconsidered. 

For example, one of the most common practices has been funding implementing partners to visit clinics four times per year to mentor and support clinical staff. While surely valuable, this type of intervention faces especially strong challenges in countries with severe human resource shortages, including Malawi and Zimbabwe. Civil society and clinicians report that understaffed clinics with huge patient loads have little time and space to receive mentoring and capacity building. More often there is a threshold issue where more trained health workers are needed to work alongside existing staff and see patients so that nurses, doctors, and clinical officers can focus on improving quality.  Instead, several of our colleagues report that some implementing partners seem to “only be there to collect the data so they can count the patients.” While this surely does not represent the work of all PEPFAR implementing groups - there is significant variation in how the different agencies PEPFAR funds operate - it is not clear how widespread this problem is.

Malawi

A review of PEPFAR Malawi’s Country Operational Plan serves as an important example.  If we look at all of the implementing “mechanisms” (aka contracts) included in the publicly available data, we can get a crude approximation of what given partners are expecting to spend providing treatment services. There are 13 implementing partners listed in COP 2015 who are set to report on targets to provide treatment through “direct service delivery” (DSD) (noting some mechanisms are not listed). Together $23 million is included in their budgets for adult treatment. About 80% of people PEPFAR planned to enroll or maintain for treatment through DSD were covered by four international NGOs. Yet those NGOs had treatment budgets of less than $30 per person to be served.  This accords with the PEPFAR 2016 report to Congress which says PEPFAR spends an average of $25 per person on adult ART—the lowest in the entire program (p.83). HIV treatment in Malawi is remarkably low-cost—yet estimates suggest it is at least $200 per patient including drugs, staff, facilities, supply chain, and management. With PEPFAR spending such small sums, it seems clear that many of PEPFAR’s “direct service” partners are covering only a small portion of the cost of initiating and keeping each person they count on ART.  

The services provided by this PEPFAR funding often seem to fall into the category of quarterly site visits mentioned above. From this perspective, spending $25-30 per patient is actually quite high for only quarterly visits and seems a confusing priority in such an overstretched system.

Civil society reports from the 2016 planning process suggest that the PEPFAR country team plans to change this model in the cities of Lilongwe, Blantyre, and Zomba—but in an era of test and start it is critical to revisit it as a whole.

Zimbabwe 

Reading the Zimbabwe Country Operational Plans show a similar concern. Frustratingly, the Zimbabwe COP’s funding mechanisms in 2015 have been redacted in the information that is publicly available. However the PEPFAR report to Congress tells us PEPFAR is spending just $46 per person on ART—among the lowest in the program.

Unlike Malawi, Zimbabwe has a significant ARV budget - $19 million in 2015 - which explains why Zimbabwe’s treatment figure is higher than Malawi’s. Still, treatment costs in Zimbabwe are still estimated at well over $200 per patient, which leaves PEPFAR funding comparatively small per patient. Similar to Malawi, the package of services provided by PEPFAR apart from ARVs is focused on mentoring and technical assistance. Visits to clinics in 36 “scale up districts” provides a model of treatment that presumes that the biggest barrier to treatment scale up and success is mentoring nurses.

We know from civil society consultations that the PEPFAR country team is focused on shifting this model in 2016, and the shifts to push more of PEPFAR’s funding to focus on the site level seem promising.

Danger of Focusing on Numbers under a Flat Budget

PEPFAR has been flat-funded for multiple years now— a fact that members of Congress and the Administration should be ashamed of. But given that reality, we should expect that when PEPFAR leadership says programs must rapidly increase the number of people who are counted as being “treated” by PEPFAR but without significant new budgets, there are significant incentives to focus on light-touch interventions that may not address the most significant problems in the AIDS response but do allow the highest number of people to be counted. It is not clear from the COPs how much this is a problem—and there is every evidence that PEPFAR implementers are doing their best in a difficult environment.

But while we strongly support setting bold targets to reach all people in care, PEPFAR needs to be attuned to ensuring the incentives and directives encourage investments in game-changing interventions. In Malawi and Zimbabwe very low portions of the cost of keeping a person in care are being spent for each person claimed, which raises worries. 

This is not to say that technical assistance cannot be valuable. However a much clearer definition is needed by PEPFAR on what constitutes direct service delivery (DSD) and ensure countries are identifying results accurately on that basis. We would submit, however, that quarterly visits to clinics alone—without funding staff and commodities—clearly does not constitute DSD.

In Zimbabwe, for example, the low DSD numbers are worrying—but we should appreciate that the accuracy of their accounting for funds as largely supporting TA. In Malawi, however, this is much more worrying—very little of what the program planned on delivering in 2015 is what many of us would consider direct.

What else can be done—Support, not Parallel Systems 

During the early years of PEPFAR it was rightly criticized for creating parallel systems. At times this was necessary in an emergency response, but after over a decade, PEPFAR has matured and is focused on not duplicating and undermining the public sector.  Malawi and Zimbabwe have notably had some of the most aggressive and effective AIDS responses without early PEPFAR funding—an affirmation of the value of a public-sector led response. PEPFAR should not disrupt or duplicate this.  

This should not, however, confine PEPFAR to funding partners to primarily provide training, mentoring, and TA. It is possible to invest in game-changing interventions that directly support a public-sector-led response and augment its work.

In 2016 PEPFAR teams in each of these countries is thinking about these issues, and we can hope for significant change. You can read some of the good ideas suggested by CSOs here.

Here are a few critical things:

1.    Health workforce in clinics.  Increasingly PEPFAR has shifted in these three countries from “above site level” to support at site level. This is part of the important fix. But at the site level, activities remain limited. One key thing PEFPAR could address is massive health worker shortages.

• Malawi, for example, is facing the most acute health worker shortage, where studies show scale up of AIDS treatment is perhaps most hindered by lack of human resources. There has been hand-wringing that there simply aren’t enough trained workers—yet there is also some clear evidence that trained health workers currently cannot be employed because the Malawian government cannot afford to do so and has been told by the IMF to freeze their wage-bill. As a result over 100 lab techs, for example, have been trained but cannot be deployed. 
• PEPFAR has spent millions in training new health workers, but the number of workers in the system has not budged—which suggests they many of them are leaving the country or just not finding employment in the health system.   The situation has also been made worse when PEPFAR funded groups have hired trained clinicians out of the public sector by paying higher wages and moved them out of clinics and into mentoring roles. In 2016, PEPFAR could fund less mentoring and focus instead on increasing the front-line health workers employed directly in the public sector. Salaries not just training is needed. PEPFAR reports this is under consideration—and should be considered throughout the country.
• Health workers in communities—arguably even more important for the success of a test & start HIV treatment effort is the support available for treatment literacy, adherence and viral suppression support, following up with patients who miss appointments, and promoting community-based care.

2. Community-based models of HIV care and treatment—The role out of “Test & Start” requires a re-envisioning of the model of HIV care, as recognized by the World Health Organization in its most recent guidelines and by PEPFAR in its 2016 guidance. It means millions of asymptomatic people living with HIV accessing and being supported to adhere to treatment over decades.  The good news is there are good models for building community-based systems—including for dispensing HIV medicines—that can reduce the burden on people living with HIV and the health sector.

• In urban areas, adherence clubs have been shown effective in supporting literacy about treatment and
• Especially in rural areas, models of community-based ART delivery in which stable patients visit clinics rarely and instead work with each other to ensure they remain health and virally suppressed while sharing the burden of picking up medicines.

In Zimbabwe, for example, these models have been effectively piloted by Médecins Sans Frontiers (MSF), and now stand to be scaled up. 

But these models are not free, and PEPFAR could specifically devote funding for long-term implementation, not just policy and technical support. Community models can decongest health clinics and bring down the cost of care substantially, but to be implemented effectively they still require human resources to help set up and support community-based groups. An over-stretched nurse serving a busy, over-capacity clinic cannot also take on supporting patients in the community. Indeed many of the current programs do not even have capacity to follow up with patients who don’t show up for appointments. Strong, clear investments by PEPFAR for multiple years that are coordinated tightly with the public sector could make a major difference. 

3. Civil Society Advocacy— the AIDS response needs more activists and policy wonks in each of these countries.  Accountability is a critical missing piece of the AIDS response—and without it technical assistance will not have a major impact. But the large service-focused NGOs funded by PEPFAR  cannot bring this kind of accountability—it’s not a technical problem, is a political one. Luckily there are good examples of how this can work:

• In Malawi networks of people living with HIV have worked with cell phone provider airtel to report drug stock-outs via SMS—but those networks are currently facing funding challenges and have not been able to scale up this work. 
• In Zimbabwe critical leaders among civil society have challenged anti-LGBT laws that undermine access to HIV care and have won critical victories in the non-enforcement of those laws in the health sector.
• Much more could be done to pair activists with key clinics to monitor, report, and advocate improvements.
  
  

2016—time for change

This year could be a critical moment of infection for PEPFAR programs in Malawi and Zimbabwe. It is clear that in Washington and in capitals, PEPFAR staff are paying attention to these messages and thinking about what they can do differently in this critical epidemiologic and political moment. With hundreds of millions of dollars to be invested and many lives on the line, this should be that year. If so, in the coming weeks I hope plans will be formulated to move some significant portion of funding out of light-touch, high cost models and into these (and many other) critical interventions.

–Matthew Kavanagh, Senior Policy Analyst, Health GAP