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PEPFAR Will Need Leadership and Signposts On its Path to Sustainability

PEPFAR’s success as an emergency health program is unquestionable and (in many respects) unparalleled.  As Amanda Glassman recently noted, the number of people receiving HIV/AIDS treatment in low and middle income countries has gone from 300,000 in 2003 to almost 14 million in 2015 – and about half of this is supported by the US Government.  PEPFAR’s major challenge today is making these gains permanent and the on-going epidemic control efforts sustainable everywhere, even while acknowledging that the same funding levels are not likely to be sustained.

PEPFAR’s Sustainability Action Agenda, launched in 2015 as part of PEPFAR 3.0, recognizes that many countries are in a position to “advance domestic HIV/AIDS investments and assume greater partner country responsibilities for increased financing, management and implementation – but the seeds for this evolution must be sown early.” In this context, PEPFAR’s Sustainability Index is an important tool for advancing towards sustainability objectives. As PEPFAR 3.0 says, the Index should inform annual investments to steadily advance sustainability across critical areas. These metrics, sign-posts and feedback loops will be critical for meeting PEPFAR’s related goal to “hardwire sustainability within PEPFAR’s business practices.”

This is an ambitious agenda that Plan supports on our own and through the Modernizing Foreign Assistance Network (MFAN).  The path to sustainability – to aligning your programs and initiatives to local priorities which are jointly implemented and co-financed -- will provide the best opportunities for lasting impact. Plan International, a $1 billion/year organization, operating in 70+ countries, has a bit of experience (some good and some not so good) pushing for a transition from service delivery to sustainable locally-owned programming. So allow me to make a couple of observations about this challenge. 

First, I will note that this will not be achieved (certainly not be achieved everywhere) in 3 to 5-years.  So being realistic about what is achievable by when is important.  Also, signposts of progress towards that ultimate goal are essential. Otherwise, it is too easy to focus only on rapid service delivery at the cost of enduring progress.

Second, we should be clear about how we are defining as a path to sustainability.   For Plan, the ultimate measure of sustainability is when local governments, civil society, the private sector or some combination fund an initiative that had been previously funded by Plan. When this happens, Plan can step aside as a donor and service provider and exit the area. Independent ex-post evaluations have shown that these results outlast Plan’s investments with both local funding and local activism clearly evident 5 to 9 years later.  We are mindful that money is fungible and of what is being displaced, so we evaluate not just what is being funded but how local civil society is engaged and exercising social accountability at the community level.

By the way, Plan research has also found that even where Plan has developed very strong local capacity, local partners all too often continue to view Plan as the owner. And as Plan, we have too often treated local NGOs as service delivery mechanisms.  Further progress towards sustainability requires consistent actions from Plan’s leadership and staff that demonstrate our commitment to yield power to local actors, to trust local processes.

As a multi-billion dollar, high-profile program of the US government, PEPFAR will likely face a number of these same challenges as it seeks to shift the perceptions of partner governments, implementing partners and staff.  If Plan’s experience is any guide, the shifting of internal business practices to build sustainability into “all planning and implementation processes at the outset,” is a goal that only the attention of the most senior executive leadership can advance effectively. We applaud Ambassador Birx’s attention to these central topics at PEPFAR. 

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