FY 2011 Country Operational Plan Guidance Fails to Offer Detailed and Realistic Plan to Support HIV-FP Integration

In PEPFAR’s (President’s Emergency Plan for AIDS Relief) annual Country Operational Plan (COP) guidance to the field, the Obama administration in principle continues to support an integrated and women and girl-centered approach to health services, but fails to provide implementers with the tools and guidance needed to make that a reality.  This is a surprising development as it is the first COP released after the announcement of the Global Health Initiative (GHI) Plus Countries and yet is out of step with public statements made by high level officials touting the women and girl-centered, integrated approach to global health.
The guidance and related appendices were finalized on July 16th, 2010, but only recently made publically available on PEPFAR’s website: http://www.pepfar.gov/guidance/index.htm.

As the COP process, GHI and PEPFAR implementation and additional guidance continue to evolve, we encourage partners in the field to communicate with staff at their mission and in the Office of the Global AIDS Coordinator about what is working and what is not in order to inform their future decisions.
A review of selected areas of the FY11 COP guidance is below.
Funding for Integrated HIV-FP Services
Any family planning services, including the provision of contraceptives for prevention of mother-to-child transmission (PMTCT), that are integrated with HIV services, must continue to be funded out of separate accounts.  While these integrated activities are encouraged, the family planning commodities must be funded using non-PEPFAR funds.

“Field teams are expected to prioritize opportunities to link PEPFAR-funded activities with those funded from separate accounts supporting reproductive health and family planning.” (p 12)

PEPFAR programs are encouraged to provide referrals to family planning programs and to co-locate services.  While this is a positive development, it does not address the family planning needs of women living in countries without family planning funding or programs.  One third of the 33 countries required to submit an FY11 COP do not receive any family planning/reproductive health (FP/RH) assistance from USAID.
Historically the U.S. has underfunded FP/RH programs and even recent important funding increases still leave FP/RH funding nearly 25% below their peak levels in 1995 (when adjusted for inflation) and below the U.S. fair share of addressing the needs of the 215 million women who want to avoid pregnancy, but do not have access to modern contraception.
Without significant scale up of funding for FP/RH, meaningful integration of these services will not occur using the referral and co-location model articulated in the COP.      
Family Planning and PMTCT
The COP rightly identifies PMTCT programs as an ideal platform to deliver other essential health services, including family planning, but again misses an opportunity to maximize the improved health outcomes through fully supporting the tools needed to prevent mother-to-child transmission.  The World Health Organization (WHO) has long identified family planning as one of four essential components of PMTCT programs and many countries have both high HIV prevalence rates and high unmet need for family planning.
For example, in Malawi (a GHI-Plus country and one of the countries required to submit a FY11 COP) the HIV prevalence rate among adults is 11.9 and 28% of women want, but lack access to, modern contraception.  In the FY10 budget request for Malawi funding for HIV/AIDS was more than triple that of FP/RH.
PEPFAR should ensure that a HIV positive woman who wants to prevent unintended pregnancy can receive family planning services at any PEPFAR location.  The ability to meet the immediate needs of a woman and provide comprehensive PMTCT programs should not be contingent on the presence of another program or funding stream.
While it was encouraging to see that PEPFAR funds could support much-needed PMTCT training for health workers that includes MCH, family planning and reproductive health services for women living with HIV, the impact of having a trained work force and increased demand for these critical interventions is limited if the commodities needed to deliver the services remain unavailable.  By issuing a COP that does not account for the increased demand for contraceptives that will likely result from training and community mobilization, PEPFAR falls short of ensuring that HIV positive women will be able to prevent unintended pregnancy and plan the timing and spacing of their pregnancies.
What’s Next?
The FY11 COP Guidance states that long-awaited specific guidance on the integration of PEPFAR funded activities and FP/RH programs will be shared soon (p13).  PEPFAR should use this guidance as an opportunity to address the issues raised above and demonstrate a real commitment to implementing an integrated program that meets the needs of the women and communities that their programs reach.
If PEPFAR continues to look to the FP/RH account to support essential PMTCT and contraceptive services for HIV-positive women without significantly scaling up FP/RH funding, they not only create a serious barrier to meaningful integration, but also run the risk of overwhelming an already underfunded program and ignores the large funding disparity between HIV/AIDS and FP/RH programs.
As a key component of the Global Health Initiative, PEPFAR’s future guidance and communication with the field must reflect the core principles of the initiative and create an enabling framework for the implementation of a woman and girl-centered, integrated approach to global health.
PAI will share any new guidance and our analysis with partners when it is released.

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