document on prevention of sexual transmission was one notable example cited as having suffered from a lengthy delay in moving from OGAC headquarters to the field (166-26-USG; 587-23-USG; 166-26-USG). One reason noted for the slow or delayed issuance of guidance was the iterative process for generating, reviewing, and approving the guidance, which usually requires information gathering, discussion, and agreement among multiple USG agencies and technical working groups. While this may ensure thorough vetting, it can also result in a lengthy period to go from the headquarters process to dissemination and implementation at the country level (NCV-11-USG; NCV-17-USG; NCV-18-USG; 587-23-USG; 166-26-USG; 587-23-USG; 166-26-USG). Another challenge that interviewees noted was that guidance sometimes takes a “one-size-fits-all” approach that does not fit all country programs, whether because of limited applicability to special circumstances in smaller, more narrowly focused country programs or because of limited room for adaptation to local culture and standards. Interviewees expressed a desire for more balance in guidance, as well as in the implementation of programs, between what is driven by USG headquarters and what is driven by the mission team in a country through its planning and coordination with partner country stakeholders (272-ES; 196-ES; 396-ES; 542-ES; 461-ES; 636-ES; 331-ES).

ORGANIZATION OF PEPFAR AT THE COUNTRY LEVEL

PEPFAR country programs that submit a Country Operational Plan (COP) to OGAC typically have an interagency U.S. mission team made up of representatives of all implementing departments and agencies working in the country (see Figure 3-3 for an illustration of a mission team). U.S. ambassadors or chiefs of mission are the leaders of interagency PEPFAR teams, ultimately responsible for ensuring that policies and programs are coordinated at the highest levels, accounting for all plans and reports submitted to OGAC, and engaging with partner-country leadership. Mission teams coordinate all of the program activities in the country and are almost all anchored by a country coordinator. The members of the mission teams work with implementing partners, other international organizations and donors, and partner country governments and nongovernmental entities to implement programs and services, develop partnerships, participate in coordination and planning processes, and support policies that contribute to an effective response to HIV and ensure that more attention and resources are put toward HIV/AIDS. Mission team staff members also participate in joint planning committees or working groups organized by the partner country government or by multilateral organizations. In addition members of the interagency mission team also work with the Global Fund’s local committee, known as the Country Coordinating Mechanism, to improve implementation of Global Fund grants programs and to facilitate coordina-



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