time the Leadership Act was passed, little information existed with which to determine precisely how resources should be allocated to achieve the performance targets across the focus countries; thus the budget allocations could not be evidence-based. Furthermore, Congress established these allocations so that they become more, not less, restrictive over time as the pandemic evolves and the program gains experience and knowledge.4 Contrary to basic principles of good management and accountability, the budget allocations have made spending money in a particular way an end in itself rather than a means to an end—in this instance, the vitally important end of saving lives today and in the future.
In the Committee’s judgment, the Coordinator and the Country Teams have made reasonable attempts to both respect the congressional budget allocations and implement within these constraints an effective program that can achieve its ambitious targets. However, their task is to implement a comprehensive, integrated, evidence-based program to address the HIV/AIDS epidemics in 15 unique, resource-constrained countries within the framework of harmonization. Particularly because Congress demonstrated no relationship between the budget allocations and the performance targets—prevention of 7 million infections, provision of ART to 2 million people, and provision of care for 10 million people—the budget allocations have further complicated this already daunting task and thus have been counterproductive. It is readily apparent that PEPFAR’s approach to and mechanisms for planning, implementing, and measuring the initiative are to a large extent structured to be able to adhere to and report on the budget allocations. PEPFAR staff, both in headquarters and on the Country Teams, have explained to the Committee and others their frustration with these allocations and have illustrated how they thwart rational and strategic planning to meet the performance targets (GAO, 2006). Thus the manner in which Congress has required resources to be allocated, rather than what is necessary to have an impact, is having an unwarranted influence on PEPFAR. The U.S. Global AIDS Initiative needs maximum flexibility and agility not only to adapt to a changing pandemic and be harmonized with the efforts of 15 different focus countries, but also to be able to incorporate what is learned through program implementation about how to have the greatest impact. Resource allocation that is the consequence of rather than
least 33 percent should be expended for abstinence-until-marriage programs”; 15 percent for “palliative care of individuals with HIV/AIDS”; and 10 percent for “assistance for orphans and vulnerable children affected by HIV/AIDS, of which such amount at least 50 percent shall be provided through non-profit, nongovernmental organizations, including faith-based organizations, that implement programs on the community level.”