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PEPFAR Implementation: Progress and Promise (2007)

Chapter: Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management

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Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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Part II
Progress on the First 5-Year Strategy—PEPFAR

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

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Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

3

PEPFAR’s Management

Summary of Key Findings

  • The Office of the U.S. Global AIDS Coordinator (OGAC) is committed to learning by doing and contributing to the evidence base for how to combat global HIV/AIDS most effectively. PEPFAR’s virtual organization, composed of OGAC, numerous other implementing agencies, and the Country Teams, has demonstrated an increasing capacity for responding to and sharing knowledge acquired over the course of the program’s implementation.

  • PEPFAR’s accomplishments include the ongoing development, revision, and dissemination of program policies and procedures, as well as dissemination of evidence on how to provide and scale up quality services to those affected by HIV/AIDS in resource-constrained settings. Mechanisms for planning and reporting, coordination, and knowledge sharing at all levels have also been developed. Going forward, OGAC needs to increase its emphasis on operations research and develop an overall plan for the collection and management of strategic information.

  • PEPFAR policies demonstrate a commitment to supporting host countries’ leadership and ownership of their responses to their HIV/AIDS epidemics. Country Teams have endeavored to work closely with host country governments and coordinating bodies, as well as other donors, to carry out PEPFAR activities within the framework of harmonization. PEPFAR has been increasingly successful in this regard, but concerns about the transparency of the planning process remain. Moreover, congressional budget allocations have created a substantial administrative burden, hampering harmonization and requiring that considerable local effort be expended on new planning, budgeting, and reporting mechanisms.

  • PEPFAR’s initial decision to jump-start the program by relying heavily on central programming and using experienced nongovernmental organizations for implementation has had mixed results. 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. Thus, strong support for creating, implementing, and strengthening a unified and coherent monitoring and evaluation system at the country level continues to be critical.

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

Recommendations Discussed in This Chapter


Recommendation 3-1: To support country leadership, the U.S. Global AIDS Coordinator should seek to identify and remove barriers to coordination with partner governments and other donors, with a particular focus on promoting transparency and participation throughout the annual planning process.


Recommendation 3-2: The commitment of the U.S. 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 injecting 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. The U.S. Global AIDS Coordinator should document how these groups are included in the program planning, implementation, and evaluation of PEPFAR activities.


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. Global AIDS Coordinator and to Congress. These mechanisms should also ensure that spending is directly linked to and commensurate with necessary efforts to achieve both country and overall performance targets for prevention, treatment, care, and orphans and other vulnerable children.

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

3
PEPFAR’s Management

The Office of the U.S. Global AIDS Coordinator (OGAC) has created a virtual organization that, as mandated by the Leadership Act, coordinates among many different entities both within and outside of the U.S. government and between the central and country levels. In contrast to recent reorganizations of other government entities, OGAC has deliberately been kept small, with use being made of temporary assignments and coordinating bodies rather than a large, entirely new structure being created. This chapter reviews key aspects of the management of this virtual organization: (1) coordination, (2) harmonization, (3) policy guidance, (4) planning and reporting, (5) technical working groups, (6) functioning as a learning organization, (7) budget allocations, (8) targets, and (9) resource allocation.

COORDINATION

This section reviews coordination among the U.S. 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). Coordination of the Country Teams with partner governments and other donors working at the country level is addressed in the next section in the discussion of the Second One of harmonization—One National HIV/AIDS Coordinating Authority.

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

The Leadership Act called for the newly established U.S. Global AIDS Coordinator (the Coordinator) to coordinate

  • Programs and policies of designated executive branch agencies and nongovernmental organizations.

  • Resolution of policy, program, and funding discrepancies among these organizations.

  • Field activities of the designated executive branch agencies.

  • Related assistance by other countries and international organizations.

The President’s Emergency Plan for AIDS Relief (PEPFAR) strategy was to identify the existing capacity of the implementing agencies and harness and expand their comparative strengths into one synergistic U.S. government response coordinated by OGAC (OGAC, 2004).

Central Coordination: The Office of the U.S. Global AIDS Coordinator

Unification of all U.S. international HIV/AIDS activities and coordination of PEPFAR implementation are the responsibility of OGAC, a relatively small central office staffed largely by people detailed from the implementing agencies and supplemented by positions created and staffed on an as-needed basis. 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).

Interagency Coordination

The two principal implementing agencies—the U.S. Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC)—have different systems and structures for operating, different established budget cycles, and even different salary scales.1 For purposes of PEPFAR, all agencies are expected to collaborate in program funding that was previously managed separately by each agency. Prior to PEPFAR, USAID and CDC had limited funds available to prepare for scale-up of antiretroviral therapy (ART). USAID’s HIV/AIDS programs had

1

Some CDC employees are part of the Public Health Service Corps; this option is not available in USAID.

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

previously been focused primarily on prevention, including prevention of mother-to-child transmission. CDC’s HIV/AIDS programs also provided support for prevention of mother-to-child transmission. CDC staff worked with ministries of health in various technical areas, such as surveillance, and on the development of national AIDS plans.

OGAC and agency officials believe that previous joint monitoring and evaluation activities provided a foundation for improving collaboration between CDC and USAID. The agencies had engaged in an ongoing coordination process that included agency visits, biweekly conference calls, quarterly meetings, review of agency-specific guidance, and cosigned letters of concurrence on major issues (Rugg et al., 2004). The agencies had also jointly organized and conducted monitoring and evaluation workshops and training courses and collaborated to develop core indicators. In addition, they had been collaborating on monitoring and evaluation with global partners, such as UNAIDS, the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the World Bank, and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). The people involved reported that this foundation for interagency collaboration on monitoring and evaluation did not develop easily and required significant ongoing effort, as well as “setting realistic expectations and seeing a balance between what is contributed and what is gained from the partnership” (Rugg et al., 2004, p. 74).

All donors, large and small, are attempting to improve their coordination with one another so as to minimize the transactional burden—the difficulties governments experience in handling the demands of multiple donors, such as attendance at meetings and reporting requirements—associated with the influx of large amounts of funding in the focus countries (UNAIDS, 2005b; Shakow, 2006). Considerable evidence shows that uncoordinated donor actions can result in pressures on country systems that weaken, rather than strengthen, the partner government’s ability to manage its own programs (OECD, 2003; The Rome Declaration, 2003; UNAIDS, 2005a,b).

As the largest single bilateral donor, PEPFAR can lead the way in furthering such efforts. Effective coordination will mean that both U.S. dollars and money from other donors will be spent effectively, minimizing the potential for waste arising from poorly coordinated independent funding streams.

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. ambassador. All agencies working in a country on HIV/AIDS—such as the Department of Defense, the Peace Corps, the National Institutes of Health, USAID, and CDC—are part of the

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

Country Team, and each team has a designated leader (OGAC, 2004). The typical coordinating mechanism is a regular meeting chaired by the ambassador or his/her most senior staff member. 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. In addition, further efforts could be made to coordinate planning and contracting cycles and requirements among the implementing agencies, particularly CDC and USAID. The Committee was told that timing discrepancies between agencies had in some cases resulted in funding gaps and resource shortages; that confusion existed around the management of certain programs, resulting in a lack of clear accountability for those programs; and that coordination at the country level continued to be complicated by the presence of numerous, large, centrally-managed contractors.

Coordination Among International Donors

OGAC recently (January 2006) met with representatives from the Global Fund and the World Bank to discuss program implementation and ways of improving donor coordination (OGAC et al., 2006). The three partners have agreed to work together, particularly on coordinating procurement, organizing annual implementation reviews, improving communication, and supporting country strategies and action plans. The role of donors in the country planning process is addressed below in the discussion of the First One of harmonization—One HIV/AIDS Action Framework.

Communications

Communication is a central element of PEPFAR’s coordination strategy. OGAC has worked to develop a number of mechanisms for communicating not only across agencies, but also between Country Teams and central staff (OGAC, 2004, 2005a, 2006a).

According to OGAC, weekly teleconferences are held between each Country Team and the Washington-based interagency core team, which includes a coordinator within OGAC. The core team is expected to be aware of both OGAC policy and country programs so it can support the Country Teams in a variety of ways, from program management to identification of areas in which technical assistance may be needed (Moloney-Kitts, 2005) (see the discussion of Technical Working Groups later in the chapter).

To enhance communication, the PEPFAR Extranet was created in 2006.

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

Currently limited to internal use, the Extranet offers access to archived News to the Field weekly newsletters, public affairs/public diplomacy resources, PEPFAR policies and guidance, presentations, budget figures and country data, and U.S. agency directories. Additionally, the Extranet is intended to give Country Teams the opportunity to collaborate and share information with their colleagues around the world. Available information includes lessons learned, best practices, national polices and guidelines, technical articles, presentations, and resources such as curricula and toolkits.

According to OGAC, the primary reason the Extranet was created was to help manage the volume of information needed to run a program as technically complex as PEPFAR and make this information available to those overseeing the program’s implementation in the field. OGAC plans to allow implementing partners outside of the U.S. government access to the Extranet at some point in the near future; implementing partners have told the Committee that they eagerly await this change.

HARMONIZATION

PEPFAR, along with all other major donors, is committed to supporting the focus countries’ ownership of their response to their AIDS epidemics. Country Teams work closely with partner governments, as well as other donors, to implement harmonized HIV/AIDS plans (OGAC, 2005a, 2006a,b,c). To this end, PEPFAR has committed to implementing its program within the Three Ones framework of harmonization agreed upon at a meeting with the United Kingdom and UNAIDS in April 2004: One agreed HIV/AIDS Action Framework, One National AIDS Coordinating Authority, and One agreed country-level Monitoring and Evaluation System (see Chapter 2) (UNAIDS, 2004a; OGAC, 2005b).

First One: One Action Framework

All of the focus countries have a national strategic plan to fight AIDS; most also have a national operational plan. The latter plans vary widely in detail and quality, particularly with regard to the specific steps to be taken and the associated costs. Responding to a call by UNAIDS, PEPFAR and other major donors are currently working with the host countries to help develop operational plans that are costed, evidence-based, and prioritized, and thus will provide the specificity necessary for funding and program development purposes for both the country itself and all donors (UNAIDS, 2004a; OGAC, 2005b).

OGAC has directed Country Teams to develop both a U.S. 5-year strategic country plan and an annual Country Operational Plan that are harmonized with the existing plans of the focus countries (OGAC, 2004,

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

2005d, 2006b,c,f). The U.S. plans are expected to reflect the priorities and interests of the partner government, as well as to identify strategic information, activities, and priorities for the coming year (OGAC, 2006a).

During the Committee’s country visits, representatives of partner governments generally expressed their satisfaction with the level of harmonization achieved. 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. Because the national strategic plans typically are not prioritized, the Committee could not determine how well PEPFAR support is aligned with national priorities. In most cases, for example, it is not possible to determine how PEPFAR allocations by the categories of prevention, treatment, care, and orphans and other vulnerable children compare with proposed national spending.

During its country visits, the Committee also heard reports of disharmony arising from constraints imposed by U.S. laws that prohibit or appear to prohibit or restrict the use of some of the means of prevention that are viewed by those in the field as important and potentially successful. These include restrictions on teaching young teens about the full scope of HIV prevention methods, the Leadership Act requirement for organizations to certify that they have a “policy explicitly opposing prostitution and sex trafficking” (P.L. 108-25, p. 734) in order to receive funding, and the prohibition against support for clean needles to combat the spread of HIV among people who use injection drugs. The Committee was told of examples of innovative programs that PEPFAR was unable to support, such as those that integrate messages about HIV prevention into traditional teaching at the time of sexual initiation, those organized by sex workers to conduct peer counseling, and those that provide clean needles in communities where injecting drug use is a major source of spread of HIV infection.

By far the most often-cited obstacle to harmonization, however, is the requirement that U.S. funds be used only for medications that have received approval from the U.S. Food and Drug Administration. Country Teams, host country officials, and implementing partners all agreed that, although workaround arrangements had been developed to deal with this requirement, such arrangements were awkward, costly, and difficult to administer, reducing the ability of PEPFAR and the host countries to use funds in the most cost-effective manner possible. This issue and the Committee’s related recommendation are discussed in greater detail in Chapter 5 in the overall context of treatment.

Coordination is also crucial to the development of a unified action framework. As noted earlier, failure of bilateral donors to coordinate with

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

one another can lead to duplication and conflict in the delivery of needed services (OECD, 2003; The Rome Declaration, 2003; UNAIDS, 2005a,b). A number of countries have more or less formal donor groups that enable donors to speak to the government, to the extent possible, with a single voice. OGAC officials stressed that a significant amount of time is dedicated to working with other international donors, and the Country Teams confirmed this. Of particular importance is for all donors to know what the others are planning so they can ensure that their money is being spent in the most effective way, whether or not they participate in basket funding. Full transparency of U.S. plans is therefore particularly important.

One complaint voiced by both donors and Country Teams during the Committee’s visits was that because the Country Operational Plans are procurement sensitive, they cannot be fully shared with other donors. The Country Teams share the Country Operational Plans with the partner governments before completion, and are required to obtain approval from the partner governments before submitting the plans to OGAC (OGAC, 2006c). 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. However, the Committee was unable to confirm with other donors at the country level whether the situation has improved in their view. Since the preparation of the Country Operational Plans is such a prominent part of the Country Teams’ work, the inability to disclose their content to other donors represents an impediment to harmonization; resolution of any remaining issues would therefore be an important improvement.

Recommendation 3-1: To support country leadership, the U.S. Global AIDS Coordinator should seek to identify and remove barriers to coordination with partner governments and other donors, with a particular focus on promoting transparency and participation throughout the annual planning process.

Second One: One National Coordination Authority

The Second One essentially challenges each country to create a single coordinating authority to develop, implement, and monitor its plans for supporting its response to its HIV/AIDS epidemic, and calls for donors to participate in that authority (UNAIDS, 2004a). Unfortunately, the Global Fund’s required Country Coordinating Mechanisms were not fully congruent with the existing National HIV/AIDS Coordinating Authorities already in place in most countries (UNAIDS, 2005a). Although some countries have

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

successfully combined the two, in many cases there are still two coordinating bodies, sometimes with conflicting and confusing mandates. Recent work by the Global Fund and the World Bank promises to help ameliorate this problem (OGAC et al., 2006; Shakow, 2006).

National HIV/AIDS Coordinating Authorities vary in their capacity to oversee the approach to the epidemic; an important donor task is to continue supporting and strengthening these bodies. As one step to that end, OGAC encourages Country Teams to sign a memorandum of understanding with the Global Fund so the PEPFAR planning process can be fully integrated under the Country Coordinating Mechanism. The Committee was told of some successful early examples of this arrangement already in place.

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. Overall, however, the view from the focus countries of PEPFAR’s support of and participation in the Second One was largely positive.

Third One: One National Monitoring and Evaluation System

The importance of creating, implementing, and strengthening a single, unified, and coherent monitoring and evaluation system at the country level cannot be overemphasized (UNAIDS, 2004a; OGAC, 2005b). A strong unified monitoring and evaluation system ensures that (1) relevant, timely, and accurate data are made available to program leaders and managers at each level of the program and health care system; (2) selected quality data can be reported to national program leaders; and (3) the national program is able to meet donor and international reporting requirements under a unified global effort to contain the HIV/AIDS pandemic (UNAIDS, 2004b).

In its first year, PEPFAR proceeded simultaneously with program implementation and the development of monitoring and evaluation systems. Since then, PEPFAR has worked with countries to develop and strengthen monitoring and evaluation plans and systems. PEPFAR, like other donors, is largely dependent on a country’s capacity to provide the data needed for monitoring and evaluation of its own programs. Thus, PEPFAR’s own monitoring and evaluation capabilities are improved by its support for the building of local capacity to collect, synthesize, and disseminate information on the HIV/AIDS programs in the host countries through technical assistance, the development of health management information systems,

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

efforts to improve data standards, and training of personnel at all levels of the health system (OGAC, 2005a, 2006a).

During its visits, the Committee found that at the country level, there is agreement with the Third One in principle, but there is frustration with the lack of progress toward achieving the aim of a single monitoring and evaluation system. A major difficulty cited by many was that of conducting joint planning for the collection of data needed immediately while concurrently building the necessary infrastructure. PEPFAR’s need to collect U.S.-specific information to report to Congress is another cited barrier to the Third One. PEPFAR’s monitoring and evaluation requirements and how they compare with those of other global donors are discussed in Chapter 8.

OGAC reported that it is currently developing guidelines for building an intermediate information system that can become part of a larger national system designed to facilitate data flow and communication. Recently, OGAC participated in global monitoring and evaluation training in collaboration with the Global Fund and WHO (OGAC, 2005d, 2006f). Despite these efforts, however, achievement of the Third One is far from a reality and will require continued support from and effort by PEPFAR and other donor programs.

Challenges of Harmonization

Harmonization does not mean simply passively accepting policies developed by partner governments. In the developing world, governments are dependent on a variety of sources for the formulation of scientific policy: faculty of their own universities; resident technical advisors funded by donors; and short-term consultants and the permanent staff of donors, both bilateral and multilateral. Outside advisors who reside in the country, speak the local language, and understand local politics are particularly valuable to government experts (UNAIDS, 2004a). The United States has the advantage of maintaining a relatively large and highly skilled staff in the countries; these individuals are often actively involved in supporting, and at times urging, efforts by the partner government to incorporate in their plans new scientific advances and lessons learned in the field. 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. 1).

Another challenge to harmonization is the development of equitable programs that ensure access for the most vulnerable members of the

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

population. The Joint United Nations Programme on HIV/AIDS (UNAIDS) recently published a document entitled Considerations for Countries to Set Their Own Targets for AIDS Prevention, Treatment, and Care (UNAIDS, 2006). The Global Steering Committee on Scaling Up Towards Universal Access recommended that national governments set a small number of their own targets in approaching universal access, rather than having UNAIDS or WHO attempt to establish global targets (UNAIDS et al., 2006). Among the principles recommended in the UNAIDS document are the following: “The movement to scale up towards universal access should address needs and rights in terms of health, nondiscrimination and gender equality”; and “The goal of moving towards universal access is only meaningful to the extent to which access is measured across different populations—ensuring that access to prevention, treatment and care is available for those least advantaged and socially marginalized” (UNAIDS, 2006, pp. 5–6).

In countries where certain marginalized groups are, in the view of donors, receiving insufficient attention in scale-up plans, PEPFAR and other donors may need to serve as advocates for those groups. Striking a balance between respecting local decisions and speaking effectively for those who do not have their own local voice is a core challenge to harmonization.

Recommendation 3-2: The commitment of the U.S. 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. The U.S. Global AIDS Coordinator should document how these groups are included in the program planning, implementation, and evaluation of PEPFAR activities.

POLICY GUIDANCE

Given the rapid implementation of PEPFAR and the formal process involved in developing official guidance documents, such documents for PEPFAR activities have been slow in coming. To date, OGAC has issued relatively few official policy documents; however, it has issued numerous less formal reports that provide information to guide program implementation. Nonetheless, during its country visits, the Committee heard that the lack of clear guidance in certain areas had caused many programs to self-censor and in some instances not to support particular services even though they are allowed. The absence of clear policy direction was confirmed by the fact that Country Teams in different countries sometimes described very

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

different “official policy” under which they were working. For example, nutritional support in the early phase of treatment was variously described as encouraged, permitted but not encouraged, and prohibited. OGAC officials reported that they are working both to provide official guidance in a timelier manner and to continue to provide information in other forms to guide program implementation. The schedule of new materials coming from the Technical Working Groups supports this assertion.

PLANNING AND REPORTING

Country Operational Plans are used as planning tools for the Country Teams and allow for the aggregation of data across funding sources. They enable the consolidation of all relevant information, such as that related to budgeting, reporting, reviewing, and data analysis. The agencies that make up a Country Team are also required to work together to submit one strategic information plan as part of the Country Operational Plan (OGAC, 2006a).

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). COPRS is also used for collecting and reporting information on the progress of PEPFAR—for example, progress toward the prevention, treatment, and care targets. To this end, it includes mechanisms for and warehouses data from semiannual and annual reports by the Country Teams. According to OGAC, COPRS was designed to allow the Country Teams to meet individual agency reporting requirements in addition to OGAC requirements.

OGAC and Country Teams informed the Committee that the process of developing and implementing the Country Operational Plans and managing COPRS strained the resources of the Country Teams, particularly in the first year. The process reportedly has improved over time, however, as the planning and reporting cycle has become more regular, the system has been streamlined and made more user-friendly, and the Country Teams have received more support and become more experienced.

At the same time, Country Teams and implementing partners described a number of remaining planning challenges. The fact that the Country Operational Plan planning cycle spans only 1 year makes it difficult for Country Teams to manage their own time and develop mid- and long-term programs. The 1-year planning cycle also takes time away from implementation and monitoring and evaluation efforts. The inability to make midcourse changes to programming decisions because of contractual obligations and the rigidity of plans makes it difficult to improve programs

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

during the year. In response to these concerns, OGAC announced at its 2006 annual meeting that it was considering moving to a 2-year Country Operational Plan cycle beginning with fiscal year 2008.

TECHNICAL WORKING GROUPS

Interagency Technical Working Groups are PEPFAR’s principal mechanism for providing technical support to Country Teams for the implementation of program activities (see Chapter 2). These groups, which include members from all agencies, both headquarters and Country Teams, are charged with drafting program guidance and making and implementing evidence-based recommendations regarding changes in current and future programming. The work of these groups is supplemented by consultations with outside experts, such as one on substance abuse and HIV/AIDS in 2005 and one on gender and HIV/AIDS in 2006. OGAC views the Technical Working Groups as an effective way to tap the scientific and technical resources of the U.S. government to ensure that guidance issued by PEPFAR is of the highest quality (OGAC, 2005a, 2006a–c). The development of indicators has been an important focus of the Technical Working Groups. 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). To support the development of the Country Operational Plans, the Technical Working Groups prepare Technical Considerations documents for their respective areas. These documents serve as sources of available evidence, as well as guides to the recommendations of global normative bodies, such as UNAIDS and WHO. They also include PEPFAR priorities for country-funded targeted evaluations (OGAC, 2006b,c). The Technical Working Groups are intended to support OGAC’s goal of reducing duplicative and/or conflicting directives from different agencies by planning and providing technical assistance as a U.S. government–wide effort.

FUNCTIONING AS A LEARNING ORGANIZATION

Over the course of this study, the Committee observed a number of examples of OGAC’s commitment to learning from experience and contributing to the evidence base on how to combat HIV/AIDS most effectively. This adaptability was necessary given the emergency nature of PEPFAR’s response to the pandemic and its consequent lack of time to develop policies and procedures prior to program implementation.

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

Garvin defines a learning organization as “… skilled at creating, acquiring, and transferring knowledge, and at modifying its behavior to reflect new knowledge and insights” (Garvin, 2000, p. 11). This definition emphasizes a systematic, ongoing commitment to the strategic collection, communication, analysis, and use of knowledge gained through experience. In attempting to determine how well PEPFAR is functioning as a learning organization, the Committee looked for evidence of transparent structures and processes, the allocation of time and resources to support learning, and changes over time showing that the organization can learn from both its mistakes and its successes.

A number of examples of PEPFAR’s willingness to learn and adapt have already been described. Further examples are presented below.

Research

When PEPFAR was initiated, the Country Teams perceived a “ban” on using PEPFAR funds other than those flowing through the National Institutes of Health for research (OGAC, 2004), and the Committee was told that this inhibited them from supporting even operations research that was an integral part of program implementation. Over time, however, OGAC has recognized the need to clarify the policy and to encourage Country Teams to support operations research. The intent of such research is both to evaluate currently funded programs and to develop information that can answer important questions about how best to respond to the pandemic (OGAC, 2006g).

OGAC is currently providing about $22 million for targeted evaluations, primarily in the focus countries (OGAC, 2005c, 2006d,e). These evaluations cover a wide range of topics related to the program categories of prevention, treatment, care, and orphans and other vulnerable children. 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). The strategy lays out a process for the review and approval of targeted evaluations. OGAC intends this process to support the systematic collection of information, as well as a mechanism for sharing that information both across the PEPFAR program and with partners. Additional discussion of PEPFAR’s targeted evaluations appears in Chapter 8.

Quality Improvement

One important element of learning by doing is the use of modern quality improvement techniques to permit practitioners to continuously measure

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

and improve their work. USAID’s Quality Assurance Project applies these techniques in developing countries and is now in its third 5-year funding phase (USAID, 2006b). The project’s objectives are to “build capacity in countries to develop and sustain quality assurance and workforce improvement activities; assist countries to achieve demonstrable results in quality of care and outcomes; strengthen USAID programming under its Global Health Strategic Objective programs through quality assurance approaches, methods, and tools; carry out research to develop and test new quality assurance and workforce development approaches and methods; and provide leadership in the technical development of the quality improvement field and in advocacy of the essential goal of high quality of care worldwide” (USAID, 2006a, p. 1). PEPFAR is supporting these activities in several of the focus countries, including Rwanda, South Africa, Tanzania, and Uganda.

PEPFAR is also supporting the updating and dissemination of two HIV clinical care data management software programs that enhance the ability of practitioners to improve their results. CAREWare, originally developed by the Health Resources and Services Administration within the Department of Health and Human Services for use in the United States, promotes quality care by providing a customizable and confidential platform for entering, collecting, and reporting demographic, service, and clinical information. An international version has been developed and implemented with PEPFAR support in Uganda, Zambia, Kenya, Tanzania, and Nigeria, with plans for adoption in Vietnam and Thailand (USAID, 2006a). PEPFAR is also supporting some focus countries’ use of the HIVQUAL software program, an HIV-specific data system designed to enhance quality improvement activities. HIVQUAL helps participants measure key quality indicators and use these measurements to benchmark and make progress toward objectives (USAID, 2006a). PEPFAR support for HIVQUAL, which was piloted in Thailand, has expanded to include Uganda, Nigeria, and Mozambique (USAID, 2006a).

PEPFAR’s Annual Meetings as a Learning Model

PEPFAR’s annual meetings have evolved to provide an opportunity for PEPFAR staff and implementing partners to discuss issues, exchange information on program and management successes and challenges, and share lessons learned. OGAC officials reported that at the first meeting, held in South Africa, there were approximately 100 invitees, including ambassadors, Country Team directors, and chargés d’affaires. The focus of the meeting, which took place less than 6 months after PEPFAR funding was available, was the management and structure of the new program. Topics discussed included policies, procedures, staffing issues, and the development

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

of Country Operational Plans. OGAC officials said that based on the results of these discussions, they decided there was a need to open future meetings to partners so that PEPFAR policies could be as widely understood as possible.

The second PEPFAR annual meeting was held in Addis Ababa, Ethiopia, in 2005. The number of invitees increased to approximately 450, including U.S. implementing partners. The press and representatives of the Committee were also invited. Country poster presentations were encouraged with no review other than a limit on the total number that each country could present. The entire meeting was a plenary session, with a scientific focus. OGAC officials believe that positive programmatic changes took place in the countries after information was shared at this meeting. After the meeting, OGAC developed a task force to address reporting burden, a commonly shared challenge in the field that was communicated during the meeting. 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. An application process was instituted instead of invitations; the sole criterion for acceptance of an application was whether the person was involved in program implementation. Approximately 1,000 people from 50 countries attended; 500 presentations were made (Dybul, 2006). New features included an abstract-driven program and the use of an International Program Committee for planning and review of abstracts. The International Program Committee also selected the topics and plenary speakers. While the Committee did not seek access to the formal evaluation of this meeting, it heard from a number of individual participants who praised the “by implementers, for implementers” approach.

OGAC reported that the fourth annual meeting, to be held in 2007, would be cosponsored by the World Bank, the Global Fund, and UNAIDS and that it expected 1,500–2,000 people to attend.

Communications

Initially, PEPFAR created ill will in some countries and among other donors because successes were attributed only to the United States in official statements and speeches. The U.S. Global AIDS Coordinator responded by changing this language to communicate the fact that PEPFAR is a partner, not a solo actor. The Coordinator has also worked closely with the Global Fund to derive jointly their estimates of the numbers of people being served by each program.

Changes have been initiated as well to respond to the focus countries’ call for more communication from headquarters on matters of policy and

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

implementation. Weekly email “Notes to the Field” disseminate the most recent news and guidance from OGAC headquarters and address issues raised in the field.

Institutionalizing the Learning Organization Concept

PEPFAR would benefit from developing a detailed, overall strategy for institutionalizing the concept of being a learning organization, including how it is going to track and report on its progress in this regard. Such a strategy would include the following:

  • Articulation of the learning agenda of PEPFAR programs, including a strategy for the conduct and use of results of operations, behavioral, and epidemiological research and implementation studies.

  • Continued support for targeted evaluation efforts.

  • Specification of how PEPFAR structures and processes will be modified to ensure ongoing communication and access to information and lessons learned at the country and cross-country levels and among others in the global HIV/AIDS community.

  • Definition of the indicators by which PEPFAR will track its progress toward becoming a learning organization and how those indicators will be measured.

An annual report, or a specific section in the overall program’s annual report, on these issues would highlight the importance of this area and enhance its visibility.

BUDGET ALLOCATIONS

PEPFAR is accountable to Congress for implementing a relatively large set of specific budget allocations (see Chapter 2). These allocations derived from Congress’ desire to articulate and enforce certain priorities, in particular to ensure that the scale-up of ART would be the centerpiece of the program. 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. Even in instances where the available information allowed reasonable estimates, the situation has since changed so rapidly that those estimates are no longer accurate. For example, when the Leadership Act was drafted, Congress estimated that antiretroviral medications (ARVs) would account for 75 percent of the cost of providing

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

ART—hence the 75 percent suballocation for ARVs within the 55 percent allocation for treatment. According to some current estimates, however, ARVs now account for a relatively small and declining proportion of the total cost of ART (Martinson, 2006), while increases in the number of children being treated, as well as in the number of individuals on second-line medications, are likely to shift cost patterns once again.

The lack of an evidence base for the budget allocations and a rationale linking the allocations to performance targets and goals has adversely affected implementation in a number of ways described by the Country Teams and others. 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. For example, approximately 10 percent of all children under age 17 are estimated to be orphans in Nigeria, whereas the proportion in Botswana is 20 percent (USAID et al., 2004).

Second, PEPFAR’s categories of prevention, treatment, and care and the subcategories within them fragment the natural continuum of needs and services, often in ways that do not correspond to global standards, do not align with an individual focus country’s perspective, and do not permit optimal management of patients and their families. ART programs (categorized as treatment) and counseling and testing programs (categorized as care) need to be closely linked so that HIV-positive people can be quickly referred from counseling and testing sites for evaluation for treatment, and the partners and families of patients can receive counseling and testing promptly. Separate funding can serve to sever these linkages.

There has also been some misalignment of activities across the program categories of prevention, treatment, and care. The result has been a lack of emphasis on some crucial activities. For example, voluntary counseling and testing is included in the care category (mainly for HIV case finding) rather than under prevention, although it has long been considered an important element of prevention approaches. Consequently, there has been insufficient emphasis on quality counseling and testing as a prevention tool. Likewise, treatment is narrowly defined as ART, but a comprehensive basic treatment package includes elements categorized as both prevention (for example, services addressing sexually transmitted infections) and care (for example, treatment of opportunistic infections and pain management) (OGAC, 2004). Care, which is the fundamental organizing principle for the full spectrum of HIV/AIDS interventions and typically includes both preventive care and ART, is instead a catch-all for what does not fit easily within the prevention and treatment categories and budget allocations. To achieve longer-term targets and the ultimate goals of the Leadership Act—

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

improvements in survival and reversal of the epidemic—it will be necessary to eliminate the fragmentation introduced by the PEPFAR categories and budget allocations and better capitalize on the synergy that results from effective integration.

The suballocations and corresponding subcategories that OGAC has developed to manage them have also been problematic within categories. According to many of the Country Teams, the abstinence-until-marriage allocation within the prevention category has been the most difficult to manage. The adverse effect of this budget allocation on prevention programming that is responsive to and harmonized with host country plans was also found in a recent Government Accountability Office study (GAO, 2006) 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.

The abstinence-until-marriage budget allocation in particular has fueled a divisive U.S. debate over the ABC concept. It is important to understand that ABC represents neither a program nor a strategy, but a goal of changing key behaviors. There is good evidence that behavior changes such as delaying sexual activity (A), reducing the number of sexual partners (B), and using condoms correctly and consistently (C), reduce the risk of transmitting HIV/AIDS (Stanton et al., 1998; Furguson et al., 2004; Bunnell et al., 2006; Riedner et al., 2006). While no one argued during the Committee’s visits that funding for ABC should exclude activities focused on changing abstinence behaviors, the Committee has been unable to find evidence for the position that abstinence can stand alone or that 33 percent is the appropriate allocation for such activities even within integrated programs.

The ABC debate has also served to obscure the importance of other behaviors that put people at high risk of contracting HIV/AIDS, such as alcohol use and violence toward women. Since programs aimed at reducing alcohol dependence or empowering women are not officially ABC activities, they are less likely to be funded.

Finally, the budget allocations do not allow program implementers sufficient flexibility to respond to change. Moreover, the Leadership Act stipulated that the budget allocations were recommended for the first 2 years of the program and many would be required beginning in 2006. Thus the allocations were set to become more, rather than less, restrictive as the program evolved and attempted to adapt to changes in science, country epidemics, and circumstances. OGAC’s management of the allocations for the first 3 years of funding are shown later in the chapter in Table 3-3.

The difficulties posed by budget allocations will become more pronounced as the HIV/AIDS pandemic and the science of controlling it evolve. For example, several new approaches to prevention are currently being

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

investigated, including male circumcision, microbicides, and vaccines. These new approaches will change the appropriate mix and costs of prevention services in unforeseen ways. Without greater flexibility, the ability of the U.S. Global AIDS Initiative to lead the way in utilizing such new techniques when proven effective will be greatly reduced.

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. Global AIDS Coordinator and to Congress. These mechanisms should also ensure that spending is directly linked to and commensurate with necessary efforts to achieve both country and overall performance targets for prevention, treatment, care, and orphans and other vulnerable children.

TARGETS

Some of the indicators being collected by PEPFAR do not yet provide appropriate information on the progress being made toward the ultimate goal of controlling the epidemic. As is appropriate for a program this early in its implementation, most results reported to date are for targets that can be measured in the short term; thus they reveal more about the process of implementation than the impact of the program. PEPFAR plans to measure more meaningful mid- and long-term results, and the program is supporting countries in developing the measures and skills needed to evaluate the impact of initiatives at the country level.

One issue related to targets concerns requiring that results be specifically and uniquely attributed to the U.S. initiative. Such a requirement creates disincentives for international coordination among donors and harmonization at the country level, and can work against the use of U.S. funds to leverage other donors’ interests in a particular area. The most important result is impact on a country’s epidemic, and that impact can best be attributed to collective actions taken in partnership with all donors and, most critically, the host country. PEPFAR would do well to consider a step taken by some other large donors: evaluating Country Teams on how well they cooperate with the partner government and the donor group as a whole and how effective they are at leveraging a successful package of services.

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

Finally, targets that are defined in terms of whether programs meet the full spectrum of needs of an individual person across his or her lifespan, of all members of the family or household, and of communities as a whole would create improved incentives for programming that is comprehensive, integrated, and accountable to those being served. At present, however, PEPFAR is not reporting referral or linkage indicators in its annual report, and few such indicators are required to be reported to OGAC across the four program categories. Over the course of the program, OGAC has increased its emphasis on integration in guidance provided to the focus countries (Dybul, 2005). Integration was included in the fiscal year 2005 guidance in a general manner; by fiscal year 2007, that guidance was expanded, outlining points of possible integration for all program activities, including voluntary counseling and testing, ART, diagnosis and treatment of sexually transmitted infections, and services for orphans and other vulnerable children (OGAC, 2006b,c). OGAC has also provided Country Teams with additional information on integrated services and activities required to address the needs of key populations, such as people living with HIV/AIDS (OGAC, 2006b,c). This improved guidance can have greater impact if it is enhanced by tracking of the results of integration.

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. If, as happened in fiscal year 2006, more money was appropriated after the plans had been approved, new versions of the plans had to be developed that described how the additional funds would be spent. These new plans, called “plus-up plans,” were then reviewed through the usual mechanisms. OGAC was dissatisfied with the quality of the plus-up plans, and the Country Teams were unhappy about writing and reviewing planning documents twice in one year. As a result, for fiscal year 2007, the interagency Deputy Principals Group assumed the highest possible level of potential funding when developing the country planning budgets and requested that Country Teams formulate a short statement indicating how spending would be prioritized if funding were decreased by 5–10 percent.

Since its inception, PEPFAR has undergone one evaluation by the Office of Management and Budget. The Office of Management and Budget developed the Program Assessment Rating Tool to assess and drive the improved

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

performance of U.S. government programs by examining all factors that affect and reflect program performance, such as program purpose and design, performance measurement, evaluations, strategic planning, program management, and results (OMB, 2007a). Programs that are categorized as performing (versus nonperforming) receive ratings from effective (highest rating) to adequate (lowest rating). All U.S. government agencies involved in PEPFAR are rated in a single assessment, and the program received an overall rating of moderately effective when assessed in 2005. Specifically for fiscal accountability, however, the assessment found that “the implementing agencies’ mechanisms for financial accountability and control did not yet meet the standards for strong financial management practices.” In addition, audits conducted by USAID’s Inspector General in 2005 and 2006 found financial management problems in PEPFAR programs implemented by USAID in some of the focus countries (USAID, 2005, 2006c).

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). Additionally, a new financial management system has been implemented at CDC and at USAID for both headquarters and Country Team management.

OGAC officials also explained to the Committee that they are funding a number of new projects aimed at improving PEPFAR’s financial management. These include the following:

  • Development of a country-level portfolio review process. This process is intended to improve program management and evaluate funding pipelines by partner and activity type.

  • A pipeline analysis to determine whether improvements can be made in how funds move from congressional appropriation to the end user.

  • An addition, on the part of the Office of Management and Budget, OGAC, and the PEPFAR implementing agencies, of an annual outlays report to the current quarterly obligations and outlays reports. According to OGAC, this new approach will serve to provide greater detail and transparency.

  • A joint effort with State Department information technology experts to develop a budget interface system that will be flexible and web-based. In related activities, OGAC is working with a contractor to improve COPRS reports.

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×
PEPFAR Focus Country Funding by Agency Account

A 357 percent increase in focus country funding from the State Department Global HIV/AIDS Initiative account from fiscal year 2004 to fiscal year 2006 resulted from both an increase in new monies for HIV/AIDS and the shifting of funding from other agency accounts, such as CDC’s Global AIDS Program account and the Department of Defense’s Prevention account. The AIDS budgets of USAID and the Department of Defense were shifted in their entirety to the State Department account, as was a large proportion of the budget of the Department of Health and Human Services for the CDC Global AIDS and Prevention of Mother-to-Child Transmission programs (see Table 3-1).

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. The majority of PEPFAR funds (84 percent), totaling almost $3 billion over the first 3 years of the program, has been planned and granted by the Country Teams. The proportion of country funds implemented through central programs has decreased by almost half—from 24 percent in fiscal year 2004 to 13 percent in fiscal year 2006 (see Table 3-2) (OGAC, 2005a, 2006a). PEPFAR’s initial rounds of funding were intended to capitalize

TABLE 3-1 Focus Country–Implemented Funding by Agency for Fiscal Years 2004–2006 (in millions of U.S. dollars)

Agency

Fiscal Year 2004

Fiscal Year 2005

Fiscal Year 2006

Total Fiscal Year 2004–2006

Funding

Percent

Funding

Percent

Funding

Percent

Funding

Percent

USAID

194

34

0

0

0

0

194

6

Department of Health and Human Services (CDC)

84

15

59

6

59

4

202

7

Department of Defense

0.4

<1

0

0

0

0

0.4

<1

State Department

292

51

969

94

1,336

96

2,597

87

Total

$570

100

$1,028

100

$1,395

100

$2,993

100

SOURCE: OGAC, 2005d, 2006f.

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

TABLE 3-2 PEPFAR Focus Country–Implemented and Central-Implemented Funding for Fiscal Years 2004–2006 (in billions of U.S. dollars)

Fiscal Year

Focus Country

Central

Total Focus Country and Central

Funding

Percent

Funding

Percent

Funding

2004

.57

76

.18

24

.75

2005

1.03

84

.19

16

1.22

2006

1.39

87

.21

13

1.60

Total 2004–2006*

$2.99

84

$.58

16

$3.58

*Numbers may not sum to the totals shown because of rounding.

SOURCE: OGAC, 2005d, 2006f.

on the existing operations of both international and country-based nongovernmental organizations to allow for rapid scale-up. 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) of the country’s PEPFAR funding was centrally managed.

While OGAC has worked to facilitate linkages between the Country Teams and centrally funded grantees, issues remain. Centrally funded programs were selected at the headquarters level, and Country Teams had little or no control over the types of activities funded, the size of the contracts, or the evaluation of performance. Although the initial centrally managed contracts were seen by OGAC as a way to get the funding on the ground as quickly as possible, Country Teams regarded them as a circumvention of country planning and Country Team funding decisions. This situation raised concerns, some of which persist, regarding PEPFAR’s ability to comply with the tenets of harmonization. Moreover, the performance of centrally funded contracts appears to be quite variable, with some being singled out for praise in terms of country knowledge and integration with country policies and others being criticized for a lack of those characteristics.

In addition, OGAC has taken several steps to shift control of centrally funded grants to Country Teams so they can better integrate the activities with the larger PEPFAR portfolio in the focus country. Central funding for these contracts has been held constant, and the organizations involved have been required to negotiate increases with the Country Teams. Two examples

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

of this shift in management of central programs are the Partnership for Supply Chain Management and the New Partners Initiative. The Partnership for Supply Chain Management is a program involving a technically skilled central structure from which Country Teams are able to buy specific commodities and services that address each country’s specific needs (OGAC, 2006b,c). Since 2004, OGAC has requested approximately $36 million in central funds for the program, used for operations and management, but the bulk of the program’s funding is expected to come from focus country budgets. The Quality Assurance Program of USAID, described previously, is managed in a similar style (USAID, 2006b).

The New Partners Initiative is a central grant-making mechanism focused on increasing the number of new partners. Initiated in 2005, it has received $35 million in central funding to date. There was concern that New Partners Initiative grants would be made with little input from the Country Teams. However, OGAC reported that it has been working with Country Teams to apply lessons learned about centrally managed programs to inform New Partners Initiative policies. Specifically, grantees are required to have Country Team approval to work in that country (OGAC, 2006a).

Both of these programs were established after the Committee made its visits to the focus countries. 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), while prevention and care have each accounted for about $.81 billion (23 percent) (see Table 3-3). The remaining $.51 billion (14 percent) has gone to other costs, such as strategic information activities, policy analysis and system strengthening, and management and staffing of the Country Teams.

With respect to the budget allocations, the proportion of funds allocated by OGAC for treatment has increased from 34 to 45 percent. The proportion for care has stayed constant at about 23 percent, while the proportion allocated for prevention has declined by about 9 percentage points. Since the program’s inception, about 28 percent of the funds allocated to care and 6 percent of overall funding has been allocated for the orphans and other vulnerable children category (OGAC, 2006a).

As reported by OGAC to the Committee, it has a method to attribute the same “other” costs described above to their corresponding program categories for each fiscal year (OGAC, 2007). When this method is used, the totals for the full dollar amounts appropriated each year for the focus

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

TABLE 3-3 PEPFAR Funding by Program Category for Fiscal Years 2004–2006 (in billions of U.S. dollars)

Category

2004

2005

2006

Total 2004–2006

Funding

Percent

Funding

Percent

Funding

Percent

Funding

Percent

Prevention

.21

28

.29

24

.31

19

.81

23

Care

.16

23

.27

22

.37

23

.81

23

Treatment

.25

34

.48

39

.72

45

1.45

40

Other Costs

.13

17

.18

15

.20

13

.51

14

Total

$.75

100

$1.22

100

$1.60

100

$3.58

100

NOTE: Numbers may not add due to rounding.

SOURCE: OGAC, 2005d, 2006f.

countries (including central support) and the percentages of funding for each program area change from the data in Table 3-3 (see Table 3-4).

Focus Country Funding

Between $53 million (Guyana) and $459 million (South Africa) has been allocated for each of the 15 focus countries since fiscal year 2004, totaling a combined $3.6 billion (see Table 3-5). PEPFAR support for the focus countries collectively has increased by 113 percent, and each of the countries has seen at least an 80 percent increase in funds since the first year of the program. Botswana, Ethiopia, Haiti, Kenya, Mozambique, Namibia, Nigeria, South Africa, and Vietnam have all seen their support increase by more than 100 percent.

One of the major concerns of the Country Teams has been the relationship between their budgets and targets for prevention, treatment, and care. For many of the focus countries, the proportions of the prevention,

TABLE 3-4 PEPFAR Funding by Program Category for Fiscal Years 2004–2006 (in billions of U.S. dollars) with Distribution of Other Costs by OGAC Method

Category

2004

2005

2006

Total 2004–2006

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.

SOURCE: OGAC, 2007.

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

TABLE 3-5 PEPFAR Funding by Focus Country for Fiscal Years 2004–2006 (in millions of U.S. Dollars)

Country

2004

2005

2006

Percent Increase 2004–2006

Total Funding 2004–2006

Botswana

24

52

55

129

131

Côte d’Ivoire

24

44

47

96

115

Ethiopia

48

84

123

156

255

Guyana

12

19

22

83

53

Haiti

28

52

56

100

135

Kenya

92

143

208

126

444

Mozambique

37

60

94

154

192

Namibia

24

43

57

138

124

Nigeria

71

110

164

131

345

Rwanda

39

57

72

85

168

South Africa

89

147

222

149

459

Tanzania

71

109

130

83

309

Uganda

91

147

170

87

409

Vietnam

17

27

34

100

79

Zambia

82

130

149

82

361

Total

$751

$1,223

$1,602

113

$3,580

NOTE: Numbers may not sum to the totals shown because of rounding. Some sources of central support for focus countries are not reflected in the table above.

SOURCE: OGAC, 2005d, 2006f.

treatment, and care targets they are responsible for achieving are close to the respective proportions of their funding. 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. In contrast, Uganda is responsible for 2 to 3 percent of the targets and receives 10 to 15 percent of the funding. On the other hand, these figures do not take into account a number of factors that could impact the level of funding, such as existing infrastructure, other funding sources (e.g., the host country and other donors), human resource capacity, and the current state of the epidemic.

Per capita PEPFAR funding for people living with HIV/AIDS also varies widely by focus country. For example, in 2006 Guyana, with an estimated 12,000 people living with HIV/AIDS, was receiving roughly $1,800 in PEPFAR funds per person living with HIV/AIDS. In contrast, South Africa, which has an estimated 5.5 million people living with HIV/AIDS, was receiving about $40 in PEPFAR funds per person living with HIV/AIDS. OGAC reported that the Deputy Principals Group decides on the total funding per fiscal year per country, but provided the Committee with no

Suggested Citation:"Part II Progress on the First 5-Year Strategy -- PEPFAR, 3 PEPFAR's Management." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

information on the process used in making these decisions. The per person allocations presented above do not take into account important factors, including the country’s own capacity to fund its programs, but they suggest a need for more transparent budgeting and planning so the rationale for these allocations can be better understood.

CONCLUSION

PEPFAR has been responsive to the Leadership Act’s challenging mandate to coordinate all U.S. international HIV/AIDS activities and has made progress in coordinating among the agencies of the U.S. government involved in the program and with other global HIV/AIDS donors at both the headquarters and country levels. The program has also made progress in harmonizing with the focus countries. 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. Global AIDS Initiative should be able to make even greater progress toward achieving the goals of the Leadership Act.

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In 2003, Congress passed the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act, which established a 5-year, $15 billion initiative to help countries around the world respond to their AIDS epidemics. The initiative is generally referred to by the title of the 5-year strategy required by the act--PEPFAR, or the President's Emergency Plan for AIDS Relief.

PEPFAR Implementation evaluates this initiative's progress and concludes that although PEPFAR has made a promising start, U.S. leadership is still needed in the effort to respond to the HIV/AIDS pandemic. The book recommends that the program transition from its focus on emergency relief to an emphasis on the long-term strategic planning and capacity building necessary for a sustainable response. PEPFAR Implementation will be of interest to policy makers, health care professionals, special interest groups, and others interested in global AIDS relief.

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