10 August 2012

Clinton Passes PEPFAR Baton to South Africa

A version of this originally appeared on the PSI Impact Blog.

Secretary of State Clinton is in the middle of her tour across Africa. Stops so far have included Senegal, Malawi and South Africa. Clinton delivered remarks at each of her visits, but health came to the forefront in South Africa.

Specifically, Clinton commended the work of South Africa in the fight against AIDS and signaled a new way for ward for PEPFAR's work in the country. "South Africa is taking the lead, and I want publicly to commend your minister of health and his associates who are widely being given great admiration around the world for the success of their efforts," said Clinton.

According to Reuters, Clinton signed a deal with South Africa that would give the country the ability to have more discretionary spending power over PEPFAR funds.

U.S. officials said South Africa will be the first PEPFAR country to begin to "nationalize" its program, but others would be expected to follow as their capacities increase and the United States seeks to more effectively target its overseas assistance in an atmosphere of budget austerity at home. 
The United States has spent $3.2 billion since 2004 on anti-AIDS programs in South Africa, where 5.7 million people are infected - or close to 18 percent of the adult population. 
It has budgeted $460 million for South Africa under PEPFAR in 2013, but U.S. officials say that amount is expected to gradually drop in the coming five years. 
"South Africa over the next decade will be committing more of its own public health funds to deal with people with HIV," a senior U.S. official travelling with Clinton's party said.
South Africa says about 1.7 million are now on treatment and the rate of mother-to-child transmission has dropped from 8 percent in 2008 to 2.7 per cent in 2011. 
But complicating the situation is a high incidence of HIV/AIDS among workers in the mining sector, which employs about 500,000 people living and working in cramped conditions that facilitate the spread of tuberculosis, a disease marching in step with HIV.
Drug resistant TB strains are spreading among miners, who have infection rates about three times higher than the general population, according to South African officials. 
The disease is further spread when foreign-born miners - tens of thousands from Lesotho, Swaziland and other neighboring countries working in South Africa's mines - return home.
Clinton made it clear that it does not mean that the US is pulling out of its commitments or abandoning South Africa. Rather it is reshaping the partnership to find a more effective way to use PEPFAR to reduce the impact of HIV/AIDS. From AFP:
"Some people may hear 'South Africa is in the lead' and think that it means that the US is bowing out," Clinton said. "Let me say this clearly: the US is not going anywhere." 
"The partnership is changing for the better," she said. "Our goal is no new patients -- zero." 
"South Africa will become the first country in Africa to plan, manage and pay for more of your own efforts to combat the epidemic," Clinton said in a speech later in the day. "The 
United States will continue to provide funding and technical support through our PEPFAR programme."
The remarks by Clinton certainly are interesting in terms of how this new partnership might actually work. Eric Goosby answered the question of country ownership during remarks at the International AIDS Conference, but was equally as vague as Clinton in terms of indicating of how it looks in practice.
I think that the idea of country ownership includes embracing those who are using the services in planning and implementation discussions, and decision-making. 
When that connection is made, in-country, to be in a dialogue with those policymakers and appropriators who make the allocation decisions, prioritize the unmet need, you create a feedback loop that allows those who are using the services to tell those who are making the decisions on program, to get on or off track, and that feedback loop creates a self-correcting system. 
When you disarticulate, if I could use that word, the feedback from those who are using the services in Geneva, where the decision is made, or in Washington, where the decision is made, you dilute that ability to self-correct. I believe country ownership is a central ingredient to creating that self-correcting system.
As the partnership changes between PEPFAR and South Africa, so too will the accountability structures. What will be done to ensure that the flexibility will maximize the effectiveness of interventions and money spent? How will PEPFAR continue to get these feedbacks and to what extent can it apply pressures when it feels that money is being spent poorly? Is PEPFAR willing to stand back a bit and allow some ideas to be tested that might not appear to be as sound as others?

Either way, there is good reason to keep a watch over the new developments in the partnership as an indicator of the direction of global health for the US.