Ethiopia: Focusing our Program for Impact & Efficiency

Jocelyn Felter BrownActing Coordinator, PEPFAR Ethiopia

AIDS 2014 – Stepping Up The Pace

Ethiopia – Important Features• Population 90 million• Predominantly rural agrarian country• Growing economy with large infrastructure development

projects• Low/decreasing national HIV/AIDS prevalence: 1.4%• Has reached the “Tipping Point”• Significant Urban to Rural HIV/AIDS disparity: mixed

epidemic• Government is the primary service provider • Strong political commitment to health & equity of

services• Significant Global Fund investment, but expected to

decline with New Funding Model

Ethiopia: Three Ways of Looking at HIV Distribution: Prevalence, No. Infected, and Density, 2011

PEPFAR Expenditures by Geographic Location & HIV Burden with Adult Prevalence

4Source: HIV Related Estimates and Projections for Ethiopia – 2012. Excludes National and Above National Spending

0 50,000 100,000 150,000 200,000 250,000$0

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$30,000,000

$35,000,000

$40,000,000

$45,000,000

Gambela

Harari

Benishangul-Gumuz

Dire Dawa

Afar

Somali

TigraySNNPR

Addis Ababa

Amhara

Oromiya

FY13 PEPFAR Expenditures by Region vs. Prevalence and Disease BurdenBubble size = HIV Prevalence Among Adult Population, 2011

People Living with HIV, 2011

PEPF

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FY20

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Focusing the Program: Start with Clinical Care & Treatment

2013 2014 2015

Number of Adults in need of ART*

431,761 530,835 542,632

National Coverage Rate & Goals

@69% = 298,336 80% 434,106

Adoption of 2013

WHO Guidelines

*Source: Spectrum HIV Related Estimates and Projections for Ethiopia, 2014

Focus on Clinical Care & Treatment

• Historically…US University treatment partners led clinical care & treatment efforts

• Partners accomplished what they were brought to Ethiopia to do; time to move more responsibility to Government of Ethiopia

• Promising results from transition of University partners to Regional Health Bureaus in 3 regions demonstrated success and ability to manage funding

• Assumption is that we can achieve same treatment goals, at same level of quality, but more efficiently – across all regions

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014*0

20

40

60

80

100

120

US/Intl Local Total

Achieving Efficiency in Clinical Care & Treatment

* 2014 reflects the COP14 submission, new funds only

USD, in millionsPEPFAR/HHS-Ethiopia Funding, by Partner Type

8

Defining Our Core

Understand: 1. Current state of epidemic—and how it’s expected to change2. National Response: What is USG’s current role -- how might

or should it change? 3. What are roles of other HIV Donors, Global Fund,

Government, private sector -- how might they change?

Design:1. What are the core program elements/critical enablers

required to Save Lives and Prevent New Infections?2. What are the core program elements /critical enablers USG is

uniquely qualified to deliver?3. How and when and to whom should non-core programs/non-

critical enablers transition or end?4. What is the cost of the core program?

We adapted the UNAIDS Investment Case Framework to further focus and rationalize our PEPFAR program in Ethiopia

Prioritizing Activities

• Activities critical to saving lives, preventing new infections - and/or which USG is uniquely qualified

Core

• Activities that directly support our goals and cannot yet be done well by other partners or host gov’t.

Near Core

• Activities that do not directly serve our HIV/AIDS goals and/or can be taken on by other partners or host gov’t or civil society.

Non Core

Must Do

Should Do

Nice to Do

9

• Treatment• Prevention (High & Med Risk)• Targeted Testing• Supply Chain TA• HIV/AIDS Commodities

• Evidence Base (SI, SS, M&E) • HC Financing/Insurance• Training• HMIS• OVC (incl. ES)

Non-Core

• Blood Safety• TA to Private Sector Health Svcs• VMMC• In-School Youth funding to

MOE

• Leadership and Governance (w/ transition plan)

• Community/Peer Support• Ongoing Construction

Commitments

• Economic Strengthening (non-OVC)

• TA In-school Youth prevention

• Low-risk prevention (GPY)

• PPP TA• Infection Prevention• Cross-border• Cervical cancer screening

Near-Core

Core

Defining the Core: Results

Using Data to Maximize Program Investment

Evidence Base Analysis• Utilized most current ANC surveillance data to ensure sufficient support in

regions and refugee sites with increasing prevalence• Tracked those emerging regions transected by major transport corridors and

targeted funding toward hottest Hot Spots• Assessed areas where HRH capacity is most limited and targeted ToT support

Economic Analysis• We utilized national PEPFAR expenditure data to calculate unit expenditures,

which allowed us to ‘cost’ our program’s core interventions • Expenditure data at regional and partner level prompted refinement to certain

activities and regional interventions

Site-Level Analysis• Directed spend toward highest-volume and highest-yield facilities; reduced

spend to facilities with low-volume/low-yield

High Yield Low Yield No Yield0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

22%

51%

26%

80%

20%

0%

SitesHIV+

Geographic Analysis:HIV+ yield distribution across PMTCT sites

80% (14,260) of patients in 22% (371) of 1,668 sites

Key: High Yield = >1 patient/monthLow Yield = <1 patient/month

Stakeholder Coordination

Government

• Years of successful TA and strong Gov’t support ensure readiness to take over Cervical Cancer, Infection Prevention, VMMC, Blood Safety

• Extensive Gov’t led Health Extension Worker program is able to take on more Community-focused activities

Global Fund

• Revolving fund for ES allows PEPFAR to focus on OVC House Holds

• On-going HSS funding can support health infrastructure needs

• Commitment to significant funding of ARVs, RTKs

Civil Society & Private Sector

• Years of USG and Global Fund support have capacitated CSOs to take on more Community and Peer Support activities

• Years of TA to Private Sector providers have strengthened their ability to serve clients and support business

With a more focused PEPFAR program, on-going stakeholder alignment is key to sustain gains and

prevent service gaps

ETHIOPIA HAS A REAL CHANCE AT AN AIDS FREE GENERATION

Thank You