 We're going to get started partly because this is the beginning of Memorial Day weekend and I suspect a few of you may have some plans to enjoy the great weather. My name is Todd Summers. I work here at the Global Health Policy Center at CSIS. This is a great opportunity for us to follow up on some previous discussions and reports that we've done on some of the opportunities and challenges in transitioning our PEPFAR program from a high reliance on some of our international NGO partners to more local partners. Chip and I were sitting together about a year and a half or so ago at one of the other CSIS events. I think it was on the PEPFAR evaluation and people were talking about this transition and he started to vibrate and I said, so what's going on Chip? And he said, well they talk about this transition as if it's somehow easy and simple to do. And in fact it's incredibly complicated and takes quite a bit of time, investment and capacity on both sides. So we promise to do something to follow up with that discussion so we are here today to do that. I suspect that in the coming months you'll see CSIS do some more events on various aspects of this question around transition and sustainability. It's something that's facing PEPFAR, it's something that's facing GAVI, it's something that's facing the Global Fund. It's an ongoing challenge with a lot of interesting and complex side issues and we want to get into those some. So you'll probably see more events that are connected somehow to today's conversation. We have three great panelists and just in the Chip Lions who runs the Elizabeth Glazer Pediatric AIDS Foundation. We have Ania Gipp Hart who's the new medical director for EggPath as well as Paula Vaz who runs an affiliate organization in Mozambique. So we're going to get both the global perspective, some of the countries perspective and then the real perspective from Paula. So we're going to go right through today with having the three of them give some introductory comments and now we're going to move right to you to do Q&A. So we should be done with the presentations in about 30 minutes and that should leave us about an hour for dialogue with those of you who are here. We also have about 100 people who are online. Thank you very much for joining us. If you want to tweet in some questions, we'll try to get those put forward as well. So Chip, over to you. Thank you, Todd. Thank you all for coming and for those that are online for making the time. I didn't realize my vibrating is what led to this, but we do appreciate the opportunity to talk about this really fascinating issue. I should just posit at the beginning. We are not here to suggest one size or one model fits all because that is clearly not the case. On the other hand, we had some very substantial challenges put to us around transition in about 2009 with a hard deadline by 2012 and we feel pretty good about the steps that we took, how deliberate and pretty methodical they were and then more importantly, of course, what the outcomes have been so far three years after that transition. I just want to say a couple words of context to make sure you sort of understand what our thinking has been, where we're coming from. Eggpath's mission, you may know, is to end AIDS in children. We pursue strategies around research, advocacy, and program implementation. We support over 7,000 sites, primarily in Sub-Saharan Africa. For many, Eggpath, Elizabeth Glazer Pediatrics Foundation is synonymous with PMTCT, the prevention of mother-to-child transmission. In fact, to end AIDS in children, we need to do much more than pursue a PMTCT strategy. I think most or many of you know that the challenges around the so-called PMTCT cascade are material to the degree that about a third of kids who should be receiving care and treatment are actually receiving it compared to closer to 60 or 65 percent of adults, particularly pregnant women. So there's a lag for kids. The PMTCT cascade has real problems. You cannot rely on that alone to achieve a mission of ending pediatric AIDS. Therefore, we are very active in several other areas, very purposeful integration of PMTCT services into a broader maternal and child health setting. Health system strengthening is crucial. And of course, this issue of transition, which is not just programmatically important, but it's politically important from a sustainability point of view. Our mission being what it is has evolved. We're 25 years old as a foundation. It was started by Elizabeth Glazer. As many of you may know, she contracted the virus from a blood transfusion giving birth in 1981, her first born Arielle Glazer got the virus through breastfeeding. Her second born, Jake, contracted the virus in utero. Arielle passed at age seven in 1988 and after a period of pretty intense mourning and almost hopelessness, Elizabeth rose up, who we often say like a mother would, and her mission really at the time was to address the needs of one child, Jake. She was bent on saving Jake's life. I won't go through the quite remarkable role that she played, but in no small part, there's a dramatic change in the trend and the trajectory of HIV and AIDS, even the face of HIV and AIDS in the United States. Elizabeth passed in 1994. Jake is alive and well and healthy and working and in many ways, obviously, is a sign of Elizabeth's success in that first small mission of one child who has become a global mission. EggPap was one of four implementation partners in CDC's award called TREC-WAN or called Project Heart. We started in the late 90s in a handful of clinics to make available netherapine, which had been identified as having a material effect on the transmission from mother to child. PEPFAR, of course, allowed that work to scale up dramatically, and CDC came forward and created the so-called TREC-WAN program. There were four implementation partners within TREC-WAN, EggPap, Harvard, AIDS Relief, and ICAP. They were charged within our award to work in five countries, Côte d'Ivoire, Zambia, South Africa, Mozambique, and Tanzania. During the course of the eight years of that award, we went through it with CDC in those five countries, EggPap's role. We worked with over 200 different partners in those countries around care and treatment as well as capacity building. Over 500,000, 560,000 patients were enrolled on ART care and treatment for a million and testing and counseling for 2.5 million HIV positive, excuse me, 2.5 million pregnant women. In 2009, though, at the start of TREC-WAN, transition and transition objectives had not been delineated. It was the follow-on funding in 2009 where that component was introduced by HRSA. It was a goal, a requirement set where the work we were doing, the services we were providing, and so on and so forth, would be transitioned to a national partner by February of 2012. We did that in all five countries in different ways. In South Africa and Zambia, we transferred our work to existing organizations in those two countries, albeit in slightly different ways, which we can talk about. In the other countries, Kotevoa, Tanzania and Mozambique, our assessment was we would need to help create a new organization, one in each of those countries that was mission-focused, that had the capability, the competence to receive direct funding from CDC. And those three organizations have been created. Paul is the executive director of the Fundesale REL in Mozambique, about which she will speak more on, as will Anya talk about a number of other things. Just closing, we went through the TREC-WAN close-out meetings and so on with CDC. They are very much to be commended with HRSA and the other TREC-WAN partners, because it really was a remarkable set of accomplishments over that period of time. They estimated, because of TREC-WAN, that in 2012, 20% of all Africans who had been enrolled on ART was a result of TREC-WAN. That's pretty stunning. The other thing that was kind of dramatic is that by putting in that transition requirement, it forced action, thinking, strategy, decision-making around transition. And I emphasize the word forced. That's very much what it felt like. I remember at the time using words like unrealistic and unreasonable in terms of what this requirement was. In hindsight, not only do I think it was the right decision on their part to take, but it was probably overdue. I think for those of us that believe strongly in sustainable outcomes, sustainable development, and yet sometimes struggle with how best to achieve that, maybe even not agreeing on the definition of sustainability. I think this is a material part and contribution to that strategy. And I occasionally wonder where would we be had we made those kinds of commitments 10 years ago or 15 years ago in terms of methodical, deliberate, measured capacity building in a variety of countries. And finally, it's clearly consistent with the policy emphasis that PEPFAR has placed for several years on increasing national ownership and national leadership. And that's a position and a policy that Ambassador Birx has already spoken to on a number of occasions. So it fits. It's not just a project outcome. It's an integral part of a larger policy and strategy for PEPFAR. There are a bunch of issues attendant to that, though, from definitions and timeframes and costs and so on, and that's what we'll be able to get into a little bit more. So you're going to dump that on Anya. Like I do most work. Thank you. Anya, welcome to your new position at Eggpath, and I think you're going to tell us a little bit about some of the opportunities and complexities that Chip alluded to. Yes. Thank you. Like Chip said, you know, it did not only fit in the overall picture of development. I think the whole transition did also very much fit in what the organization has always believed needs to happen. And even all our other existing programs work through ministries of health, work at district level. We provide at the moment over 200 subgrants to local entities. So the whole experience did fit very much already in our beliefs of long-term sustainability and local ownership. But like Chip said, the timeframe was slightly different than we maybe had in mind initially. So also like Chip mentioned, we did establish the three affiliates in Mozambique, Tanzania, and Côte d'Ivoire. Because after our assessment, knowing that we had to transition to national entities, either government or NGOs, we didn't find any suitable candidates at that point in time in those countries. So what does it really mean, the affiliates, and how do we relate to them? It's really based on the idea that to fulfill our mission, we need to work with lots of partners. And that's also what we share very strongly with our affiliate organizations, the same mission to eliminate pediatric HIV. The other tenant that's really important for this relationship is that there is this assessment of capacity that is continuous. We have an accreditation review where the affiliate first looks at a number of critical areas and does a self-assessment, and then later on ACPAP comes to verify and discuss what are the areas where additional support could happen. The other area is really that we continue to work together and see where the capacity needs to be built and how we share lessons learned, because we learn as much from the affiliates as the affiliates learn from us, hopefully. So how did we go about it? We initially started in those three countries with our existing ACPAP staff who looked at recruiting a highly qualified board in country, created bylaws, registered the affiliate, and then subsequently we started out by providing a sub-grant to the affiliates so that they could get the experience of actually supporting program implementation. We did that also with actually seconding some of our own staff to the organization. This created the situation that they did have a track record and therefore were able to subsequently secure funding from the U.S. government. And at the same time ACPAP also was able to secure follow-on funding to continue supporting both program implementation but as well also really support to the affiliate on a longer-term basis. And I think that transition, at least for us, I think has proven to be very successful. It was very well thought through. It was stepwise. Like I said, initially we were responsible for the service support in certain areas. Then it was transferred to the affiliate but through a sub-grant, so still ACPAP was ultimately responsible. And then finally the affiliate did receive their own funding to continue that support. But then again we still had a relationship with the affiliate through the affiliation agreement and with the funding to continue looking how that went and where support was needed. And I think that has resulted that in all those three countries the affiliates has been very successful but also their program implementation portfolio has continued to grow and the sites that were supported through this never had a gap and services continued without any fault. So I think one of the challenges that we're facing currently is really to see how are we moving forward both having ACPAP and the affiliates in country and what is our role going to be. I think talking from what Chip said earlier the Elizabeth Glazer Pediatric AIDS Foundation has evolved a lot over time. We started out really focusing on advocacy, putting children on the HRV agenda and providing funds for the necessary research. Then when there was a way of preventing mothers with child transmission we started getting much more involved in program implementation and support because that was the biggest need. I think now we are evolving more and more working at a global level working with UN agencies, with PEPFAR, with Global Fund to see what needs to be done to make sure that children do stay on the agenda and the elimination is very much in the forefront. As well that we also just recently received a TA Award through CDC where we have the capacity now and the capabilities to support countries receiving PEPFAR funding as well as Global Fund funding and provide technical assistance. I think we're again evolving into a new area. Having said that, with our mission to eliminate pediatric HRV we do feel strongly that there is a role also for us at the moment in program implementation and country presence but we're figuring out when do we transfer that to more TA and providing other types of support again. So that's kind of maybe where I hand over to Paula. That sounds so lovely. So Paula, what's the reality? I was just going for you. Thank you. So I'll be speaking on behalf of Fundosan Real Glazer. We are a local organization working in Mozambique to achieve that vision of eliminating pediatric AIDS at country level. I mean it was difficult but I'm sorry, I'm just playing with this. There you go. So we are one of the three affiliates and in Mozambique prior to the transition Elizabeth Glazer Pediatric AIDS Foundation worked in four provinces and in a period of two years there were two provinces that transitioned from Agpaf to Real. So by transition we mean that both the staff and the activities in that province entirely transitioned from the international organization to the local organization. And in this transition period we had to grow and deliver high quality programs at the same time trying not to jeopardize the gains that had been done by Agpaf over the years. So it was a huge challenge. We had an advantage of being affiliated to Elizabeth Glazer Pediatric AIDS Foundation. That meant that we received a lot of support at the beginning. We didn't have to create the systems, the policies and everything, we just adapted it. But we had to hire staff and we had to run. In this slide I had two kind of highlights aspects that I think are critical for the success of this overall transition process that happened in a really short period and with fairly good results. In three years we have moved from one staff to 98. We are now providing support today to 190 sites. In three years we have provided counseling and testing to more than 300,000 people and we have nearly 110,000 people on antiretroviral treatment. So it was huge to achieve this. And I think that I would put it in three categories internal growth, program implementation and networking. And I think that if I had to point out the most important factor for this, it's human resources, the staff. The staff are critical to achieve success and we had the opportunity to hire skilled staff. The staff is 100% national. We have board of directors that is national but ECPAF has appointed a representative in the board of directors that the representative stays here in Washington but participates in the governance either sometimes being present or at distance. The governance structure also plays an important role in the overall conduction and the guiding and orientation of the way the organization is structured. And is actually implementing the programs. So besides the staff I think that it's very important that from the beginning we have a strategic thinking and we actually conduct a strategic planning involving all the actors in place. Not just ECPAF but other partners, international partners or local partners, donors, we have involved the CDC and other donors in country and it was a thorough and deep thinking while we were structuring our strategic planning and actually our strategic planning has been our backbone to not to lose our mind while we are growing because there are so many opportunities and so much to do that we really need to have a strong backbone. And of course audits. The affiliation agreement allows ECPAF to do an accreditation of the affiliate and we consider that accreditation process as an organizational audit. They come, there is a team coming from Washington and that team does a thorough review of programmatic and operations and governance in every area. And it's very constructive during the accreditation process. We identify strengths and weaknesses and based on those weaknesses we build an action plan that actually helps us to focus on our weaknesses and have a strong and fast growth. At the level of program implementation I have already told about staff and by having local staff with the thorough knowledge of the local context, the cultural, the health, the environmental issues is very important. We work very closely with the local structures, the Ministry of Health, the local partners at all levels and I think that deep knowledge facilitates us implementing in a better way. We are more, I would say, more easy to adapt to the country changes, to the country needs and we are always trying to innovate and to think ahead of how to deliver better programs. And networking is also important. I think that we haven't paid enough attention to communications and communication is critical, internal and external communications. Not everybody knows about this process. The transition process had lots of question marks at the beginning. As Sheep said, it was a bit forced and everybody thought, who are these locals? What are they going to do? I mean, local organizations have a better reputation, especially for mismanagement and also at the technical level. So we have proved that we can deliver both technically and financially and our portfolio is fast growing. So I'm sorry, my being back. So I would like to thank you for your attention and I'm looking forward to your questions. Thanks, Carl. I'm going to put you on the spot in a minute. One of the things that we did recently, Steve led a delegation about a year and a half ago to South Africa and I was on a follow-up discussion or trip last spring. Both of them looking at the issue of PEPFAR transition in South Africa, which is one of the leading countries to move in that direction. And we identified a lot of positive things but also a lot of challenges, particularly in actually transitioning patient care from one provider to another. And one of the challenges that we saw was as the South African government took over responsibility, its translation of what that meant was actually taking over the programs, literally. So they were hiring the doctors and nurses that worked for the NGOs into government positions and not hiring a lot of the community health workers who had been the backbones of those programs because there wasn't a coding in government employment for them. So they were, at least in the views of some, kind of eviscerating the best qualities of the NGOs that have been surviving and doing work in that country even under very adverse situations. So I'm wondering if you could Paul tell us a little bit around how has it been working with the Mozambique government and you as an NGO and how does this interaction on the international place work and then maybe if you have some comments on that and then we'll turn to Karl who runs another large NGO. I think we have some thoughts on this and then we'll turn it to others. Thank you. In Mozambique right now we have this acceleration plan. It's a minister of health acceleration plan for improving access to 80% of the eligible people until the end of next year. So people are virtually running against the clock to do a massive scale up. So the minister of health itself was not really sure about are these international organizations transitioned to local organizations that have not yet performed? Is this going to mess up with our plan of getting more people on treatment? And yes, the curves continue to grow. Today there are two local organizations. The local organization that was created by ICAP and us that are affiliated to EGPATH and the two organizations today account for 25% of the overall patients in the country. So it is a growth and the numbers just continue rising and that has helped the minister of health to be confident in the local organizations and I mean it's not a big country. It's a 20 million people country. So there is a network in health and we kind of have created confident relationships and the local governments have greeted us with every year we have been awarded this diploma of recognition from the government that Knowledge Rial Foundation has a performant organization and I mean it makes us proud. We have a very good relationship with the minister of health. Yeah, to answer your question I think our experience in the three countries Cody Vartanzania and Mozambique has just been very different than the one in South Africa and so in those three countries it wasn't the government who was taking over from our original support it was the affiliates who took over and as I just earlier described I think there was really this faced approach where there was a lot of follow-up and discussion between the two organizations supporting the sites. Also I think what is different in South Africa that there are a lot of seconded staff working in the facilities I think that's the seconded from ECPAF. Yes, seconded from ECPAF to the facilities while in the other countries we have that far, far less there might be some seconded people but most of the time it's at like a national level supporting overseeing a much larger scope of work but not actually healthcare providers that are ECPAF employees providing the services so I think that's made it very different. Todd also in South Africa of the five countries it was the only country where by virtue of the Favillon awards that were made ECPAF transitioned 100% of its programmatic work all of those staff that had been seconded were moved into Department of Health for example or into other organizations Health Systems Trust received Favillon funding to take that handoff if you will with the transition and it's the one out of the five where ECPAF did not have an ongoing role we don't have a presence in South Africa anymore and so have a limited window on the subsequent actions and the patient care after 2012 whereas we're still in the other four countries in some capacity or another. Great, so we're going to turn to you for questions or comments there's a couple seats up here if you want to come have a seat there's some here. Carl I just noticed you here I'm going to put you on the spot but you run another international NGO and you certainly have confronted this issue it would be great to get your perspective Lindsay will give you the mic so the people online can hear. Thank you very much Todd and thank you to the panelists very interesting so I'm Carl Hoffman I run a PSI Population Services International and as Todd says we and everybody else as a series of national offices our presence strategy faces this challenge and also is getting a lot of pressure from our US funders in particular to follow the sort of path that you described and so one of my questions was about the governance relationship between the two organizations but you already answered that followed by saying that ECPAF sits on your board in a minority capacity it sounds like I guess I have three other questions and let's put them all under the heading of financial related so the first question would be what's the financial relationship like between ECPAF and the Fundaceo the second is under your affiliation agreement could the foundation partner with another international NGO receive funding through another international NGO or are they tied uniquely to ECPAF and third and perhaps most important you know our friends at CDC and at USAID but certainly at CDC sometimes believe it or not have problems with funding cycles so what happens in that period when in the case where CDC may be funding the activities of the foundation what happens when there's a three or six month gap in the cash that they're prepared to provide does ECPAF step in three finance related questions go ahead well thank you for your questions we are let's say financially independent because we receive our grant directly from CDC though we receive a small grant of private funds from ECPAF that it's like it creates a bit of a cushion if there are other activities to be financed that cannot be funded through the CDC grant I would say like we have published our strategic planning or our first year of activities or second year of activities we use that money so we are accountable to CDC through the affiliation agreement I think that is a contract that does allow the two organizations to independently partner to other organizations either national or international I mean it gives us freedom to do that and finally we have been lucky with that funding cycle but if we say like you've given an example of five or six months without funding it causes huge stress I don't have yes I don't have yes so we got online so use the microphone so I think you're saying that most organizations don't have unrestricted funds well many national organizations even those that we have helped create might have very limited unrestricted funds or they might rely on the original partner for a grant to help them do the sorts of things that funders won't fund but for the major core activities I'm sure this is the case for Chip and his team I mean we essentially wind up funding CDC during long periods when they are between funding cycles and the same is true with USAID and it's more than probably the young foundation can do and I think it's a real challenge it's a real challenge please it's definitely a challenge and I think one of the types of support that we are moving into now compared to initially like Paula said working on the financial system and the HR systems it's now really focusing more and more on resource mobilization and diversification to try to at least be ahead of the game but it is definitely one of the challenges I think the unrestricted limited or no availability of unrestricted funding to do these things Carl can I add a fourth financial bucket point that you kindly didn't ask which is what happens if Arielle and Eggpath are pursuing the same funding source for activity in Mozambique Paula wins right I would never dare to compete with Paula Paula but we just this spring we have a little program review with Paula and the executive directors of the other two affiliates the short answer is we don't know exactly it's just going to take a cold-eyed view of that our commitment is for the growth and the sustainability of Arielle and Mozambique and so there's a sort of premise into Paris position there but what is the donor looking for what are the criteria in particular can we partner for something like that at a certain level it would look like both organizations would want to pursue that but that doesn't make sense for us to compete with each other we don't intend to or want to do that but it also requires on the international organization a real comfort level with the client in resources I mean there's 30 million dollars right now in direct programming assistance through the three affiliates that six years ago would have been at EggPath is your board comfortable with that there are watchdog organizations that ding you if you don't show consistent growth by virtue of your bottom line which is to my view nonsensical are you more effective 25% smaller than you were five years ago I think that ought to be probably the first consideration but we've internalized these things we are comfortable it helps to be really focused on the mission and to know that what you do well is focused on the mission we want them to succeed or invest in their success and you have a global agenda so you also could run the risk where one of these affiliates isn't fulfilling the responsibilities that you see as needed to accomplish your global agenda so what do you do if they fail their review and you feel a need to basically go in and do what they're not doing well I frankly think we can't go in they are independent organizations so we can I'm into the country not to the organization because otherwise I would say they are independent organizations and we can advise and if we really feel they are not performing we could break the affiliation agreement but otherwise they make their own decisions and that's absolutely true but there's also the component if they're not meeting targets for example the conversations are also with us because of the nature of our collaboration but those conversations are also with the donor and it doesn't go from accolades for your progress to we're cutting all of your funding right now so I don't know that it would be quite as abrupt as you described and I don't think the first response would be let's get egg path back here we'd have to go through a very deliberate process directly with the affiliate but we in different ways formally and formally would be a part of the conversation so questions from folks who are here have one here why don't we do a couple and then we'll get people to respond in groups so hi Rachel Desim at Intra Health I'm curious to know we've talked a lot about the international financing and I'd be curious to hear about national financing the role of MISAU or other health financiers within the country and in addition from the human resources perspective Paul I'd be really interested to hear also about the communication strategy you had with health care providers themselves on the ground and how that transition took place thanks other questions over in that neighborhood over here well why don't we take this one while you sort of work up your courage because I've got lots of questions so we're going to bore you to tears if you don't start raising your hands so let's go with the question around sort of your communication with some of the local health workers and some of the local funding sources talking about the local funding we are also looking internally MISAU the Ministry of Health is not a potential funding the Ministry of Health itself is struggling to get funds to run the programs on a routine basis but there are potential for public private partnerships and we are exploring that Mozambique has been known over the past couple of years for lots of local resources that have been recently discovered there are lots of national and international companies exploring that and we are working on to establish PPPs with them in order to raise some money and appealing to their social responsibility in what relates your second question about communication with providers at the health facility I mean it was it was easier easy it was relatively easy because we were working at the province level with the teams that were already in place and with good relationships with people at the health facility and we prior to the transition we started communicating about the transition process the meaning of it and ensuring that there won't be differences in terms of support provided financially or technically and based on that open communication we had lots of meetings at provincial district and health facility level and it has worked well there was not a change in the people that were actually providing support at the site level so yes Paula, you emphasize that some of that activity happened before the transition how did that get funded if Ariel didn't exist yet how did you get to conduct those kinds of activities that were contributing to the transition process that said the transition didn't happen all of a sudden while we were created there was a gap between the transition of one province and there was a six month period of preparing the transition of the first province and then a one year period before the transition of the second province that allowed us to do transition preparation together with that so one of the things that must worry you a little bit I assume is now that you have over 100,000 people for whom you're providing direct treatment that's a lifelong responsibility it sounds like most of your funding is coming from here how does that make you feel do you have anxiety around the ability to be able to sustain that support over a long time are you looking for the most government to kick in are you expecting that the mineral resources have been found how do you see 5 or 10 years out into the future that's right there is a bit of anxiety around that it's not just at the personal level or at the organizational level I would say at the country level at the global level there is a general anxiety about all these people being put on treatment and the resources needed to guarantee treatment life treatment for them I would say that we are building on and we have great work doing through health system strengthening I mean we are building local capacity that doesn't mean that the funds will be there but there is an increased political commitment for the government to absorb the programs progressively and we are working towards a second phase of transition that is transition the programs to the government from the local NGOs like yours to the government interesting Admiral Tom Cullison from Uniform Services University I apologize for arriving late and you may have covered this in your remarks before I arrived but along with Todd's question with that many people under treatment that requires healthcare workers and professional staff to carry out those responsibilities for many years does your organization are you concerned about the number and capability of the staff that will do this to support efforts to educate, train and develop that staff yes, we we have 98 staff 98 staff is not enough to provide treatment for more than 100,000 people what we do is providing support to the existing minister of health structures and health facility levels we do a direct technical assistance work we do a health system strengthening we do capacity building we do lots of training and we also have a system of sub-agreements in place by which we allocate a certain amount of money to the provincial health directorate or to the district or to the health facility or to the nurses school to train people and by that sub-agreement we we do a joint planning and we kind of negotiate the targets to be achieved and the activities or equipment the activities to be done or the equipment to be bought in order to achieve those targets and that's the same for training we are providing sub-agreements to improve and to increase the training of nurses medical officers technical pharmacists lab people so that more staff will be there to be able to accomplish Anya what does that look like in the other countries that you're working in and what do you think is the situation that Paula describes we have the same approach we don't have ACPAP clinics or anything like that ACPAP doctors we work through the existing systems like I started out saying that really from the beginning when we started supporting those programs it is working through the existing systems supporting either ministry of health facilities or some of the it's their staff that are actually providing the services but our role is to make sure that they have the technical skills that they have the knowledge either through training or through mentorship to exchange visits or things like that and like Paula said also supporting the facilities that they have the actual physical space to do things in the right equipment but it's not ACPAP who are delivering the services we are supporting the existing sites so I think like Paula mentioned our vision is that the transition goes in steps and it goes maybe first in some countries to a local organization that's providing that support or it's continued through what we are doing but ultimately the sites and the system should be able to provide these services they might then still be depending on funding to do that but at least the capacity and the infrastructure should be there to continue that and then I think the final step will be the financial responsibility back to the countries but that might be quite a bit longer but it's really this whole capacity building and health system strengthening within the existing systems and within the existing services we didn't talk much about integration within maternal and child health services but that's another way where we never set up separate prevention of mother to child transmission clinics or anything it's all within the existing maternal and child health services. But that's an interesting question and maybe it's an adaptation of Carl's questions around financial capacity to do things that aren't directly related to your contract so if you're getting a contract with the CDC to provide services that are specific to HIV maybe there's some flexibility around some related health systems but if you're getting into integrated delivery of child health services that's a whole range of things that are probably not going to be covered with the CDC contract. So how do you deal with your want and desire and need to plug into a broader approach when your money is still pretty tightly structured around HIV? Yeah, I think from the beginning we have always been very strong supporters of more integrated support. Most of our people that we work with in our countries they were never HIV specialists. They were always doctors and nurses who provided support and services to all the different diseases. So initially we kind of did it more secretively. We did some work in the delivery room and with the idea that you know we sold it like well if women don't come back to deliver we can't single those in the therapy and what was the initial thing. So we kind of played it that way. I think later on in PEPFAR it became almost a prerequisite to actually have a broader impact and so I think it is much more possible but our role at a global level and with PEPFAR and Global Fund is still to push more for this integrated services and being allowed to use our funding for broader health system strengthening which I think is really the direction that we're going and moving PEPFAR from an emergency response to a much more integrated response is I think the right way and really helps us do what we want to do all along. It's an interesting point but I'm curious how people here see this but I know when we were in South Africa with the health staff and we had this discussion around moving away from being in the front of delivery and often funding the direct delivery of care to stepping behind and actually being more involved in health system strengthening the hill staff started vibrating too and they said well you know the mathematical benefit of saying this much money from the US government provides this treatment that saves this many lives has been extremely helpful for PEPFAR's funding when they were asked how you're going to measure health system strengthening somebody got up and said well we have a 13 matrix that's developed and the political people were like oh my god so I think what's going to be really interesting is as organizations and PEPFAR both broaden their work but also look to be more supportive as opposed to directly funding the provision of care how do we measure that in a way that's still politically satisfying and keeps the funds flowing I think that's got to be an issue for some so a couple hands over here Christine you're going to tell us how to solve that problem right? So like Todd several of us went to South Africa last summer and actually I will be more candid what we saw about transition was actually very disturbing there at least in the Durban area in terms of tracking patients in terms of capacity of public health clinics to provide care so I'm very heartened to hear about your model and it seems to me it's the kind of process that should go on irrespective of whether a country is ready to quote so-called transition certainly financially so my question is how is your experience and the kind of program we're hearing about today locally grown with your help in Mozambique being communicated to the broader PEPAR community because from what I hear I mean things are different in different countries Track 1 partners had different processes for transitioning and so for example are you all presenting at the PEPAR annual meeting June 1st through 3rd has this been written up by your teams there's a couple other hands over in this neighborhood up here Hi, I'm Debbie Cleil from USAID and it's sort of a similar question but thinking about monitoring this transition and how you're measuring what's happened are you thinking about doing an evaluation of this or is there an external evaluation going on of how this transition is working in Mozambique great, you want to give it to Janet and then we'll do answers and we'll come back over here this is very much in the same vein, I'm Janet Fleischman with the CSIS Global Health Policy Center and I had the opportunity to meet with your affiliate and your regular egg path team in Tanzania a couple years ago as this was all underway so it's fascinating to hear some of the experiences in Mozambique as well and I guess one of the questions I had is to draw out some of the other lessons learned from this process you were candid in saying this was really forced by CDC so I guess questions like do you have enough time has there been backsliding how have you measured that what would you recommend for others that are undergoing this transition what are some of the key things that they need to know if they're going to undertake a transition somewhat like the one that you have done even though they'll all be different we'd love to hear your thoughts thanks so a series of questions but all related why don't we work our way through and Chip you want to come back with some answers it's a straight forward question but there's a lot to it in the answer so what advice or what should be considered where one is thinking about forcing this transition as a part of an award or what have you at the beginning I said it very much did feel forced unreasonable and unrealistic in terms of the time frame and I went back and forth on that because and I've settled on we like many others might have been kicking the can down the road if we hadn't had a really hard deadline when we had the close out meeting with CDC at the end of the award a senior CDC official was extremely complimentary about the egg path component and I'm sure he was with other track one implementing partners but he referred to what had been accomplished over that eight or nine years as epic which is not, I don't hear that word very often in terms of program accomplishments and impact so it was gratifying to get but I was very quick to say it's because we had epic resources we can do these things I don't think there's a lot of challenges and we'll fall down and make mistakes and so on the key two points I would say to anybody that's having to walk down this road as Carl said two key questions to ask are what kind of time frame are we talking about is this a two to three year process or is this a five to seven year process or a seven to ten year process are we clear and agreed on definitions what is transition transition to whom by whom you can have a definition the transition is entirely to government at a district or even a sub district level I'm reasonably healthy but in my professional lifetime I don't think we're going to achieve that definition of transition we've succeeded in terms of three years of transition model we've pursued but there are people have different views and definitions about what transition is that's got to be tackled to go off with different kinds of assumptions or hopes even we're going to be in real trouble and then are the resources commensurate with the outcome sought or the targets and we're in an environment of flat or even declining depending on how you crunch your numbers we're in a period of targets being increased with the same or fewer resources so where are the resources going to come from that pay for the incredible amount of work that goes into planning and executing transition strategies and being able to recruit and retain the kind of professionals like Paula and other colleagues who are fully capable of doing it but with what definitions over what period of time with what resources and those things can't just be wished to appear somehow particularly in the present financial environment Anja to answer your question as far as I know there is no external evaluation planned we are in the process of writing up our experience I think we deliberately waited for a while to start doing so because we did want to see it I mean it's one thing to establish them and to secure funding which in itself was a success but then to be able to really describe how then the affiliate started working independently is a different story and so we are in the process of writing that up we would welcome any venues to talk more about this we're happy to be here today we did mention it when we had a meeting with Ambassador Birx recently he also really shows some of the work that we've done and might be of value for PEPFAR so to answer your question in terms of what else did we learn I think one of the things that we learned as an international organization and that we weren't really anticipating is what effect it had on our own teams in country because I think we were so focused at the affiliates and making sure that they got all the support that they needed to be successful that we to be honest kind of forgot that we lost a lot of valuable staff to the affiliate and we didn't think that that weakened our own teams and that we needed to pay as much attention to them as to the team on the affiliate so I think that's really a lesson learned that we maybe foolishly hadn't really thought about it. Can I just comment on that as well with the whole dynamic also of when we seconded EGPAP staff to the new affiliate so it wasn't as simple as that but Friday afternoon at 5 o'clock you work for an international NGO Monday morning at 9 a.m. you work for a national NGO folks were nervous for them that was a risk do I want to leave the prestige of working for an international organization to work for a new organization whose board is just coming together whose executive director has just been appointed who doesn't have the same reputation you'll notice the Arielle Glazer name in all three of the affiliates that was one way they felt that it was affiliation but also the the connection to the international organization they felt however sort of ephemeral was was a connection to an international organization that there was a kind of implied credibility that went with that but I think there are real kudos necessary for the risk takers among the staff who wanted to sign up for this new idea of a brand new organization being stood up in relatively short order with a uncertain future about dedicated funding from outside the country etc etc etc so that's just one a couple of examples of it but the the management questions about recruiting and retaining staff seconding them or not do you second your very best you know perceived very best staff but what about us we're still having to perform we still have funding there's some really complicated human resources and human resources management questions in there Paula yes I think that I would agree with you this overall thing could happen without appropriate levels of funding and the premise for this is that the funding is available but that said I will repeat human resources are key in this overall process and I've testified other models of transition and in this context I really praised the ACPAP affiliation model because it has provided us the support we needed from the beginning it has helped us identify what we needed to grow quickly because I compare these two kind of jumping on a train that is driving fast and I mean we are jumping there naked and we have to put the clothes naked and you have to put on the clothes and the clothes are not supposed to be and you need to drive the train not to let it derail and I mean there are so many things happen at the same time and if you have a strong mature organization at your side giving the hand holding your hand and helping you through the process I mean it's a great start you you really have you fit on earth and that's what the affiliation model has provided us that good start can I just add again of the three affiliates in Cote d'Ivoire the person that became the executive director of the organization was former egg path he was technical director at egg path and then became executive director whereas Paula and the executive director not ours but that affiliate executive director also came from the outside so they hired as independent outside so it wasn't just wholesale egg path material sort of cohort of egg path in those early days that allowed for you could have a meeting they opened at 9 a.m. again I'm being simplistic but open for business 9 a.m. on Monday they could have a staff meeting at 2 o'clock and talk about where their systems were and where the etc in time though quite obviously as they recruited they were pulling from much wider sources to bring in the staff to implement that they needed so any questions over here hi I'm Juliette Glastroth from Friends of the Global Fight I know we're talking about PEPFAR specifically today but I'm curious in the long term resource mobilization vision what are your plans to integrate with the Global Fund or collaborate with the country coordinating mechanism have you had any interactions with them to date and in this in the new funding model you know there's this desire for a more holistic country planning process how are you integrating into that thanks back here and then Steve hi my name is Natasha Sokolski and I'm with FHI 360 I have two questions the first is with regard to the three countries where you deemed it appropriate to set up an affiliate you mentioned you couldn't find suitable organizations to transition to so I'm wondering what criteria you use to determine that and then secondly around the issue of working for an international organization one day and then a national organization the next what the approach to salary has been and salary differentials in that regard I'm Steve Morrison CSIS thank you so much for this my question is about where do you see the growth in your programs coming in the future I mean the changes that you've enacted were ones that occurred as you described at sort of the end of the epic period right you had a strong pipeline you had very ample resources you had some major efficiency gains achieved so it's possible to to have continued growth in the last several years with what seemed like relatively flat resources but we're out of that period now and we're moving into a period where it's really not clear where the next growth is going to come from if it's not coming from partner governments or if it's not coming from private sector sources like the people seem reasonably comfortable with the thought that the USG can hold the line in terms of its baseline commitments there's been resilience there's a little support for that but people are not expecting any major step up of resources and we've gone beyond that period where the pipeline was huge the efficiency gains were very good the reallocation of resources and that sort of thing so what happens next what next so a series of questions Paul start with you well we have been working with the country coordination mechanism in country we have been working on the current proposal and we have started like observers observers but we aim at go further step ahead and check if we can start by being sub-recipients because the main recipients are clearly defined and explore it further during these three years we have applied we have submitted many proposals and many weren't successful but it was a way of creating capacity within the team and recently some of them have been awarded and we are slowly increasing our funding diversification and we are preparing the future ahead by stepping a bit out of HIV and integrating HIV into child survival and we have been recently awarded proposals on the nutrition field that is one of the pillars of our strategic planning so we are slowly preparing the future can I add on the global fund question from an egg path point of view we are a sub-recipient as a technical technical agency relationship in Lesotho for example we participate in CCM process in a number of countries and so on but there's a fundamental challenge there we'd be very interested and we think able to play a larger sort of formal role with the global fund as a principal recipient potentially but there's a structural impediment to that which is the cost and which is the cost recovery policy and so on so you know a 40 million dollar principal recipient grant is going to cost an organization depending on their micro rate 3, 4, 5 million dollars to subsidize that grant that's real money and we don't have that in an unrestricted budget nor do we have donors that would pick that up so we've got concerns because we've been asked to we were asked to in one country to submit a letter of interest to be a principal recipient it was a hard decision to decline to do that because we knew we were capable of it it's a substantial resources but that one would have been nearly 5 million dollars from an unrestricted budget that it can't doesn't have that kind of capacity to play that role so you have the invitation you have the competence and then you get blocked so there's no lack of interest in integrating I think was your word or engaging or bringing organizational and professional expertise to the table but there's a it's prohibitive for many not for all some are very good figured out how to do that or have angel donors who will cover that because you can make the case you put a dollar in you're going to get a $10 leverage by virtue of that you know that's a easy point or comment to make that into a donor is prepared to come up with 4 million dollars for that to cover somebody else's over and it's not like or getting the government to pitch in some resources because part of the other challenge of the global fund is it has co-investment requirements and since half of its grantees are NGOs where does the co-investment come from I think the expectation is the government is going to pick up that share but it's a bit of a problem in a lot of countries. Anya you had a question around the salary scale how did that work in criteria? It's a very interesting question because there is no one answer fits all three affiliates all of them started with like salary scales that were kind of based on the experience of ACPAF just because that was the easiest but all three of them have evolved in different ways none of the affiliates have international staff which we do have in Mozambique and in Tanzania we don't have in Côte d'Ivoire so that's a difference we have by the way also a number of other countries ourselves no international staff but we happen to have in Mozambique and Tanzania subsequently when they started out kind of at the same level there have been different past taken by different affiliates one has argued that because they do not have headquarters that provides them with support the responsibility of the technical director for example and an affiliate is more than the one in the international organization so they have they have argued that their salaries need to go up and then another affiliate they have really tried and I think it also has to do with the local labor law but I have to be honest I don't know exactly their salary scales ended up being lower so I think again they are independent organizations they can decide what they want to do with their salaries but it has gone both ways your question around the criteria used when we were looking at that I wasn't at headquarters I actually was in Tanzania so we looked at organizations in Tanzania that we felt were able or good potential candidates to take over the responsibility and we looked both in terms of technical capacity managing whatever 10 million dollars of grants as well as some level of shared mission and those were kind of the three main buckets that we looked at to see in Zambia for example we did transfer to an existing local organization SIDERS and we had been working with very closely in the past already so we felt very comfortable there so I hope that answered your question so when you're going to come back and answer Steve's big question which is you know as you see expanding or unmet needs you talked about your percentage in the beginning we're still seeing quite a bit of coverage deficits on the basic PMTCT package much less the broader pediatric HIV and the broader child health agenda in an area where the major donors are showing less interest in giving more and where there's quite a bit of effort put in to even hold the line on what we've got Gavi announced recently its request for its replenishment and frankly it was relatively modest the Global Fund just had a replenishment and asked for 15 and got 12.5 or 13 depending on how you count so you know as you sit in Mozambique and you look out at the world particularly the donor world where do you see new money coming in for you to address all the unmet needs you see day in and day out where do you see opportunity and where are you most concerned that's a tough question the important amount of money really comes from the US government the other donors play a different level of funding it also depends on whether we continue to just work strictly on the HIV or whether you broaden up your portfolio thereby increasing your chances of getting some other funding opportunities and also we in Mozambique can't exclude the huge opportunities that we have now in country with all these huge gas and coal reserves being explored and those natural resources that in some ways should benefit the country my brain is saying China, China, China I don't know why Steve let's get a microphone to the affiliate countries how is it going to be possible in those three countries to get the respective governments to take on a heavier commitment I mean that at the end of the day is the code that no one's cracked yet in terms of sustainability and some kind of real transition towards the countries owning this problem the growth is not going to come in this next decade it's going to be internal sources so if there's going to be growth it's going to have to come from internal and what's the strategy and how do you see the prospects for it it's a very good question because actually as an answer to your question I was thinking when I attended the IKASA meeting in international consulate service organizations it's the Africa IAS meeting different IKASA there was a lot of talk about you know country ownership in terms of countries stepping up financially also to start contributing more and I think you know there are quite a number of low income countries already moving into becoming middle income countries and how are they indeed going to take more responsibility to be honest it's a very good question I'm not sure if I have the answer exactly how we are going to contribute to that discussion at country level and make them start thinking more about that but I do think that is the way that we need to go there is no way that we can continue expecting the US or the European donors or China to come up with more money the countries have to ultimately step up to the plate as well and start contributing more Steve I don't think anyone has a great or very specific ideas about that but there are solutions rather Kyle does but he's not going to tell us I do but I think there are at least two things that have to happen and maybe I should just posit this will be a personal view instead of an organizational view people are going to have to get squeezed people don't respond well if you can get away with a certain amount of complacency or expectations that it's just going to be ever thus at this funding level and I think a part of when that squeeze comes because depending on who you listen to and what numbers you can count on or what time frame we're talking about it could very well be that that squeeze comes I think it is so important that we have partners like Arielle in Mozambique programmatically and technically but also from a civil society voice point of view Paula can make a case to a minister of health or to other officials in Mozambique I can do the same guess who they're going to listen to and it's not me so the I think the integrity of a Mozambican organization and multiple Mozambican organizations that are talking about circumstances in Mozambique that have their own expertise this isn't about the outsiders coming in or the donors coming in etc etc I think and that's over quite a period of time I think that's probably the most effective and the crucial step in terms of advocacy or lobbying whatever you want to call it for increased national level investment the meeting that Anya was referring to the sort of Africa AIDS conference the last two I've attended on and out of December last in two years previous both times I left struck by the number of Africans at the meeting who were demanding more of their own governments they weren't standing up and saying why is PEPFAR reducing or why is this donor there is an expectation whether it's pride or realism or growing economies or natural resources becoming available that far more needs to come out of national governments I think the other component of this is maybe ironically or unexpectedly is programming effectiveness by which I mean the kind of progress just the last couple of days in Geneva we went through a whole bunch of stuff around the global plan to eliminate pediatric AIDS and so on it's just remarkable what has been accomplished over the last five years and this is almost a you know a weaker argument but at the end of the day the investments from PEPFAR what USAID is doing what CDC has done what implementing partners are achieving are quite remarkable and yet we're still at 30% coverage for kids we're less than 70% coverage for adults you know I don't know how long it will last to say have the argument be you can't cut now I wouldn't want to put total faith in that as a political argument but it has the virtue of being true we will lose huge gains if there are material reductions in the budget so at the very least the call has to be for maintaining funding levels over the next several years but I have not myself sort of figured out what the magical argument is or strategy to change that I think we have to hold or expect or at least call for more on the outside side the Brits can't they are being spectacularly generous and they're funding lots of things but this isn't going to rise or fall just on what DFID is able to do and I think the voices of civil society calling for their own investment I think are going to become exponentially more important from a sort of 5 and 7 and 10 year perspective for new resources Carl let me give Carl a microphone I just want to get a couple closing comments because you certainly are an organizational basis and then we'll give our panelists a chance to come back with any final thoughts and then we'll end for today Thanks Todd Steve posed the question that is the transcendent question how do we sustain these sorts of gains that you're describing here and given the funding picture and Chip has given a very enlightened response to that I would say yes and from my perspective there are four ways in which you can look at this funding challenge one is and each of them by the way I think would be a great topic for the next CSIS panel there's pieces of paper for you to write topics down one of them is cost effectiveness right and there's a very good debate that could be had about whether that's best achieved in the short to medium term through international NGOs or through national NGOs it's not clear really when you talk about cost effectiveness of impact that's one globalizing national resources you've talked about that and I think it's great to hear that civil society voices are really pressuring African governments in particular but I think we all sense that that's a long way down the road before they respond meaningfully and in a way African governments are behaving rationally to the extent we're here or others are here to fund these needs why should they the third I think is the sort of untapped pool of resources that all of us in this implementing space look at it's not the big foundations and it's not the governments it's the corporate sector which is small but growing and it's the sort of successor generation of philanthropists who are going to be receiving huge amounts of money in the coming years and who will want to be really effective at what they do with it and I think that's a resource that all of us are trying to understand how to exploit and put to good use and the fourth area that I also think is worth a much longer conversation it's really tied to your point about people getting squeezed at some point the market takes over the market will take over in the absence of resources and we go back to a much more severe situation where those who have are able to deal with their problems their health problems and those who don't have suffer the market is also an opportunity to more rationally allocate the subsidy that's available as it goes down and we have to ensure that as the subsidy is either flat or declining and the needs are growing and we don't overlook the ability of the market to help us do that if we guide it appropriately as I said you can have four conversations about those four topics but can we vote for a CSIS session on that last topic please because that's market solutions to this problem that's an interesting one in social insurance schemes which maybe are an aspect of local it's something that others are looking at so before we turn to the panel for final comments there is a half a piece of paper on every chair with a little very quick evaluation we review these assiduously so if you can fill those out we really appreciate it if we've done a great job good to hear about it if there's something that hasn't worked details help so if you just say Todd sucked that's not so good Todd sucked why is a little bit more helpful so Paul we have a chance to kind of give people sort of some final thoughts today you traveled a long distance thank you very much for coming to share your experiences with us what's your message to the US audience that's involved in helping to attract the resources that have helped Mozambique and also is going to be looking for Mozambique to take care of more of its own solution what are your thoughts well first of all thank you for inviting this has been a very interesting session I think that the lessons learned is that local organizations can perform and I think that that's a good lesson and we have premises that are funding and support and we have not talked enough about the governance structure and the board because it really plays a role and I was thinking in relation to communications and the advocacy and the role by networking and influencing the government in terms of having an increased government uptake of the programs so by saying that I think that we need to think about the future and how we can grow synergies between the international and the local organizations so that we don't end by undermining each other work but we rather build up and grow as a block in terms of providing better healthcare for those who need it for the vulnerable population yeah thank you as well I think it was an interesting session I just wanted to draw some attention I think these are outside we did talk about the affiliation model but there's much more detail about it of course that you can find in here I think my final comment is really that the affiliation is one model that we have used for transition that I think the experience we have so far has been really good but it's been a process and it's an ongoing process and it takes money so I think really thinking that you can just flip very quickly without this relationship can be through an affiliation model can also be in a different model but the continuation over time I think to me is very important for success in this overlap I just want to emphasize Paul a couple of times commented about human resources and people I made a comment about track one and remarkable accomplishment for CDC for HRSA and implementation partners it was also possible in a spectacular accomplishment for the healthcare workers who were delivering all those services who were enrolling all those patients on ART for their ministries of health that performed probably at a level that they hadn't imagined eight years before it was going to be possible I think too often we think in terms of the donors of the partners and we forget about who's really doing the work so I just want to emphasize that because those numbers are driven by nurses and nurse assistants and others at the health sites and then on the theme of it's about people more than brilliant egg charts egg charts or org charts or strategies I want to congratulate Paula but by extension her team and her board of directors in Tanzania Anthony Tonya, his team their board of directors and in did I say Tanzania Anthony is in Cote d'Ivoire and Lorianne Buonacuna in Tanzania his board and his team because we could have done a similar sort of slice and examination of what the process is like what the accomplishments are and so on in Cote d'Ivoire, Tanzania we happen to focus on Mozambique but Paula you did a very good job thank you as ever thank you Todd I think so isn't a lot of these things a lot of issues get raised and we try to keep these brief enough to maintain interest but we poke down a lot of things we'll do some future sessions on this hopefully with the guidance that you're going to write down and enjoy the time together thank you very much for attending Paula especially for traveling so far join me in thanking our panelists