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U.S. Funding for the PEPFAR Initiative

INTRODUCTION

The President’s Emergency Plan for AIDS Relief (PEPFAR) is the largest global health initiative focused on a single disease ever undertaken, and the United States is the single largest donor to global HIV/AIDS efforts in the world (Donnelly, 2012c; OGAC, 2009d).The committee reviewed PEPFAR funding because it represents one of the most direct measures of the U.S. government’s (USG’s) investment to address the global AIDS pandemic and, as such, is an important metric by which to understand and assess the program’s impact. It also represents a critical input for answering the questions pertaining to PEPFAR’s effects that were considered in the evaluation of programmatic areas using the program impact pathway framework described in Chapter 2. The distribution of PEPFAR funding over time can provide insight into HIV prevention, treatment, and care programs as well as into additional broader goals, such as country ownership, sustainability, and the strengthening of health systems.

To describe the investments that the USG has made through PEPFAR and to assess the relationship between these investments and program’s effects, the committee examined, to the extent possible, the level of funding over time and how the funds were budgeted and distributed. Unfortunately, because of limitations in the available financial data that are described more fully in this chapter, it was not feasible to make all of the assessments that the committee set out to make. In particular, it was difficult to describe the distribution of the annual direct expenditure of PEPFAR in partner



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4 U.S. Funding for the PEPFAR Initiative INTRODUCTION The President’s Emergency Plan for AIDS Relief (PEPFAR) is the largest global health initiative focused on a single disease ever undertaken, and the United States is the single largest donor to global HIV/AIDS efforts in the world (Donnelly, 2012c; OGAC, 2009d).The committee reviewed PEPFAR funding because it represents one of the most direct measures of the U.S. government’s (USG’s) investment to address the global AIDS pandemic and, as such, is an important metric by which to understand and assess the program’s impact. It also represents a critical input for answering the questions pertaining to PEPFAR’s effects that were considered in the evalu- ation of programmatic areas using the program impact pathway framework described in Chapter 2. The distribution of PEPFAR funding over time can provide insight into HIV prevention, treatment, and care programs as well as into additional broader goals, such as country ownership, sustainability, and the strengthening of health systems. To describe the investments that the USG has made through PEPFAR and to assess the relationship between these investments and program’s ef- fects, the committee examined, to the extent possible, the level of funding over time and how the funds were budgeted and distributed. Unfortunately, because of limitations in the available financial data that are described more fully in this chapter, it was not feasible to make all of the assessments that the committee set out to make. In particular, it was difficult to describe the distribution of the annual direct expenditure of PEPFAR in partner 93

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94 EVALUATION OF PEPFAR countries, to comprehensively match accounting budget codes to program- matic activities, and to fully follow the types of partners that ultimately receive funding and implement PEPFAR-supported activities. Nonetheless, the funding data that were available did allow for the insights and observa- tions that were important information for the evaluation, and these finding are presented in this chapter. As described in Chapter 2, the committee focused most of its data col- lection and its assessment on the 31 countries that were writing Country Operational Plans (COPs) when the IOM evaluation study process began in 2009.1 As such, in some cases the committee’s examination of PEPFAR funding in this chapter is limited to this subset of 31 countries. These countries represented 96 percent of PEPFAR planned funding in FY 2011 (OGAC, 2011d).2 In addition, although the committee reviewed data on PEPFAR funding over time to contribute to this evaluation, the committee was not charged to conduct a financial audit of PEPFAR; that function is performed by the Offices of Inspectors General at the USG agencies respon- sible for the implementation of PEPFAR programs and activities, including the Department of State (DoS), the Department of Health and Human Ser- vices (HHS), and the U.S. Agency for International Development (USAID). This chapter begins with a brief discussion of the broader global fund- ing environment for HIV/AIDS within which PEPFAR operates as a reflec- tion of the context in which PEPFAR contributes to the HIV response in partner countries. This is followed by an overview of the USG budget and PEPFAR funding processes and a presentation of PEPFAR financial data describing the amount and distribution of funding over time as well as the characteristics of the partner countries that have been recipients of PEPFAR funding. The chapter then presents a brief discussion of the strategic use of PEPFAR resources. The chapter also discusses some questions of interest to the committee that could not be addressed because of limited availability of quality data. 1  The 31 PEPFAR countries submitting Country Operational Plans at the time were the original 15 focus countries (Botswana, Republic of Côte d’Ivoire, Federal Democratic Republic of Ethiopia, Cooperative Republic of Guyana, Republic of Haiti, Republic of Kenya, Republic of Mozambique, Republic of Namibia, Federal Republic of Nigeria, Republic of Rwanda, Re- public of South Africa, United Republic of Tanzania, Republic of Uganda, Socialist Republic of Vietnam, and Republic of Zambia) plus the following additional countries: Republic of An- gola, Kingdom of Cambodia, People’s Republic of China, Democratic Republic of the Congo, Dominican Republic, Republic of Ghana, Republic of India, Republic of Indonesia, Kingdom of Lesotho, Republic of Malawi, Russian Federation, Republic of the Sudan, Kingdom of Swaziland, Kingdom of Thailand, the Ukraine, and the Republic of Zimbabwe. 2  Planned/approved funding as reported in the FY 2011 PEPFAR Operational Plan. The committee’s sources for this and other types of funding information will be explained through- out the chapter.

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U.S. FUNDING FOR THE PEPFAR INITIATIVE 95 The primary focus of this chapter is on funding processes within PEPFAR. The committee recognizes that in the response to HIV in PEPFAR partner countries there is an inherent interconnectedness among PEPFAR, partner countries, and other donors. This is touched upon briefly in this chapter, but the primary discussion can be found in the section on financing in Chapter 9, which discusses health systems strengthening, and in Chap- ter 10, which discusses progress toward a sustainable response in partner countries. PEPFAR’S CONTRIBUTION RELATIVE TO OTHER DONORS In most countries PEPFAR is situated within a broader landscape of global funding for HIV/AIDS, which includes partner country governments; other donor governments; the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund); the World Bank; and other multilateral institutions.3 The committee sought data on other sources of funding for HIV/AIDS in order to understand the context in which PEPFAR is imple- mented and to contribute to an assessment of the USG’s relative HIV/AIDS investment. Unfortunately, few data were available to examine the financial contribution of partner countries to national HIV/AIDS responses. The committee reviewed data from National Health Accounts and National AIDS Spending Assessments for the 31 countries that are the focus of this evaluation, but it was unable to address partner country contribution be- cause data are unavailable for many countries and years. Thus, the data presented here focus on the contribution of PEPFAR only in the context of external donor assistance for HIV/AIDS. Chapter 9 provides a more thor- ough discussion of domestic financing for national HIV/AIDS responses and the implications of these data limitations. To contextualize PEPFAR’s financial contribution within the broader external donor funding landscape, the committee examined disbursement data on official development assistance for HIV/AIDS, as reported to the Organisation for Economic Co-operation and Development Creditor Re- porting System. For the 31 countries in the committee’s analysis, total donor disbursements for HIV/AIDS were $21.8 billion from 2004 to 2010 (OECD, 2012b).4 As shown in Figure 4-1, total disbursements for HIV/ AIDS increased each year, from $1.3 billion in 2004 to $4.7 billion in 2010. Disbursements increased over time from all types of donors, including USG 3  Multilateral institutions are “international institutions with governmental membership” (OECD, 2012a). In the context of development assistance, multilateral institutions pool donor contributions and disburse funding at their own discretion. 4  This 7-year period of time captures donor funding from the beginning of PEPFAR imple- mentation to the most recent year available.

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96 EVALUATION OF PEPFAR 100% $5 90% Constant 2010 USD Billions 80% $4 70% 60% $3 50% 40% $2 30% 20% $1 10% 0% $0 2004 2005 2006 2007 2008 2009 2010 Other Multilaterals 9% 11% 7% 8% 5% 4% 4% Other Bilaterals 19% 20% 20% 19% 12% 13% 9% Global Fund 20% 25% 22% 25% 24% 18% 25% U.S. Government 52% 44% 51% 49% 60% 65% 62% Total Funding (billions) $1.3 $1.8 $2.3 $3.2 $4.1 $4.3 $4.7 FIGURE 4-1 Total donor disbursements for HIV/AIDS in PEPFAR partner countries (con- stant 2010 USD billions). NOTE: Figure presents disbursements for the 31 PEPFAR countries that were writing COPs when the IOM evaluation study process began in 2009. Disbursements represent the sum of two OECD sector codes: STD (sexually transmitted disease) control, including HIV/AIDS, and social mitigation of HIV/AIDS. Funding from the U.S. government and other bilaterals represents only bilateral funding (funding from a donor government to a partner country) and not contributions to the Global Fund. SOURCE: OECD, 2012b. bilateral funding for PEPFAR, the Global Fund, other bilateral government donors, and other multilateral organizations.5 The largest proportion of donor funding over this period was provided by the USG through bilateral funding for PEPFAR, followed by the Global Fund, for which the USG is the largest contributor (Goosby et al., 2012). During this time period, the proportion of donor funding from other bilateral donors and multilateral organizations decreased, while the proportions from the USG and the Global Fund increased. As these data indicate, the USG’s bilateral investments implemented through PEPFAR constitute the largest external source of funding in the response to the HIV epidemic across these 31 countries, providing almost two-thirds of the external funding for HIV in 2010. Although these descrip- tive data do not demonstrate a causal relationship between funding and impacts on the epidemic, it is reasonable to conclude from the magnitude of PEPFAR’s investment and the proportion of HIV funding that it represents 5  Bilateral funding is provided to an aid-recipient country directly from a donor country (OECD, 2012a).

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U.S. FUNDING FOR THE PEPFAR INITIATIVE 97 that PEPFAR funding did contribute to changes in the trajectory of the HIV epidemic and in HIV-related outcomes. Using the approach of the program impact pathway described in Chapter 2, this evaluation report presents the committee’s assessment of the effects of the activities and programs sup- ported with these funds. PEPFAR funding has represented a historic contribution in countries with few resources and a great need for support in their response to HIV. The dominance of one external donor, however, also brings with it the pos- sibility that this one donor will drive the agenda and that the response in countries will be vulnerable to changes in that one donor’s investment or policies. These issues are discussed throughout this report, and, in particu- lar, the role of donor funding in supporting the response to HIV in partner countries, along with the additional factors of national investments, health systems financing, and implications for future sustainable management of the HIV pandemic, are discussed in Chapters 9 and 10. OVERVIEW OF THE PEPFAR FUNDING PROCESS Through review of publicly available documents and interviews with the Office of the U.S. Global AIDS Coordinator (OGAC) and other USG stakeholders, the committee developed a framework to represent the flow of PEPFAR funding and how it is ultimately used for the implementation of programs in partner countries. Figure 4-2 represents a simplified overview of this flow (NCV-1-USG; NCV-11-USG) (IOM and NRC, 2010).6 In most respects, it mirrors the administrative and programmatic structure of PEPFAR as described in Chapter 3. The rest of this section expands on the subcompo- nents represented in Figure 4-2, describing the processes for the major steps within the framework. Box 4-1 provides definitions for key terms used in this chapter as part of the description of the U.S. federal budget process and PEPFAR’s budgeting, planning, and programming. 6  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 Coun- try) Bilateral; OGOV = Other Government; ONGO = Other Country NGO.

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98 EVALUATION OF PEPFAR Congress Congress approves the federal budget and appropriates funding for PEPFAR to OGAC and other USG agencies. Some funding remains at OGAC for administraƟon and HHS/CDC central programs. Most OGAC funding is transferred to the USG agencies responsible for implemenƟng PEPFAR USAID acƟviƟes in partner countries. Peace DOD DOL Spending authority for Corps PEPFAR funding may be transferred to PEPFAR mission teams in countries or remain at USG agency USG Agency HQ/PEPFAR Mission Team headquarters. USG agencies and PEPFAR mission teams develop funding agreements with prime partners for Prime Partners implementaƟon of PEPFAR acƟviƟes. Prime partners may or may not contract with sub- partners for implementaƟon. Beneficiaries Sub-Partners Beneficiaries vary depending on the type of acƟvity supported and may include PLHIV/paƟents/clients (e.g., delivery of services) as well as partner country governments/universiƟes/non-profits (e.g., technical assistance). Beneficiaries FIGURE 4-2 PEPFAR overall funding flows framework. NOTE: CDC = U.S. Centers for Disease Control and Prevention; DoD = U.S. Department of Defense; DoL = U.S. Department of Labor; HHS = U.S. Department of Health and Human Services; HQ = headquarters; OGAC= Office of the U.S. Global AIDS Coordinator; PLHIV = people living with HIV/AIDS; USAID = U.S. Agency for International Development; USG = U.S. government. SOURCE: Developed by the committee after document review and consultations with OGAC.

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U.S. FUNDING FOR THE PEPFAR INITIATIVE 99 BOX 4-1 Definitions for Selected Financial Terms Appropriations: “An appropriations measure provides budget authority to an agency for specified purposes. Budget authority allows federal agencies to incur obligations and authorizes payments to be made out of the Treasury” (Heniff, 2008, p. 2). Authorization: “An authorizing measure can establish, continue, or mod- ify an agency or program for a fixed or indefinite period of time” and “authorizes the enactment of appropriations for an agency or program” (Heniff, 2008, p. 2). Obligations: Commitments of funding, such as placing an order or awarding a contract, made by USG agencies in order to implement and carry out programs, projects, and activities. Outlays: Payments from the U.S. Treasury, usually in the form of cash or check, for goods or services. Planned/Approved Funding: How OGAC and PEPFAR mission teams plan to obligate and outlay funds, documented in annual operational plans. SOURCES: OGAC, 2011d; OMB, 2011. Congressional Authorization and Appropriations The United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (the Leadership Act)7 authorized up to $15 billion in funding, including funds for bilateral PEPFAR efforts and annual yearly contributions to the Global Fund, for fiscal years (FYs) 2004 through 2008.8 In 2008 the U.S. Congress reauthorized PEPFAR for an additional 5 years (FY 2009–FY 2013) for up to $48 billion: $39 billion for bilateral HIV/AIDS programs and contributions to the Global Fund and $9 billion for bilateral tuberculosis and malaria programs.9 These two pieces of legis- lation authorized Congress to appropriate up to a maximum level of fund- ing in a 5-year period, but PEPFAR’s annual budget is still dependent on the annual federal budget process. Congress may appropriate less or more than 7  United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, P.L. 108-25, 108th Cong., 1st sess. (May 27, 2003). 8  Ibid., §401(a). 9  Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tu- berculosis, and Malaria Reauthorization Act of 2008, P.L. 110-293, 110th Cong., 2nd sess. (July 30, 2008).

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100 EVALUATION OF PEPFAR what is authorized. Early each year, the President prepares a budget for the following year and submits it to the Congress. The Global AIDS Coordina- tor requests a certain level of funding for each recipient country, and these requests are included in the President’s budget proposal. Congress reviews the President’s budget proposals, determines the final revenue and spending plan for the country, and eventually passes appropriations measures that provide budget authority to USG agencies (Heniff, 2008; OMB, 2011). The annual amount of PEPFAR funding is decided during this budget process. The red arrows in Figure 4-2 represent the appropriations process whereby Congress appropriates a specific level of funding for USG agencies to implement PEPFAR programs and activities. The greater part of PEPFAR funding is initially appropriated by Congress directly to OGAC at the De- partment of State, and then most is eventually transferred to the other USG agencies responsible for implementing programs in partner countries (rep- resented by the blue arrows in Figure 4-2). USAID, HHS and the Centers for Disease Control and Prevention (CDC), and the Department of Defense (DoD) may also receive direct appropriations of PEPFAR funding through separate appropriations acts. All PEPFAR funding, regardless of the agency to which it is appropri- ated or transferred, is planned and coordinated through an interagency process overseen and led by OGAC (NCV-1-USG; NCV-4-USACA). Each year the USG agencies responsible for implementing PEPFAR work together to develop the PEPFAR Operational Plan as well as country and regional operational plans that include descriptions of previous achievements, proposals for new and continued activities, and funding requests for implementation of these activities. These plans are based on the amount of money requested by OGAC in the President’s budget proposal, and operational plans must be approved by the Global AIDS Coordinator (NCV-1-USG; NCV-4-USACA). As de- scribed above, the ultimate amount of PEPFAR funding for each year is determined through the congressional budget and appropriations processes. The PEPFAR Operational Plan provides information about the planned distribution of congressionally appropriated funding to USG agencies for PEPFAR activities as well as details about how the funding that remains at OGAC is used for central programs, oversight, and administration. COPs provide further information about which USG agencies will receive funding for implementation of specific activities and the mechanisms for disburs- ing that funding to implementing partners. Together, these operational plans document summary budget information regarding the planned and approved use of PEPFAR funding, including which activities will be imple- mented by which agencies, as determined during the interagency planning process (OGAC, 2011d). Stakeholders interviewed for this evaluation identified challenges to program planning and implementation as a result of this annual USG fund-

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U.S. FUNDING FOR THE PEPFAR INITIATIVE 101 ing process. In particular, interviewees indicated that long-term planning is often difficult for U.S. mission teams, partner countries, and implementing partners because of uncertainty from year to year about whether they will receive funding and how much they will receive (NCV-4-USACA; NCV-9-USG; NCV-11-USG; 166-10-USNGO; 166-13-PCGOV; 935-2-USG; 935-8-PCGOV; 396-16-PCGOV; 240-33-USG). These challenges are considered further in Chapters 9 and 10, where health systems financ- ing and achieving sustainable management of the response are discussed. Obligations and Outlays Once Congress has appropriated funding for a given year and the headquarters and country-level planning processes are complete, PEPFAR funding is available to be obligated and outlaid for program implementa- tion. Obligations are commitments of funding, such as awarding a contract, made by USG agencies in order to implement and carry out programs, projects, and activities (OMB, 2011). Outlays are the actual payments made from the U.S. Treasury (OMB, 2011). USG agencies obligate and outlay PEPFAR funding to prime partners. Prime partners may be nonprofit organizations, academic institutions, for-profit firms, multilateral organiza- tions, partner country governments, or USG agencies. PEPFAR funding is obligated when a USG agency enters into a legally binding agreement (also known as an implementing mechanism) such as a contract, grant, or coop- erative agreement with a prime partner. PEPFAR funding is outlaid when the U.S. Treasury actually makes a payment to a prime partner. Prime part- ners implement PEPFAR activities either directly or through sub-partners. Historically, most PEPFAR funding appropriated to OGAC has been “no-year” money that will never “expire”; that is, funding appropriated in any given fiscal year could be obligated or outlaid in that year or any year that follows (OGAC, 2008c). This type of funding remains available until expended and provides OGAC with some flexibility (Sessions, 2006). In FY 2012, a 5-year limit was put in place for the obligation of this funding (Donnelly, 2012b; OGAC, 2013a).10 Funding that is directly appropriated to other USG agencies, including USAID, HHS, and DoD, may be subject to different periods of availability as determined by the relevant appropria- tions acts (OGAC, 2010e). 10  Department of State, Foreign Operations, and Related Programs Appropriations Act, 2012, P.L. 112-74, 112th Cong., 1st sess. (December 23, 2011), 392.

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102 EVALUATION OF PEPFAR PEPFAR FUNDING LEVELS AND DISTRIBUTION BY PROGRAMS AND PARTNERS To understand the level of investment and the allocation and distri- bution of PEPFAR resources, the committee collected data from multiple available sources on appropriations, which reflect congressional intent; obli- gations, which represent programmatic intent; and outlays, which represent the disbursement of funding for implementation. The following sections present the committee’s findings, to the extent that data were available, at each level within the overall framework for the flow of PEPFAR funding (Figure 4-2). Although the committee was interested in understanding the flow of funding through all levels, data were only available to the level of distribution of funds to prime partners, as discussed in more detail below. Because the committee was charged with evaluating PEPFAR since its inception, FY 2004 was used as the baseline for assessing the financial data, and the following section presents financial data through the last complete year of data available during the timeframe of the evaluation, typically FY 2011. It is important to note that although FY 2004 was the first year of funding for PEPFAR, it was not the first year of USG funding for global HIV/AIDS efforts. Rather, USG assistance for global HIV/AIDS efforts began in 1986, with an initial investment of $1 million. By 2000, annual funding had grown to just more than $360 million, and it reached about $1.5 billion in 2003 (Kates and Summers, 2004). Compared to this prior funding, PEPFAR represented a major scale-up and expansion of U.S. support, authorizing up to $15 billion for bilateral programs over its first 5-year period and creating a new position in the DoS for the coordination of the USG global HIV/AIDS response.11 What follows is a presentation of financial data for FYs 2004 through 2011 (where available). Congressional Appropriations Appropriations reflect the level of congressional commitment for PEPFAR programs. From 2004 to 2011, more than $38 billion (current USD) was appropriated to USG agencies for PEPFAR programs and the Global Fund (OGAC, 2011a). During PEPFAR I (FY 2004–FY 2008), actual congressional appropriations surpassed the $15 billion authorized in the Leadership Act. Total congressional appropriations over the 5-year period were $18.3 billion for bilateral HIV/AIDS programs and contribu- tions to the Global Fund (excluding funding for tuberculosis and malaria) (OGAC, 2009a). In the first 3 years of PEPFAR II, actual appropriations totaled $19.8 billion, just more than half of the $39 billion authorized 11  Supra, at note 7, §102(a)(2), 22 U.S.C. 2651a(f).

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U.S. FUNDING FOR THE PEPFAR INITIATIVE 103 $7 $6 Current USD Billions $5 $4 $3 $2 $1 $0 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 Global Fund $0.5 $0.3 $0.5 $0.7 $0.8 $0.8 $1.0 $1.3 HHS/NIH Research $0.3 $0.3 $0.4 $0.4 $0.4 $0.5 $0.5 $0.5 Focus and Other Country $1.4 $1.9 $2.3 $3.2 $4.6 $5.2 $5.1 $4.8 HIV/AIDS Activities Total Appropriations $2.2 $2.6 $3.3 $4.3 $5.8 $6.5 $6.6 $6.6 FIGURE 4-3 Congressional appropriations for PEPFAR, FY 2004–FY 2011 (current USD billions). NOTE: Data represent total funding appropriated (made available) for all PEPFAR countries within each U.S. fiscal year (October 1–September 30) in current USD billions. HHS = U.S. Department of Health and Human Services; NIH = National Institutes of Health. SOURCES: OGAC, 2004, 2006a, 2007a, 2008a, 2009a, 2010a,b, 2011a. through FY 2013 (OGAC, 2011a). From FY 2004 to FY 2011, $28.6 bil- lion, or the greater part of PEPFAR funding, was appropriated for support of PEPFAR country programs. Approximately $3.3 billion was appropri- ated for research at the U.S. National Institutes of Health (NIH), and $6.1 billion was appropriated for the Global Fund (OGAC, 2004, 2006a, 2007a, 2008a, 2009a, 2010a,b, 2011a). Figure 4-3 shows the annual appropria- tions for each of those categories from FY 2004 to FY 2011. Cumulative Obligations and Outlays To understand the level of PEPFAR investment intended by Congress that has been spent to support PEPFAR activities over time, the commit- tee first assessed how appropriated funds have been obligated and outlaid over time. Figure 4-4 summarizes the cumulative funds made available, obligated, and outlaid for PEPFAR programs in all partner countries. For the funds shown in Figure 4-4, Figure 4-5 provides more detail on the proportions that have been obligated and outlaid at the end of each fiscal year. As of the end of FY 2011, 72 percent of the total funding made available for PEPFAR through congressional appropriations had been out- laid, 17 percent had been obligated but not yet outlaid, and 11 percent had yet to be obligated or outlaid. The cumulative amount of available PEPFAR

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146 EVALUATION OF PEPFAR to match the needs of the national response (Goosby, 2012b). Efforts to improve routine business practices for the whole of the program have re- sulted in considerable cost savings (Donnelly, 2012b). Several strategies for streamlining processes are described here. Cost Reductions for Drugs Procured by PEPFAR Systemic changes in the selection and procurement of ARVs has con- tributed to dramatic reductions in the cost of treatment; per-patient treat- ment costs have fallen from more than $1,100 per year to approximately $335 (OGAC, 2012c). To ensure quality, ARVs purchased with PEPFAR funding must be approved by the U.S. Food and Drug Administration (FDA) or another acceptable regulatory authority. When PEPFAR began, only proprietary/brand name ARVs had been approved by FDA, which re- sulted in significantly higher costs for first-line regimens (up to $450 more per patient per year) compared to the lowest-priced generics available in fo- cus countries and/or provided by other global HIV/AIDS initiatives (GAO, 2005). To increase the availability of generic ARVs for purchase with PEPFAR funding, FDA modified an expedited review process—FDA tenta- tive approval—to rapidly evaluate the quality of generic ARVs (Holmes et al., 2010). The percentage of generic ARVs purchased with PEPFAR fund- ing increased from 16 percent in 2005 to 89 percent in 2008, reducing drug costs by more than $323 million; in 2010, 97 percent of ARVs procured by PEPFAR were generic (El-Sadr et al., 2012; Holmes et al., 2010). The Supply Chain Management System estimates that switching to generics has saved $1.1 billion through September 2011 (SCMS, 2012). In addition to decreased costs due to use of generic ARVs, pooled procurement of commodities (including ARV drugs as well as other com- modities such as laboratory reagents) within, across, and between countries has led to savings in the form of discounts from suppliers. Changing the methods by which these ARVs are procured and delivered has also achieved significant cost savings (Jamieson, 2011). Through FY 2011 PEPFAR saved more than $59 million by using sea and road freight instead of air freight (SCMS, 2012). USG Interagency Implementation Process A key feature of PEPFAR (and the Global Health Initiative) is that pro- grams are to be implemented through a “whole-of-government” approach with the aim that agencies will focus on their core competencies and coor- dinate efforts to maximize the effectiveness of PEPFAR funding (OGAC, 2009d). Within PEPFAR mission teams, OGAC has mandated that all USG agencies be involved in the annual COP process (described briefly above)

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U.S. FUNDING FOR THE PEPFAR INITIATIVE 147 (OGAC, 2007b, 2008b). This interagency implementation approach was also described in Chapter 3. Stakeholders in partner countries had mixed perspectives on the “whole-of-government” approach. In some countries, interviewees reported competition for funding among USG agencies (934-40-ML; 935-17-USG; 461-4-USG; 272- ES). One interviewee described situations where CDC and USAID put out competing funding announcements and another situation in which repre- sentatives from both agencies ‘looked like fools in front of the government because they were fighting with each other’ (NCV-6-USNGO). Many interviewees from PEPFAR mission teams described challenges with interagency coordination (240-3-USG; 272-1-USG; 272-36-USG; 461-4-USG; 935-17-USG) and struggles to reduce duplication and overlap of activities by USG agencies (240-8-USG; 587-2-USG; 272-1-USG; 272-33-USG; 272-ES). In some cases the time spent on in- teragency coordination was described as a burden that took away from other responsibilities (461-4-USG; 396-47-USNGO; 166-4-USG; 331-3-USG) and an inefficient use of resources (587-25-ML; 396-47-USNGO; 331-3-USG). The following comments are representative: “I think what that’s also meant is we spent a lot of our time doing coordination and collaboration. And you could see that as a good thing, or you could see that as a potentially inefficient thing. A lot of time and energy and effort and probably money is spent mak- ing sure that everyone under the PEPFAR umbrella, all included, all said their say, all harmonized. And it takes up a lot of time. And it’s definitely, I think we all would have examples of where it’s obstructed the pace or the results of implementation, for sure.” (396-47-USNGO) ‘The PEPFAR team feels under-resourced for coordination. The USG staff often feels burdened by huge workloads and limited time.’ (166-4-USG) The COP preparation and submission process for interagency mission teams was also described in multiple countries as a significant burden of time and effort, especially as the size and scope of PEPFAR-supported pro- grams has grown, resulting in lengthy COPs and time-consuming prepara- tion (240-1-USG; 240-3-USG; 331-48-USG; 636-16-USG; 166-4-USG; 272-24-USG; 542-3-USG; 396-1-USG). To help address this, OGAC has recently streamlined the COP process by shift- ing to a 2-year framework with a reduced COP every other year (OGAC, 2010c). At least two mission teams remarked that the new streamlined COP process was an improvement (240-1-USG; 240-33-USG; 272-24-USG). The relationship and decision-making status between country programs and USG HQ was also noted as part of the challenge. For example, inter- viewees asserted that ‘OGAC does not promote interagency cooperation,

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148 EVALUATION OF PEPFAR no leadership in this area’ (331-3-USG), noted ‘a lack of clear guidance from DC [HQ] regarding what USAID should be doing versus CDC’ (240-3-USG), and described the “one USG” philosophy as ‘theoretical’ (587-2-USG). Interviewees provided contrasting solutions to these challenges: ‘HQ should leave the division of labor to the country office to work out. HQ can influence discussions about activities with a mentality of, “Our agency portfolio should look like this.”’ (240-8-USG) ‘Why not have the fights over money and resources at the DC [HQ] level not transfer the coordination burden to every country. If the money was earmarked to the agencies in DC [HQ], then it would lead to less planning burden in the country and more time to do development thinking.’ (461-4-USG) ‘Would prefer funding decisions made at a higher level. Would rather trust DC to make the funding decisions than fight it out on the country team level.’ (331-3-USG) Despite the challenges described with the interagency process, some interviewees described interagency cooperation and coordination as at least partially successful or as having improved over time (396-57-USG; 116-27-USG; 636-16-USG; 934-1-USG; 461-19-USG; 935-10-USG; 935-28-USG). Interviewees highlighted some examples of successful efforts to use and improve the interagency process to more strategically use PEPFAR funds. In some countries, having mul- tiple technical working groups with representatives across agencies was described as helpful for coordinating the planning and implementation of activities (396-57-USG; 461-4-USG). Interviewees in some cases described efforts that had been put in place or were planned to identify the comparative advan- tages of each USG agency and assign responsibility for projects accordingly (240-8-USG; 331-2-USG; 331-15-USG; 272-36-USG). Some countries conducted a review of the PEPFAR portfolio or processes to identify areas of overlap and opportuni- ties to reduce duplication (587-2-USG; 587-12-USG; 272-36-USG). One team mentioned that the Partnership Framework process helped its program identify what each agency was doing (116-7-USG). Other interviewees believed that successful interagency collaboration is dependent on the personalities and leadership of the staff involved (636-16-USG; 934-1-USG). Coordination of Implementing Partners Another ongoing approach or future opportunity for more strategic and effective use of resources that emerged from country visit interviews is improving coordination among PEPFAR implementing partners. Although

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U.S. FUNDING FOR THE PEPFAR INITIATIVE 149 the number of implementing partners varies by country, some partner coun- try programs have more than 100 prime partners and at least that many sub-partners. The sheer number of implementing partners in some countries was described as a challenge (240-5-PCGOV; 240-21-PCGOV; 272-5-PCGOV). In some coun- tries, multiple implementing partners are funded to deliver the same services (e.g., ART) or to conduct similar activities (e.g., capacity building), and this duplication or overlap was seen as a challenge (636-ES; 272-5-PCGOV; 272-36-USG; 196-11-USNGO; 196-12-PCGOV; 240-15-USG). An implementing partner that shares techni- cal assistance responsibilities with another implementing partner noted that ‘there are two projects, with two chiefs of party, two finance directors, two offices, two monitoring and evaluation processes, two head offices [. . . it] is not effective and efficient—it is a duplication of positions’ (196-11-USNGO). In one country multiple partners are funded to provide different yet related services (e.g., prevention of mother-to-child transmission, HIV care, TB/ HIV) within the same district, which has caused challenges for integration; the implementing partner interviewed expressed a desire to be responsible for all the services within a district (636-9-USACA). To address these challenges, some PEPFAR mission teams have con- vened partners meetings, done portfolio reviews, or used other approaches to reduce overlap and duplication among implementing partners (636-6-USG; 935-ES; 461-18-USG; 587-23-USG; 272-36-USG). In one country, for example, PEPFAR part- ners were described by a partner country government interviewee as ‘well- coordinated’ (240-7-PCGOV). Several PEPFAR mission teams described various reasons for choosing to fund multiple implementing partners for related activities, such as having different partners provide comprehensive services within certain geographic regions (935-2-USG; 461-18-USG) or specific facilities (166- 20-USG) and ensuring that a specific service or activity receives the necessary funding and attention: ‘It’s difficult to have one implementing partner do everything, be- cause some things get lost. In previous PEPFAR-funded programs, capacity building wasn’t getting the attention it needed. Therefore, they decided to split into two PEPFAR implementing partners, one of which would focus explicitly on organizational capacity build- ing, and the other would focus on technical assistance.’ (196-28-USG) Another challenge was that partners may be funded by multiple USG agencies (396-47-USNGO; 636-11-PCNGO; 636-21-USNGO). In one case where there are few local organizations, these local partners may be funded by multiple USG agencies through multiple funding streams (as high as four); there was a concern that these organizations may not have the capacity to address the reporting needs of multiple funders (636-11-PCNGO; 636-21-USNGO).

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150 EVALUATION OF PEPFAR Public–Private Partnerships PEPFAR’s authorizing and reauthorizing legislation specified that public–private partnerships (PPPs) should be an element of the U.S. strategy against HIV/AIDS; in some cases these offer another way of making strate- gic use of partnerships and resources. PPPs are part of a “broader trend in global health and development practice that began in the 1980s” (Sturchio and Cohen, 2012, p. 1451). OGAC has created multiple partnerships across program areas and agencies that typically involve a 50–50 joint investment by the USG and a private-sector partner. The private-sector partner usually contributes expertise and in-kind resources such as training (Sturchio and Cohen, 2012). Some examples of PPPs that have introduced efficiencies or reductions in resource use are • Supply Chain Management System (SCMS), managed by the Part- nership for Supply Chain Management (a legal entity established by JSI Research & Training Institute, Inc., and Management Sci- ences for Health) is “a network of commercial private-sector or- ganizations, nonprofits, academic institutions, and faith-based organizations with a wide range of capabilities [brought together] to expand and strengthen global supply chains for antiretrovirals, HIV test kits, laboratory supplies, and other products” (Sturchio and Cohen, 2012, p. 1452). In 2011, 71 percent of ARVs funded by PEPFAR were delivered by SCMS (SCMS, 2012). • In 2012, PEPFAR, USAID, UNITAID, and the Bill & Melinda Gates Foundation partnered to increase access to a new rapid test to diagnose tuberculosis. Funding provided through this PPP reduces the cost of the rapid test for high-burden and develop- ing countries by 40 percent for 10 years (through 2022) (OGAC, 2012b). Conclusion: PEPFAR is increasingly emphasizing a range of efforts to use its resources more strategically and efficiently through the generation and use of economic and financial data; the allocation of resources based on anticipated impact; improved collaboration with partner country governments, other donors, and the Global Fund to align priorities and programs; and the streamlining of busi- ness processes. PEPFAR has started to see some gains from these ef- forts. Continuing to identify and implement opportunities for more strategic and efficient use of resources will be critical for making progress toward optimal return on investment in the response to HIV in partner countries.

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U.S. FUNDING FOR THE PEPFAR INITIATIVE 151 SUMMATION The committee reviewed the overall PEPFAR funding process and data on PEPFAR funding over time as an important means by which to under- stand how the program is implemented and as a critical input for answering questions pertaining to the effects of PEPFAR-supported programs. The United States is the single largest donor to global HIV/AIDS efforts in the world, and between 2004 and 2011 the U.S. Congress appropriated more than $38 billion (current USD) for PEPFAR, of which $28.6 billion was designated for programs in partner countries. PEPFAR spending has been invested primarily, although not exclusively, in countries with low incomes and high disease burden. Because of limitations in the available financial data, it is difficult to fully describe the distribution of the annual direct investment of PEPFAR in partner countries, to match the accounting budget codes to programmatic activities, and to follow the types of partners that ultimately receive the funding and implement PEPFAR-supported activities. This led the commit- tee to conclude that PEPFAR would benefit from the collection and report- ing of financial data that not only serve an accounting purpose but also are more closely aligned with programmatic data and program implementation. These data could thus be more easily and effectively used to understand and assess how PEPFAR is being implemented and the relationships between the amount and distribution of the investment and the targets and goals for PEPFAR-supported programs. PEPFAR has begun to take steps in this direction. REFERENCES 30-Day Notice. 2012. 30-Day Notice of Proposed Information Collection: Form DS–4213, PEPFAR Program Expenditures; OMB Control Number 1405–XXXX (notice of request for public comment and submission to OMB of proposed collection of information). Federal Register 77(153):47489-47490. 60-Day Notice. 2012. 60-Day Notice of Proposed Information Collection: Form DS–4213, PEPFAR Program Expenditures; OMB Control Number 1405–XXXX (notice of request for public comments). Federal Register 77(90):27266. Bilimoria, N. F. 2012. Lessons learned from a decade of partnership between PEPFAR and the Global Fund: A case study from Tanzania. Health Affairs (Millwood) 31(7):1415-1421. CGD (Center for Global Development). 2008. PEPFARFundingData-fullDataset.xls. Wash- ington, DC: CGD. Donnelly, J. 2012a. PEPFAR’s broad guidelines for spending $1.5 billion backlog. http:// www.globalpost.com/dispatches/globalpost-blogs/global-pulse/pepfars-broad-guidelines- spending-15-billion-backlog (accessed September 4, 2012). Donnelly, J. 2012b. A Q&A with US Global AIDS Coordinator Eric Goosby. http://www. globalpost.com/dispatches/globalpost-blogs/global-pulse/qa-us-global-aids-coordinator- eric-goosby (accessed September 4, 2012).

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152 EVALUATION OF PEPFAR Donnelly, J. 2012c. US reveals nearly $1.5 billion in unspent AIDS money. http://www. globalpost.com/dispatch/news/health/us-reveals-nearly-15-billion-unspent-aids-money (accessed August 17, 2012). DoS OIG (U.S. Department of State Office of Inspector General). 2010. Audit of sources and uses of Global HIV/AIDS Initiative Global Health and Child Survival funds related to the President’s Emergency Plan for AIDS Relief (PEPFAR) for FYs 2007 and 2008. Report number AUD/SI-11-10. Washington, DC: U.S. Department of State and the Broadcasting Board of Governors Office of Inspector General. El-Sadr, W., C. Holmes, P. Mugyenyi, H. Thirumurthy, T. Ellerbrock, R. Ferris, I. Sanne, A. Asiimwe, G. Hirnschall, R. Nkambule, L. Stabinski, M. Affrunti, C. Teasdale, I. Zulu, and A. Whiteside. 2012. Scale-up of HIV treatment through PEPFAR: A historic pub- lic health achievement. Journal of Acquired Immune Deficiency Syndromes 60(Suppl 3):S96-S104. GAO (U.S. Government Accountability Office). 2005. Selection of antiretroviral medications provided under U.S. emergency plan is limited. GAO-05-133. Washington, DC: GAO. GAO. 2011. PEPFAR program planning and reporting. GAO-11-785. Washington, DC: GAO. GAO. 2012. President’s Emergency Plan for AIDS Relief—agencies can enhance evaluation quality, planning, and dissemination: Report to congressional committees. Washington, DC: GAO. GHI (Global Health Initiative). 2012. Interagency paper on country ownership. Washington, DC: GHI. Goosby, E. 2012a. An update from the Global Fund board meeting in Geneva. In DipNote: U.S. Department of State Official Blog. Washington, DC: U.S. Department of State. Goosby, E. 2012b. The way forward: Maximizing our impact through shared responsibility and smart investments. Journal of Acquired Immune Deficiency Syndromes 60(Suppl 2):S44-S47. Goosby, E., M. Dybul, A. S. Fauci, J. Fu, T. Walsh, R. Needle, and P. Bouey. 2012. The United States President’s Emergency Plan for AIDS Relief: A story of partnerships and smart investments to turn the tide of the global AIDS pandemic. Journal of Acquired Immune Deficiency Syndromes 60(Suppl 3):S51-S56. Heniff, B. 2008. Overview of the authorization-appropriations process. CRS Report for Con- gress. Order Code RS20371. Holmes, C. B., W. Coggin, D. Jamieson, H. Mihm, R. Granich, P. Savio, M. Hope, C. Ryan, M. Moloney-Kitts, E. P. Goosby, and M. Dybul. 2010. Use of generic antiretroviral agents and cost savings in PEPFAR treatment programs. Journal of the American Medical Association 304(3):313-320. Holmes, C. B., J. M. Blandford, N. Sangrujee, S. R. Stewart, A. DuBois, T. R. Smith, J. C. Martin, A. Gavaghan, C. A. Ryan, and E. P. Goosby. 2012. PEPFAR’S past and future efforts to cut costs, improve efficiency, and increase the impact of global HIV programs. Health Affairs 31(7):1553-1560. IOM and NRC (Institute of Medicine and National Research Council). 2010. Strategic ap- proach to the evaluation of programs implemented under the Tom Lantos and Henry J. Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthori- zation Act of 2008. Washington, DC: The National Academies Press. Jamieson, D. 2011. Efficiency gains through smarter transportation and pooled procurement. Paper presented at PEPFAR’s Smart Investments to Save More Lives: Efficiencies, Innova- tion, Impact, Washington, DC, February 10. Kates, J., and T. Summers. 2004. HIV/AIDS policy brief: U.S. government funding for global HIV/AIDS through FY 2005. Washington, DC: Kaiser Family Foundation.

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U.S. FUNDING FOR THE PEPFAR INITIATIVE 153 Kates, J., A. Wexler, E. Lief, C. Avila, and B. Gobet. 2011. Financing the response to AIDS in low- and middle-income countries: International assistance from donor governments in 2010. Washington, DC: Kaiser Family Foundation and UNAIDS. KFF (Kaiser Family Foundation). 2009. Fact sheet: The U.S. & the Global Fund to Fight AIDS, Tuberculosis, and Malaria. http://www.kff.org/globalhealth/upload/8003.pdf (ac- cessed February 14, 2013). OECD (Organisation for Economic Co-operation and Development). 2012a. DAC glossary of key terms and concepts. http://www.oecd.org/dac/glossary (accessed December 11, 2012). OECD. 2012b. OECD.Stat (database). Paris: OECD. OGAC (Office of the U.S. Global AIDS Coordinator). 2004. The Emergency Plan for AIDS Relief: Summary financial status as of September 30, 2004. Year one of implementation. Washington, DC: OGAC. OGAC. 2005. Emergency Plan for AIDS Relief fiscal year 2005 operational plan: June 2005 update. Washington, DC: OGAC. OGAC. 2006a. The Emergency Plan for AIDS Relief: Summary financial status as of Septem- ber 30, 2005. Year two of implementation. Data represents all of FY 2004 and FY 2005 through Q4. Washington, DC: OGAC. OGAC. 2006b. The U.S. President’s Emergency Plan for AIDS Relief fiscal year 2006: Op- erational plan. 2006 August update. Washington, DC: OGAC. OGAC. 2007a. The Emergency Plan for AIDS Relief: Summary financial status as of Sep- tember 30, 2006 (4th quarter—FY 2006). Data for FY 2004–2006 appropriations. Washington, DC: OGAC. OGAC. 2007b. The President’s Emergency Plan for AIDS Relief: FY 2008 country operational plan guidance. Washington, DC: OGAC. OGAC. 2007c. The U.S. President’s Emergency Plan for AIDS Relief fiscal year 2007: Opera- tional plan. 2007 June update. Washington, DC: OGAC. OGAC. 2008a. The Emergency Plan for AIDS Relief: Summary financial status as of Sep- tember 30, 2007 (4th quarter—FY 2007). Data for FY 2004–2007 appropriations. Washington, DC: OGAC. OGAC. 2008b. The President’s Emergency Plan for AIDS Relief: FY 2009 country operational plan guidance. Washington, DC: OGAC. OGAC. 2008c. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) fiscal year 2008: PEPFAR operational plan. June 2008. Washington, DC: OGAC. OGAC. 2009a. The Emergency Plan for AIDS Relief: Summary financial status as of Sep- tember 30, 2008 (4th quarter—FY 2008). Data for FY 2004–2008 appropriations. Washington, DC: OGAC. OGAC. 2009b. Guidance for PEPFAR partnership frameworks and partnership framework implementation plans. Version 2.0. Washington, DC: OGAC. OGAC. 2009c. The President’s Emergency Plan for AIDS Relief: FY 2010 country operational plan guidance. Washington, DC: OGAC. OGAC. 2009d. The U.S. President’s Emergency Plan for AIDS Relief: Five-year strategy. Washington, DC: OGAC. OGAC. 2010a. The Emergency Plan for AIDS Relief: Summary financial status as of Sep- tember 30, 2009 (4th quarter—FY 2009). Data for FYs 2004–2009 appropriations. Washington, DC: OGAC. OGAC. 2010b. The Emergency Plan for AIDS Relief: Summary financial status as of Sep- tember 30, 2010 (4th quarter—FY 2010). Data for FYs 2004–2010 appropriations. Washington, DC: OGAC. OGAC. 2010c. The President’s Emergency Plan for AIDS Relief: FY 2011 country operational plan guidance. Washington, DC: OGAC.

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154 EVALUATION OF PEPFAR OGAC. 2010d. The President’s Emergency Plan for AIDS Relief: FY 2011 country operational plan guidance appendices. Washington, DC: OGAC. OGAC. 2010e. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) fiscal year 2009: PEPFAR operational plan. November 2010. Washington, DC: OGAC. OGAC. 2011a. The Emergency Plan for AIDS Relief: Summary financial status as of Sep- tember 30, 2011 (4th quarter—FY 2011). Data for FYs 2004–2011 appropriations. Washington, DC: OGAC. OGAC. 2011b. The President’s Emergency Plan for AIDS Relief: FY 2012 country operational plan guidance. Washington, DC: OGAC. OGAC. 2011c. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) fiscal year 2010: PEPFAR operational plan. April 2011. Washington, DC: OGAC. OGAC. 2011d. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Fiscal Year 2011: PEPFAR operational plan. December 2011. Washington, DC: OGAC. OGAC. 2011e. The U.S. President’s Emergency Plan for AIDS Relief: Seventh annual report to Congress. Washington, DC: OGAC. OGAC. 2012a. Countries. http://www.pepfar.gov/countries (accessed July 31, 2012). OGAC. 2012b. Public-private partnership announces immediate 40 percent cost reduction for rapid TB test. http://www.pepfar.gov/press/releases/2012/196090.htm (accessed Sep- tember 11, 2012). OGAC. 2012c. Report on costs of treatment in the President’s Emergency Plan for AIDS Relief (PEPFAR). Washington, DC: OGAC. OGAC. 2013a. Email communication between OGAC staff and IOM: “Follow-up to IOM questions for clarification.” Washington, DC: OGAC. OGAC. 2013b. Email communication between OGAC staff and IOM: “IOM questions for clarification.” Washington, DC: OGAC. OGAC. 2013c. Partners. http://www.pepfar.gov/funding/budget/partners/index.htm (accessed May 31, 2013). OGAC. n.d. Collaboration with UNAIDS. http://www.pepfar.gov/partnerships/coop/unaids/ index.htm (accessed January 14, 2013). OMB (Office of Management and Budget). 2011. OMB circular No. A–11: Preparation, submission, and execution of the budget. Washington, DC: OMB. PEPFAR (President’s Emergency Plan for AIDS Relief). 2012. Report on pilot expenditure analysis of PEPFAR programs in 6 countries. Washington, DC: OGAC. Rosen, S. 2011. Innovations in costing health care delivery models: Boston University’s experi- ence. Paper presented at PEPFAR’s Smart Investments to Save More Lives: Efficiencies, Innovation, Impact, Washington, DC, February 10. SCMS (Supply Chain Management System). 2012. Six years of saving lives through stronger public health supply chains: A report on SCMS contributions to PEPFAR results. Ar- lington, VA: SCMS. Sessions, M. 2006. Overview of the President’s Emergency Plan for AIDS Relief (PEPFAR). Washington, DC: CGD. Sturchio, J. L., and G. M. Cohen. 2012. How PEPFAR’s public–private partnerships achieved ambitious goals, from improving labs to strengthening supply chains. Health Affairs (Millwood) 31(7):1450-1458. UNAIDS (Joint United Nations Programme on HIV and AIDS). 2010a. Global report: UNAIDS report on the global AIDS epidemic 2010. Geneva: UNAIDS. UNAIDS. 2010b. UNAIDS vision and mission. Geneva: UNAIDS. UNAIDS. 2012a. AIDSinfo: Estimated HIV Prevalence. http://www.unaids.org/en/dataanalysis/ datatools/aidsinfo (accessed September 24, 2012). UNAIDS. 2012b. AIDSinfo: People living with HIV. Source: UNAIDS_Estimate_2010. http:// www.unaids.org/en/dataanalysis/datatools/aidsinfo (accessed September 24, 2012).

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