such as poverty and malnutrition; generally weak public health infrastructures; other prevalent diseases, such as malaria and tuberculosis; nascent civil society sectors; and severe human resource shortages. Because PEPFAR both is disease-specific and works in parallel with rather than through partner governments, these challenges are especially compelling, requiring PEPFAR to be particularly vigilant to ensure that its implementation does not have unintended negative consequences for overall public health in the focus countries.

Facilities

In the focus countries, facilities for delivering HIV/AIDS services are generally limited in number, geographic distribution, and capacity. The Committee visited areas that had no facilities of certain types, sites that were the only facility of their kind in large catchment areas requiring lengthy travel for the people who needed to use them, and facilities that appeared to be very small relative to the numbers of people they were intended to serve. PEPFAR is supporting a range of activities to address these limitations, from mobile testing and treatment programs to construction projects. During its visits to the focus countries, the Committee saw many examples of PEPFAR-supported renovations of facilities and a few examples of PEPFAR-supported new construction, and some of the Country Teams reported being able to support the construction of new facilities through various mechanisms. However, the Country Teams expressed to the Committee a great deal of confusion about the differing regulations of the many PEPFAR implementing agencies concerning new construction. OGAC reported that it recently issued a report clarifying these regulations and the capabilities of the implementing agencies and that it encourages Country Teams to support new construction where necessary and appropriate. This report was issued after the Committee had completed its visits to the focus countries, and thus the Committee was not able to confirm its effect with the Country Teams.

Community-Based Organizations

Although PEPFAR initially relied heavily on existing U.S.- and country-based contractors and large contracts, it has several mechanisms in place to strengthen the civil sectors of the focus countries by increasing the number and capacity of indigenous, particularly community-based organizations (OGAC, 2005a, 2006a). Country Teams are evaluated on the basis of the number of new and indigenous partners they are bringing into the program, and OGAC has policies in place to limit the proportion of a Country Team’s budget that can go to any one partner, which has decreased over time (OGAC, 2005c, 2006d,e). Early in the program, OGAC utilized an



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