Ethiopia: Focusing our Program for Impact & Efficiency Jocelyn Felter Brown Acting Coordinator, PEPFAR Ethiopia

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

PEPFAR Expenditures by Geographic Location & HIV Burden with Adult Prevalence Source: HIV Related Estimates and Projections for Ethiopia – 2012. Excludes National and Above National Spending

Focusing the Program: Start with Clinical Care & Treatment Adoption of 2013 WHO Guidelines 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 *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

Achieving Efficiency in Clinical Care & Treatment USD, in millions PEPFAR/HHS-Ethiopia Funding, by Partner Type COP14 local partner funding breakdown (rounded) is as follows: $ 31m RHBs, $ 4m USE (NDFE + Police), $ 5 local universities, $ 3.6m MOH+EHNRI, $ 17m local NGOs (EPHA, FGAE, NEP+, etc) * 2014 reflects the COP14 submission, new funds only

Defining Our Core Understand: Design: We adapted the UNAIDS Investment Case Framework to further focus and rationalize our PEPFAR program in Ethiopia Understand: Current state of epidemic—and how it’s expected to change National Response: What is USG’s current role -- how might or should it change? What are roles of other HIV Donors, Global Fund, Government, private sector -- how might they change? Design: What are the core program elements/critical enablers required to Save Lives and Prevent New Infections? What are the core program elements /critical enablers USG is uniquely qualified to deliver? How and when and to whom should non-core programs/non-critical enablers transition or end? What is the cost of the core program? With success and efficiencies shown w/ C&T Transition, in 2013 we realized the need to focus the program further, to apply a more focused approach to all program areas, with the goal to maximize public health impact

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

Defining the Core: Results Economic Strengthening (non-OVC) TA In-school Youth prevention Low-risk prevention (GPY) PPP TA Infection Prevention Cross-border Cervical cancer screening 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 Near-Core 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) Core

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 80% (14,260) of patients in 22% (371) of 1,668 sites Key: High Yield = >1 patient/month Low Yield = <1 patient/month

Stakeholder Coordination With a more focused PEPFAR program, on-going stakeholder alignment is key to sustain gains and prevent service gaps 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

ETHIOPIA HAS A REAL CHANCE AT AN AIDS FREE GENERATION Thank You