PEPFAR Implementation Progress and Promise (2007) / Chapter Skim
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Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management
Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management
Pages 79-112
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From page 79... ...
Part II Progress on the First 5-Year Strategy -- PEPFAR
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From page 81... ...
Although some of the disadvantages of this approach are still evident, OGAC has shifted greater control of centrally funded grants to Country Teams to facilitate integration of these activities within the larger PEPFAR portfolios in the focus countries. • PEPFAR and other donors plan to rely on national data from the focus countries to determine the program's impact in the long term.
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Recommendation 3-3: Although they may have been helpful initially in ensuring a balance of attention to activities within the four categories of prevention, treatment, care, and orphans and vulnerable children, the Committee concludes that rigid congressional budget allocations among categories, and even more so within categories, have also limited PEPFAR's ability to tailor its activities in each country to the local epidemic and to coordinate with the level of activities in the countries' national plans. Congress should remove the budget allocations and replace them with more appropriate mechanisms that ensure accountability for results from Country Teams to the U.S.
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implementing agencies under the auspices of OGAC both at the headquarters and country levels, between OGAC and other international HIV/AIDS donors, and between OGAC and the U.S. teams working in the focus countries (Country Teams)
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OGAC officials reported that the office has also relied heavily on numerous interagency coordinating committees, task forces, and working groups to address the challenge of bringing together the many disparate implementing agencies. To ensure coordination among participating agencies at the central headquarters level, OGAC created the Deputy Principals Group, which handles program management and logistics and includes high-level representation from all of the implementing agencies (see Chapter 2)
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Field Coordination: The Country Teams In the focus countries, PEPFAR Country Teams are coordinated through the U.S. embassy and thus led by the U.S.
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OGAC intends this structure to ensure coordination among all agencies, and to provide a single voice speaking for the entire Country Team in interactions with partner governments and other donors. In its visits to the focus countries, the Committee observed that Country Teams were generally collaborating effectively, although a few examples of rivalry and poor communication persist.
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5-year strategic country plan and an annual Country Operational Plan that are harmonized with the existing plans of the focus countries (OGAC, 2004,
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To complement these reports, the Committee reviewed PEPFAR's annual Country Operational Plans against the plans of the focus countries and found them to be generally congruent. In most cases, however, the Committee was able to compare only the highly specific PEPFAR Country Operational Plans for fiscal years 2005 and 2006 with the much more general national strategic plans.
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. Subsequent to the Committee's visits, OGAC made nonsensitive versions of the Country Operational Plans available on the PEPFAR website, and OGAC officials reported that they have taken additional steps to encourage Country Teams to share as much information as appropriate with their counterparts from other donors working in a country.
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From page 90... ...
During its visits to the focus countries, the Committee was told by all parties involved -- partner governments, Country Teams, and other donors -- that they recognize the importance of a unified, country-led coordinating authority but find this challenging to achieve. The Committee heard some concern expressed, particularly by other donors, about PEPFAR's domination of the agenda by virtue of its large size.
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In so doing, Country Teams need to be able to collaborate with other donors and the partner government in policy development, as well as to be patient when new technology is not adopted as quickly as might appear desirable. As a recent study conducted for the Gates Foundation notes, the country must take the lead in determining the "timing, pace and scale of new technology and policies" if their implementation is to be sustainable (McKinsey and Company, 2005, p.
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Global AIDS Initiative to work toward reducing stigma and discrimination against people living with HIV/AIDS requires that marginalized and difficult to-reach groups receive prevention, treatment, and care services. These groups include sex workers, prisoners, those who use injection drugs, and men who have sex with men -- groups that not only are characterized by their high-risk behavior, but also tend to be stigmatized and subject to discrimination.
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. OGAC officials described how a 2004 discussion between PEPFAR's central office and the Country Teams led to the development and implementation of a fully web-based system for developing and managing the Country Operational Plans -- the Country Operational Plan and Reporting System (COPRS)
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From page 94... ...
According to OGAC, all PEPFAR programs, regardless of implementing agency, were reporting on the same indicators by June 2006. A major charge to the Technical Working Groups is providing several types of technical assistance to the Country Teams, including program design and/or reviews, direct assistance to implementing partners, training sessions, and assistance with the development of Country Operational Plans (OGAC, 2006b,c)
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OGAC recently published a PEPFAR strategy for targeted evaluation to ensure the best use of these funds, and a list of priorities for such evaluations was included among the materials distributed to support the development of fiscal year 2007 Country Operational Plans (OGAC, 2006b)
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. PEPFAR is also supporting some focus countries' use of the HIVQUAL software program, an HIV-specific data system designed to enhance quality improvement activities.
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OGAC officials and Country Teams reported that since then, the task force and its recommendations have contributed to progress in streamlining reporting requirements. The third annual meeting was held in Durban, South Africa, in June 2006.
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At the time the legislation was passed, the international community, including CDC and USAID, was still debating whether treatment on this scale could be achieved. Relatively little information existed with which to determine precisely how resources should be allocated to achieve the performance targets in the focus countries; thus the budget allocations could not be fully evidence-based.
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First, the budget allocations limit the Country Teams' ability to harmonize PEPFAR's activities with those of the partner government and other donors. Although OGAC requires each Country Team to meet the same allocations, national plans and epidemiologic data suggest that the relative allocations among categories would appropriately vary by country.
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that examined countries in addition to the focus countries. By requiring the Country Teams to isolate funding for these activities, this budget allocation has undermined the teams' ability to integrate prevention programming.
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Recommendation 3-3: Although they may have been helpful initially in ensuring a balance of attention to activities within the four categories of prevention, treatment, care, and orphans and vulnerable children, the Committee concludes that rigid congressional budget allocations among categories, and even more so within categories, have also limited PEPFAR's ability to tailor its activities in each country to the local epidemic and to coordinate with the level of activities in the countries' national plans. Congress should remove the budget allocations and replace them with more appropriate mechanisms that ensure accountability for results from Country Teams to the U.S.
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RESOURCE ALLOCATION Financial Management Over the course of the program, there have been a number of changes in the way funding is managed, as well as in the interactions between the Country Operational Plans and funding decisions. Country Teams originally developed Country Operational Plans under the assumption that they would have the available minimum level of funding OGAC had assigned to them.
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. OGAC's response to its assessment was that it was establishing and implementing a new system to capture program expenditures by country and undertaking an internal review of budget allocations to focus countries based on performance data and pipeline capacity (OMB, 2007b)
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. PEPFAR Central and Focus Country Funding PEPFAR activities are funded either centrally -- through OGAC or one of the implementing agencies -- or through the Country Teams.
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Contracts with international organizations -- which were required to be already operating in at least four of the focus countries -- were centrally managed, while contracts with country-based organizations were managed by the Country Teams. During the Committee's country visits, Country Teams described the challenges of managing a comprehensive HIV/AIDS program when as much as a third (on average 16 percent)
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Thus the Committee was unable to obtain the perspective of the Country Teams on whether the implementation of these centrally managed programs represents an improvement. PEPFAR Funding by Program Category Of the approximately $3.6 billion allocated for the focus countries during the first 3 years of funding, the treatment category has accounted for approximately $1.4 billion (40 percent)
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with Distribution of Other Costs by OGAC Method 2004 2005 2006 Total 2004–2006 Category Funding Percent Funding Percent Funding Percent Funding Percent Prevention .28 33 .38 27 .40 23 1.06 27 Care .24 28 .39 28 .54 31 1.17 29 Treatment .32 38 .62 44 .82 47 1.76 44 Total $.83 100 $1.40 100 $1.76 100 $3.99 100 NOTE: Data presented as received from OGAC.
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From page 108... ...
For 9 of the 15 focus countries, the target and funding proportions are within 3 percentage points of one another across the three program categories with targets. However, South Africa, which is responsible for approximately 25 percent of the targets in all three categories, is receiving between 11 and 14 percent of funding, depending on the program area.
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From page 109... ...
The virtual organization created by OGAC, the implementing agencies, and the Country Teams exhibits many of the positive features of a learning organization and has evolved considerably during the initial years of the program. With the improvements in transparency and accountability for marginalized groups of people recommended by the Committee, and with the increased flexibility that would be afforded by removal of the congressional budget allocations, the U.S.
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2006b. PEPFAR: Technical considerations for the FY00 country operational plans.
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Washington, DC and Geneva, Switzerland: Global Fund to Fight AIDS, Tu berculosis, and Malaria, and World Bank. http://www.cgdev.org/doc/event%20docs/ 2.7.06%20HIV/GFWBReportFinalVersion.pdf (accessed November 3, 2006)
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