Sustainability Readiness in PEPFAR Countries

Countries Included

We limited our analysis to the 25 PEPFAR countries that are required to prepare Country Operational Plans (COPs) in 2023. We grouped these countries by epidemic control status, as defined by PEFPAR. For four countries where epidemic control status was not defined by PEPFAR (the Dominican Republic, Mozambique, Ukraine, and Vietnam), we determined their group using PEPFAR’s definition (see Box 1) and by relying on data from UNAIDS’ AIDSinfo, PEPFAR’s Sustainability Index and Dashboard (SID), and the Population-Based HIV Impact Assessment (PHIA) from Columbia University; we used the latest year of data available.¹ Lastly, we identified PEPFAR countries that are considered fragile or conflict-affected using the World Bank’s FY 2023 Fragile and Conflict-Affected Situations (FCS) List.

Indicators and Targets

We selected 14 indicators across four broad indicator areas to analyze each PEPFAR country’s level of “sustainability readiness”. The four areas include:

1. Commitment to HIV – indicators on the status of policies and laws that either enable or hamper the HIV response;
2. Basic Health System – indicators, like immunization rates and share of births attended by skilled health personnel, that shed light on the general strength or weakness of a country’s health system;
3. Economic – indicators that point to country economic growth or vulnerability broadly, as well as financial independence of HIV programs from donor support; and
4. Commitment to Health – indicators of financial commitment to health by country governments, such as how much of a government’s budget is spent on health.

In order to measure sustainability readiness, we assessed whether a country had met or exceeded the globally set target for each indicator, where such targets were available. In two cases – Central Government Debt and GNI Per Capita – we used an alternate approach. For Central Government Debt, we used the COP country average as the target. For GNI Per Capita, we used the World Bank income classification cutoff for upper-middle-income economies for FY 2023 as the target.

Sustainability Scoring

Each country was scored according to how many global targets it had met or exceeded for the 14 indicators (one point for each target met), with the sum resulting in a total country score (14 was the highest possible total score for any given country). Instances of missing data were counted as not having met the target for that indicator. To group and array countries by sustainability readiness, we used a “Majority Target Score” approach where we grouped countries by epidemic control status and whether or not they had a score of at least 7 (a majority of indicators). 

Definitions & Sources
Indicator Area	Indicator Name	Indicator Description and Source	Global Target	Global Target Description and Source
Commitment to HIV	Care and Treatment Policies	HIV policy alignment score for policies on HIV treatment and related health services. Source: HIV Policy Lab, using 2021 data. Accessed February 23, 2023. https://www.hivpolicylab.org/data.	≥ 60%	According to the HIV Policy Lab, countries that have policy adoption scores greater than or equal to 60% are considered to have “many” or “most” of the recommended policies adopted. Source: HIV Policy Lab, https://www.hivpolicylab.org/compare.
Commitment to HIV	Health Systems Policies	HIV policy alignment score for policies on financing and management of the health system. Source: HIV Policy Lab, using 2021 data. Accessed February 23, 2023. https://www.hivpolicylab.org/data	≥ 60%	According to the HIV Policy Lab, countries that have policy adoption scores greater than or equal to 60% are considered to have “many” or “most” of the recommended policies adopted. Source: HIV Policy Lab, https://www.hivpolicylab.org/compare.
Commitment to HIV	Structural Policies	HIV policy alignment score for policies on political and social drivers of HIV, including criminalization, gender, and human rights issues. Source: HIV Policy Lab, using 2021 data. Accessed February 23, 2023. https://www.hivpolicylab.org/data	≥ 60%	According to the HIV Policy Lab, countries that have policy adoption scores greater than or equal to 60% are considered to have “many” or “most” of the recommended policies adopted. Source: HIV Policy Lab, https://www.hivpolicylab.org/compare.
Commitment to HIV	Testing and Prevention Policies	HIV policy alignment score for policies on biomedical and socio-behavioral HIV prevention and testing. Source: HIV Policy Lab, using 2021 data. Accessed February 23, 2023. https://www.hivpolicylab.org/data	≥ 60%	According to the HIV Policy Lab, countries that have policy adoption scores greater than or equal to 60% are considered to have “many” or “most” of the recommended policies adopted. Source: HIV Policy Lab, https://www.hivpolicylab.org/compare.
Basic Health System	ANC4	Percentage of women aged 15-49 attended by any provider (antenatal care or ANC) at least four times during pregnancy. Source: UNICEF global database of antenatal care based on MICS, DHS, and other nationally representative household survey data, using 2022 data. Accessed February 23, 2023. https://data.unicef.org/topic/maternal-health/antenatal-care/#data.	≥ 90%	In 2021, the World Health Organization (WHO) and United Nations Population Fund (UNFPA) launched five coverage targets, for achievement by 2025, to help countries track progress toward the Sustainable Development Goals (SDGs) and to reduce preventable maternal deaths. One of those targets was 90% of pregnant women attending four or more ANC visits. Source: World Health Organization, “New global targets to prevent maternal deaths,” https://www.who.int/news/item/05-10-2021-new-global-targets-to-prevent-maternal-deaths.
Basic Health System	Skilled Birth Attendance	Percentage of births attended by skilled health personnel. Source: WHO Global Health Observatory, using 2013-2021 data. Accessed March 13, 2023. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/births-attended-by-skilled-health-personnel-(-).	≥ 90%	In 2021, WHO and UNFPA launched five coverage targets, for achievement by 2025, to help countries track progress toward the SDGs and to reduce preventable maternal deaths. One of those targets was 90% of births to be attended by skilled health personnel. Source: World Health Organization, “New global targets to prevent maternal deaths,” https://www.who.int/news/item/05-10-2021-new-global-targets-to-prevent-maternal-deaths.
Basic Health System	Pneumonia Care-seeking	Percentage of children under 5 with suspected pneumonia taken to an appropriate health facility or provider. Source: WHO Global Health Observatory, using 2000-2021 data. Accessed March 13, 2023. https://www.who.int/data/maternal-newborn-child-adolescent-ageing/indicator-explorer-new/mca/proportion-of-children-under-5-years-with-acute-respiratory-infection-taken-to-a-health-facility.	≥ 90%	In 2013, WHO and the United Nations Children’s Fund (UNICEF) launched the integrated Global Action Plan for Prevention and Control of Pneumonia and Diarrhea (GAPPD) to develop targets to reduce mortality related to pneumonia and diarrhea, for achievement by 2025. One of those targets was 90% access to appropriate pneumonia care and diarrhea case management. Source: World Health Organization, The Integrated Global Action Plan for Prevention and Control of Pneumonia and Diarrhea (GAPPD), https://www.who.int/publications/i/item/the-integrated-global-action-plan-for-prevention-and-control-of-pneumonia-and-diarrhoea-(gappd).
Basic Health System	Immunization Rate	Immunization rate, calculated as the simple average of the 2021 diphtheria-tetanus-pertussis (DPT3) coverage rate and the 2021 measles (MCV) coverage rate. Immunization rates calculated according to the Millennium Challenge Corporation methodology for estimating immunization coverage. Source: KFF analysis of UNICEF immunization data, using 2021 data. Accessed February 21, 2023. https://data.unicef.org/topic/child-health/immunization/.	≥ 90%	As part of the Immunization Agenda 2030, one of the targets is 90% global coverage for selected essential vaccines, including DTP3 and MCV, to be achieved by 2030. Source: Immunization Agenda 2030, https://scorecard.immunizationagenda2030.org/ig3.1.
Basic Health System	Service Coverage Index	Coverage of essential health services as an index on a scale of 0 to 100 which is computed as the geometric mean of the 14 tracer indicators of health coverage. Source: WHO Global Health Observatory, using 2019 data. Accessed March 13, 2023. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/uhc-index-of-service-coverage.	≥ 60	According to the World Bank, countries with Service Coverage Index scores above 60 are considered as having “high” service coverage. Source: The World Bank, “Universal Health Coverage as a Sustainable Development Goal,” https://datatopics.worldbank.org/world-development-indicators/stories/universal-health-coverage-as-a-sustainable-development-goal.html.
Economic	Donor Share of HIV Funding	Share of domestic HIV funding contributed by donor governments and other donors, such as the Global Fund to Fight AIDS, TB and Malaria. Source: PEPFAR, PEPFAR 2022 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR-Supported Countries, Jan. 2022; KFF special data request fulfilled by Office of the Global AIDS Coordinator (OGAC), May 6, 2022.	≤ 65%	Based on Gavi, the Vaccine Alliance’s (Gavi) co-financing policies in which countries reach an ‘accelerated transition phase’ after meeting certain GNI per capita requirements and co-financing at least 35% of its vaccine costs. The target used, therefore, is the remaining donor share (less than 65%) when at least 35% of costs are financed by the country. Source: Gavi, “Co-financing policy,” https://www.gavi.org/programmes-impact/programmatic-policies/co-financing-policy.
Economic	Central Government Debt	Total stock of debt liabilities issued by the central government as a share of gross domestic product (GDP). Source: International Monetary Fund (IMF), using 2021 data. Accessed March 13, 2023. https://www.imf.org/external/datamapper/CG_DEBT_GDP@GDD/SWE.	≤ 60%*	Average value of PEPFAR COP country’s central government debt data due to unavailability of widely accepted global standard. Average was 60%. Source: KFF data analysis.
Economic	GNI Per Capita	Estimated gross national income (GNI) per capita. Source: World Bank, using 2021 data. Accessed March 1, 2023. https://data.worldbank.org/indicator/NY.GNP.PCAP.CD.	≥ $4,256*	Using the World Bank’s FY 2023 Country and Lending Groups, $4,256 is the cut-off value for GNI per capita for upper-middle income countries. Source: World Bank, “World Bank Country and Lending Groups,” https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups.
Commitment to Health	Out-of-Pocket Spending	Household out-of-pocket expenditure as a percentage of total current health expenditure. Source: WHO Global Health Observatory, using 2020 data. Accessed March 13, 2023. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/out-of-pocket-expenditure-as-percentage-of-current-health-expenditure-(che)-(-).	≤ 25%	As part of the SDGs, households spending 25% or more of household expenditure on health are considered as having ‘catastrophic health spending.’ Source: World Health Organization, “Global monitoring report on financial protection in health 2021,” https://www.who.int/publications/i/item/9789240040953.
Commitment to Health	Health as Share of Domestic Government Budget	Domestic general government health spending as a percentage of general government expenditures. Source: WHO Global Health Observatory, using 2020 data. Accessed March 13, 2023. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/domestic-general-government-health-expenditure-(gghe-d)-as-percentage-of-general-government-expenditure-(gge).	≥ 15%	As part of the Abuja Declaration, adopted in 2001 by the African Union, countries pledged to dedicate at least 15% of domestic government budgets to the health sector. Source: World Health Organization, “The Abuja Declaration: Ten Years On,” https://apps.who.int/iris/bitstream/handle/10665/341162/WHO-HSS-HSF-2010.01-eng.pdf?sequence=1.