Review Rationale & Context for MER: Programmatic Shifts

Amy Gottlieb, PhD, MPHOVC M&E Meeting

February 19 – 20, 2014

PEPFAR Support – A View of the First 10 YearsPEPFAR after 10 years, two phases• Emergency to sustainability • Increased collaboration with multilateral partners • Emphasizing contribution to national programs, alignment with national

strategies, evidence based for national epidemics• Continued emphasis on results and efficienciesPhase I (FY04-FY08) driven by 2-7-10• PEPFAR processes routinized and country teams formed • Reported on: Direct, Indirect, and Total• With many revisions in first five years

• (e.g. Reduced burden of reporting)Phase II (FY09-FY13) driven by 3/6-12-12• Reported on: Direct and National • Limited attention to policy, quality, capacity (lab), HSS (HRH)• Implementation in context of Partnership Frameworks with multilaterals, in

support of national programPhase III (FY14-FY18) seeks to evolve how we describe PEPFAR support • Reporting on: Direct Service Delivery & Technical Assistance • Improved M&E of capacity, quality, country ownership, impact• Implementing in context of Country Health Partnerships to advance results and

country ownership, in close collaboration with multilaterals2

PEPFAR MER Introduction 2013_11_21

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Background of Phase III

• As part of the MER, an interagency task team was established to review the definition of ‘direct’ and provide guidance for FY14-18.

• The task team proposed that PEPFAR should adhere to the historical intent of ‘direct’ while refining and clarifying its definition.

• Field and TWGs provided input on revised definition. Definition was further clarified in response to their feedback.

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Why Revise the Definition of “Direct”• To date, PEPFAR has counted individuals as ‘directly supported

by PEPFAR’ using broad criteria, largely left to program areas and country teams to define.

• As PEPFAR support evolves, we need a more rigorous and standardized definition of ‘direct support’.

• As country capacity increases, PEPFAR support evolves in response, and PEPFAR results will change.

• This revised definition acknowledges that not all PEPFAR efforts will count as ‘directly supported’.

• This change is appropriate because it more accurately characterizes the nature of our support.

Defining “Direct Support” – Before and After

Previous Updated

• ‘Direct support’ is interpreted broadly

• Definition is clarified

• Refers largely to individuals• Few alternative indicators to

document TA/capacity building to sites, organizations, communities, and health systems at various level.

• New MER indicators allow focus on TA/capacity building and application of definition now allows teams to report these areas as ‘directly supported’ by PEPFAR

• PEPFAR reporting helps ensure accountability at the agency level (i.e. help agencies manage implementing partner contracts & aggregate results at country level)

• Same

• Allows PEPFAR to report to internal stakeholders (OMB, Congress, etc) on program progress

• Within the context of national results; retain ability to speak to program achievements

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Revised Definition of PEPFAR SupportMore accurately describes PEPFAR’s evolving contributions in alignment with national HIV strategies and programs:

• Refined definition of direct service delivery (DSD) support to individuals

• Introduce definition of technical assistance (TA) support to sites and above sites

• What is a ‘site’? ‘Site’ is a proxy for ‘points of service delivery’ and refers to health facilities, labs, communities, CBOs, school wards, and other such entities.

• Above ‘site’ level includes support to districts, regions, and national government offices that is above the level of service delivery.

Revised Definition of PEPFAR Support Individual Level

Individuals receiving HIV related services will be counted as receiving direct support for service delivery (DSD) from PEPFAR when the support:

1) is critical* to the delivery of the service to the counted individuals;

AND

2) involves established presence at and/or routinized, frequent (at least quarterly) support to those services to those individuals at the point of service delivery.

Both conditions must be met in order to count individuals as directly supported by PEPFAR.

* “Critical support” is defined on an indicator by indicator basis 7

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Indicator: Number of HIV-infected adults and children receiving ART

Number of key populations reached with individual and/or small group level HIV preventive interventions that are based on evidence and/or meet the minimum standards required

Critical Support: Commodities, human resource salary support. For ART this can include ongoing provision of critical re-occurring costs or commodities (such as ARVs) or funding of salaries or provision of Health Care Workers for ART clinic services.

For example, procurement of condoms, salary of personnel providing any of these services (i.e. outreach workers, program manager), or program design i.e. the development of training curricula, prevention guidance development, or standard operating procedures (SOPs), & follow-up to ensure fidelity to the program design)

TA - Established presence, routinized frequent (at least quarterly) support:

For example, clinical mentoring and supportive supervision of staff at ART sites, Quality Improvement services support, patient tracking system support, routine support of ART M&E and reporting, commodities consumption forecasting and supply management

Such as mentoring/supportive supervision; training; organizational strengthening; QA/QI; regular assistance with M&E functions and DQAs; or condom forecasting and supply management

Examples of Critical Support & Established Presence (TA Support) by Indicator

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“Site” Level

Distinguished as DSD or TA-only

Sites, facilities, labs, organizations, communities, schools, etc. can be counted as receiving PEPFAR direct service delivery (DSD) support when:

• individuals served at that ‘site’ are receiving support as defined on the previous slide.

Sites, facilities, labs, organizations, communities, schools, etc. can be counted as receiving PEPFAR technical assistance (TA)- only support when PEPFAR is:

• providing recurrent (at least quarterly) technical support to improve the functioning or capacity of that entity

Revised Definition of PEPFAR Support

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Above “Site” Level

Districts, regional, and national governments or organizations above the service delivery level can be counted as receiving PEPFAR technical assistance (TA) support when PEPFAR is:

• providing recurrent (at least quarterly) technical support to improve the functioning or capacity of that entity.

Revised Definition of PEPFAR Support

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Review Partner Agreements

Re-Classify Partner Support By Program Area, By Facility

Re-Allocate FY14 Targets and Results to DSD, TA, Neither

DSD TA Neither

Applying Revised Definitions Through Portfolio Review

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Type of Partner Support Influences Reporting Requirements

Partners providing DSD support to sites will report individual level counts for all applicable indicators

Partners providing TA only support to sites will report individual level counts only for selected indicators (determined by our legislative reporting requirements)

Partners providing DSD or TA only support will both report on site level quality indicators (when applicable)

• Mostly likely scenario: partner provides same type of support within a given program area. However, we need to create room for exceptions.

• For example, within the same program some partners may provide DSD to some sites, TA only to other sites. Again, this is about classifying the type of support provided to the site.

Indi

vidu

als

Site

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What does this mean for our numbers? They will change

20062007

20082009

20102011

20122013

20142015

20162017

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

NATIONALNGI DirectMER DSD

Some of distance be-tween green and red will be explained by TA-only support

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Here’s the “How to”:

Applying MER definitions in COP14

(Practical examples are in the next slides…)

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Example: Applying MER Definitions to a Prevention (Key Pop) Support Partner

In FY14, does the partner provide support ‘critical’ (i.e. procurement of condoms, salary of personnel providing any of these services (i.e. outreach workers,

program manager), or program design i.e. the development of training curricula, prevention guidance development, or standard operating procedures (SOPs), & follow-up to ensure fidelity to the program design)

to the delivery of Key Pop interventions to individuals where services are delivered ?

In FY14, does the partner provide recurrent (at least quarterly) technical support to the service delivery

org/ site to improve functioning/capacity in key pop interventions (such as mentoring/supportive supervision; training;

organizational strengthening; QA/QI; regular assistance with M&E functions and DQAs; or condom forecasting and supply management)?

yes

DSD TA Neither*

yes yes no

Neither

In FY14, will the partner report on P8.3.D Number of key populations reached with individual and/or small group level HIV preventive interventions that are based on evidence and/or

meet the minimum standards required using NGI definition of Direct? yes

no

no

no

In FY14, does the partner provide recurrent (at least quarterly) technical support to the service delivery

org/ site to improve functioning/capacity in key pop interventions (such as mentoring/supportive supervision; training;

organizational strengthening; QA/QI; regular assistance with M&E functions and DQAs; or condom forecasting and supply management)?

DETERMINE REPORTING REQUIREMENTS*If not previously NGI – not critical, no recurrent tech support, continue not to report

Revised PEPFAR REPORTING TIMELINEOct

/Nov/Dec

Jan/

Feb/

March

•Introduction of MER & TA Indicators

April/

May/

June

July/Aug/

Sept

•Q1FY14

Oct/Nov/Dec Jan/Feb/March

April/May/June July/Aug/Sept

• Q2 • Q4• Q3 • Q1 FY15

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Thank you!

Questions, Comments?