Country ownership and the turning point for HIV/AIDS
Authors: Chris Collins, Chris Beyrer
Journal: The Lancet Global Health (2013)

There is no substitute for either local knowledge or national leadership as the world moves towards the endgame in the HIV/AIDS epidemic. Increased country engagement, or so-called country ownership, in HIV and health programming is central to achieve adequate scale in service delivery, improve the acceptability of interventions, increase domestic investments in health, and advance integration of HIV programming with national health goals and systems. The concept of country ownership was established as a cornerstone of international assistance by the 2005 Paris Declaration on Aid Effectiveness,1OECDThe Paris declaration on aid effectiveness.http://www.oecd.org/dataoecd/11/41/34428351.pdfGoogle Scholar and was reaffirmed by the 2008 Accra Agenda for Action. Nowadays, major global health donors, including the US Government, identify country ownership as a main goal of their programming. Definitions of country ownership vary,2UNAIDSCountry ownership for a sustainable AIDS response: from principles to practice.http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2012/20120717_JC2134_UNAIDS_Country_Ownership_Discussion_Paper.pdfGoogle Scholar but the term generally refers to an expanded role by the affected country in planning, implementation, and financing of health programming.Increased country ownership is fundamental to long-term progress in global health, but too rapid a transition runs the very real risk of undercutting access to services and squandering the potential to accelerate progress in HIV/AIDS. Not all partners are ready; countries heavily affected by HIV include some middle-income countries with substantial internal resources, and some UN least-developed nations that will probably need sustained donor support and building of technical capacity for years to come. Four areas raise particular concern and deserve close attention.First, rapid transitions could decelerate scale-up of effective HIV services, including antiretroviral treatment, prevention of mother-to-child transmission services, and voluntary medical male circumcision. We now know that speed is an important element in success. Recent assessment of UNAIDS data shows that faster decreases in incidence took place in countries that rapidly increased coverage of HIV treatment than in those that were slower.3UNAIDSTreatment 2015.http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2013/JC2484_treatment-2015_en.pdfGoogle Scholar Major shifts in support for treatment and other services could slow the pace of scale up, and, thus, the effectiveness of these programmes. The US Institute of Medicine, in its assessment4Institute of MedicineEvaluation of PEPFAR.http://www.iom.edu/Reports/2013/Evaluation-of-PEPFAR.aspxGoogle Scholar of the President's Emergency Plan for AIDS Relief (PEPFAR) in February of this year, warned that transition to new models of PEPFAR support, including less direct support for service delivery, has the inherent risk, at least in the short run, that programme and data quality, and access to services, might suffer.4Institute of MedicineEvaluation of PEPFAR.http://www.iom.edu/Reports/2013/Evaluation-of-PEPFAR.aspxGoogle Scholar Both the US Government Accountability Office5Government Accountability OfficeShift toward partner-country treatment programs will require better information on results.http://www.gao.gov/products/gao-13-460Google Scholar and UNAIDS2UNAIDSCountry ownership for a sustainable AIDS response: from principles to practice.http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2012/20120717_JC2134_UNAIDS_Country_Ownership_Discussion_Paper.pdfGoogle Scholar have raised concerns about the readiness of some implementing countries to implement effective data and monitoring systems. An assessment6Center for Strategic and International StudiesThe future of the US-South Africa HIV/AIDS Partnership.http://csis.org/publication/future-us-south-africa-hivaids-partnershipGoogle Scholar by the Center for Strategic and International Studies of PEPFAR in South Africa noted "legitimate fears" that a rushed transition could disrupt the HIV treatment programme in that country. These issues are all the more relevant now that the PEPFAR Stewardship and Oversight Act has been introduced in the US Congress to strengthen the programme.Second, in many settings, country ownership could undermine the nascent response to HIV in many of the most vulnerable populations, including marginalised groups such as men who have sex with men, transgender people, people who inject drugs, and sex workers. In many of the countries with high burdens of HIV/AIDS, these marginalised groups are criminalised and can be the subject of severe social stigma and police harassment. UNAIDS has reported7UNAIDSGlobal report: UNAIDS report on the global AIDS epidemic.http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2012/gr2012/20121120_UNAIDS_Global_Report_2012_en.pdfDate: 2012Google Scholar that more than 90% of funding to address the HIV-related needs of these groups in low-income and middle-income countries comes from external donors, not the implementing government. Outside of sub-Saharan Africa, HIV is mostly an epidemic of key populations, and these groups are at an elevated risk of HIV, including in larger, generalised epidemics. Key populations and their sex partners account for 33% of new HIV infections in Kenya and 51% in Nigeria.8UNAIDSWorld BankNew HIV infections by mode of transmission in West Africa: a multi-country analysis.http://www.unaids.org/en/media/unaids/contentassets/documents/countryreport/2010/201003_MOT_West_Africa_en.pdfGoogle Scholar PEPFAR and the Global Fund have placed increasing emphasis on key populations, but in many countries, social and political barriers mean that support for HIV services to these marginalised groups might need external financing for the foreseeable future.Third, the transition to increased country ownership will require attention to the participation of various stakeholders in health decision making. As many have reported, country ownership must not come to mean simply government ownership; if it does, the voices of affected communities might not be heard and accountability will suffer. A report9Hodel D amfARthe Health Policy Projectthe International Planned Parenthood Federation Africa Regionthe Planned Parenthood Federation of AmericaAdvancing country ownership: civil society's role in sustaining public health.http://www.amfar.org/uploadedFiles/_amfarorg/On_the_Hill/Country-Ownership-Meeting-Report-June-2013.pdfGoogle Scholar from a 2012 international consultation on country ownership and civil society's involvement in HIV and family planning programming noted that in many countries the notion of civil society engagement remains ill-defined and unsupported. The report raised the concern that "without careful and thoughtful implementation [of transitions to greater country ownership] there is the risk of undermining the civil society engagement that has proved so critical to global health responses."9Hodel D amfARthe Health Policy Projectthe International Planned Parenthood Federation Africa Regionthe Planned Parenthood Federation of AmericaAdvancing country ownership: civil society's role in sustaining public health.http://www.amfar.org/uploadedFiles/_amfarorg/On_the_Hill/Country-Ownership-Meeting-Report-June-2013.pdfGoogle ScholarFinally, adequate financing remains a crucial challenge as countries assume a greater role in their AIDS responses. An often-heard argument for increased country ownership is to achieve greater sustainability for AIDS and other health services. But in view of the fragile financial realities of many countries heavily affected by HIV, quick transitions could seriously undermine sustainability. Findings from an analysis of domestic financing for HIV in lower-income and middle-income countries10Avila C Loncar D Amico P De Lay P Determinants of government HIV/AIDS financing: a 10 year trend analysis from 125 low- and middle-income countries.BMC Public Health. 2013; 13: 673Crossref PubMed Scopus (15) Google Scholar showed an increase of three times in country spending from 2000 to 2010, with greater spending associated with increased economic growth and higher burden of HIV. Yet growth of domestic resources in sub-Saharan Africa was mostly in upper-middle-income countries. The investigators noted that poor countries with high HIV prevalence, such as Zimbabwe, Kenya, Uganda, Ethiopia, and Malawi, are especially vulnerable and are probably unable to attain adequate resources for their HIV response in the near future.10Avila C Loncar D Amico P De Lay P Determinants of government HIV/AIDS financing: a 10 year trend analysis from 125 low- and middle-income countries.BMC Public Health. 2013; 13: 673Crossref PubMed Scopus (15) Google Scholar As the Institute of Medicine reported,4Institute of MedicineEvaluation of PEPFAR.http://www.iom.edu/Reports/2013/Evaluation-of-PEPFAR.aspxGoogle Scholar "it is not realistic to expect that partner countries would be able to independently finance the entirety of HIV programming as it is currently implemented…" Vietnam is a case in point, where steep cutbacks in PEPFAR funding imperil sustainability of that country's HIV programming.11IRIN NewsVietnam concerned over HIV donor funding cuts.http://www.irinnews.org/report/98402/vietnam-concerned-over-hiv-donor-funding-cutsGoogle ScholarEach country is unique, but the transition to country ownership can be considered as having three tiers: (1) countries with well-established health infrastructure that can monitor and implement a substantial share of HIV programming, such as South Africa; (2) countries that can assume substantial expanded ownership in the next 5 years, such as Kenya; and (3) countries where the severity of the HIV epidemic and insufficient domestic resources mean that greatly increased financial ownership is farther off, including Ethiopia, the Democratic Republic of Congo, Malawi, and South Sudan. In each type of setting, implementing countries should take an increased role in planning, but they will require varying degrees of external funding for services, and ongoing technical and other support. A clear transition plan (with metrics to gauge progress in each of four areas above) is needed in each country, as is continued external commitment and careful monitoring to ensure external donors fill gaps to maintain scale-up of strategic services.An assessment12Sgaier SK Ramakrishnan A Dhingra N How the Avahan HIV prevention program transitioned from the Gates Foundation to the Government of India.Health Affairs. 2013; 32: 1265-1273Crossref Scopus (46) Google Scholar of the transition of the Avahan programme from the the Bill & Melinda Gates Foundation to the Government of India found that success is possible but requires thoughtfulness and patience. Avahan was designed with existing national and state-level health systems in mind to facilitate an eventual hand off. Achievement of that level of integration and sustainability in national programming will take many HIV/AIDS programmes years. At this pivotal point in tackling the epidemic, we need to advance nationally owned decision making while acting decisively on the evidence of what works to accelerate the end of AIDS.Both authors contributed to the writing and editing of this piece. We declare that we have no conflicts of interest. There was no funder for this piece. There is no substitute for either local knowledge or national leadership as the world moves towards the endgame in the HIV/AIDS epidemic. Increased country engagement, or so-called country ownership, in HIV and health programming is central to achieve adequate scale in service delivery, improve the acceptability of interventions, increase domestic investments in health, and advance integration of HIV programming with national health goals and systems. The concept of country ownership was established as a cornerstone of international assistance by the 2005 Paris Declaration on Aid Effectiveness,1OECDThe Paris declaration on aid effectiveness.http://www.oecd.org/dataoecd/11/41/34428351.pdfGoogle Scholar and was reaffirmed by the 2008 Accra Agenda for Action. Nowadays, major global health donors, including the US Government, identify country ownership as a main goal of their programming. Definitions of country ownership vary,2UNAIDSCountry ownership for a sustainable AIDS response: from principles to practice.http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2012/20120717_JC2134_UNAIDS_Country_Ownership_Discussion_Paper.pdfGoogle Scholar but the term generally refers to an expanded role by the affected country in planning, implementation, and financing of health programming. Increased country ownership is fundamental to long-term progress in global health, but too rapid a transition runs the very real risk of undercutting access to services and squandering the potential to accelerate progress in HIV/AIDS. Not all partners are ready; countries heavily affected by HIV include some middle-income countries with substantial internal resources, and some UN least-developed nations that will probably need sustained donor support and building of technical capacity for years to come. Four areas raise particular concern and deserve close attention. First, rapid transitions could decelerate scale-up of effective HIV services, including antiretroviral treatment, prevention of mother-to-child transmission services, and voluntary medical male circumcision. We now know that speed is an important element in success. Recent assessment of UNAIDS data shows that faster decreases in incidence took place in countries that rapidly increased coverage of HIV treatment than in those that were slower.3UNAIDSTreatment 2015.http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2013/JC2484_treatment-2015_en.pdfGoogle Scholar Major shifts in support for treatment and other services could slow the pace of scale up, and, thus, the effectiveness of these programmes. The US Institute of Medicine, in its assessment4Institute of MedicineEvaluation of PEPFAR.http://www.iom.edu/Reports/2013/Evaluation-of-PEPFAR.aspxGoogle Scholar of the President's Emergency Plan for AIDS Relief (PEPFAR) in February of this year, warned that transition to new models of PEPFAR support, including less direct support for service delivery, has the inherent risk, at least in the short run, that programme and data quality, and access to services, might suffer.4Institute of MedicineEvaluation of PEPFAR.http://www.iom.edu/Reports/2013/Evaluation-of-PEPFAR.aspxGoogle Scholar Both the US Government Accountability Office5Government Accountability OfficeShift toward partner-country treatment programs will require better information on results.http://www.gao.gov/products/gao-13-460Google Scholar and UNAIDS2UNAIDSCountry ownership for a sustainable AIDS response: from principles to practice.http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2012/20120717_JC2134_UNAIDS_Country_Ownership_Discussion_Paper.pdfGoogle Scholar have raised concerns about the readiness of some implementing countries to implement effective data and monitoring systems. An assessment6Center for Strategic and International StudiesThe future of the US-South Africa HIV/AIDS Partnership.http://csis.org/publication/future-us-south-africa-hivaids-partnershipGoogle Scholar by the Center for Strategic and International Studies of PEPFAR in South Africa noted "legitimate fears" that a rushed transition could disrupt the HIV treatment programme in that country. These issues are all the more relevant now that the PEPFAR Stewardship and Oversight Act has been introduced in the US Congress to strengthen the programme. Second, in many settings, country ownership could undermine the nascent response to HIV in many of the most vulnerable populations, including marginalised groups such as men who have sex with men, transgender people, people who inject drugs, and sex workers. In many of the countries with high burdens of HIV/AIDS, these marginalised groups are criminalised and can be the subject of severe social stigma and police harassment. UNAIDS has reported7UNAIDSGlobal report: UNAIDS report on the global AIDS epidemic.http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2012/gr2012/20121120_UNAIDS_Global_Report_2012_en.pdfDate: 2012Google Scholar that more than 90% of funding to address the HIV-related needs of these groups in low-income and middle-income countries comes from external donors, not the implementing government. Outside of sub-Saharan Africa, HIV is mostly an epidemic of key populations, and these groups are at an elevated risk of HIV, including in larger, generalised epidemics. Key populations and their sex partners account for 33% of new HIV infections in Kenya and 51% in Nigeria.8UNAIDSWorld BankNew HIV infections by mode of transmission in West Africa: a multi-country analysis.http://www.unaids.org/en/media/unaids/contentassets/documents/countryreport/2010/201003_MOT_West_Africa_en.pdfGoogle Scholar PEPFAR and the Global Fund have placed increasing emphasis on key populations, but in many countries, social and political barriers mean that support for HIV services to these marginalised groups might need external financing for the foreseeable future. Third, the transition to increased country ownership will require attention to the participation of various stakeholders in health decision making. As many have reported, country ownership must not come to mean simply government ownership; if it does, the voices of affected communities might not be heard and accountability will suffer. A report9Hodel D amfARthe Health Policy Projectthe International Planned Parenthood Federation Africa Regionthe Planned Parenthood Federation of AmericaAdvancing country ownership: civil society's role in sustaining public health.http://www.amfar.org/uploadedFiles/_amfarorg/On_the_Hill/Country-Ownership-Meeting-Report-June-2013.pdfGoogle Scholar from a 2012 international consultation on country ownership and civil society's involvement in HIV and family planning programming noted that in many countries the notion of civil society engagement remains ill-defined and unsupported. The report raised the concern that "without careful and thoughtful implementation [of transitions to greater country ownership] there is the risk of undermining the civil society engagement that has proved so critical to global health responses."9Hodel D amfARthe Health Policy Projectthe International Planned Parenthood Federation Africa Regionthe Planned Parenthood Federation of AmericaAdvancing country ownership: civil society's role in sustaining public health.http://www.amfar.org/uploadedFiles/_amfarorg/On_the_Hill/Country-Ownership-Meeting-Report-June-2013.pdfGoogle Scholar Finally, adequate financing remains a crucial challenge as countries assume a greater role in their AIDS responses. An often-heard argument for increased country ownership is to achieve greater sustainability for AIDS and other health services. But in view of the fragile financial realities of many countries heavily affected by HIV, quick transitions could seriously undermine sustainability. Findings from an analysis of domestic financing for HIV in lower-income and middle-income countries10Avila C Loncar D Amico P De Lay P Determinants of government HIV/AIDS financing: a 10 year trend analysis from 125 low- and middle-income countries.BMC Public Health. 2013; 13: 673Crossref PubMed Scopus (15) Google Scholar showed an increase of three times in country spending from 2000 to 2010, with greater spending associated with increased economic growth and higher burden of HIV. Yet growth of domestic resources in sub-Saharan Africa was mostly in upper-middle-income countries. The investigators noted that poor countries with high HIV prevalence, such as Zimbabwe, Kenya, Uganda, Ethiopia, and Malawi, are especially vulnerable and are probably unable to attain adequate resources for their HIV response in the near future.10Avila C Loncar D Amico P De Lay P Determinants of government HIV/AIDS financing: a 10 year trend analysis from 125 low- and middle-income countries.BMC Public Health. 2013; 13: 673Crossref PubMed Scopus (15) Google Scholar As the Institute of Medicine reported,4Institute of MedicineEvaluation of PEPFAR.http://www.iom.edu/Reports/2013/Evaluation-of-PEPFAR.aspxGoogle Scholar "it is not realistic to expect that partner countries would be able to independently finance the entirety of HIV programming as it is currently implemented…" Vietnam is a case in point, where steep cutbacks in PEPFAR funding imperil sustainability of that country's HIV programming.11IRIN NewsVietnam concerned over HIV donor funding cuts.http://www.irinnews.org/report/98402/vietnam-concerned-over-hiv-donor-funding-cutsGoogle Scholar Each country is unique, but the transition to country ownership can be considered as having three tiers: (1) countries with well-established health infrastructure that can monitor and implement a substantial share of HIV programming, such as South Africa; (2) countries that can assume substantial expanded ownership in the next 5 years, such as Kenya; and (3) countries where the severity of the HIV epidemic and insufficient domestic resources mean that greatly increased financial ownership is farther off, including Ethiopia, the Democratic Republic of Congo, Malawi, and South Sudan. In each type of setting, implementing countries should take an increased role in planning, but they will require varying degrees of external funding for services, and ongoing technical and other support. A clear transition plan (with metrics to gauge progress in each of four areas above) is needed in each country, as is continued external commitment and careful monitoring to ensure external donors fill gaps to maintain scale-up of strategic services. An assessment12Sgaier SK Ramakrishnan A Dhingra N How the Avahan HIV prevention program transitioned from the Gates Foundation to the Government of India.Health Affairs. 2013; 32: 1265-1273Crossref Scopus (46) Google Scholar of the transition of the Avahan programme from the the Bill & Melinda Gates Foundation to the Government of India found that success is possible but requires thoughtfulness and patience. Avahan was designed with existing national and state-level health systems in mind to facilitate an eventual hand off. Achievement of that level of integration and sustainability in national programming will take many HIV/AIDS programmes years. At this pivotal point in tackling the epidemic, we need to advance nationally owned decision making while acting decisively on the evidence of what works to accelerate the end of AIDS. Both authors contributed to the writing and editing of this piece. We declare that we have no conflicts of interest. There was no funder for this piece.