PEPFAR planning process changes raise transparency concerns

The U.S. government’s flagship global health initiative will pursue a “much shortened and streamlined” approach to planning this year. Some worry the decision could limit participation and transparency in one of the world’s most important processes for setting goals and charting investments to tackle infectious disease.

On March 5, acting U.S. Global AIDS Coordinator Angeli Achrekar laid out the revised process for creating country operational plans and regional operational plans — known respectively as COPs and ROPs — for the U.S. President’s Emergency Plan for AIDS Relief. The notice served as an update to news from a month prior that the fiscal year 2021 planning process had been temporarily paused due to disruption caused by COVID-19.

In an email to PEPFAR partners, which was also published online, Achrekar announced that the COP process will resume on April 1 and that it will be “shorter and much more flexible than in previous years.”

The ongoing fallout from COVID-19 has raised questions about PEPFAR’s future and whether President Joe Biden and Vice President Kamala Harris’ administration might restructure U.S. global health initiatives in response to the pandemic.

The new planning process kicks off with a virtual opening plenary on April 1, followed by two weeks of internal deliberations at U.S. government agencies and two more weeks of rolling virtual meetings at the country and regional levels.

These country and regional sessions will be limited to two days, with four hours of meetings per day — down from the weeklong reviews of years prior. Countries and regions will then submit their plans for approval by May 21 so that PEPFAR’s leadership can work through the summer to secure necessary funding approvals from the U.S. Congress to transfer funds at the beginning of the next fiscal year.

“PEPFAR is firmly committed to ensure that collaborative, transparent, and data-driven COP/ROP 2021 plans are completed in every PEPFAR-supported country and region and that there is no disruption in HIV services at the start of fiscal year,” Achrekar wrote.

The Office of the U.S. Global AIDS Coordinator, which leads PEPFAR, did not respond to an inquiry from Devex.

While the COP process might appear to be a largely procedural bureaucratic exercise, it would be a mistake to see it that way, said Matthew Kavanagh, director of the Global Health Policy & Politics Initiative at Georgetown University’s O’Neill Institute for National and Global Health Law.

“The secretary of state and the White House don’t seem to understand how critical planning for and executing PEPFAR programs is in Africa — not only for fighting HIV but also frankly for fighting COVID right now, since many of the same people are actually involved in the COVID and HIV response,” Kavanagh said.

During former President Barack Obama’s administration, then-U.S. Global AIDS Coordinator Eric Goosby began a gradual transition of PEPFAR planning from a closed U.S. government process to one that was more open to civil society and other partners, Kavanagh said.

The result now is that civil society, governments, the World Health Organization, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and U.S. government agencies “are all literally sitting together at a table deciding how to spend $4.5 billion to fight AIDS,” Kavanagh said.

“The U.S. government has actually shared how much money they’re spending on each and every activity in each and every country, and have discussed things like whether or not the implementing partners are delivering high-quality services … and actually put the users of those services at the table where they actually make decisions,” he added.

Under former U.S. Global AIDS Coordinator Deborah Birx, who faced a constant threat of budget cuts from former President Donald Trump, the country planning process became contentious. A report by the State Department’s Office of Inspector General in February 2020 received 229 responses from country team members about the COP development process and found that 80% of them were negative.

The George W. Bush Institute, a nonpartisan policy organization, last week announced that Birx has joined the Dallas-based organization as a senior fellow and will work to apply lessons from the COVID-19 pandemic to tackle health disparities.

The White House has yet to announce a nominee to replace Birx at PEPFAR, and some in the U.S. global health community have worried about the signal that sends in conjunction with a delayed, now-abbreviated planning process.

PEPFAR’s current leadership appeared to anticipate that concern in an FAQ document accompanying the new COP-ROP guidance, which included a question about whether the temporary pause of the planning process signaled “a lack of commitment by the Biden-Harris Administration to PEPFAR.”

“No,” the response reads. “The Biden-Harris Administration is fully committed to and supportive of PEPFAR’s mission to control the HIV/AIDS epidemic as successfully led and managed by the State Department, executed through U.S. government implementing agencies, and conducted in close collaboration with our many partners and communities around the globe.”