Ethiopia: Focusing our Program
for Impact & Efficiency
Jocelyn Felter Brown
Acting 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
FY13 PEPFAR Expenditures by Region vs. Prevalence and Disease Burden
Bubble size = HIV Prevalence Among Adult Population, 2011
$50,000,000
Amhara
PEPFAR Expenditures (FY2013 EA)
$45,000,000
Oromiya
$40,000,000
$35,000,000
Addis Ababa
$30,000,000
$25,000,000
SNNPR
Tigray
$20,000,000
$15,000,000
Harari
$10,000,000
Somali
Dire Dawa
$5,000,000
Benishangul-Gumuz
Afar
Gambela
$0
0
50,000
100,000
150,000
200,000
250,000
300,000
People Living with HIV, 2011
Source: HIV Related Estimates and Projections for Ethiopia – 2012.
Excludes National and Above National Spending
4
Focusing the Program: Start with Clinical
Care & Treatment
Number of Adults
in need of ART*
National Coverage
Rate & Goals
2013
2014
2015
431,761
530,835
542,632
@69% = 298,336
*Source: Spectrum HIV Related Estimates and Projections for Ethiopia, 2014
80%  434,106
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
Achieving Efficiency in Clinical
Care & Treatment
USD, in millions
120
PEPFAR/HHS-Ethiopia Funding, by Partner Type
100
80
60
40
20
0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014*
US/Intl
Local
Total
* 2014 reflects the COP14 submission, new funds only
Defining Our Core
We adapted the UNAIDS Investment Case Framework to further focus and rationalize
our PEPFAR program in Ethiopia
Understand:
1. Current state of epidemic—and how it’s expected to change
2. 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/noncritical enablers transition or end?
4. What is the cost of the core program?
8
Prioritizing Activities
Must Do
Core
• Activities critical to saving
lives, preventing new
infections - and/or which USG
is uniquely qualified
Near
Core
• Activities that directly support
our goals and cannot yet be
done well by other partners
or host gov’t.
Non
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.
Should Do
Nice to Do
9
Defining the Core: Results
NonCore
NearCore
Core
• Economic Strengthening
(non-OVC)
• TA In-school Youth
prevention
• Low-risk prevention (GPY)
•
•
•
•
•
•
•
•
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
•
•
•
•
•
Treatment
Prevention (High & Med Risk)
Targeted Testing
Supply Chain TA
HIV/AIDS Commodities
•
•
•
•
PPP TA
Infection Prevention
Cross-border
Cervical cancer screening
Evidence Base (SI, SS, M&E)
HC Financing/Insurance
Training
HMIS
• OVC (incl. ES)
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
Geographic Analysis:
HIV+ yield distribution across PMTCT sites
90%
80% (14,260)
of patients in
22% (371) of
1,668 sites
80%
80%
70%
60%
51%
50%
Sites
HIV+
40%
30%
26%
22%
20%
20%
10%
0%
0%
High Yield
Key:
High Yield = >1 patient/month
Low Yield = <1 patient/month
Low Yield
No Yield
Stakeholder Coordination
With a more focused PEPFAR program, on-going
stakeholder alignment is key to sustain gains and
prevent service gaps
Government
Global Fund
• 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
• 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
ETHIOPIA HAS A
REAL CHANCE AT
AN AIDS FREE
GENERATION
Thank You