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Evaluation of PEPFAR (2013)

Chapter: Appendix B: Recommendations

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Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Appendix B

Recommendations
1

PREVENTION

Recommendation 5-1: To contribute to the sustainable management of the HIV epidemic in partner countries, PEPFAR should support a stronger emphasis on prevention. The prevention response should prioritize reduction of sexual transmission, which is the primary driver of most HIV infections, while maintaining support for interventions targeted at other modes of transmission. The response should incorporate an approach balanced among biomedical, behavioral, and structural interventions that is informed by epidemiological data and intervention effectiveness evidence. PEPFAR should support advances in prevention science to expand the availability of effective interventions where knowledge is lacking.

Further considerations for implementation of this recommendation:

PEPFAR has made a commitment to overarching goals for prevention and for achieving an AIDS-free generation, but this does not constitute a long-term prevention strategy that clearly states prevention objectives and the pathways to achieving them. The following elements will be

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1 The recommendation numbers represent the chapters in which the recommendations appear and their order within each chapter.

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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critical for a more comprehensive strategy to achieve successful execution of prevention programs:

•   PEPFAR should continue to enhance its efforts to involve partner country stakeholders and incorporate country-specific epidemiology, context, and priorities in planning appropriately matched prevention programs that achieve a balanced approach to HIV prevention across the available modalities. To provide greater technical and operational clarity, the Office of the U.S. Global AIDS Coordinator (OGAC)2 should provide mechanisms to support the development, implementation, and monitoring of comprehensive prevention portfolios, including how to determine what populations need which directed prevention activities in which settings. Areas of prevention where current interventions are successful and effective, such as prevention of mother-to-child transmission (PMTCT), should be continued and scaled up to ensure access, coverage, and quality. As new PEPFAR-supported prevention activities are adopted, OGAC should communicate its objectives and the methods for introducing or scaling up with specified populations.

•    OGAC should improve mechanisms to collect and incorporate evidence on the effectiveness of prevention activities implemented in partner countries. The key components for future assessment and evaluation of HIV prevention should include need, coverage of need, quality of services provided, and behavioral and epidemiological outcomes. OGAC should provide clearly defined process and outcome measures as well as impact assessment methods to evaluate progress.

•    PEPFAR’s prevention strategy should include balanced support for innovation, research, and evaluation to contribute to the evolving evidence base and advance understanding of the effectiveness of interventions within all prevention modalities. To define and ensure this balance, OGAC should, through its existing mechanisms, convene and use expertise spanning behavioral, structural, and biomedical prevention intervention approaches. PEPFAR-supported research and evaluation activities should employ appropriate methodologies and study designs, without unduly emphasizing random assignment designs. PEPFAR should support innovations in preven-

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2 It is the committee’s intent that actions recommended to be taken by OGAC should be carried out through PEPFAR’s interagency coordination mechanism, which involves not only the OGAC staff but also the leadership and technical staff of the U.S. government (USG) implementing agencies.

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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     tion science methodologies where needed to achieve its programmatic research aims (see also Recommendation 11-1).

CARE AND TREATMENT

Recommendation 6-1: To improve the implementation and assessment of nonclinical care and support programs for adults and children, including programs for orphans and vulnerable children,3 the Office of the U.S. Global AIDS Coordinator should shift its guidance from specifying allowable activities to instead specifying a limited number of key outcomes. The guidance should permit country programs to select prioritized outcomes to inform the selection, design, and implementation of their activities. The guidance should also specify how to measure and monitor the key outcomes.

Further considerations for implementing this recommendation:

•    Outcomes for consideration for OGAC’s guidance should reflect the aims of care and support programs, which are to optimize quality of life, promote health, slow the progression of AIDS, and reduce HIV-related complications and mortality.

•    To enable this shift to a more outcomes-oriented approach, partner countries will need support and assistance to prioritize outcomes and targeting of services. PEPFAR U.S. mission teams should work with partner country stakeholders and implementers to assess country-specific needs and to select a subset of the core key outcomes to focus on when planning, selecting, and developing evidence-informed activities and programs for implementation.

•    OGAC should provide general guidance for country programs on continuous program evaluation and quality improvement to help them measure and monitor achievement of the key outcomes. This guidance may include, for example, template evaluation plans and methodological guidance. To allow for comparability across countries and programs, evaluation plans should include (but not be limited to) the defined indicators or other measures of the core key outcomes. Evaluations should emphasize the use of in-country local expertise (e.g., local implementing partners and subpartners and local academic institutions) to enhance capacity building and

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3 The discussion of the care of orphaned and vulnerable children (OVC) care leading to this aspect of this recommendation can be found in Chapter 7 and the parallel Recommendation 7-1.

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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     contribute to country ownership. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.)

•    PEPFAR should develop a system for active dissemination and sharing of evaluation outcomes and best practices both within and across countries that is driven as much by country-identified needs for information as by opportunities for exchange of information identified by headquarters (HQ)-level leadership and technical working groups. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.)

Recommendation 6-2: To contribute to sustainable care and treatment programs in partner countries, PEPFAR should build on its experience and support efforts to develop, implement, and scale up more effective and efficient facility- and community-based service delivery models for the continuum of adult and pediatric testing, care, and treatment. These efforts should aim to enhance equitable access, improve retention, increase clinical and laboratory monitoring, ensure quality, and implement cost-efficiencies.

Further considerations for implementation of this recommendation:

•    This recommendation should be implemented in coordination with recommendations and considerations discussed in Chapter 9 on health systems strengthening.

•    PEPFAR should develop a system for active dissemination and sharing of best practices in service delivery both within and across countries. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.)

Recommendation 6-3: To assess PEPFAR-supported HIV care and treatment programs and to evaluate new service delivery models, the Office of the U.S. Global AIDS Coordinator should support an enhanced, nested program monitoring effort in which additional longitudinal data on core outcomes for HIV-positive adults and children enrolled in care and treatment are collected and centrally reported from a coordinated representative sample across multiple countries and implementing partners.

Further considerations for implementation of this recommendation:

•    This activity would serve as a targeted, nested evaluation within routine program monitoring systems to allow for long-term op-

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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     erational assessment of performance and outcomes for care and treatment, across a representative sample of PEPFAR-supported programs. The aim would be to focus on key areas for evaluation and improvement of programs going forward, including as PEPFAR supports innovations in service delivery and as PEPFAR-supported programs transition to new models of implementation.

•    Data collected and reported for this sample should be harmonized with existing data collection whenever possible, including data already collected by implementing partners but not centrally reported (e.g., see the discussion of Tier 3 data in the implementation considerations for Recommendation 11-1A). Collaborative opportunities may be feasible with existing or new large-scale national and multi-country samples.

•    This data collection effort should be designed by first identifying and prioritizing the key questions that require longitudinal data and then focusing on relevant key outcomes with measures that are standardized across the sample. Priorities should include core outcomes related to clinical care and treatment, including adherence and retention; outcomes related to the reduction of HIV transmission through biomedical and behavioral prevention interventions for people living with HIV; quality measures; and program measures, such as the costs of services, that can help inform strategies for efficiencies, sustainable management, and resource planning for the trajectory of need.

•    There may also be opportunities for an established data collection effort of this kind to serve as a synergistic platform for targeted implementation research studies in subset samples to assess innovations and advance those best practices that are most ready for translation and scale-up.

•    In addition to implementing this approach prospectively, OGAC should explore working with and coordinating Track 1.0 partners to pool data for retrospective outcome analyses.

CHILDREN AND ADOLESCENTS

Recommendation 7-1: To improve the implementation and assessment of nonclinical care and support programs for adults4 and children, including programs for orphans and vulnerable children, the Office

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4 The discussion of nonclinical care and support for adults leading to this aspect of this recommendation can be found in Chapter 6 and the parallel Recommendation 6-1.

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×

of the U.S. Global AIDS Coordinator should shift its guidance from specifying allowable activities to instead specifying a limited number of key outcomes. The guidance should permit country programs to select prioritized outcomes to inform the selection, design, and implementation of their activities. The guidance should also specify how to measure and monitor the key outcomes.

Further considerations for implementing this recommendation:

•    For OVC, the new guidance and the ongoing developments for program evaluation already represent advances in addressing some of the challenges identified in this evaluation; this recommendation and the further considerations are intended to reinforce and further inform and support progress in achieving PEPFAR’s goals for children and adolescents.

•    Outcomes for consideration should be linked to the aims of OVC programs and therefore could include, for example, increased rates of staying in school, decreased excessive labor, reduced rates of exposure to further traumas, increased immunization completion, and increased coverage of HIV testing and treatment. With a continued focus on supporting developmentally informed programs, consideration should be given to identifying appropriate core outcomes for different age groups and for achieving developmental milestones. The program evaluation indicators currently being developed already offer a reasonable opportunity to link measures to core target outcomes for OVC programs.

•    The core key outcomes should also include quality of services and measures to reflect the potential sustainability of programs.

•    A shift to a more outcomes-oriented implementation model will require that partner countries receive support to define their prioritized outcomes and their target population and then to conduct baseline assessments so that progress toward outcomes can be measured.

•    PEPFAR U.S. mission teams should work with partner country stakeholders and implementers to assess country-specific needs and to select a subset of the core key outcomes to focus on when planning, selecting, and developing evidence-informed activities and programs for implementation.

•    Prioritization is critical in the presence of great need and finite resources. When planning with partner countries, PEPFAR should

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×

     improve targeted coverage and the quality of supported services for affected children and adolescents by not only prioritizing outcomes and activities but also by more explicitly, clearly, and narrowly defining the eligibility for PEPFAR-supported services. This prioritization should be based on an assessment of country-specific needs with a process that consistently applies considerations and criteria across countries and programs. This prioritization should be done in coordination across program areas that address the needs and vulnerabilities of children and adolescents. These areas, which may target and serve a broader eligible population of children and adolescents than is determined for specific OVC programs, include care and treatment, PMTCT, other prevention services, and gender programs.

•    To improve the targeted coverage and sustainability for children and adolescents, PEPFAR and its implementing partners should continue to enhance services through existing systems and infrastructure and to support national governments in expanding social support services and the workforce to meet the health, education, and psychosocial needs of affected children and adolescents.

•    OGAC should provide general guidance for country programs on continuous program evaluation and quality improvement in order to measure and monitor the achievement of key outcomes. This may include, for example, template evaluation plans and methodological guidance. To allow for comparability across countries and programs, evaluation plans should include (but not be limited to) the defined indicators or other measures of the core key outcomes. Evaluations should emphasize the use of in-country local expertise (e.g., local implementing partners and subpartners as well as local academic institutions) to enhance capacity building and contribute to country ownership. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.)

•    PEPFAR should develop a system for the active dissemination and sharing of evaluation outcomes and best practices both within and across countries that is driven as much by country-identified needs for information as by opportunities for exchange of information identified by HQ-level leadership and technical working groups. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.)

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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GENDER

Recommendation 8-1: To achieve PEPFAR’s stated aim of addressing gender norms and inequities as a way to reduce HIV risk and increase access to HIV services, the Office of the U.S. Global AIDS Coordinator (OGAC) should develop and clearly state objectives and desired outcomes for gender-focused efforts. OGAC should issue guidance for how to operationalize, implement, monitor, and evaluate activities and interventions to achieve these objectives.

Further considerations for implementation of this recommendation:

•    The objectives and guidance should be informed by the available evidence on how gender dynamics influence both HIV outcomes and the implementation of activities and services, as well as evidence on intervention effectiveness from the existing knowledge base, expert consultation, and experiences from pilot programs in partner countries.

•    OGAC’s guidance on gender-focused efforts should encompass programs specific to addressing gender norms and inequities and efforts to incorporate gender-focused objectives within prevention, care, and treatment activities.

•    The development of guidance for gender-focused efforts should take advantage of lessons learned from the processes used for PEPFAR’s recent updates to guidance for prevention and OVC programs.

•    PEPFAR U.S. mission teams should work with partner country stakeholders and implementers to strategically plan, select, develop, implement, and measure evidence-informed activities and programs to achieve the gender-focused objectives.

•    Strategic implementation of gender-focused efforts will require strong technical leadership, and as such additional capacity in gender expertise will be needed at both the OGAC and U.S. mission team levels. If gender efforts are to be appropriately integrated into all the aspects of service delivery and effectively implemented, then this capacity cannot be limited to gender-specific experts but should also be incorporated as part of the core competencies of mission team staff across PEPFAR’s programmatic areas.

•    As an engaged participant with other global and partner country stakeholders, through its implementation PEPFAR should contribute to generating evidence to inform gender-focused efforts through

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×

     research and evaluation. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.)

STRENGTHENING HEALTH SYSTEMS

Recommendation 9-1: To support the delivery of HIV-related services, make progress toward sustainable management of the HIV response, and contribute to other health needs, PEPFAR should continue to implement and leverage efforts that have had positive effects within partner country health systems. PEPFAR should maintain efforts in all six building blocks but have a concerted focus on areas that will be most critical for sustaining the HIV response, especially workforce, supply chain, and financing.

Further considerations for implementation of this recommendation:

•    An important focus for PEPFAR’s future activities and policies should be support for partner country capacity to locally produce and retain clinical, nonclinical, and management professionals whose training and scope of practice are appropriate and optimized for the tasks needed. The Medical Education Partnership Initiative (MEPI) and Nursing/Midwifery Education Partnership Initiative (NEPI) have provided a starting point for the training of physicians and nurses; however, the training of associate clinicians and other cadres will also be critical to sustainable management of the response. In addition, PEPFAR needs to augment its efforts to build partner country capacity to track the placement of trained workers, to promote retention, and to develop long-term human resources plans. (See also the discussion and recommendation for capacity building in Chapter 10.)

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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•    Building on the progress made through the public–private partnership with Supply Chain Management System (SCMS), PEPFAR should enhance and expand efforts with a greater focus on capacity building for accountable supply chain management in partner countries. The aim of this improved capacity should be to gradually shift to local or regional leadership, coordination, and management to ensure a reliable supply chain for essential medicines and commodities.

•    Financing and leadership and governance are particularly critical for sustainable management of the HIV response, and this area is addressed in Recommendation 10-1 (see Chapter 10).

•    To contribute to the knowledge base for health systems strengthening, PEPFAR should include this area in its research and evaluation agenda and its knowledge dissemination efforts. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.)

TRANSITIONING TO A SUSTAINABLE RESPONSE IN PARTNER COUNTRIES

Recommendation 10-1: To contribute to a country-owned and sustainable HIV response, the Office of the U.S. Global AIDS Coordinator should develop a comprehensive plan for long-term capacity building in partner countries. The plan should target four key areas: service delivery, financial management, program management, and knowledge management.

Further considerations for implementation of this recommendation:

•    In all four key areas, OGAC should invest more resources in initiatives for long-term capacity building and infrastructure development such as strengthening in-country academic institutions, degree programs, and long-course trainings, to improve in-country capacity and to accelerate progress toward country ownership and sustainability. These investments should foster the placement and retention of trained personnel in partner countries.

•    These initiatives should be monitored routinely at the country level to assess progress and identify necessary modifications. Special periodic multi-country studies could be used to evaluate the outcome and impact of the PEPFAR capacity-building initiative. To achieve this, OGAC should, using input from country programs, identify milestones toward achieving specified goals, define core metrics to assess capacity-building efforts, encourage innovative approaches through pilot initiatives and develop tools to help country programs monitor and evaluate these efforts:

Recommendation 10-2: Building on the Partnership Framework implementation process, PEPFAR should continue to work with partner country governments and other stakeholders to plan for sustainable management of the response to HIV. PEPFAR should support and participate in comprehensive country-specific planning that includes the following:

•    Ascertain the trajectory of the epidemic and the need for prevention, care and treatment, and other services.

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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•    Identify gaps, unmet needs, and fragilities in the current response.

•    Estimate costs of the current response and project resource needs for different future response scenarios.

•    Develop plans for resource mobilization to increase and diversify funding, including internal country-level funding sources.

•    Encourage and participate in country-led, transparent stakeholder coordination and sharing of information related to funding, activities, and data collection and use.

•    Establish and clearly articulate priorities, goals, and benchmarks for progress.

Further considerations for implementing this recommendation:

•    PEPFAR is not alone in trying to achieve locally led, sustainable health and development objectives. Contributing stakeholders, including partner countries, will need mutually agreed, principle-based resource allocation to achieve a strategic and ethical balance among the priorities of maintaining current coverage, expanding to meet existing unmet needs, and increasing coverage eligibility. Having processes in place to support this arduous decision making is a critical part of achieving sustainable HIV programs and sustainable management of the HIV epidemic in partner countries.

•    Partners in developing resource mobilization plans and potential sources for more diverse funding and other resources could include national and sub-national governments other bilateral donors, multilateral agencies, global and regional development banks, and private-sector consultants.

•    There may be learning opportunities at both the HQ and country levels for PEPFAR and other USG entities involved in development assistance to exchange strategies, best practices, and lessons learned for sustaining development objectives.

PEPFAR’S KNOWLEDGE MANAGEMENT

Recommendation 11-1: The Office of the U.S. Global AIDS Coordinator should develop a comprehensive knowledge management framework, including a program monitoring and evaluation strategy, a prioritized and targeted research portfolio, and systems for knowledge dissemination. This framework should adapt to emerging needs to as-

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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sess PEPFAR’s models of implementation and contribution to sustainable management of the HIV response in partner countries.

This knowledge management framework will require that PEPFAR implement and strategically allocate resources for the following:

A.   To better document PEPFAR’s progress and effectiveness, OGAC should refine its program monitoring and evaluation strategy to streamline reporting and to strategically coordinate a complementary portfolio of evaluation activities to assess outcomes and effects that are not captured well by program monitoring indicators. Efforts should support innovation in methodologies and measures where needed. Both monitoring and evaluation should be specifically matched to clearly articulated data sources, methods, and uses at each level of PEPFAR’s implementation and oversight.

B.   To contribute to filling critical knowledge gaps that impede effective and sustainable HIV programs, OGAC should continue to redefine permitted research within PEPFAR by developing a prioritized portfolio with articulated activities and methods. The planning and implementation process at the country and program level should inform and be informed by the research portfolio, which should focus on research that will improve the effectiveness, quality, and efficiency of PEPFAR-supported activities and will also contribute to the global knowledge base on implementation of HIV/AIDS programs.

C.   To maximize the use of knowledge created within PEPFAR, OGAC should develop systems and processes for routine, active transfer and dissemination of knowledge both within and external to PEPFAR. As one component, OGAC should institute a data-sharing policy, developed through a consultative process. The policy should identify the data to be included and ensure that these stipulated data and results generated by PEPFAR or through PEPFAR-supported activities are made available in a timely manner to PEPFAR stakeholders, external evaluators, the research community, and other interested parties.

Further considerations for implementation of Recommendation 11-1A: Program monitoring and evaluation

•    OGAC’s current tiered program monitoring indicator reporting structure should be further streamlined to report upward only those indicators essential at each PEPFAR level:

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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o   Tier 1: A small set of core indicators, fewer than the current 25, to be reported to central HQ level. These data should be used to monitor performance across PEPFAR as a whole, for congressional reporting, and to document trends; as such, these indicators should remain consistent over time. Whenever possible and appropriate, these indicators should be harmonized with existing global indicators and national indicators; therefore, some centrally reported indicators will reflect PEPFAR’s contribution rather than aiming to measure direct attribution.

o   Tier 2: A larger menu of indicators defined in OGAC guidance, from which a subset are selected for their applicability to country programs to be reported by implementing partners to the U.S. mission teams but not routinely reported to HQ. These data should be used to monitor the effectiveness of the in-country response and to support mutual accountability with partner countries and their citizens. These data could be considered for occasional centralized use to inform special studies or respond to congressional requests but aggregation and comparability across countries may be limited in this tier because all mission teams may not collect the same data.

o   Tier 3: Indicators selected by implementing partners to monitor and manage program implementation and effectiveness that are not routinely reported to mission teams. Implementing partners should select appropriate indicators defined in OGAC guidance and augment these with other indicators as needed for their programs. Implementing partners should work with mission teams in developing their program monitoring plans with selected indicators. Mission teams should provide oversight and technical assistance to ensure implementation of these plans and to promote local quality data collection, use, and mutual accountability. Although not routinely reported, some of these data could be considered for occasional country-level and centralized use.

o   OGAC should create mechanisms for implementing partners, mission teams, and agency HQ to mutually contribute to a periodic review across all tiers of indicator development, applicability, and utility and to make modifications if necessary.

o   Tier 1 indicators should be harmonized whenever possible and appropriate with existing global indicators and national indicators. For indicators that are not routinely reported centrally (Tiers 2 and 3), country program planning should facilitate

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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o     alignment of indicator selection and data collection with partner country HIV monitoring and health information systems.

•    OGAC should complement program monitoring with a unified evaluation portfolio that includes periodic program evaluation at the PEPFAR country program and implementing partner levels to assess process, progress, and outcomes as well as periodic impact evaluations at the country, multi-country, and HQ levels.

o   OGAC evaluation guidance should provide information about prioritizing areas for evaluation, the types of evaluation questions, methodological guidance, potential study designs, template evaluation plans, examples of key outcomes, and how evaluation results should be used and disseminated. PEPFAR should support a range of appropriate methodologies for program evaluation, including mixed qualitative and quantitative methods, and should shift emphasis from probability designs to plausibility designs that provide valid evidence of impact.

img   To allow for some comparability across countries and programs, OGAC and HQ technical working groups should, with input from country teams, strategically plan and coordinate a subset of evaluations within programmatic areas that include (but are not limited to) a minimum set of centrally identified and defined outcome measures and methodologies.

img   Within PEPFAR-supported evaluation activities there should be an emphasis on the use of in-country local expertise to enhance capacity building for program evaluation and contribute to country ownership.

•    For both program monitoring and evaluation OGAC should continue its work on defining and developing measures to assess progress in the currently under-measured areas of country ownership, sustainability, gender, policy, capacity building and technical assistance.

Further considerations for implementation of Recommendation 11-1B: Research

•    OGAC should clearly define which activities and methodologies will be included under the umbrella of PEPFAR-supported research, as distinguished from program evaluation.

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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•    OGAC should draw on input from implementing agencies, mission teams, partner countries, implementing partners, the Scientific Advisory Board, and other experts to identify and articulate research priorities and appropriate research methodologies. The research proposals and funding mechanisms should be designed to ensure that these priorities are met and that methodologies are applied through requests for applications and other investigator-driven research proposals as well as through targeted solicitations of research in gap areas not met through open requests.

•    Given PEPFAR’s legislative and programmatic objectives to support research that assesses program quality, effectiveness, and population-based impact; optimizes service delivery; and contributes to the global evidence base on HIV/AIDS interventions and program implementation, at the time of this evaluation the committee identified the following gaps in PEPFAR’s research activities:

o   Behavioral and structural interventions, especially in areas such as prevention, gender, nonclinical and OVC care and support, and treatment retention and adherence. These research activities should employ appropriate methodologies and study designs, without being unduly limited to random assignment designs.

o   Costs, benefits, and feasibility of integrating gender-focused programs with clinical and community-based activities.

o   Health systems strengthening interventions across the World Health Organization (WHO) building blocks, with a prioritized goal of determining setting- and system-specific feasibility, effectiveness, quality of services, and costs for innovative models.

•    To contribute to country ownership, PEPFAR should facilitate in-country local participation and research capacity building through simplified, streamlined, and transparent application and review processes that encourage submissions from country-based implementing partners and researchers.

Further considerations for implementation of Recommendation 11-1C: Knowledge transfer and dissemination

•    The knowledge created within PEPFAR that should be more widely documented and disseminated includes program monitoring data, financial data, research results, evaluation outcomes, best practices, and informal knowledge such as implementation experience, and lessons learned.

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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•    To institutionalize internal and external knowledge transfer and learning, PEPFAR should develop appropriate systems and processes for the most needed types and scale of knowledge transfer. To achieve this, PEPFAR should draw on broad stakeholder input to assess the strengths and weaknesses in current processes and to identify needs and opportunities for improved knowledge transfer.

•    PEPFAR should invest in innovative mechanisms and technology to facilitate knowledge transfer across partner countries and implementing partners. Mechanisms currently used successfully on a small scale and an ad hoc basis could be formally scaled up across PEPFAR. OGAC should also look to other organizations with wide geographic reach and organizational complexity, such as multi-country PEPFAR implementing partners, other large global health initiatives, and global corporations, for models of successful knowledge transfer systems.

•    OGAC should develop a policy for data sharing and transparency that facilitates timely access to PEPFAR-created knowledge for analysis and evaluation. The purpose of this policy would be to ensure that, within a purposefully and reasonably defined scope, specified program monitoring data and financial data, evaluation outcomes, and research data and results generated with PEPFAR support by contractors, grantees, mission teams, and USG agencies be made available to the public, research community, and other external stakeholders. OGAC and the PEPFAR implementing agencies should consult with both internal and external parties that would be affected by this policy to help identify the data that are most critical for external access and that can be reasonably subject to data-sharing requirements, as well as to help develop feasible mechanisms to implement a data-sharing policy.

o   For routinely collected financial and program monitoring data, a limited set of essential data should be identified and made available for external use in a timely way.

o   Evaluation and research reports and publications using data collected through PEPFAR-supported programs should be tracked and made available in a publicly accessible central repository. USG agencies with similar repositories can be considered as models.

o   For research data and other information that is expressly generated for new knowledge, the policy should respect time-bound exclusivity for the right to engage in the publication process, yet

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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     also ensure the timely availability of data, regardless of publication, for access and use by external evaluators and researchers. OGAC should look to USG agencies with similar research data policies as models.

o   In developing the policy and specifying the scope of data to be included, several key factors and potential constraints that can affect the implementation of the policy will need to be addressed. These include patient and client information confidentiality; the financial resources, personnel, and time needed to make data available; and issues of data ownership, especially in the context of increasing responsibility in partner countries and the provision of PEPFAR support through country systems or through activities and programs supported by multiple funding streams.

Suggested Citation:"Appendix B: Recommendations." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Next: Appendix C: Evaluation Methods »
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The U.S. government supports programs to combat global HIV/AIDS through an initiative that is known as the President's Emergency Plan for AIDS Relief (PEPFAR). This initiative was originally authorized in the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 and focused on an emergency response to the HIV/AIDS pandemic to deliver lifesaving care and treatment in low- and middle-income countries (LMICs) with the highest burdens of disease. It was subsequently reauthorized in the Tom Lantos and Henry J. Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (the Lantos-Hyde Act).

Evaluation of PEPFAR makes recommendations for improving the U.S. government's bilateral programs as part of the U.S. response to global HIV/AIDS. The overall aim of this evaluation is a forward-looking approach to track and anticipate the evolution of the U.S. response to global HIV to be positioned to inform the ability of the U.S. government to address key issues under consideration at the time of the report release.

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