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PEPFAR Implementation: Progress and Promise
investigated, including male circumcision, microbicides, and vaccines. These new approaches will change the appropriate mix and costs of prevention services in unforeseen ways. Without greater flexibility, the ability of the U.S. Global AIDS Initiative to lead the way in utilizing such new techniques when proven effective will be greatly reduced.
Recommendation 3-3:Although they may have been helpful initially inensuring a balance of attention to activities within the four categoriesof prevention, treatment, care, and orphans and vulnerable children,the Committee concludes that rigid congressional budget allocationsamong categories, and even more so within categories, have alsolimited PEPFAR’s ability to tailor its activities in each country to thelocal epidemic and to coordinate with the level of activities in thecountries’ national plans.Congress should remove the budget allocationsand replace them with more appropriate mechanisms that ensureaccountability for results from Country Teams to the U.S. Global AIDSCoordinator and to Congress. These mechanisms should also ensure thatspending is directly linked to and commensurate with necessary effortsto achieve both country and overall performance targets for prevention,treatment, care, and orphans and other vulnerable children.
Some of the indicators being collected by PEPFAR do not yet provide appropriate information on the progress being made toward the ultimate goal of controlling the epidemic. As is appropriate for a program this early in its implementation, most results reported to date are for targets that can be measured in the short term; thus they reveal more about the process of implementation than the impact of the program. PEPFAR plans to measure more meaningful mid- and long-term results, and the program is supporting countries in developing the measures and skills needed to evaluate the impact of initiatives at the country level.
One issue related to targets concerns requiring that results be specifically and uniquely attributed to the U.S. initiative. Such a requirement creates disincentives for international coordination among donors and harmonization at the country level, and can work against the use of U.S. funds to leverage other donors’ interests in a particular area. The most important result is impact on a country’s epidemic, and that impact can best be attributed to collective actions taken in partnership with all donors and, most critically, the host country. PEPFAR would do well to consider a step taken by some other large donors: evaluating Country Teams on how well they cooperate with the partner government and the donor group as a whole and how effective they are at leveraging a successful package of services.