One of the functions of the interagency coordination and advisory mechanisms is to develop and communicate operational guidance, technical considerations, and programmatic guidance to PEPFAR mission teams and implementing partners (IOM, 2007). Some overall aspects of the guidance process are discussed here, while the content of the guidance in specific program areas, including the timing and extent of changes over time, are discussed in the relevant chapters in this report.

In many technical areas related to HIV programs, PEPFAR does not issue programmatic guidance of its own, but instead defers to the normative guidance of other authoritative technical bodies when it is available, primarily from the World Health Organization (NCV-7-USG; NCV-10-USG; NCV-13-ML).5 Guidance for the implementation of such normative international guidance is often covered in PEPFAR’s operational guidance or technical considerations. In other areas of the HIV response, PEPFAR issues its own programmatic guidance, for example, when there are programmatic needs not comprehensively addressed by existing normative guidance or when there are legislative directives and USG policies that may not align with international standards (PEPFAR, 2013c). The number and frequency of guidance documents issued varies by programmatic area, and in some areas PEPFAR’s programmatic guidance has changed substantially since the beginning of the program. The use of evidence and the threshold for evidence required to instigate a change in guidance also seems to have varied by programmatic area. Guidance is discussed in more depth for each PEPFAR program area in the subsequent chapters of this report.

Interviewees at both headquarters and at the country level described several challenges related to central guidance from OGAC. One is a lack of clarity concerning such things as appropriate service packages, allowable activities, and efforts in emerging areas of program emphasis, such as country ownership, capacity building, health systems strengthening, and transitioning to new models of implementation (396-ES; 272-ES; 196-ES; 331-ES). Another challenge noted by interviewees is the timeliness of guidance. The guidance


Committee; Adult Treatment; PMTCT/Pediatric AIDS; Tuberculosis (TB) and HIV/AIDS; Care and Support; Orphans and Vulnerable Children; Community/Faith Based Organizations, Food, Nutrition, and HIV/AIDS; Gender; Public–Private Partnerships; Health Systems Strengthening; Human Resources for Health; Laboratory; Finance and Economics; Strategic Information Steering Committee; Monitoring and Evaluation; Surveillance and Survey; Health Management Information Systems. Staff from USG agencies, USG-funded partners, and non-USG-funded partners may participate in each TWG (OGAC, 2012).

5 For citations of interview data:

Country Visit Exit Synthesis Key: Country # + ES Country Visit Interview Citation Key: Country # + Interview # + Organization Type Non-Country Visit Interview Citation Key: “NCV” + Interview # + Organization Type Organization Types: United States: USG = U.S. Government; USNGO = U.S. Nongovernmental Organization; USPS = U.S. Private Sector; USACA = U.S. Academia; Partner Country: PCGOV = Partner Country Government; PCNGO = Partner Country NGO; PCPS = Partner Country Private Sector; PCACA = Partner Country Academia; Other: CCM = Country Coordinating Mechanism; ML = Multilateral Organization; OBL = Other (non-U.S. and non-Partner Country) Bilateral; OGOV = Other Government; ONGO = Other Country NGO.

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