PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
Private Sector Program
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
This activity remains similar to activities described in the COP08 narrative. Budget increase is attributed to
expansion of private clinics requiring external quality control, supportive supervision and training. Therefore
this narrative will not be d in COP09 with exception to targets.
COP 08 ACTIVITY NARRATIVE:
Building on FY05-FY07 activities, the Private Sector Program (PSP) led by Abt Associates will continue
interventions in large (1000+ employees) and medium-sized companies (500+ employees) in seven regions
to improve access to quality tuberculosis (TB) and TB/HIV clinical services for employees, their dependants,
and surrounding communities.
PSP will also expand integrated TB/HIV services in 100 additional private health facilities. In FY08, the
project will providing continuing supportive supervision for clinical programs in up to 60 workplaces and 120
private clinics. In the same period, the project will begin to work with 100 additional private clinics to
introduce quality HIV and TB services, including TB/HIV prevention, TB detection, TB diagnosis, and
directly observed, short-course therapy (DOTS).
The process of engaging 100 new private facilities consists of ten key steps. To engage stakeholders in the
planning process, PSP will work with the regional health bureaus (RHB) to convene meetings that build
consensus and sensitize stakeholders to the regions' needs for the expansion of TB/HIV services to include
private-sector clinics.
PSP will assist the regions in developing and applying transparent criteria to select up to 100 additional
private facilities to provide TB/HIV services. The project will work with the RHB to conduct a rapid
assessment of the private health facilities identified as potential TB/HIV service providers, in order to
examine their resources and the needs of the facility.
After identifying the most qualified private facilities, PSP will work with the RHB and the private facilities to
establish a Memorandum of Understanding (MOU) between the bureau and the clinics. The MOU
establishes a formal relationship and clearly articulates the roles and responsibilities of the RHB, the district
health office, and the private health facility.
To maintain quality in implementation, healthcare providers must be appropriately trained to provide the
best level of service. PSP will continue to adapt existing training materials for health providers to better fit
the needs of private providers. The training will address the integration of counseling and testing (CT), TB,
TB/HIV, provider-initiated counseling and testing (PICT). PSP will strengthen the facilities' skills in reporting
and recording, internal quality assurance, monitoring and evaluation, and basic finance and management
skills to support service delivery and sustainability.
PSP will help to strengthen a referral network between the private and public sector which ensures
continuity of care, is able to track patient progress, and gets patients the care that they need. The project
will work with the RHB to build a shared understanding of how the referral links between the public and the
private sectors should function, to map the geographic links between the facilities, and to build and
strengthen the links between facilities.
Community awareness can help reduce the barriers to TB/HIV prevention, diagnosis, and treatment. PSP
will encourage the RHB to support community awareness through mass media campaigns, information
leaflets, and posters. PSP will also work actively to promote media coverage of TB and HIV services in the
private sector.
Supervision ensures national guidelines are implemented for provision of care, laboratory and pharmacy
services, and overall facility maintenance, including record-keeping and reporting. PSP will work with the
RHB, and potentially with professional associations, to promote an approach to supervision which goes
beyond a checklist and involves careful direct observation of infrastructure, data entry in registers, and all
other reporting formats, referral tracking, reporting on defaulters, and TB drug supplies, expiry dates, and
requisitions for new stocks.
PSP will assist the RHB and district health offices to develop reliable logistics systems to supply anti-TB
drugs. Depending on the agreements set out in the MOU, there is the potential to include HIV rapid-test kits,
as well. The project will build the capacity of the facility to properly store, manage, and requisition required
stocks of TB drugs.
PSP will assist the RHB in establishing a monitoring and evaluation system which ensures appropriate use
of resources, assure quality, and generates data for decision-making. Monitoring and evaluation of
implementation activities will help to evaluate the outcomes achieved, while measuring both short- and long-
term impact.
This activity will increase access to TB and HIV services through private-sector facilities. The activity will
add 100 new facilities which can identify and treat TB infections and provide HIV counseling and testing
services which are integrated and coordinated. The project will also provide continuing supportive
supervision to 60 existing workplace sites and 100 FY07 private-sector clinics which offer TB/HIV services.
PSP-Ethiopia will closely integrate its TB/HIV activities with the other PSP activity for Mobile and Private
Sector Counseling and Testing Services (10538). In addition, the project will coordinate with other related
projects by sharing its strategies, tools, and ‘lessons learned' with the related contracts. It will request the
same level of information sharing from the related PEPFAR partner programs. The key programs for
information sharing and coordination are the Care and Support Program for TB/HIV, Palliative Care, and
Counseling and Testing (10399, 10400, and 10647), and Community-Level Counseling and Testing Service
Support (10588).
Activity Narrative: This initiative focuses on the general population which uses private-sector health facilities for care and
treatment. PSP will build the capacity of the RHB and district health offices to integrate the private-sector
facilities into delivery of the key TB and HIV public health services. PSP will assist the Ethiopian Ministry of
Health with facility selection, logistics, supportive supervision, reporting, and monitoring and evaluation.
PSP will build the private-sector facilities' capacity for clinical services, referral, reporting, internal quality
assurance, and general management.
New/Continuing Activity: Continuing Activity
Continuing Activity: 16567
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
16567 5604.08 U.S. Agency for Abt Associates 7471 645.08 Private Sector $340,000
International Program
Development
10375 5604.07 U.S. Agency for Abt Associates 5465 645.07 Private Sector $286,000
5604 5604.06 U.S. Agency for Abt Associates 3767 645.06 Abt Private $250,000
International Sector
Development Partnership
Emphasis Areas
Health-related Wraparound Programs
* TB
Workplace Programs
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.12:
Piloting Ethiopia's National and Community Health Insurance for Sustainability
The Ministry of Health (MOH) released a draft Strategic Framework for National Health Insurance in August
2007. This framework outlines the MOH's intention and commitment to institute national health insurance in
Ethiopia with broader coverage that parallels the Rwanda's Mutuelles and Ghana's National Insurance
approach.
Per the MOH's implementation plan in 2007/2008, National Health Insurance will be piloted in 15 districts to
address informal urban/peri-urban and rural populations. The desired results of this pilot will be 1)
increased service utilization of all members of the community by reducing cost barriers to primary care
services; 2) increased quality service in health facilities through greater resources; and 3) protection of
family units from catastrophic out-of-pocket expenditures which exacerbate poverty and barriers to
HIV/AIDS care and treatment.
PEPFAR Ethiopia noted three priority pillars for COP09: Quality, Targeting and Sustainability with a cross
cutting theme of Human Resources. National Health Insurance, a MOH priority, addresses sustainability of
health service delivery through demanded-driven approaches and addresses quality at the health facility
through strengthened systems.
PEPFAR Ethiopia's financial assistance would provide 1) technical support for the design and
implementation of the pilot; 2) assist in financing a quantity of insurance premiums for those receiving
chronic care services, specifically HIV/AIDS care and treatment and OVC services in areas collocated with
PEPFAR supported networks; and 3) assessment of the pilot for program performance and model
evaluation.
Supporting National Health Insurance will result in
1)Increased service utilization in key PEPFAR implementation areas that co-locate with the pilot districts. At
present, national service utilization is approximately 30 percent;
2)Cost barriers for HIV/AIDS affected family members will be covered in the pilot districts and will be fully
served by health facilities including infection prevention, laboratory and pharmaceuticals; and
3)Assessment of technical feasibility of community health insurance in Ethiopia.
Sustainable programming has emerged as a major OGAC priority in COP08. This technical approach
supports piloting of National Health Insurance to address the demand side characteristics of health service
delivery in hospitals and health centers. This complements existing clinical activities in HIV/AIDS care and
treatment by reducing socio-economic barriers to accessing services. USAID's bilateral HPN provides
financial support for technical assistance for implementation of this activity. The activity poses an
opportunity for PEPFAR to leverage non-PEPFAR and non-USG resources as other bi-lateral and multi-
lateral donors support this technical approach during broader implementation. Furthermore, the activity
demonstrates USG commitment to aspects of host country system strengthening and program
sustainability.
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.18:
Assistance to the Ministry of Health's Health Care Finance Reform Program
This activity will leverage $1,500,000 in non-PEPFAR USAID resources. PEPFAR supports Health Sector
Finance Reform to improve quality and management in the public health system. This activity has a
significant impact on sustainability and quality of service delivery, health worker retention and the availability
of commodities at facilities. During COP08 this activity transitioned from a bilateral award to a five year
competitive contract awarded to Abt Associates leveraging $10,000,000 in USAID bilateral funds. Progress
to date includes regional legal reforms permitting health facilities to retain and utilize local revenue, large
training programs and establishment of facility boards to enabling professional management of health
resources at district and facility level. Net outcome of the reforms include improvements in quality and
sustainability of health services through the use of retained user fees. This included recruitment and
retention of health professionals and improvements in infrastructure. This activity will expand in COP09 to
meet growing requirements of the Ministry of Health and Regional Health Bureaus fully implement
legislative requirements of Health Sector Finance Reform and scale up training and implementation of
Health Care Financing at hospitals and health centers on a national basis.
COP08 Narrative:
This is a new activity leveraging $800,000 in bilateral Child Survival and Health (CSH) funds.
The third round National Health Accounts (NHA) in Ethiopia showed that with per capita spending of
US$7.14, the Ethiopian health sector is highly underfinanced as compared to the WHO/Commission for
Macroeconomics and Health's recommendation of per capita spending of US$34 for delivering essential
health care services. It is also less than the Sub-Saharan Africa average of US$13 in 2005. The per capita
spending in health is not commensurate with the wide range of health problems which are further
complicated with emerging health problems such as the HIV/AIDS epidemic and associated opportunistic
infections. Public hospitals and health centers cannot provide quality HIV/AIDS care services with
extremely low non-salary operating budget that they get from the government. If PEPFAR's technical
systems strengthening efforts are to be sustained over time, there must be increased and focused attention
to financial systems as well.
The Government of Ethiopia (GOE) has embarked on a Health Sector Financing Reform program that is
instituting policy changes intended to increase resources for the health sector, improve the efficiency of
resource use, and increase the quality of health care services at public hospitals and health centers. One of
the major recent health finance innovations supported is the Reform Proclamation to build a sustainable
health system that accommodates alternative financing and management mechanisms. The Reform
Proclamation encourages retention of user fees by the collecting facilities (hospitals and health centers) for
use at those facilities (managed by autonomous boards) to improve quality of health services. This will
result in a net increase in resources available to these health care facilities as the user fees are additive to
the budget they receive from existing federal and regional block grants. USG bilateral CSH assistance has
been instrumental for initiation of policy dialogue and consultation, for designing of the Strategic Framework,
development and eventual ratification of the legal frameworks in Oromiya, Amhara, Southern Nations,
Nationalities and Peoples' Regions (SNNPR) and Tigray as well as Addis Ababa City Administration.
The reform components include revenue retention and use, systematizing and standardizing fee-waiver and
exemption systems, ensuring health facility autonomy (provisions for establishment of hospital boards and
hiring of hospital general managers), and outsourcing of non-clinical services. These reform components
are fundamental and ground breaking to make change in the health care delivery in the country. The
implementation of the reforms is also progressing very well in the three big regions (e.g. Amhara, Oromiya,
and SNNPR) and encouraging results are being seen in terms of the amount of revenue generated and its
use for improving the quality of health services in more financially sustainable way.
However, the various reform initiatives and the achievements gained need to be further strengthened
through capacity building in financial management and to ensure that resources are used for quality
improvement. There is also strong need to expand the implementation of the reform packages to other
Regions.
In FY08, this activity will focus on providing guidance and technical assistance to federal government policy
makers and regional health officials. Introduction of the health care financing reforms to new regions
requires dialogue and consultation and active participation of different stakeholders and regional officials.
Thus, there is a need to organize various consultative workshops and review meetings at district level, and
similar forums need to be organized at regional and federal levels in coordination with current implementing
partners operating at regional and site levels. Through this activity technical assistance will be provided to
prepare directives and guidelines on health revenue retention, and utilizations, on outsourcing of non-
clinical activities, management of the waiver system and hospital and health center board management.
The directives and guidelines will be disseminated and training-of-trainers provided in coordination with
current implementing partners on the applications.
Health facility autonomy and financial management is a very new venture introduced by the health care
financing reform. The activity will provide direct support in the provision of training to the health center board
members and managers in the area of planning, budgeting, procurement and financial management to
improve quality of services. There is a strong need for regular supportive supervision, and putting in place of
appropriate M&E system. This also implies institutionalization of financial management at the regional and
district and health center levels.
PEPFAR Ethiopia partners working at the hospital level who meet regularly with hospital management
teams will strengthen and expand the health care financing component of their work plans to include how
best to standardize fees and exemptions, how best to invest funds collected through fees, overall better
budgeting. Guidance and support will be provided by the national health care financing project.
Activity Narrative: With the ever increasing demand for comprehensive services and rapid expansion of service sites,
adequate mechanisms should be in place so that quality of services is not overwhelmed by volume and
speed. Improved availability of finance and efficient utilization of resources at the facility and
district/zonal/regional office levels will enhance quality of services and its sustainability.
This activity will leverage other USG resources from USAID health funding. This activity will also leverage
existing US university hospital/health center site level support to scale-up HIV services and strengthen
quality of care. It will strengthen ongoing efforts on health care financing in three regions and also expand
the program implementation to additional regions.
Current implementing partners, health centers board members, administrators and financial managers play
a major role in this activity. They will be introduced to the concepts of health care financing and be trained
on practical implementation mechanisms. The support and buy-in from officials at the regional, zonal, and
district levels is very critical for the smooth adoption and implementation of this program. In general, the
design and roll out of this activity will be participatory that will involve key stakeholders throughout. Using
the national implementation manual, relevant staff from health centers and administrative offices will be
trained on health care financing. This will ensure immediate implementation of program as well as long-term
capacity building of local organizations.
USG will support provision of training to the health center board members and managers in the area of
planning, budgeting, procurement and financial management to improve quality of services.
Continuing Activity: 18066
18066 18066.08 U.S. Agency for Abt Associates 7471 645.08 Private Sector $1,000,000
