Government to Government (G2G) Model for HIV Service Delivery - An Approach for Program Ownership and Sustainability in Four Provinces of Zambia

IntroductionZambia has achieved ambitious programmatic targets of HIV diagnosis, treatment coverage, and viral load suppression among persons living with HIV (PLHIV) with the support of the United States Presidents Emergency Plan for AIDS Relief (PEPFAR) and other donors. Beginning in fiscal year (FY) 2019, U.S. CDC Zambia transitioned its PEPFAR Direct Service Delivery (DSD) support in Eastern, Lusaka, Southern, and Western Provinces from non-governmental organizations (NGOs) to a government to government (G2G) provincial health office (PHO) service delivery model for program ownership and sustainability. We reviewed programmatic and financial data during and after the period of this transition. MethodsProgrammatic performance using PEPFARs Monitoring, Evaluation, and Reporting and expenditure reporting data were used to assess changes over the period of transition from an NGO-led to government-led DSD model in Zambia. Data were reviewed across six FYs from October 2018 - September 2019 (FY19) through October 2023 - September 2024 (FY24) in four provinces across Zambia. Programmatic and expenditure performance indicators were analysed across time to assess PLHIV on antiretroviral therapy (ART), viral load coverage and suppression, and costs associated with care and treatment services. ResultsFrom FY19 to end of FY24, the number of PLHIV on ART across the four provinces increased by 31% (520,628 to 680,781). Viral load coverage and suppression in the transition provinces increased from 73% to 88% and 91% to 98%, respectively. Annual PEPFAR financial investments for care and treatment activities (in 2019 US dollars) increased by 25% ($12.7 million) from $38.3 million in FY19 to $51.0 million in FY21, as the amount invested in DSD increased concurrently with investments to implementing partners. From FY21 to FY24, spending declined by 41% ($21.1 million), while the total number of PLHIV on ART increased. The amount spent per PLHIV on ART decreased from $79 in FY21 to $44 in FY24, a decline of 44%. ConclusionsThe G2G model of service delivery and funding is an efficient and sustainable model for HIV epidemic control in Zambia. This government-led model shows a path forward to achieving sustainable HIV program success, reductions in costs, and expanded government ownership of the HIV program.