Determining Sustainability Factors in PEPFAR-Sponsored Programs and Products Transitioned to Local Ownership

Abstract

The United States established the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 in response to the worldwide AIDS epidemic. In 2005, the Paris Declaration on Aid Effectiveness highlighted the need to plan for transition of aid investments to local country ownership and to assure sustainability of these investments over time. This study was conducted in collaboration with the International Training and Education Center for Health (I-TECH) at the University of Washington. I-TECH manages an international network that assists Ministries of Health to strengthen their healthcare delivery systems and has proven capacity to scale and transition programs to country ownership. This study undertook to learn more about six projects that were transitioned by I-TECH to local ownership and reported by stakeholders to be sustained for at least two years. The PEPFAR Sustainability Index Dashboard (SID) was used and measures sustainability based on four general domains – Governance, Leadership and Accountability; the National Health System and Service Delivery; Strategic Investments, Efficiency and Sustainable Financing; and Strategic Information. The SID was used as an organizing framework for analysis of interviews with key informants. A structured interview guide gathered data from I-TECH Country Directors, Technical Advisors, and Project Managers. Four factors were mentioned most frequently by respondents as critical to successful transition and sustainability, including the availability of external funding for continued technical assistance, demand or need, institutional buy-in from key stakeholders, and the presence of an advocating champion. Seven core elements from the PEPFAR SID were prominent in the interview data - Planning and Coordination; Policies and Governance; Service Delivery; Human Resources for Health; Domestic Resource Mobilization; Epidemiological and Health Data; and Performance Data. The study discovered that, despite the presence of major supporting factors such as having a champion and institutional buy-in, the majority of the projects were still dependent on some level of external funding (i.e., technical assistance) to be sustained. This raises the question as to whether transitioned projects are truly sustainable if the local partner, usually government, cannot provide sufficient support to maintain and improve upon the aid investment.