President's Emergency Plan for AIDS Relief
Efforts to Align Programs with Partner Countries' HIV/AIDS Strategies and Promote Partner Country Ownership Gao ID: GAO-10-836 September 20, 2010The President's Emergency Plan for AIDS Relief (PEPFAR), reauthorized at $48 billion for fiscal years 2009 through 2013, supports HIV/AIDS prevention, treatment, and care services overseas. The reauthorizing legislation, as well as other key documents and PEPFAR guidance, endorses the alignment of PEPFAR activities with partner country HIV/AIDS strategies and the promotion of partner country ownership of U.S.-supported HIV/AIDS programs. This report, responding to a legislative directive, (1) examines alignment of PEPFAR programs with partner countries' HIV/AIDS strategies and (2) describes several challenges related to alignment or promotion of country ownership. GAO analyzed PEPFAR planning documents and national strategies for four countries--Cambodia, Malawi, Uganda, and Vietnam--selected to represent factors such as diversity of funding levels and geographic location. GAO also reviewed documents and reports by the U.S. government, research institutions, and international organizations and interviewed PEPFAR officials and other stakeholders in headquarters and the four countries.
PEPFAR activities are generally aligned with partner countries' national HIV/AIDS strategies. GAO's analysis of PEPFAR planning documents and national HIV/AIDS strategies, as well as discussions with PEPFAR officials in the four countries GAO visited, showed overall alignment between PEPFAR activities and the national strategy goals. In addition, statements by global and country-level PEPFAR stakeholders indicate that PEPFAR activities support the achievement of partner countries' national strategy goals. PEPFAR officials noted that a number of factors may influence the degree to which PEPFAR activities align with national strategy goals, including the activities of other donors, the size of the PEPFAR program, and policy restrictions. PEPFAR may also support activities not mentioned in the national HIV/AIDS strategies but that are addressed in relevant sector- or program-specific strategies. PEPFAR officials reported various efforts to help ensure that PEPFAR activities support the achievement of national strategy goals, including assisting in developing national strategies, participating in formal and informal communication and coordination meetings, engaging regularly with partner country governments during the annual planning process, and developing a new HIV/AIDS agreement, known as a partnership framework, between PEPFAR and partner country governments. PEPFAR stakeholders highlighted several challenges related to aligning PEPFAR programs with national HIV/AIDS strategies or promoting country ownership of U.S.-supported HIV/AIDS programs. First, PEPFAR indicators, including indicator definitions and timeframes, sometimes differ from those used by partner countries and other international donors. Second, gaps may exist in the sharing of PEPFAR information with partner country governments and other donors. Third, limitations in country leadership and capacity, such as lack of technical expertise to develop strategies and manage programs, affect country teams' ability to ensure that PEPFAR activities support achievement of national strategy goals. Fourth, Office of the U.S. Global AIDS Coordinator (OGAC) guidance to country teams regarding development of partnership frameworks does not include indicators for establishing baseline measures of country ownership prior to implementation of partnership frameworks. Without baseline measures, country teams may have limited ability to measure the frameworks' impact and make needed adjustments. GAO recommends that the Secretary of State direct OGAC to develop and disseminate a methodology for establishing baseline measures of country ownership prior to implementing partnership frameworks. OGAC concurred with this recommendation.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: David B. Gootnick Team: Government Accountability Office: International Affairs and Trade Phone: (202) 512-3149GAO-10-836, President's Emergency Plan for AIDS Relief: Efforts to Align Programs with Partner Countries' HIV/AIDS Strategies and Promote Partner Country Ownership
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
September 2010:
President's Emergency Plan For Aids Relief:
Efforts to Align Programs with Partner Countries' HIV/AIDS Strategies
and Promote Partner Country Ownership:
GAO-10-836:
GAO Highlights:
Highlights of GAO-10-836, a report to congressional committees.
Why GAO Did This Study:
The President‘s Emergency Plan for AIDS Relief (PEPFAR), reauthorized
at $48 billion for fiscal years 2009 through 2013, supports HIV/AIDS
prevention, treatment, and care services overseas. The reauthorizing
legislation, as well as other key documents and PEPFAR guidance,
endorses the alignment of PEPFAR activities with partner country
HIV/AIDS strategies and the promotion of partner country ownership of
U.S.-supported HIV/AIDS programs. This report, responding to a
legislative directive, (1) examines alignment of PEPFAR programs with
partner countries‘ HIV/AIDS strategies and (2) describes several
challenges related to alignment or promotion of country ownership. GAO
analyzed PEPFAR planning documents and national strategies for four
countries”Cambodia, Malawi, Uganda, and Vietnam”selected to represent
factors such as diversity of funding levels and geographic location.
GAO also reviewed documents and reports by the U.S. government,
research institutions, and international organizations and interviewed
PEPFAR officials and other stakeholders in headquarters and the four
countries.
What GAO Found:
PEPFAR activities are generally aligned with partner countries‘
national HIV/AIDS strategies. GAO‘s analysis of PEPFAR planning
documents and national HIV/AIDS strategies, as well as discussions
with PEPFAR officials in the four countries GAO visited, showed
overall alignment between PEPFAR activities and the national strategy
goals. In addition, statements by global and country-level PEPFAR
stakeholders indicate that PEPFAR activities support the achievement
of partner countries‘ national strategy goals. PEPFAR officials noted
that a number of factors may influence the degree to which PEPFAR
activities align with national strategy goals, including the
activities of other donors, the size of the PEPFAR program, and policy
restrictions. PEPFAR may also support activities not mentioned in the
national HIV/AIDS strategies but that are addressed in relevant
sector- or program-specific strategies. PEPFAR officials reported
various efforts to help ensure that PEPFAR activities support the
achievement of national strategy goals, including assisting in
developing national strategies, participating in formal and informal
communication and coordination meetings, engaging regularly with
partner country governments during the annual planning process, and
developing a new HIV/AIDS agreement, known as a partnership framework,
between PEPFAR and partner country governments.
PEPFAR stakeholders highlighted several challenges related to aligning
PEPFAR programs with national HIV/AIDS strategies or promoting country
ownership of U.S.-supported HIV/AIDS programs. First, PEPFAR
indicators, including indicator definitions and timeframes, sometimes
differ from those used by partner countries and other international
donors. Second, gaps may exist in the sharing of PEPFAR information
with partner country governments and other donors. Third, limitations
in country leadership and capacity, such as lack of technical
expertise to develop strategies and manage programs, affect country
teams‘ ability to ensure that PEPFAR activities support achievement of
national strategy goals. Fourth, Office of the U.S. Global AIDS
Coordinator (OGAC) guidance to country teams regarding development of
partnership frameworks does not include indicators for establishing
baseline measures of country ownership prior to implementation of
partnership frameworks. Without baseline measures, country teams may
have limited ability to measure the frameworks‘ impact and make needed
adjustments.
What GAO Recommends:
GAO recommends that the Secretary of State direct OGAC to develop and
disseminate a methodology for establishing baseline measures of
country ownership prior to implementing partnership frameworks. OGAC
concurred with this recommendation.
View [hyperlink, http://www.gao.gov/products/GAO-10-836] or key
components. For more information, contact David Gootnick at (202) 512-
3149 or gootnickd@gao.gov.
[End of section]
Contents:
Letter:
Background:
PEPFAR Programs Generally Support Partner Countries' National HIV/AIDS
Strategies:
PEPFAR Stakeholders Noted Several Factors That Can Hinder PEPFAR
Alignment with National Strategies:
Conclusions:
Recommendation for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Cambodia Case Study:
Appendix III: Malawi Case Study:
Appendix IV: Uganda Case Study:
Appendix V: Vietnam Case Study:
Appendix VI: Comments from the U.S. Department of State, Office of the
U.S. Global AIDS Coordinator:
Appendix VII: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: National HIV/AIDS Strategies in Cambodia, Malawi, Uganda, and
Vietnam:
Table 2: Alignment of 2010 COPs with National HIV/AIDS Strategies for
Cambodia, Malawi, Uganda, and Vietnam:
Table 3: Planned Allocation of PEPFAR Funding for Cambodia, by
Technical Area, Fiscal Year 2010:
Table 4: Planned Allocation of PEPFAR Funding for Malawi, by Technical
Area, Fiscal Year 2010:
Table 5: Planned Allocation of PEPFAR Funding for Uganda, by Technical
Area, Fiscal Year 2010:
Table 6: Planned Allocation of PEPFAR Funding for Vietnam by,
Technical Area, Fiscal Year 2010:
Figures:
Figure 1: Cambodia Background:
Figure 2: HIV/AIDS Development Assistance Funding for Cambodia by
Donor, 2004-2008:
Figure 3: PEPFAR Funding in Cambodia, Fiscal Years 2004-2010:
Figure 4: Malawi Background:
Figure 5: HIV/AIDS Development Assistance Funding for Malawi, by
Donor, 2004-2008:
Figure 6: PEPFAR Funding in Malawi, Fiscal Years 2004-2010:
Figure 7: Uganda Background:
Figure 8: HIV/AIDS Development Assistance Funding for Uganda, by
Donor, 2004-2008:
Figure 9: PEPFAR Funding in Uganda, Fiscal Years 2004-2010:
Figure 10: Vietnam Background:
Figure 11: HIV/AIDS Development Assistance Funding for Vietnam, by
Donor, 2004-2008:
Figure 12: PEPFAR Funding in Vietnam, Fiscal Years 2004-2010:
Abbreviations:
2008 Leadership Act: Tom Lantos and Henry J. Hyde United States Global
Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization
Act of 2008:
CDC: Centers for Disease Control and Prevention:
COP: country operational plan:
HHS: U.S. Department of Health and Human Services:
IOM: Institute of Medicine:
OGAC: Office of the U.S. Global AIDS Coordinator:
Paris Declaration: Paris Declaration on Aid Effectiveness:
PEPFAR: President's Emergency Plan for AIDS Relief:
UNAIDS: Joint United Nations Programme on HIV/AIDS:
UNDP: United Nations Development Programme:
UNGASS: United Nations General Assembly Special Session on HIV/AIDS:
USAID: U.S. Agency for International Development:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
September 20, 2010:
Congressional Committees:
In 2008, approximately 2 million people worldwide died of HIV-related
causes and an estimated 2.7 million people were newly infected with
HIV. The first 5-year phase of the President's Emergency Plan for AIDS
Relief (PEPFAR) was authorized by Congress in 2003 at $3 billion for
each of 5 fiscal years.[Footnote 1] In July 2008, Congress passed the
Tom Lantos and Henry J. Hyde United States Global Leadership Against
HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (2008
Leadership Act),[Footnote 2] authorizing PEPFAR appropriations of $48
billion through fiscal year 2013 and strengthening the U.S.
government's efforts to combat the global HIV/AIDS pandemic and other
diseases. The U.S. government reported that in 2009, PEPFAR directly
supported treatment for more than 2.4 million patients with HIV/AIDS
and care and support for more than 11 million people affected by the
disease. Although PEPFAR initially targeted 15 countries, known as
focus countries, since its establishment PEPFAR has made significant
investments in more than 30 partner countries and regions.
U.S. policy for combating global HIV/AIDS emphasizes the alignment, or
harmonization, of PEPFAR programs with the countries' HIV/AIDS
strategies and the promotion of partner country ownership of U.S.-
supported HIV/AIDS programs. The 2008 Leadership Act, among its other
purposes and findings, endorses the principles of harmonization and
coordination to combat HIV/AIDS and cites improving harmonization of
U.S. efforts with national strategies of partner governments and other
public and private entities as an element in strengthening and
enhancing U.S. leadership and the effectiveness of the United States
response to HIV/AIDS. The Paris Declaration on Aid Effectiveness
(Paris Declaration), which the U.S. government signed in 2005, calls
on developed and developing countries to take steps to improve aid
effectiveness, such as by increasing alignment of foreign assistance
programs with partner countries' priorities, strategies, and
procedures.[Footnote 3] In addition, PEPFAR's new 5-year strategy,
released in December 2009,[Footnote 4] and other PEPFAR guidance
highlight the principles of the Paris Declaration and reaffirm the
U.S. government's commitment to support partner country ownership of
the programs, in part by aligning PEPFAR with national HIV/AIDS
strategies and programs.
In response to a directive in the 2008 Leadership Act,[Footnote 5]
this report (1) examines alignment[Footnote 6] of PEPFAR programs with
partner countries' HIV/AIDS strategies and (2) describes several
challenges related to alignment of PEPFAR programs with the national
strategies or promotion of partner country ownership.[Footnote 7]
We analyzed U.S. agency documents and relevant studies and interviewed
PEPFAR stakeholders (i.e., PEPFAR officials, representatives of
partner government ministries, HIV/AIDS donors, and PEPFAR
implementing partners). We reviewed the 2008 Leadership Act, PEPFAR
guidance, and the Paris Declaration to define alignment and to
identify criteria for examining alignment of PEPFAR programs with
partner countries' HIV/AIDS strategies. We interviewed PEPFAR
officials in Washington, D.C., and Atlanta, Georgia, regarding their
processes for developing PEPFAR plans and efforts to align PEPFAR
programs with country strategies. In addition, we interviewed PEPFAR
stakeholders in Cambodia, Malawi, Uganda, and Vietnam regarding
alignment of goals and objectives, program activities, and indicators.
To select the four countries we considered a number of factors
including funding levels, geographic diversity, and whether or not the
country was designated a focus country during the first phase of
PEPFAR. To examine alignment of PEPFAR activities with national
HIV/AIDS strategies, we analyzed key PEPFAR and national strategy
documents for these four countries. Specifically, we reviewed the
goals and objectives outlined in each country's national multisectoral
HIV/AIDS strategy and compared this information with the activities
and programs laid out in key sections of corresponding PEPFAR
documents for each country. In addition, in our visits to the four
countries, we discussed our analysis with PEPFAR officials to identify
reasons for identified areas of divergence between the national
strategies and PEPFAR documents. To identify PEPFAR alignment efforts
as well as challenges related to alignment and promotion of country
ownership, we reviewed the PEPFAR 5-year strategy, prior GAO reports,
a relevant study by the Institute of Medicine, and the results of our
interviews with PEPFAR stakeholders. (See appendix I for further
details of our scope and methodology.)
We conducted this performance audit from July 2009 to September 2010
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence we obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
Background:
PEPFAR Leadership and Implementation:
The Department of State's Office of the U.S. Global AIDS Coordinator
(OGAC) establishes overall PEPFAR policy and program strategies,
coordinates PEPFAR programs, and allocates resources to several U.S.
agencies to implement PEPFAR activities. These agencies (referred to
in this report as implementing agencies) include, among others, the
U.S. Agency for International Development (USAID) and the U.S.
Department of Health and Human Services' (HHS) Centers for Disease
Control and Prevention (CDC).[Footnote 8] OGAC coordinates U.S.
government implementing agencies and resources, establishes policy and
guidance for the PEPFAR program, and is responsible for allocating
resources to implementing agencies. OGAC executes its coordinating
role in part by providing implementing agencies, both in the United
States and in PEPFAR countries, annual guidance on reporting program
results, and guidance on planning. In addition, OGAC collaborates with
implementing agency officials through technical working groups on a
range of issues. OGAC also disseminates weekly updates to implementing
agency staff in PEPFAR countries regarding topics such as deadlines
and changes to official guidance. USAID and CDC, which oversee most
PEPFAR-funded programs, are among PEPFAR's primary implementing
agencies. Of almost $16.5 billion obligated for HIV/AIDS activities in
fiscal years 2004 through 2009, $9.6 billion was obligated by USAID
and $6.4 billion was obligated by HHS.
In each partner country, teams of implementing agency officials
(PEPFAR country teams) jointly develop country operational plans (COP)
for use in coordinating, planning, reporting, and funding PEPFAR
programs. The COP is the vehicle for documenting annual investments in
HIV/AIDS, and serves as the basis for approving, allocating, tracking,
and notifying Congress of budgets and targets.
U.S. Policy Documents Endorsing PEPFAR Alignment or Country Ownership:
* 2008 Leadership Act. The 2008 Leadership Act, PEPFAR's reauthorizing
legislation, cites improving harmonization of U.S. efforts with
national strategies of partner governments and other public and
private entities as an element in strengthening and enhancing United
States leadership and the effectiveness of the U.S. response to HIV/
AIDS.[Footnote 9] The act requires the President to report to Congress
on OGAC's strategy.[Footnote 10] The act specifies that the report
must discuss many elements of the strategy including a description of
the strategy to promote harmonization of U.S. assistance with that of
other international, national, and private actors; and to address
existing challenges in harmonization and alignment.[Footnote 11] The
act also requires the President to report on efforts to improve
harmonization, in terms of relevant executive branch agencies,
coordination with other public and private entities, and coordination
with partner countries' national strategic plans.[Footnote 12]
* Paris Declaration. In 2005, 133 countries and territories, including
the United States, and 28 participating international organizations,
endorsed the Paris Declaration on Aid Effectiveness, an international
agreement committing countries to increase efforts in supporting
country ownership, harmonization, alignment, results, and mutual
accountability.[Footnote 13] Specifically, donors committed to taking
a number of steps to implement the principles of the Paris
Declaration: to respect partner country leadership and help strengthen
their capacity to exercise it; base support on national strategies;
implement common arrangements for reporting to partner governments on
donor activities and aid flows; harmonize monitoring and reporting
requirements; and provide timely, transparent, and comprehensive
information on aid flows to enable partner authorities to present
comprehensive budget reports to their legislatures and citizens.
* Three Ones. In 2004, key donors, including the United States,
reaffirmed their commitment to strengthening national HIV/AIDS
responses led by the affected countries themselves and endorsed the
"Three Ones" principles. These principles aim to achieve the most
effective and efficient use of resources and greater collaboration
among donors in order to avoid duplication and fragmentation.
Specifically, the donors agreed to base support on one HIV/AIDS action
framework that provides the basis for coordinating the work of all
partners, one national AIDS coordinating authority with a broad
multisectoral mandate, and one country-level monitoring and evaluation
system in each country.
* PEPFAR 5-year strategy. PEPFAR's updated 5-year strategy, released
in 2009 as mandated by the 2008 Leadership Act,[Footnote 14]
highlights alignment with national strategies as a key component of
promoting sustainability of U.S.-supported HIV/AIDS efforts through
partner country ownership. In the first 5 years of the program, PEPFAR
focused on establishing and scaling up prevention, care, and treatment
programs. During the second 5-year phase, PEPFAR will focus on
transitioning from an emergency response to promotion of sustainable
country programs. PEPFAR's emphasis on country ownership includes
ensuring that the services PEPFAR supports are aligned with the
national plans of partner governments and integrated with existing
health care delivery systems. The new 5-year strategy acknowledges
that during the first phase of PEPFAR, PEPFAR implementation did not
always fully complement existing national structures and some PEPFAR
programs and services were established apart from existing health care
delivery systems. The new strategy affirms the principles of the Paris
Declaration and states that PEPFAR is working with its multilateral
and bilateral partners to align responses and support countries in
achieving their nationally defined HIV/AIDS goals.
PEPFAR Partnership Frameworks:
The Leadership Act authorized the U.S. government to establish
partnership frameworks with host countries to promote a more
sustainable approach to combating HIV/AIDS, characterized by
strengthened country capacity, ownership, and leadership.[Footnote 15]
Partnership frameworks are 5-year joint strategic agreements for
cooperation between the U.S. government and partner governments to
combat HIV/AIDS in the partner country through technical assistance,
support for service delivery, policy reform, and coordinated funding
commitments.[Footnote 16]
PEPFAR guidance states that the partnership framework process should
involve significant collaboration with the partner government and may
also include active participation from other key partners from civil
society, community-based and faith-based organizations, the private
sector, other bilateral and multilateral partners, and international
organizations.[Footnote 17] PEPFAR guidance further states that a key
objective of the partnership framework is to ensure that PEPFAR
programs reflect country ownership, with partner governments at the
center of decision making, leadership, and management of their
HIV/AIDS programs and national health systems. The expectation is that
at the end of the partnership framework, in addition to achieving
results in HIV/AIDS prevention, treatment, and care, partner country
governments will be better positioned to assume primary responsibility
for the national responses to HIV/AIDS in terms of management,
strategic direction, performance monitoring, decision making,
coordination, and, where possible, funding support and service
delivery. The partnership framework is meant to support government
coordination of different funding streams under the framework of a
national strategy. The partnership framework should be fully in line
with the national HIV/AIDS plan of the country and emphasize
sustainable programs with increased country decision-making authority
and leadership.
PEPFAR guidance defines the partnership framework as consisting of two
interrelated documents, the partnership framework and the partnership
framework implementation plan. The partnership framework is to focus
on establishing a collaborative relationship, negotiating the
overarching 5-year goals of the framework and the commitments of each
party, and setting forth these agreements in a concise signed
document. The partnership framework implementation plan is to include
a more detailed description of the approach to supporting increased
country ownership, baseline data, specific strategies for achieving
the 5-year goals and objectives, and a monitoring and evaluation plan.
PEPFAR Country Operational Plans:
The COP is used for planning annual U.S. investments in HIV/AIDS and
approving annual U.S. bilateral HIV/AIDS funding, and it serves as the
annual work plan for PEPFAR activities. The COP database, which houses
all COP information submitted by PEPFAR country teams, provides
information for funding review and approval and serves as the basis
for congressional notification, allocation, and tracking of budget and
targets. According to OGAC, PEPFAR country teams in 31 countries
completed COPs for fiscal year 2010.[Footnote 18] In addition three
regions developed and submitted regional operational plans for fiscal
year 2010: Caribbean, Central America, and Central Asia.
The COP development process involves interagency coordination as well
as consultation with other PEPFAR stakeholders. The U.S. Ambassador
leads the development of COPs, which are created through a
collaborative process involving PEPFAR country teams. The COP
development process also involves collaboration with country and
international partners in an annual review and planning process.
According to PEPFAR COP guidance, developing an annual COP provides an
opportunity to bring the U.S. country team together with partner
government authorities, multilateral development partners, and civil
society as an essential aspect of effective planning, leveraging
resources, and fostering sustainability of programs. The draft COPs
are ultimately reviewed by interagency headquarters teams, which make
recommendations to OGAC regarding final review and approval.
PEPFAR 2010 COP guidance notes that PEPFAR programs should be fully in
keeping with developing countries' national strategies and that PEPFAR
country teams should identify areas of partner countries' national
HIV/AIDS programs for U.S. government investment and support.
[Footnote 19] The guidance also states that the U.S. government is
firmly committed to the principles of alignment with national
programs, including alignment with other international partners.
National HIV/AIDS Strategies:
At the 2001 United Nations General Assembly Special Session on
HIV/AIDS (UNGASS), member countries committed to developing
multisectoral HIV/AIDS strategies and finance plans. In our four case
study countries--Cambodia, Malawi, Uganda, and Vietnam--the
multisectoral strategy serves as a multiyear broad outline of its
HIV/AIDS prevention, treatment, and care objectives[Footnote 20].
While a national commission may be the lead coordinating authority for
HIV/AIDS policy and programs, the development and implementation of
such a strategy can also involve many government ministries and
offices. Additional strategy documents, such as sector-specific
strategies and HIV program-specific strategies or action plans can
also provide further guidance for national programs to combat HIV/AIDS
(see table 1 for information on national HIV/AIDS strategies in four
countries). Other government ministries and agencies, such as the
Ministry of Health, may also be charged with implementing sector-or
program-specific strategies and programs.
Table 1: National HIV/AIDS Strategies in Cambodia, Malawi, Uganda, and
Vietnam:
Name of main national strategy and dates covered:
Cambodia: Revised National Strategic Plan II for a Comprehensive and
Multi-Sectoral Response to HIV/AIDS, 2008-2010;
Malawi: Malawi HIV and AIDS Extended National Action Framework (2010-
2012);
Uganda: National HIV and AIDS Strategic Plan, 2007/8-2011/12;
Vietnam: National Strategy on HIV/AIDS Prevention and Control in
Vietnam Until 2010 With a Vision to 2020.
Lead coordinating multisectoral ministry or entity:
Cambodia: National AIDS Authority;
Malawi: National AIDS Commission;
Uganda: Uganda AIDS Commission;
Vietnam: National Committee for AIDS, Drugs and Prostitution;
Prevention and Control.
Examples of other responsible ministries:
Cambodia: Ministry of Health; Ministry of the Interior;
Ministry of Social Affairs; Veterans and Youth Rehabilitation;
Ministry of Education; Ministry of Women's Affairs; Ministry of Labour
and Vocational Training;
Malawi: Ministry of Health and Population; Ministry of Gender, Child
Development and Community Development; Ministry of Local Government
and Rural Development; Ministry of National Defense; Ministry of
Information and Civic Education;
Uganda: Ministry of Health; Ministry of Finance, Planning and Economic
Development; Ministry of Gender, Labour and Social Development;
Ministry of Education and Sports;
Vietnam: Ministry of Public Security; Ministry of Labor, War Invalids
and Social Affairs; Ministry of Health; Standing Board of the
Presidium of the Vietnam Fatherland Front Central Committee.
Examples of sector-or program-specific strategies or other documents:
Cambodia: Strategic Plan for HIV/AIDS and STD Prevention and Care in
Health Sector; National Strategic Plan to Prevent and Control HIV
Transmission among Entertainment Workers, Their Clients and Partners;
Medical Laboratory Services Strategic Plan;
Malawi: National Operational Plan; Integrated Annual Work Plans;
National Monitoring and Evaluation Framework; Malawi Government
Development Strategy;
Uganda: National Priority Action Plan; National Health Policy and the
Health Sector Strategic Plans; National Policy on Mainstreaming
HIV&AIDS; Road Map to Accelerating HIV Prevention 2008; President's
Initiative on AIDS Strategy for Communication to Youth;
Vietnam: Directive 54: Strengthening the Leadership in HIV/AIDS
Prevention and Control in New Situation; The Law on the Prevention and
Control of HIV/AIDS; Vietnam's Comprehensive Poverty Reduction and
Growth Strategy.
Source: PEPFAR country team officials and the national multisectoral
strategy documents from Cambodia, Malawi, Uganda, and Vietnam.
[End of table]
PEPFAR Programs Generally Support Partner Countries' National HIV/AIDS
Strategies:
PEPFAR activities generally support the goals laid out in partner
countries' national HIV/AIDS strategies. Our analysis of PEPFAR
documents and national strategies and discussions with PEPFAR country
teams in the four countries we visited showed overall alignment
between PEPFAR activities and the national strategy goals. In
addition, PEPFAR officials--including officials at OGAC, USAID, and
CDC in headquarters and in four countries--as well as partner
government ministry officials, other HIV/AIDS donors, and civil
society representatives whom we interviewed also said that PEPFAR
activities generally support the goals and objectives set forth in
national strategies. According to PEPFAR officials, a number of
factors may influence the degree to which PEPFAR activities align with
national strategy goals. As a result, PEPFAR may support activities to
achieve some, but not all, goals and objectives outlined in national
strategies. Conversely, PEPFAR may support activities not mentioned in
the national HIV/AIDS strategy but that are addressed in relevant
sector-or program-specific strategies. PEPFAR country teams have
engaged in various efforts to help ensure that PEPFAR activities
support the achievement of national strategy goals, including
assisting in developing national strategies, participating in formal
and informal communication and coordination meetings, engaging
regularly with partner country governments during the COP development
process, and developing new partnership frameworks.
PEPFAR and Country Documents and Statements by PEPFAR and HIV/AIDS
Stakeholders Indicate Alignment of Program Activities with National
HIV/AIDS Goals:
Our analysis shows that PEPFAR activities described in the 2010 COPs
for Cambodia, Malawi, Uganda, and Vietnam directly or partially
address most of the goals and objectives outlined in the countries'
national HIV/AIDS strategies.[Footnote 21] (See table 2.)
Table 2: Alignment of 2010 COPs with National HIV/AIDS Strategies for
Cambodia, Malawi, Uganda, and Vietnam:
Number of goals and objectives in the national strategy;
Cambodia: 44;
Malawi: 31;
Uganda: 25;
Vietnam: 20.
Number of goals and objectives directly addressed by 2010 COP;
Cambodia: 30;
Malawi: 22;
Uganda: 25;
Vietnam: 18.
Example of goal or objective directly addressed by PEPFAR activity
description;
Cambodia: National strategy goal: Increased coverage of effective
prevention interventions and additional interventions developed;
PEPFAR activity: Activities including prevention of biomedical
transmission, blood safety, prevention of sexual transmission, and
prevention of mother-to-child transmission;
Malawi: National strategy goal: To prevent mother-to-child HIV
transmission; PEPFAR activity: Past, ongoing, and planned activities
in the area of prevention of mother-to-child transmission;
Uganda: National strategy goal: To accelerate the prevention of sexual
transmission of HIV through established as well as new innovative
strategies; PEPFAR activity: Past, ongoing, and planned activities in
the area of prevention of sexual transmission, including prevention
and education services for adults, youth, and high-risk groups;
Vietnam: National strategy goal: To ensure effective HIV/AIDS
surveillance and voluntary counseling and testing; PEPFAR activity:
Activities including surveillance and delivery of data, counseling and
testing, and laboratory infrastructure.
Number of goals and objectives partially addressed in the 2010 COP;
Cambodia: 11;
Malawi: 9;
Uganda: 0;
Vietnam: 2.
Example of goal or objective partially addressed by PEPFAR activity
description;
Cambodia: National strategy goal: Improved understanding of the socio-
economic impact of HIV/AIDS and possible interventions to mitigate
impact; PEPFAR activity: Activities related to legal, educational, and
economic support services, but no clear activities that directly
address this goal;
Malawi: National strategy goal: To promote the enforcement of legal
and social rights of people living with HIV, orphans and vulnerable
children, and other affected individuals; PEPFAR activity: Activities
related to legal and social rights for certain populations, but no
clear activities that address this goal;
Uganda: Not applicable;
Vietnam: National strategy goal: Enhancing the leadership of local
administrations at all levels over HIV/AIDS prevention and control;
PEPFAR activity: Activities related to capacity building mostly
focused on civil society and health workers.
Number of goals and objectives not addressed in 2010 COP;
Cambodia: 3;
Malawi: 0;
Uganda: 0;
Vietnam: 0.
Example of goal or objective not addressed in 2010 COP;
Cambodia: National strategy goal: Increased engagement of the media
and arts in the national response to HIV and AIDS; PEPFAR activity: No
mention of related activities or goals;
Malawi: Not applicable;
Uganda: Not applicable;
Vietnam: Not applicable.
Source: GAO analysis of 2010 COPs and national HIV/AIDS strategies for
Cambodia, Malawi, Uganda, and Vietnam.
[End of table]
Statements and analysis by a number of PEPFAR and HIV/AIDS
stakeholders further indicate that PEPFAR program activities are
aligned with partner countries' HIV/AIDS strategies. PEPFAR officials--
including officials at OGAC, USAID, CDC, and HHS--and other HIV/AIDS
stakeholders and experts operating at a global level,[Footnote 22] as
well as partner government ministry officials, other donors, civil
society representatives, and PEPFAR officials in four countries told
us that PEPFAR activities are aligned with the goals and objectives
outlined in partner countries' national strategies and support the
overall national program. Moreover, a 2007 Institute of Medicine (IOM)
review of PEPFAR in the 15 focus countries also found that PEPFAR
programs were generally congruent with these countries' national
strategies.[Footnote 23] IOM reported that partner government
representatives in the 13 countries they visited generally expressed
satisfaction with the level of alignment between PEPFAR and national
strategies.
PEPFAR Officials Noted Several Factors Influencing Alignment of PEPFAR
Activities with National Strategy Goals:
Several factors may influence the degree to which PEPFAR activities
align with national HIV/AIDS strategy goals, according to PEPFAR
officials.
* Other partner activities. PEPFAR country programs are planned with
consideration of other donors' and groups' activities in the
countries, and therefore PEPFAR activities may not address all
national strategy goals. In many PEPFAR countries a number of other
bilateral and multilateral development partners also fund and
implement programs to support the national program. Country team
officials noted that in planning PEPFAR programs, they coordinate with
other partners so that PEPFAR and partner activities will complement,
rather than duplicate, one another and together support the national
program. For example, the PEPFAR Malawi team explained that although
the Malawi national strategy contains a goal of expanding workplace
programs on HIV and AIDS in the public and private sectors and civil
society, the 2010 PEPFAR Malawi COP does not include activities that
directly address this goal because other donors and groups are
implementing programs that address it.
* Size of PEPFAR program. The portion of a national strategy supported
by PEPFAR activities also depends in part on the size of the PEPFAR
program in that country relative to other donors' activities in the
country. For example, OGAC and country team officials told us that
PEPFAR is more likely to cover larger portions of the national
strategy in former focus countries where PEPFAR is generally the
largest donor of HIV/AIDS funds. This corresponds with our finding
that in the 2010 COPs for former focus countries Uganda and Vietnam,
where U.S. funding makes up a large share of the national HIV/AIDS
response--75 percent in Uganda and 59 percent in Vietnam from 2004 to
2008--the activity descriptions directly address most national
strategy goals and objectives. OGAC and PEPFAR country team officials
also noted that in non-focus countries, PEPFAR programs may support
the achievement of priority goals, rather than cover every national
strategy goal. For instance, in the non-focus countries Cambodia and
Malawi, where U.S. funding makes up a smaller share of the national
HIV/AIDS response--47 percent in Cambodia and 22 percent in Malawi
from 2004 to 2008--we found that PEPFAR activities generally supported
national strategy goals by filling resource gaps and focusing on
interventions in which country teams have technical expertise.
* Policy restrictions. PEPFAR may not support particular activities
because of PEPFAR policy restrictions or other conflicts. For example,
according to country team officials in Vietnam, until recently PEPFAR
funds could not be used to support needle exchange programs for
intravenous drug users. As a result, PEPFAR has not supported this
component of Vietnam's national strategy.
PEPFAR programs also may involve activities that are not specifically
addressed in the national strategy but that support national strategy
goals. In the four countries we visited, PEPFAR officials, government
officials, donors, and PEPFAR implementing partners generally agreed
that national strategies outline broad principles, goals, and
objectives rather than specific programs or activities. According to
these officials, the general nature of the national strategies allows
flexibility to support specific programs to achieve these goals and
respond to countries' evolving HIV/AIDS epidemics. For example,
according to PEPFAR officials, the Malawi PEPFAR program has
prioritized male circumcision for many years as an effective means of
preventing the spread of HIV, although this activity was not mentioned
in Malawi's previous national strategy. However, PEPFAR officials told
us that these programs support Malawi's broad goal to reduce the
number of new infections. Moreover, as a result of the country team's
working with the Malawi government and sharing information and data,
male circumcision has since been incorporated into Malawi's most
recent strategy. Similarly, in Uganda, PEPFAR supports prevention and
treatment activities for a potentially high-risk target group, men who
have sex with men, although Uganda's national strategy does not
address prevention and treatment for this group. PEPFAR officials told
us they consider these activities aligned with Uganda's high-level
goal to reduce the number of new infections and treat HIV-positive
patients. PEPFAR team officials in the four countries we visited told
us they take into account sector-or program-specific subcomponents of
national strategies--such as a protocol for prevention of mother-to-
child transmission of HIV--as well as relevant epidemiological and
evaluation data, all of which may be more up to date or detailed than
the broad national HIV/AIDS strategy.
PEPFAR Stakeholders Reported Various Efforts to Align PEPFAR
Activities with National Strategy Goals:
PEPFAR country teams and other stakeholders described several means by
which the country teams work to achieve alignment of PEPFAR activities
with partner country HIV/AIDS goals.
* Participation in development of national strategies. PEPFAR country
teams actively participate in the development and revision of partner
countries' national HIV/AIDS strategies, according to PEPFAR
officials, partner government officials, and civil society groups.
When host governments are developing or reformulating their
strategies, they often invite HIV/AIDS stakeholders in the country,
including bilateral and multilateral donors and civil society and
private sector groups, to participate in the strategy's development.
As part of this process, according to PEPFAR officials in
headquarters, the PEPFAR country team often participates heavily in
the development of such strategies through direct advising as well as
technical assistance through implementing partners. For example, the
CDC officials in-country often help with surveillance activities and
providing data to the host government in order to base the strategy on
the most updated information on the epidemic. PEPFAR officials and
other stakeholders in three of the four countries we visited also
spoke about heavy PEPFAR involvement in the development of the
strategies in those countries. These officials told us that PEPFAR's
participation in these processes both improves the quality of the
national strategy and creates buy-in among program stakeholders,
ultimately enhancing PEPFAR alignment with national strategies. PEPFAR
country team officials also told us that national strategy time frames
may affect PEPFAR's ability to align its programs. For example, in
Malawi, PEPFAR country officials were able to generate the 2010 COP
based on Malawi's newly revised and updated multisectoral national
strategy. Conversely, PEPFAR officials in Cambodia told us that
Cambodia's outdated strategy, which was undergoing revision at the
time of COP development and submission, complicated the country team's
ability to base the current year COP on the dated strategy.
* Meetings with partner governments and other stakeholders. PEPFAR
country team participation in periodic meetings with partner country
government officials, other donors, and civil society organizations
helps to ensure that PEPFAR program activities support national
strategies, according to PEPFAR officials and other HIV/AIDS
stakeholders.[Footnote 24] Country team officials, partner government
officials, and other donor representatives in the four countries we
visited told us that PEPFAR country team officials participate in
periodic advisory and technical area meetings with government
officials and other donor representatives. For example, in the four
countries we visited, we heard that PEPFAR officials participate in
HIV/AIDS or health sector committees, which generally are led by the
host government and include other relevant donors. In addition, PEPFAR
officials participate in government-led technical working groups
focused on specific HIV/AIDS-related areas, such as prevention of
mother-to-child transmission or monitoring and evaluation.
* Informal engagement with partner government officials. Regular
informal engagement with partner country government officials helps
PEPFAR country teams to be aware of the needs and goals of the
national HIV/AIDS program, according to PEPFAR country team officials.
For example, the officials noted that in-country CDC staff are
embedded in the Ministry of Health and thus have daily interaction
with partner government officials. This daily communication helps the
PEPFAR team focus on the needs of the partner government and align its
activities with such needs. Country team officials also noted the
importance of other regular interaction and communication between
PEPFAR officials and partner government officials. For example,
regular interaction with a number of ministry officials involved in
the national HIV/AIDS program enables the PEPFAR team to better
coordinate with the national program.
* COP development process. PEPFAR country teams engage with country
officials and implementing partners throughout the annual COP
development process, according to PEPFAR officials, partner government
officials, and civil society groups. PEPFAR guidance states that
developing the annual COP provides an opportunity to share information
with partner government officials, which is an essential aspect of
effective planning.[Footnote 25] In the four countries we visited,
officials from ministries including the national AIDS authority and
Ministry of Health told us that they had discussed the fiscal year
2010 COP with PEPFAR officials. PEPFAR country team officials and
implementing partners in the four countries also told us that the
country teams share information with their implementing partners in a
collaborative process during the annual COP development process. For
example, in the four countries we visited, PEPFAR officials told us
they convened technical working group meetings of PEPFAR, partner
government, and implementing partner officials throughout the COP
process. Through these technical working groups and ongoing
collaboration throughout the COP development process, implementing
partners are able to provide input on the PEPFAR program and alignment
with national strategies.
* Partnership framework development. Development of partnership
frameworks has had a positive effect on PEPFAR alignment and
coordination with other donors, according to OGAC, USAID, and CDC
officials and other PEPFAR stakeholders. OGAC officials reported in
June 2010 that 24 countries and two regions had been invited to
develop partnership frameworks[Footnote 26] and that 7 of these
countries, as well as both regions--Angola, Caribbean, Central
America, Ghana, Kenya, Lesotho, Malawi, Swaziland, and Tanzania--had
completed and signed a framework document.[Footnote 27] PEPFAR
officials--including OGAC, USAID, and CDC officials--told us that
partnership framework development in these countries created a vehicle
for more open dialogue among PEPFAR, the country governments, and
other donors. PEPFAR officials also stated that alignment of PEPFAR
activities with these countries' national HIV/AIDS strategies improved
as a result of close interaction with a range of stakeholders.
Likewise, during our visit to Malawi, PEPFAR and government officials,
as well as other donors, noted improvement in PEPFAR alignment with
national strategies as well as coordination with other donors'
HIV/AIDS programs as a result of the partnership framework development
process. In addition, our review of the Malawi partnership framework
showed that the goals and objectives are closely aligned with those
laid out in the national strategy. However, OGAC officials noted that
the impact of partnership frameworks on country ownership remained to
be seen. As of August 2010, Malawi had completed and signed a
partnership framework implementation plan.
PEPFAR Stakeholders Noted Several Factors That Can Hinder PEPFAR
Alignment with National Strategies:
PEPFAR stakeholders highlighted several factors that can make it
difficult to align PEPFAR activities with national HIV/AIDS
strategies. First, PEPFAR indicators sometimes differ from indicators
used by partner countries and other international donors.[Footnote 28]
Second, gaps may exist in the sharing of PEPFAR information with
partner country governments and other donors. Third, lack of country
leadership and capacity to develop strategies and manage programs
affects PEPFAR country teams' ability to ensure that PEPFAR activities
align with national strategy goals. Fourth, OGAC's guidance to PEPFAR
country teams on developing partnership frameworks and implementation
plans does not include indicators for measuring progress toward
country ownership.
Differences between PEPFAR Indicators and National and International
Indicators:
Many PEPFAR stakeholders noted differences between PEPFAR performance
indicators and national and international performance
indicators.[Footnote 29] Other PEPFAR stakeholders, including partner
country officials, other donors, and PEPFAR implementing partners in
the four countries we visited highlighted difficulties in harmonizing
PEPFAR indicators with the national indicators, owing to variance
between indicator definitions and reporting time frames used to
collect and report data. For example, according to Vietnamese
government officials, PEPFAR defines orphans and vulnerable children
using different age groupings than the government of Vietnam. In
addition, other HIV/AIDS stakeholders and experts noted that PEPFAR
often relies on indicators that can be compiled to report globally but
may differ from those used by individual countries. A PEPFAR official
also noted that national strategy indicators may not always align with
international indicators.
Moreover, PEPFAR's 5-year strategy states that PEPFAR's extensive
performance reporting requirements were not always harmonized with
other international indicators. The PEPFAR strategy also states that
PEPFAR will support transition to a single, streamlined national
monitoring and evaluation system. To address this problem, OGAC
published an updated guide for indicators in August 2009, intended to
increase both the inclusion of quality PEPFAR indicators and the
alignment of such indicators with those of other development partners.
OGAC collaborated with international donors and organizations
including the Global Fund, UNAIDS, WHO, and UNICEF to align most
PEPFAR-essential indicators with international standards.
Specifically, OGAC is working internationally with multilateral
partners to achieve a minimum core set of global reporting indicators
that provides standardized data for comparison across countries and
allows for aggregation at the global level. According to PEPFAR
guidance, through the UNAIDS Monitoring and Evaluation Reference
Group, OGAC and 18 other international multilateral and bilateral
agencies have agreed on a minimum set of standardized indicators. In
addition, PEPFAR will continue to work with this group on global
harmonization of indicators. OGAC's updated indicator guidance also
notes that a second wave of recommended indicators will be released in
2010, providing additional indicators that PEPFAR country teams may
choose to monitor at a country level.
Gaps in Partner Countries' Access to PEPFAR Information:
Some partner government officials told us they lack information about
PEPFAR programs and funding in their country and expressed concern
over this lack of access to PEPFAR data.[Footnote 30] For example,
government officials in Vietnam reported they do not have sufficient
information on PEPFAR spending and are not able to fully account for
PEPFAR funding to local civil society organizations. In addition, in
one country we visited, officials from some ministries told us they
had not received copies of the COP. However, according to PEPFAR
officials, this may be caused by lack of information sharing within or
among the partner government ministries and agencies. UNGASS[Footnote
31] 2010 progress reports for the four countries we visited, which
detail the progress in the national HIV/AIDS response, appear to
include PEPFAR funding information, indicating that PEPFAR had shared
such information with the partner governments. However, two of these
countries' 2008 UNGASS progress reports included estimated or partial
information on PEPFAR activities and aid flows; all four countries'
reports noted difficulties in obtaining international donors' HIV/AIDS
spending data. In addition, IOM reported in 2007 that other donors had
expressed concern about the degree of information on PEPFAR programs
that could be shared due to procurement rules.[Footnote 32]
PEPFAR's 5-year strategy states that PEPFAR is committed to
transparent reporting of investments and notes that opportunities
exist to improve reporting mechanisms. The strategy also states that
PEPFAR will work to expand publicly available data. According to COP
guidance, the extent to which the information in the COP can be shared
with stakeholders is limited because procurement-sensitive information
must be protected to adhere to U.S. competitive acquisition and
assistance practices.
Capacity Limitations in Partner Country Governments:
Limited resources and partner country capacity to develop, lead, and
implement the national HIV/AIDS program affects PEPFAR's ability to
effectively coordinate with the host country government, according to
PEPFAR officials in headquarters and in the countries we visited.
[Footnote 33] PEPFAR officials, as well as donors, PEPFAR implementing
partners, and other HIV/AIDS stakeholders, mentioned one or more of
the following challenges to engaging with partner governments:
unwillingness or inability to commit resources, public corruption and
financial mismanagement, and lack of technical expertise.
PEPFAR's 5-year strategy states that PEPFAR will work to assist
partner governments, in part through technical assistance and
mentoring, to support increases in government sustainability and
partner country capacity. The strategy also notes that full transition
to partner country ownership and increased financing will take longer
than 5 years to achieve.
Guidance for Measuring Progress of Partnership Frameworks Does Not
Include Metrics of Country Ownership:
PEPFAR guidance on developing partnership frameworks and
implementation plans includes detailed instructions for developing
baseline assessments of partner countries' HIV/AIDS epidemics and of
efforts to respond to the epidemics. For example, the guidance directs
PEPFAR country teams to measure these efforts' outputs or outcomes,
such as the number of newly trained healthcare workers. However, the
guidance does not address the establishment of baselines, including
indicators, for measuring progress toward country ownership--one of
OGAC's stated goals for the frameworks.[Footnote 34] In keeping with
various Paris Declaration resolutions, the guidance that OGAC has
provided to PEPFAR country teams for developing the frameworks
describes promotion of country ownership as expanding partner
government's capacity to plan, oversee, manage, deliver, and
eventually finance HIV/AIDS programs. The guidance requires country
teams to link partnership framework goals with partner countries'
national HIV/AIDS and health strategies and states that partnership
frameworks should emphasize sustainable programs with increased
country decision-making authority and leadership. The guidance also
specifies that the framework should outline plans to assess progress
in achieving the goals agreed to in the partnership framework,
including country ownership.
However, the guidance does not provide instructions for developing
indicators needed to establish baseline measures of country ownership
and to assess progress toward this goal. According to an OGAC
official, OGAC has not yet devised an approach for developing such
indicators or for measuring progress toward country
ownership.[Footnote 35] Moreover, developing indicators to measure
aspects of country ownership, such as capacity to plan, oversee,
manage, deliver, and eventually finance HIV/AIDS programs, can be--as
has been recognized by development experts--a difficult and complex
undertaking.[Footnote 36] An OGAC official acknowledged that
generating such indicators would involve a process of working with
development partners and PEPFAR country teams to develop a consensus
on both definitions and measurements. Prior GAO work suggests that
performance reports are likely to be more useful if they provide
baseline and trend data. By providing baseline and trend data--which
show an agency's progress over time--the agency can give decision
makers a more historical perspective within which to compare the
year's performance with performance in past years.[Footnote 37] PEPFAR
country teams that begin implementing partnership frameworks without
baseline assessments of country ownership will have limited ability to
track progress and make necessary adjustments to the frameworks.
Conclusions:
PEPFAR's commitment to the principles of alignment with national HIV/
AIDS strategies and country ownership of U.S.-supported programs is
reflected in the new 5-year PEPFAR strategy and in OGAC guidance to
PEPFAR country teams. According to our analysis of PEPFAR and national
strategy documents as well as interviews with multiple PEPFAR
stakeholders, PEPFAR efforts to align its activities have resulted in
programs that are generally supportive of partner countries' national
strategy goals and objectives. In addition, the partnership frameworks
that OGAC recently introduced are designed to, among other goals,
enhance partner country ownership of PEPFAR programs. In particular,
OGAC expects that at the conclusion of the 5-year partnership
frameworks, country governments will be better positioned to assume
primary responsibility for national responses to HIV/AIDS in terms of
management, strategic direction, performance monitoring, decision
making, coordination, and, where possible, funding support and service
delivery. OGAC also expects the development of partnership frameworks
to ultimately enhance alignment of PEPFAR programs with national HIV/
AIDS strategies. In Malawi, PEPFAR stakeholders, including PEPFAR and
partner government officials, as well as other donors, observed that
the partnership framework development process improved alignment with
national strategies as well as on coordination with other donors.
However, OGAC has not yet established an approach for PEPFAR country
teams to use in developing indicators needed for baseline measurements
of country ownership, although the development of such indicators and
baselines is recognized as difficult and complex. Without these
indicators and baselines, country teams that implement the frameworks
may be constrained in their ability to measure progress in promoting
country ownership and to make adjustments to the frameworks to enhance
such progress.
Recommendation for Executive Action:
To enhance PEPFAR country teams' ability to achieve the goal of
promoting partner country ownership of U.S.-supported HIV/AIDS
activities, we recommend that the Secretary of State direct OGAC to
develop and disseminate a methodology for establishing indicators
needed for baseline measurements of country ownership prior to
implementation of partnership frameworks.
Agency Comments and Our Evaluation:
Responding jointly with HHS and USAID, State provided written comments
on a draft of this report (see appendix VI for a copy of these
comments). In addition, State's OGAC, in coordination with HHS and
USAID as well as the PEPFAR country teams in Cambodia, Malawi, Uganda,
and Vietnam, provided technical comments, which we incorporated as
appropriate. In their joint written comments, State, HHS, and USAID
concurred with our findings and recommendation to develop a
methodology for establishing baseline measures of country ownership.
The joint written comments also note that the departments plan to
incorporate such a methodology into the broader Global Health
Initiative, in consultation with their field offices.
We are sending copies of this report to the Secretary of State, the
Office of the Global AIDS Coordinator, USAID Office of HIV/AIDS, HHS
Office of Global Health Affairs, and CDC Global AIDS Program. In
addition, the report will be available at no charge on the GAO Web
site at [hyperlink, http://www.gao.gov].
If you or your staffs have any questions about this report, please
contact me at (202) 512-3149 or gootnickd@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix VII.
Signed by:
David Gootnick:
Director, International Affairs and Trade:
List of Committees:
The Honorable John Kerry:
Chairman:
The Honorable Richard Lugar:
Ranking Member:
Committee on Foreign Relations:
United States Senate:
The Honorable Patrick Leahy:
Chairman:
The Honorable Judd Gregg:
Ranking Member:
Subcommittee on State, Foreign Operations, and Related Programs:
Committee on Appropriations:
United States Senate:
The Honorable Howard Berman:
Chairman:
The Honorable Ileana Ros-Lehtinen:
Ranking Member:
Committee on Foreign Affairs:
House of Representatives:
The Honorable Nita Lowey:
Chair:
The Honorable Kay Granger:
Ranking Member:
Subcommittee on State, Foreign Operations, and Related Programs:
Committee on Appropriations:
House of Representatives:
[End of section]
Appendix I: Scope and Methodology:
In response to a directive in the 2008 Leadership Act,[Footnote 38]
this report (1) examines alignment[Footnote 39] of the President's
Emergency Plan for AIDS Relief (PEPFAR) programs with partner
countries' HIV/AIDS strategies and (2) describes several challenges
related to alignment of PEPFAR programs with the national strategies
or promotion of partner country ownership.[Footnote 40]
To identify guidance for alignment of U.S. programs to national
programs and country ownership, we reviewed the Tom Lantos and Henry
J. Hyde United States Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act of 2008 (2008 Leadership
Act); the previous and current PEPFAR 5-year strategy; the Paris
Declaration on Aid Effectiveness (Paris Declaration); the "Three Ones"
principles; PEPFAR partnership framework guidance; and fiscal year
2010 country operational plan (COP) guidance.
To examine the extent to which PEPFAR programs support the goals laid
out in partner countries' national strategies and to identify country
teams' challenges in aligning PEPFAR programs with national strategies
and promoting country ownership, we performed the following:
* Interviewed PEPFAR officials, including the Office of the U.S.
Global AIDS Coordinator (OGAC), Centers for Disease Control and
Prevention (CDC), and U.S. Agency for International Development
(USAID); and U.S. Department of Health and Human Services (HHS)
officials in Washington, D.C., and Atlanta, Georgia, using a
questionnaire regarding alignment of PEPFAR programs globally with
national strategies at three levels: goals and objectives, program
activities, and indicators.
* Interviewed representatives of other key PEPFAR stakeholders,
including the Joint United Nations Programme on HIV/AIDS (UNAIDS); the
Global Fund to Fight AIDS, Tuberculosis and Malaria; the Center for
Global Development; and the Bill & Melinda Gates Foundation, regarding
global PEPFAR alignment at these three levels.
* Analyzed U.S. agency documents, including guidance and strategy
documents, and performed a literature review of other studies that
examined PEPFAR alignment with national strategies. Among these
studies was a 2007 Institute of Medicine (IOM) study that reviewed a
number of aspects of PEPFAR implementation in all 15 focus countries,
including alignment with national programs.[Footnote 41] The IOM
review involved discussions with PEPFAR officials and other
stakeholders and an analysis of PEPFAR documents as well as field
visits to 13 of the 15 countries.
* Conducted case studies in Cambodia, Malawi, Uganda, and Vietnam.
This work included assessing the level of correspondence between goals
and objectives laid out in the national multisectoral HIV/AIDS
strategy and the 2010 PEPFAR COP for each country. During our visits
to these countries, we conducted semi-structured interviews with
PEPFAR country team officials, including the PEPFAR coordinator in
each country as well as USAID and CDC officials. We also met with
partner government officials in various ministries involved in the
national HIV/AIDS program in each country. In addition, we interviewed
representatives of other international donors working in HIV/AIDS and
of PEPFAR implementing partners in each country. With each of these
groups, we conducted semi-structured interviews regarding PEPFAR
support for the national strategy at three levels: goals and
objectives, program activities, and indicators.
To select the four countries for case studies, we considered a number
of factors, including funding levels, geographic diversity, progress
in developing partnership frameworks, and focus country status.
Regarding funding levels, the four countries we selected represent
both high and mid-range levels of PEPFAR funding. Regarding geographic
diversity, the four countries represent variations in the epidemic and
programs that exist across regions, including Africa and Asia.
Regarding progress in developing partnership frameworks, the four
countries were at different phases, enabling us to observe the impact
of the partnership framework development process on alignment.
Regarding focus country status, two of the four countries we selected
were focus countries during the first phase of PEPFAR, while the other
two were not. Although OGAC has noted that there will no longer be a
distinction between PEPFAR focus countries and non-focus countries, we
theorized that differences in programming and alignment might exist
between the 15 former focus countries and non-focus countries.
In evaluating alignment of PEPFAR activities with national HIV/AIDS
strategies, we considered PEPFAR program activities that are
supportive of the achievement of national strategy goals and
objectives and generally complementary of the national HIV/AIDS
program to be well aligned. Our analysis involved several steps.
1. For each of the four case study countries, we reviewed the national
multisectoral HIV/AIDS strategy to identify goals and objectives. We
then analyzed the technical assistance narratives, which describe the
ongoing and planned activities for each PEPFAR technical area, in the
fiscal year 2010 COP for each of the four countries.[Footnote 42] Our
analysis of the COP narratives focused on whether each objective and
goal in the national strategy was fully, partially, or not addressed
by activities described in the technical assistance narratives of the
2010 COP. Two of our staff independently analyzed the COP narratives
to identify areas of alignment between the PEPFAR activities and the
national strategy goals and objectives.
2. During our visits to the four countries, we discussed our analysis
of national HIV/AIDS strategies and PEPFAR COPs with PEPFAR officials
to identify reasons for identified areas of divergence between the
documents. In particular, we discussed every goal and objective in the
national strategy that our analysis deemed only partially or not
supported by activities described in the technical assistance
narratives of the COP. These conversations enabled us to identify four
general reasons why the technical assistance narratives did not
describe activities that fully support the particular goal or
objective: (a) The goal was being supported by activities of other
donors, so PEPFAR had chosen not to focus in that area. (b) The goal
was generally the responsibility of the national government, or the
national government was not interested in receiving PEPFAR support in
that area. (c) PEPFAR policy restrictions prevented PEPFAR from
supporting certain areas of the national program. (d) PEPFAR
activities fully supported the goal, but owing to space limitations
for COP reporting, these activities were not described in the COP or
were described in a different area of the document, such as the
activity descriptions. One of these four explanations by the PEPFAR
team applied in each instance where we found no or partial alignment
between the COP and the national strategy. We did not find any
national strategy goals and objectives that were accidentally or
deliberately not considered or supported by PEPFAR for reasons other
than the four listed above.
3. We used our interviews with PEPFAR officials in headquarters and
with other HIV/AIDS stakeholders, as well as our literature and
document review, to verify and complement the results of the case
study work.
We conducted this performance audit from July 2009 to September 2010
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence we obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
[End of section]
Appendix II: Cambodia Case Study:
Figure 1: Cambodia Background:
[Refer to PDF for image: map and data]
Map of Cambodia:
Population: 14.8 million[A];
GDP per capita (PPP): $1,900 (rank 187 out of 227)[B];
Life expectancy at birth: 63 years (rank 177 out of 224)[A];
HIV/AIDS adult prevalence rate: 0.8% (rank 56 out of 170)[C];
Number of people living with HIV/AIDS: 75,000 (rank 54 out of 165)[C];
Number of AIDS orphans: Not available;
HIV/AIDS epidemic: HIV prevalence in Cambodia is among the highest in
Asia. Cambodia‘s HIV/AIDS epidemic is spread primarily through
heterosexual transmission and revolves largely around the sex trade. A
low prevalence rate in the general population masks far higher
prevalence rates in certain subpopulations, such as injecting drug
users, people in prostitution, men who have sex with men, karaoke
hostesses, and mobile and migrant populations.
Sources: CIA World Factbook and PEPFAR.
[A] Estimate as of 2010.
[B] Estimate as of 2009.
[C] Estimate as of 2007.
[End of figure]
National HIV/AIDS Program:
Although Cambodia is one of the poorest countries in the world, HIV
prevention and control efforts exerted by the Government of Cambodia
and its partners have helped to reduce the spread of HIV. Cambodia is
recognized as one of the few countries that has been successful in
reversing the HIV epidemic, as the adult prevalence decreased from a
high of 2 percent in 1998 to 0.8 percent in 2008. The Cambodia
HIV/AIDS strategy--the National Strategic Plan for a Comprehensive and
Multisectoral Response to HIV/AIDS 2006-2010, developed under the
leadership of the National AIDS Authority--guides the national
response to the epidemic. The national strategy outlines three main
goals: to reduce new infections of HIV; to provide care and support to
people living with and affected by HIV; and to alleviate the
socioeconomic and human impact of AIDS on the individual, family,
community, and society. In addition, the multisectoral strategy also
lays out seven complementary strategies to (1) increase coverage of
effective prevention interventions; (2) increase coverage of effective
interventions for comprehensive care; (3) increase coverage of
effective interventions for impact mitigation; (4) develop effective
leadership by government and nongovernment sectors for implementation
of the response to AIDS at central and local levels; (5) create a
supportive legal and public policy environment for the AIDS response;
(6) increase the availability of information for policy makers and for
program planners through monitoring, evaluation, and research; and (7)
enhance sustainable and equitable resource allocation for the national
response to AIDS.
A large number of institutions are involved in Cambodia's national
multisectoral response to HIV and AIDS. These include ministries and
other government departments, such as the Ministry of Health, Ministry
of Women's Affairs, Ministry of Rural Development, Ministry of
Interior, and the National Center for HIV/AIDS, Dermatology, and STD.
In addition, there are a number of other strategies and documents that
support and elaborate on the national multisectoral strategy
including, the Ministry of Interior HIV/AIDS strategy, Medical
Laboratory Services National Strategic Plan, and the National Blood
Transfusion Services of Cambodia Strategic Plan. Each of these
successive plans and strategies has been supported by technical
assistance and financial support from multilateral and bilateral
donors, including the U.S. government.
HIV/AIDS Partners and Donors:
In addition to the support of the U.S. government, the Cambodian HIV/
AIDS program is supported by a number of other multilateral and
bilateral donors. Funding from the Global Fund has comprised over 30
percent of all HIV/AIDS development assistance to Cambodia from 2004
to 2008 (see figure 2). In addition, the Global Fund has continued to
scale up its funding and programs in Cambodia in recent years, and in
2009 Global Fund contributions comprised 53 percent of HIV funding in
Cambodia according to PEPFAR officials. The United Kingdom has also
provided significant financial support for Cambodia's national
HIV/AIDS program for many years, contributing 13 percent of all
HIV/AIDS development assistance in Cambodia from 2004 to 2008. In
addition, other donors in HIV/AIDS in Cambodia include, Belgium,
UNAIDS, UNICEF, the United Nations Development Programme (UNDP),
Spain, Denmark, France and Germany.
Figure 2: HIV/AIDS Development Assistance Funding for Cambodia by
Donor, 2004-2008:
[Refer to PDF for image: pie-chart]
United States: 47%;
Global Fund: 32%;
United Kingdom: 13%;
Other: 8%.
Source: GAO analysis of OECD data.
[End of figure]
PEPFAR Program:
PEPFAR Funding:
The U.S. government has been working in HIV/AIDS in Cambodia for many
years, even prior to PEPFAR, making the U.S. government one of the
largest funders of HIV/AIDS programs in Cambodia dating back to the
mid-1990s. Thus, while Cambodia was not a PEPFAR focus country during
the first phase of PEPFAR, funding in Cambodia went from $16.8 million
in 2004 to $18.5 million in 2010. As noted above, in recent years, the
Global Fund has emerged as the largest funder of HIV/AIDS in Cambodia.
Figure 3: PEPFAR Funding in Cambodia, Fiscal Years 2004-2010:
[Refer to PDF for image: vertical bar graph]
Year: 2004;
PEPFAR funding: $16.8 million.
Year: 2005;
PEPFAR funding: $17.5 million.
Year: 2006;
PEPFAR funding: $19.3 million.
Year: 2007;
PEPFAR funding: $19.0 million.
Year: 2008;
PEPFAR funding: $17.9 million.
Year: 2009;
PEPFAR funding: $18.0 million.
Year: 2010;
PEPFAR funding: $18.5 million.
Source: GAO analysis of OGAC data.
[End of figure]
PEPFAR Program Information:
The PEPFAR program in Cambodia supports an array of activities for
HIV/AIDS prevention, treatment, and care. For example, PEPFAR focuses
on peer education activities for the most at-risk population including
sex workers, men who have sex with men, drug users, and clients of sex
workers. PEPFAR Cambodia also supports programs such as condom social
marketing, HIV counseling and testing services, prevention of mother-
to-child transmission, prevention of tuberculosis and HIV co-
infection, surveillance for planning, laboratory support, and blood
safety. In addition, PEPFAR funds community-and clinic-based care
activities such as home care, care for orphans and vulnerable
children, and pediatric AIDS.
Table 3: Planned Allocation of PEPFAR Funding for Cambodia, by
Technical Area, Fiscal Year 2010:
Technical area: Prevention of Sexual Transmission;
Funding: $6,167,491.
Technical area: Adult Care and Treatment;
Funding: $1,806,697.
Technical area: Health Systems Strengthening;
Funding: $1,344,900.
Technical area: Orphans and Vulnerable Children;
Funding: $1,080,471.
Technical area: Biomedical Prevention;
Funding: $1,000,000.
Technical area: Strategic Information;
Funding: $949,425.
Technical area: Prevention of Mother-to-Child Transmission;
Funding: $865,058.
Technical area: Counseling and Testing;
Funding: $573,294.
Technical area: Pediatric Care and Treatment;
Funding: $501,449.
Technical area: Laboratory Infrastructure;
Funding: $398,900.
Technical area: TB/HIV;
Funding: $382,835.
Technical area: Antiretroviral Drugs;
Funding: 0.
Source: Country Operational Plan data from PEPFAR.
[End of table]
Partnership Framework:
Cambodia is one of several countries with smaller PEPFAR investments
and programs focused largely on technical assistance that are pursuing
a strategy document instead of a partnership framework. According to
PEPFAR officials in Cambodia, there are currently no plans to initiate
a partnership framework in Cambodia.
[End of section]
Appendix III: Malawi Case Study:
Figure 4: Malawi Background:
[Refer to PDF for image: map and data]
Map of Malawi:
Population: 15.4 million[A];
GDP per capita (PPP): $900 (rank 217 out of 227)[B];
Life expectancy at birth: 51 years (rank 211 out of 224)[A];
HIV/AIDS adult prevalence rate: 11.9% (rank 9 out of 170)[C]
Number of people living with HIV/AIDS: 930,000 (rank 15 out of 165)[C];
Number of AIDS orphans: 560,000[C];
HIV/AIDS epidemic: The highest HIV prevalence exists among vulnerable
groups like sex workers and their clients. However, the majority of
new infections occur in couples and among partners of people who have
multiple concurrent partners. In addition, mother-to-child
transmission is estimated to account for almost a quarter of new
infections. Of the almost 1 million people who are estimated to live
with HIV in Malawi, 10 percent of them are children.
Sources: CIA World Factbook and PEPFAR.
[A] Estimate as of 2010.
[B] Estimate as of 2009.
[C] Estimate as of 2007.
[End of figure]
National HIV/AIDS Program:
According to Malawi's national strategy, the Malawi government program
to address HIV/AIDS seeks to prevent the spread of HIV infections in
Malawi, provide access to treatment for people living with HIV and
mitigate the health, socio-economic and psychosocial impact of HIV and
AIDS on individuals, families, communities, and the nation.
Specifically, there are seven priority areas that drive the national
response, which include prevention and behavior change; treatment,
care, and support; impact mitigation; mainstreaming and
decentralization; research, monitoring, and evaluation; resource
mobilization and utilization; and policy and partnerships. The
President leads the government HIV/AIDS efforts and the Department of
Nutrition, HIV, and AIDS in the Office of the President and Cabinet is
the lead government agency responsible for policy, oversight, and
advocacy. In 2001, the government established the National AIDS
Commission as a national coordinating authority to provide leadership
and coordinate the national program. This commission is comprised of
members from the private and public sector, civil society, and people
living with HIV. A number of key ministries implement the national
program, including the Ministry of Health, Ministry of Finance, and
the Ministry of Economic Planning and Development.
The current HIV/AIDS national strategy for Malawi covers 2010 through
2012. While the Malawi HIV/AIDS National Action Framework is the
primary HIV/AIDS strategy, other Malawi government documents also
comprise the complete HIV/AIDS strategy for the country. For example,
other components of the national strategy include the National HIV
Prevention Strategy for 2009 through 2013, integrated annual work
plans, a national monitoring and evaluation framework for 2006 to
2010, as well as other frameworks, technical strategies, and
guidelines.
HIV/AIDS Partners and Donors:
Bilateral and Multilateral Donors in HIV/AIDS:
Malawi's national HIV/AIDS program receives support from a variety of
bilateral and multilateral donors in addition to PEPFAR. The Global
Fund is the largest donor for HIV/AIDS programs in Malawi, spending
almost $190 million on HIV programs in Malawi from 2004 to 2008, which
comprised almost 40 percent of all HIV development assistance over
that period (see figure 5). Other major donors in the HIV/AIDS area in
Malawi include the United Kingdom, Norway, and the World Bank. The
Malawi government has a funding arrangement whereby each of these
donors contributes to a pooled fund managed by the National AIDS
Commission.
Figure 5: HIV/AIDS Development Assistance Funding for Malawi, by
Donor, 2004-2008:
[Refer to PDF for image: pie-chart]
Global Fund: 39&;
United States: 22%;
United Kingdom: 19%;
World Bank: 3%;
Other: 4%.
Source: GAO analysis of OECD data.
[End of figure]
Civil Society and Private Sector:
Civil society and private sector organizations also play a role in
carrying out the national program. Civil society organizations
implement activities, carry out advocacy, mobilize resources, document
community practices, and support capacity-building programs. In
addition, private sector organizations have the responsibility to
mainstream HIV/AIDS through workplace policies and programs.
PEPFAR Program:
PEPFAR Funding:
While Malawi was not one of the original 15 PEPFAR focus countries,
PEPFAR maintained a presence in Malawi with funding increasing from
$15 million in 2004 to $55.3 million in 2010 (see figure 6). U.S.
government development assistance for HIV/AIDS comprised 22 percent of
total development assistance to Malawi for HIV/AIDS from 2004 to 2008.
As noted above, the majority of the HIV/AIDS program in Malawi is
funded by other donors such as the Global Fund.
Figure 6: PEPFAR Funding in Malawi, Fiscal Years 2004-2010:
[Refer to PDF for image: vertical bar graph]
Year: 2004;
PEPFAR funding: $15.0 million.
Year: 2005;
PEPFAR funding: $15.2 million.
Year: 2006;
PEPFAR funding: $16.4 million.
Year: 2007;
PEPFAR funding: $18.9 million.
Year: 2008;
PEPFAR funding: $44.7 million.
Year: 2009;
PEPFAR funding: $43.2 million.
Year: 2010;
PEPFAR funding: $55.3 million.
Source: GAO analysis of OGAC data.
[End of figure]
PEPFAR Program Information:
The PEPFAR program in Malawi supports interventions for HIV/AIDS
prevention, treatment, and care. PEPFAR intervention strategies
include strengthening care services provided by the public sector and
indigenous organizations, expanding and strengthening services for
orphans and vulnerable children in urban and rural areas, and building
capacity to support strengthening of critical areas, including
laboratory infrastructure and strategic information. According to
PEPFAR officials, the Malawi PEPFAR program takes into consideration
the programs and funding support provided by the other donors and
focuses resources on filling gaps in the national program.
Table 4: Planned Allocation of PEPFAR Funding for Malawi, by Technical
Area, Fiscal Year 2010:
Technical area: Prevention of Mother-to-Child Transmission;
Funding: $12,006,294.
Technical area: Prevention of Sexual Transmission;
Funding: $8,750,481.
Technical area: Health Systems Strengthening;
Funding: $5,730,310.
Technical area: Orphans and Vulnerable Children;
Funding: $3,949,388.
Technical area: Adult Care and Treatment;
Funding: $3,845,686.
Technical area: Strategic Information;
Funding: $3,838,252.
Technical area: Laboratory Infrastructure;
Funding: $3,563,783.
Technical area: Counseling and Testing;
Funding: $3,446,036.
Technical area: Biomedical Prevention;
Funding: $2,653,168.
Technical area: Pediatric Care and Treatment Narrative;
Funding: $1,616,652.
Technical area: TB/HIV;
Funding: $912,997.
Technical area: Antiretroviral Drugs;
Funding: $233,916.
Source: Country Operational Plan data from PEPFAR.
[End of table]
Partnership Framework:
Malawi was the first country to complete a partnership framework,
which was signed in May 2009. The framework lays out a 5-year
strategic agreement between PEPFAR and the Malawi government, which
focuses on reducing new HIV infections, improving the quality of
treatment and care, mitigating the impacts of HIV/AIDS on individuals
and households, and supporting systems needed to achieve these goals.
Malawi signed a partnership framework implementation plan in July 2010
that provides additional detail including specific strategies for
achieving the 5-year goals and objectives. According to PEPFAR
officials in Malawi, additional funding was made available to Malawi
for implementing this partnership framework.
The development of the partnership framework in Malawi coincided with
the update and revision of the National Action Framework. According to
PEPFAR and Malawi government officials, the timing of the two
processes resulted in close collaboration between government officials
that increased alignment of the PEPFAR program with the national
program. For example, as a result of the partnership framework
development process, the PEPFAR country team was invited by the Malawi
government to participate in the pooled donors meetings, even though
PEPFAR does not participate in the pooled funding arrangement.
[End of section]
Appendix IV: Uganda Case Study:
Figure 7: Uganda Background:
[Refer to PDF for image: map and data]
Map of Uganda:
Population: 33.4 million[A];
GDP per capita (PPP): $1,300 (rank 204 out of 227)[B];
Life expectancy at birth: 53 years (rank 205 out of 224)[A];
HIV/AIDS adult prevalence rate: 5.4% (rank 14 out of 170)[C];
Number of people living with HIV/AIDS: 940,000 (rank 14 out of 165)[C];
Number of AIDS orphans: 1.2 million[C];
HIV/AIDS epidemic: Uganda faces a generalized HIV epidemic. There were
sharp declines in HIV prevalence in the mid- and late-1990s, but in
recent years, prevalence trends have stabilized. Nationwide, HIV
prevalence is higher in urban areas than in rural areas. Major
vulnerable population groups include young women, people in
prostitution and military personnel.
Sources: CIA World Factbook and PEPFAR.
[A] Estimate as of 2010.
[B] Estimate as of 2009.
[C] Estimate as of 2007.
[End of figure]
National HIV/AIDS Program:
According to its national HIV/AIDS strategy, Uganda aims to reduce new
HIV infection by 40 percent, expand social support, and provide care
and treatment services to 80 percent of needy individuals by 2012. The
strategy outlines four areas: prevention, care and treatment, social
support, and systems strengthening. Each area sets out specific
objectives and targets. For example, under the prevention area, the
strategy states that Uganda will reduce mother-to-child transmission
of HIV by 50 percent by 2012. Under the systems strengthening area,
the strategy includes several objectives, such as effectively
coordinating and managing the response at various levels. The Uganda
AIDS Commission, established in 1992, coordinates the multisectoral
response to the HIV/AIDS epidemic. The National AIDS Policy has yet to
be approved by the Ugandan parliament. However, in addition to
Uganda's National HIV&AIDS Strategic Plan 2007/8-2011/12, Uganda has
developed national policies related to HIV counseling and testing,
antiretroviral therapy, and orphans and other vulnerable children. The
Ministries of Health; Gender, Labour, and Social Development; and
Finance, Planning, and Economic Development, among others, are
involved in the national multisectoral HIV/AIDS strategy. Coordinated
by the Uganda AIDS Commission, these ministries, along with UNAIDS and
other stakeholders, make up the Partnership Committee, which is in
turn made up of various technical working groups and subcommittees.
HIV/AIDS Partners and Donors:
Bilateral and Multilateral Donors:
Although the United States is by far the largest bilateral HIV/AIDS
program donor in Uganda, the United Kingdom, Ireland, and many other
countries also contribute to Uganda's national HIV/AIDS program. In
addition, the Global Fund spent over $72 million in Uganda for
HIV/AIDS programs from 2004 to 2008.
Figure 8: HIV/AIDS Development Assistance Funding for Uganda, by
Donor, 2004-2008:
[Refer to PDF for image: pie-chart]
United States: 75%;
Global Fund: 8%;
Other: 8%;
United Kingdom: 5%;
Ireland: 3%.
Source: GAO analysis of OECD data.
Note: Percentages may not sum to 100 due to rounding.
[End of figure]
Civil Society Organizations:
Civil society organizations play a key role in implementing the
national strategic framework. In 2007, with financial support from
various development partners, the government of Uganda established a
Civil Society Fund (CSF) and since has issued a number of grants to
civil society organizations, including community-and faith-based
organizations, and district governments to support provision of
specific services by civil society groups in these areas.
PEPFAR Program:
PEPFAR Funding:
Uganda was selected in 2004 as one of the original PEPFAR focus
countries. As such, U.S. support for HIV/AIDS programs in Uganda
increased rapidly, from about $90.8 million in 2004, to $286.3 million
in 2010. As noted above, the U.S. government is the largest HIV/AIDS
development partner in Uganda.
Figure 9: PEPFAR Funding in Uganda, Fiscal Years 2004-2010:
[Refer to PDF for image: vertical bar graph]
Year: 2004;
PEPFAR funding: $90.8 million.
Year: 2005;
PEPFAR funding: $146.9 million.
Year: 2006;
PEPFAR funding: $170.0 million.
Year: 2007;
PEPFAR funding: $236.6 million.
Year: 2008;
PEPFAR funding: $283.6 million.
Year: 2009;
PEPFAR funding: $285.9 million.
Year: 2010;
PEPFAR funding: $286.3 million.
Source: GAO analysis of OGAC data.
[End of figure]
PEPFAR Program Information:
PEPFAR-supported programs span a number of HIV program areas,
including prevention, treatment, care, laboratory services, health
systems strengthening, and strategic information. In collaboration
with the government of Uganda, as of March 2009, PEPFAR supports
antiretroviral treatment for more than 150,000 HIV-positive Ugandans.
Table 5: Planned Allocation of PEPFAR Funding for Uganda, by Technical
Area, Fiscal Year 2010:
Technical area: Adult Care and Treatment;
Funding: $49,294,007.
Technical area: Antiretroviral Drugs;
Funding: $45,439,658.
Technical area: Prevention of Sexual Transmission;
Funding: $28,400,685.
Technical area: Orphans and Vulnerable Children;
Funding: $25,197,969.
Technical area: Counseling and Testing;
Funding: $16,817,113.
Technical area: Pediatric Care and Treatment;
Funding: $15,365,625.
Technical area: Prevention of Mother-to-Child Transmission;
Funding: $14,910,546.
Technical area: Laboratory Infrastructure;
Funding: $13,800,894.
Technical area: Health Systems Strengthening;
Funding: $12,100,444.
Technical area: Strategic Information;
Funding: $11,891,032.
Technical area: Biomedical Prevention;
Funding: $11,624,687.
Technical area: TB/HIV;
Funding: $9,113,758.
Source: Country Operational Plan data from OGAC.
[End of table]
Partnership Framework:
The government of Uganda plans to develop new national development,
health, and HIV/AIDS strategies. PEPFAR officials in Uganda indicated
that these revisions create opportunities for the government of Uganda
to demonstrate renewed leadership and build relationships with its
development partners. In this context, PEPFAR envisions that it could
pursue a Partnership Framework with Uganda.
[End of section]
Appendix V: Vietnam Case Study:
Figure 10: Vietnam Background:
[Refer to PDF for image: map and data]
Map of Vietnam:
Population: 89.6 million[A];
GDP per capita (PPP): $2,900 (rank 165 out of 227)[B];
Life expectancy at birth: 72 years (rank 128 out of 224)[A];
HIV/AIDS adult prevalence rate: 0.5% (rank 73 out of 170)[C];
Number of people living with HIV/AIDS: 290,000 (rank 24 out of 165)[C];
Number of AIDS orphans: Not available;
HIV/AIDS epidemic: Vietnam has a concentrated HIV epidemic, with the
highest prevalence among key populations at higher risk. These include
injecting drug users with a prevalence rate of 28.6 percent, female
sex workers with a prevalence rate of 4.4 percent, and men who have
sex with men with a prevalence of 9 percent in Hanoi and 5 percent in
Ho Chi Minh City. Injecting drug use is a major factor driving the
spread of HIV in Vietnam, posing a number of complex challenges.
Sources: CIA World Factbook and PEPFAR.
[A] Estimate as of 2010.
[B] Estimate as of 2009.
[C] Estimate as of 2007.
[End of figure]
National HIV/AIDS Program:
The Vietnam national HIV strategy, the National Strategy on HIV/AIDS
Prevention and Control in Vietnam until 2010 with a Vision to 2020,
lays out objectives and priorities for the government response to the
HIV/AIDS epidemic in Vietnam. The strategy's goals are to control the
HIV prevalence among the general population to below 0.3 percent by
2010 and with no further increase after 2010, and to reduce the
adverse impacts of HIV on socio-economic development. In addition, the
strategy also lays out a number of specific priority areas in the area
of prevention, treatment and care, and HIV governance. In the HIV
prevention area, the government program focuses on prevention and
behavior change through information, education and communication, harm
reduction targeting high-risk populations, prevention of mother-to-
child transmission, management and treatment of sexually transmitted
infections, and safe blood transfusion. The treatment and care
elements of the strategy focus on care and support for people living
with HIV and access to HIV treatment including antiretroviral drugs.
The strategy highlights HIV governance issues including HIV
surveillance, monitoring and evaluation, capacity building, and
international cooperation enhancement. The government of Vietnam
supports activities and services in each of these areas.
The National Committee for AIDS, Drugs, and Prostitution Prevention
and Control is the multisectoral body leading the government HIV
program. This multisectoral body is headed by a Deputy Prime Minister,
and members include vice-ministers from relevant line ministries.
Technical coordination of activities is delegated to the Vietnam
Administration for AIDS Control within the Ministry of Health. There
are also a number of other ministries and entities involved in
coordinating and implementing various aspects of the national program
including, the Ministry of Public Security; the Ministry of Labor, War
Invalids, and Social Affairs; the Ministry of Health; the Ministry of
Education and Training; the Ministry of Finance; and the Ministry of
Planning and Investment. While the current multisectoral national HIV
strategy for Vietnam covers 2004 to 2010 with a vision to 2020,
according to the Vietnam PEPFAR country team there are a number of
other strategies, documents, and laws that guide the national program
including, the Law on the Prevention and Control of HIV/AIDS and
Vietnam's Comprehensive Poverty Reduction and Growth Strategy.
HIV/AIDS Partners and Donors:
While U.S. funding comprises the majority of HIV/AIDS development
assistance funding in Vietnam, the national HIV/AIDS program receives
support from a variety of other bilateral and multilateral donors as
well. After PEPFAR, the United Kingdom is the largest HIV/AIDS donor
in Vietnam, spending over $24 million from 2004 to 2008, which
comprised 12 percent of all HIV development assistance over that
period (see figure 11). The United Kingdom HIV development assistance
is focused largely in the area of HIV prevention and harm reduction.
In addition, the Global Fund comprised 9 percent of all HIV
development assistance from 2004 to 2008, and this funding was focused
in areas including prevention of mother-to-child transmission, and HIV
counseling and testing. Other major donors in Vietnam include the
World Bank, which funds programs in HIV prevention, harm reduction,
blood safety, and care and treatment; and Germany, which funds HIV
prevention activities and procures test equipment for HIV counseling
and testing services. However, according to PEPFAR officials, donor
support in Vietnam is decreasing because of a number of factors,
including Vietnam's progress towards becoming a middle-income country.
Figure 11: HIV/AIDS Development Assistance Funding for Vietnam, by
Donor, 2004-2008:
[Refer to PDF for image: pie-chart]
United States: 59%;
United Kingdom: 12%;
Global Fund: 9%;
World Bank: 8%;
Other: 7%;
Germany: 5%.
Source: GAO analysis of OECD data.
[End of figure]
PEPFAR Program:
PEPFAR Funding:
During the first phase of PEPFAR, Vietnam was classified as one of the
15 PEPFAR focus countries.[Footnote 43] PEPFAR funding in Vietnam has
grown from $17.7 million in 2004 to $97.8 million in 2010 (see figure
12). In addition, U.S. funding in Vietnam comprised most HIV/AIDS
development assistance to Vietnam from 2004 to 2008.
Figure 12: PEPFAR Funding in Vietnam, Fiscal Years 2004-2010:
[Refer to PDF for image: vertical bar graph]
Year: 2004;
PEPFAR funding: $17.7 million.
Year: 2005;
PEPFAR funding: $26.9 million.
Year: 2006;
PEPFAR funding: $34.1 million.
Year: 2007;
PEPFAR funding: $65.8 million.
Year: 2008;
PEPFAR funding: $88.9 million.
Year: 2009;
PEPFAR funding: $89.0 million.
Year: 2010;
PEPFAR funding: $97.8 million.
Source: GAO analysis of OGAC data.
[End of figure]
PEPFAR Program Information:
Since 2004, the PEPFAR program has provided more than $320 million to
support the delivery of comprehensive HIV/AIDS prevention, care,
treatment, and support activities in Vietnam. PEPFAR activities in
Vietnam have included assisting Vietnam to develop comprehensive
prevention, treatment, care and support networks; supporting the
government of Vietnam's efforts to reduce stigma and discrimination
against people living with and affected by HIV/AIDS; training
Vietnamese physicians in clinical HIV/AIDS treatment and care;
assisting the Ministry of Health to develop peer outreach for at-risk
populations; increasing the public health management capacity of
Vietnamese government workers; assisting the Ministry of Health to
develop a national HIV reference laboratory; and providing support in
establishing one national surveillance and monitoring and evaluation
system.
According to the Vietnam PEPFAR country team, over the next 5 years,
PEPFAR will place a renewed emphasis on partnering with Vietnam to
build Vietnam's national HIV/AIDS response, and continue to work
together with all sectors of Vietnam as they craft strategies and
programs to stop HIV/AIDS. In addition, as part of the new Global
Health Initiative, PEPFAR will support Vietnam as it works to further
integrate and expand access to other health care services, such as
those that address tuberculosis, malaria, maternal and child health,
and family planning with HIV/AIDS programs.
Table 6: Planned Allocation of PEPFAR Funding for Vietnam by,
Technical Area, Fiscal Year 2010:
Technical area: Adult Care and Treatment;
Funding: $18,514,091.
Technical area: Prevention of Sexual Transmission;
Funding: $9,846,990.
Technical area: Biomedical Prevention;
Funding: $8,881,166.
Technical area: Strategic Information;
Funding: $6,495,182.
Technical area: Laboratory Infrastructure;
Funding: $5,637,455.
Technical area: Counseling and Testing;
Funding: $5,109,557.
Technical area: Prevention of Mother-to-Child Transmission;
Funding: $4,235,992.
Technical area: Health Systems Strengthening;
Funding: $4,027,393.
Technical area: Orphans and Vulnerable Children;
Funding: $3,552,515.
Technical area: TB/HIV;
Funding: $3,359,172.
Technical area: Antiretroviral Drugs;
Funding: $2,850,000.
Technical area: Pediatric Care and Treatment;
Funding: $2,652,078.
Source: Country Operational Plan data from PEPFAR.
[End of table]
Partnership Framework:
The Vietnam country team recently negotiated and signed a partnership
framework with the Vietnam Administration for AIDS Control within the
Ministry of Health. Development of the partnership framework
implementation plan is currently under way, with completion scheduled
for October 2010.
[End of section]
Appendix VI: Comments from the U.S. Department of State, Office of the
U.S. Global AIDS Coordinator:
United States DEpartment of State:
Chief Financial Officer:
Washington, DC 20520:
August 18, 2010:
Ms. Jacquelyn Williams-Bridgers:
Managing Director International Affairs and Trade:
Government Accountability Office:
441 G Street, N.W.
Washington, D.C. 20548-0001:
Dear Ms. Williams-Bridgers:
We appreciate the opportunity to review your draft report,
"President's Emergency Plan For Aids Relief: Efforts to Align Programs
with Partner Countries' HIV/AIDS Strategies and Promote Partner
Country Ownership," GAO Job Code 320726.
The enclosed Department of State comments are provided for
incorporation with this letter as an appendix to the final report.
If you have any questions concerning this response, please contact
Chantal Knight, Congressional Relations Officer, Office of the U.S.
Global AIDS Coordinator at (202) 663-2579.
Sincerely,
Signed by:
James L. Millette:
cc: GAO - David Gootnick:
S/GAC ” Eric Goosby:
State/OIG ” Tracy Burnett:
[End of letter]
Department of State Comments on GAO Draft Report:
President's Emergency Plan For Aids Relief: Efforts to Align
Programs with Partner Countries' HIV/AIDS Strategies and Promote Partner
Country Ownership (GAO-10-836, GAO Code 320726):
On behalf of the President's Emergency Plan for AIDS Relief (PEPFAR),
the U.S. Departments of State (DOS) and Health and Human Services
(HHS), and the U.S. Agency for International Development (USAID), I
would like to express our appreciation for the opportunity to comment
on the draft report from the Government Accountability Office (GAO)
titled, "President's Emergency Plan for AIDS Relief Efforts to Align
Programs with Partner Countries' HIV/AIDS Strategies and Promote
Partner Country Ownership (GA0-10-836, GAO Code 320726).
We welcome the report's conclusion that PEPFAR efforts to align its
activities have resulted in programs that are generally supportive of
partner countries' national strategy goals and objectives. As PEPFAR
works to advance country ownership and further refine the Partnership
Framework (PF) process, we also welcome the report's identification of
areas in which PEPFAR alignment processes could be strengthened. As
PEPFAR enters its seventh year of operations, we agree that there arc
still lessons to learn and significant variation among country teams'
ability to ensure that PEPFAR programs support all elements of
national HIV strategies. In this sense, the report is very timely, and
we will take its recommendation into consideration as we move forward.
The report outlines concern that the lack of baseline measures around
country ownership may limit country teams in measuring the impact of
their respective PFs and making necessary adjustments. We concur with
the report's recommendation that there is a need to develop and
disseminate a methodology for establishing indicators needed for
baseline measurements of country ownership, and that ideally, this
would take place prior to implementation of the PFs. Although a number
of countries have signed PFs and initiated implementation in advance
of developing standardized country ownership indicators, we recognize
the importance of such baselines measures for a results-driven program
like PEPFAR, and will work to advance this effort in consultation with
the field and as part of the broader Global Health Initiative. In the
interim, we will continue to monitor implementation and progress of
PEPFAR 5-year strategies in close collaboration with our in-country
counterparts, with the understanding that countries will progress
toward country ownership at varying paces.
In closing, we would like to again express our appreciation both for
GAO's examination of this important issue and for its recommendation.
We look forward to continuing to work to strengthen PEPFAR processes
to ensure alignment with national strategies, wherever possible, and
to promote country ownership of their national HIV response.
[End of section]
Appendix VII: GAO Contact and Staff Acknowledgments:
GAO Contact:
David Gootnick, (202) 512-3149 or gootnickd@gao.gov:
Staff Acknowledgments:
[End of section]
In addition to the contact named above, Audrey Solis (Assistant
Director), Todd M. Anderson, Diana Blumenfeld, Giulia Cangiano, David
Dornisch, Lorraine Ettaro, Etana Finkler, Reid Lowe, Grace Lui, and
Mark Needham made key contributions to this report. Additional
technical assistance was provided by Chad Davenport, Marissa Jones,
Bruce Kutnick, Mae Liles, Ellery Scott, and Michael Simon.
[End of section]
Related GAO Products:
President's Emergency Plan for AIDS Relief: Partner Selection and
Oversight Follow Accepted Practices but Would Benefit from Enhanced
Planning and Accountability. [hyperlink,
http://www.gao.gov/products/GAO-09-666]. Washington, D.C.: July 2009.
Global HIV/AIDS: A More Country-Based Approach Could Improve
Allocation of PEPFAR Funding. [hyperlink,
http://www.gao.gov/products/GAO-08-480]. Washington, D.C.: April 2008.
Global Health: Global Fund to Fight AIDS, TB and Malaria Has Improved
Its Documentation of Funding Decisions but Needs Standardized
Oversight Expectations and Assessments. [hyperlink,
http://www.gao.gov/products/GAO-07-627]. Washington, D.C.: May 2007.
Global Health: Spending Requirement Presents Challenges for Allocating
Prevention Funding under the President's Emergency Plan for AIDS
Relief. [hyperlink, http://www.gao.gov/products/GAO-06-395].
Washington, D.C.: April 2006.
Global Health: The Global Fund to Fight AIDS, TB and Malaria Is
Responding to Challenges but Needs Better Information and
Documentation for Performance-Based Funding. [hyperlink,
http://www.gao.gov/products/GAO-05-639]. Washington, D.C.: June 2005.
Global HIV/AIDS Epidemic: Selection of Antiretroviral Medications
Provided under U.S. Emergency Plan Is Limited. [hyperlink,
http://www.gao.gov/products/GAO-05-133]. Washington, D.C.: January
2005.
Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges to
Expanding Treatment, but Others Remain. [hyperlink,
http://www.gao.gov/products/GAO-04-784]. Washington, D.C.: June 2004.
Global Health: Global Fund to Fight AIDS, TB, and Malaria Has Advanced
in Key Areas, but Difficult Challenges Remain. [hyperlink,
http://www.gao.gov/products/GAO-03-601]. Washington, D.C.: May 2003.
[End of section]
Footnotes:
[1] United States Leadership Against HIV/AIDS, Tuberculosis, and
Malaria Act of 2003, Pub. L. No. 108-25, § 401, 117 Stat. 711, 745.
[2] Tom Lantos and Henry J. Hyde United States Global Leadership
Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of
2008, Pub. L. No. 110-293, § 401, 122 Stat. 2918, 2966.
[3] Organization for Economic Co-operation and Development, The Paris
Declaration on Aid Effectiveness (2005).
[4] The U.S. President's Emergency Plan for AIDS Relief: Five-Year
Strategy (Washington, D.C.: 2009).
[5] Pub. L. No. 110-293, § 101(d).
[6] For the purposes of this report, alignment refers to the extent to
which PEPFAR programs support the goals and objectives laid out by
partner governments in their national strategy, while harmonization
refers to coordination among other development partners.
[7] PEPFAR guidance describes promotion of country ownership as
expanding partner governments' capacity to plan, oversee, manage,
deliver, and eventually finance national HIV/AIDS programs. See
Guidance for PEPFAR Partnership Frameworks and Partnership Framework
Implementation Plans, Version 2.0 (Washington, D.C.: 2009).
[8] USAID and HHS's CDC and Health Resources and Services
Administration (HRSA) are the primary PEPFAR implementing agencies.
Other implementing agencies include the Departments of State, Defense,
Labor, and Commerce and the Peace Corps.
[9] Pub. L. No. 110-293, § 4.
[10] Pub. L. No. 110-293, § 101(b).
[11] Pub. L. No. 110-293, § 101(b).
[12] Pub. L. No. 110-293, § 301(e).
[13] The Paris Declaration on Aid Effectiveness.
[14] Pub. L. No. 110-293, § 101.
[15] Pub. L. No. 110-293, § 301(c)(6).
[16] According to OGAC-issued guidance, partnership frameworks are not
intended to be legally binding. Rather, they are intended as
nonbinding joint strategic planning documents that outline the goals
and objectives to be achieved and the commitments and contributions of
all participating framework members. Office of the U.S. Global AIDS
Coordinator, Guidance for PEPFAR Partnership Frameworks and
Partnership Framework Implementation Plans, Version 2.0 (Sept. 14,
2009).
[17] Office of the U.S. Global AIDS Coordinator, Guidance for PEPFAR
Partnership Frameworks and Partnership Framework Implementation Plans.
[18] The following 31 countries completed a COP for fiscal year 2010:
Angola, Botswana, Cambodia, China, Côte d'Ivoire, Democratic Republic
of the Congo, Dominican Republic, Ethiopia, Ghana, Guyana, Haiti,
India, Indonesia, Kenya, Lesotho, Malawi, Mozambique, Namibia,
Nigeria, Russia, Rwanda, South Africa, Sudan, Swaziland, Tanzania,
Thailand, Uganda, Ukraine, Vietnam, Zambia, and Zimbabwe.
[19] The President's Emergency Plan for AIDS Relief (PEPFAR). Country
Operational Plan (COP) Guidance: Programmatic Considerations. Fiscal
Year 2010. June 29, 2009.
[20] A 2005 World Bank Operations Evaluation Department review of 21
national strategies found that most could be considered general
frameworks setting fundamental principles, broad strategies, and the
institutional framework, acting as a basis for subsequent operational
planning. See Review of National HIV/AIDS Strategies for Countries
Participating in the World Bank's Africa Multi-Country AIDS Program
(MAP), 36194 (Washington, D.C.: 2005).
[21] See appendix I for details on our methodology for analyzing the
alignment of COP documents with national strategies.
[22] Some of these groups also noted that PEPFAR's creation and use of
parallel mechanisms to implement programs negatively affect alignment.
[23] The 2007 IOM study of all 15 focus countries reviewed a number of
aspects of PEPFAR implementation including alignment with national
programs. This review involved discussions with PEPFAR officials and
other stakeholders, an analysis of PEPFAR documents including COPs,
congressional notifications, and annual reports, as well as field
visits to 13 of the 15 countries. Institute of Medicine of the
National Academies, PEPFAR Implementation: Progress and Promise
(Washington, D.C.: 2007).
[24] In 2008, we reported that most PEPFAR country team officials
(PEPFAR coordinators, and USAID and CDC officials in the 15 focus
countries) who responded to GAO's survey reported collaborating with
partner country representatives and major donor representatives in
selecting PEPFAR interventions. In particular, 34 of 38 respondents
noted that partner country technical working groups--groups organized
by the partner country government that usually comprise partner
country and donor representatives--were extremely or very important.
In addition, 26 of 36 officials who responded to a question about
country officials' participation in the selection of PEPFAR
interventions reported that partner country authorities were extremely
or very involved in this process. See GAO, Global HIV/AIDS: A More
Country-Based Approach Could Improve Allocation of PEPFAR Funding,
[hyperlink, http://www.gao.gov/products/GAO-08-480] (Washington, D.C.:
Apr. 2, 2008).
[25] PEPFAR guidance notes that the extent to which information in the
COP can be shared with stakeholders is limited, because procurement-
sensitive information must be protected to adhere to U.S. competitive
acquisition and assistance practices.
[26] The following countries and regions have been invited to develop
a partnership framework: Botswana, Caribbean region, Central America
region, Cote d'Ivoire, Democratic Republic of the Congo, Dominican
Republic, Ethiopia, Ghana, Guyana, Haiti, India, Kenya, Lesotho,
Malawi, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Swaziland,
Tanzania, Thailand, Uganda, Ukraine, Vietnam, and Zambia.
[27] According to OGAC officials, an additional 6 countries and one
region--Cambodia, Central Asia region, China, Indonesia, Russia,
Sudan, and Zimbabwe--that have smaller PEPFAR investments, with
programs largely based on technical assistance rather than service
delivery, are pursuing a strategy document instead of a partnership
framework. The officials said that increasing country ownership and
sustainability will be long-term goals of the strategy document, like
the partnership framework, but it will be negotiated and signed by
each government at a lower level than the framework.
[28] PEPFAR indicators are measurements used to monitor quality,
coverage and effectiveness of HIV/AIDS programs and track the progress
in the fight against HIV/AIDS. Indicators are intended to provide
information of performance on one key or standardized element of a
program. For example, to track the progress toward the legislative
goal of providing treatment for at least 3 million people, PEPFAR
measures the percentage of adults and children with advanced HIV
infection receiving antiretroviral therapy.
[29] In 2008, we reported that 27 of 38 survey respondents (PEPFAR
coordinators, USAID, and CDC officials in the 15 countries formerly
known as focus countries) characterized information from the partner
country's national strategy and targets as extremely or very important
for setting annual targets. See [hyperlink,
http://www.gao.gov/products/GAO-08-480].
[30] According to a 2005 report by the Global Task Team on Improving
AIDS Coordination Among Multilateral Institutions and International
Donors, multilateral institutions and international partners did not
systematically share information among themselves or with national
AIDS authorities, fragmenting the national response to HIV/AIDS and
constraining the ability of the partner country to identify problems.
The Global Task Team recommended that multilateral and international
partners regularly provide information on planned and actual
commitments and disbursements, including the recipients and intended
uses to national AIDS coordinating authorities and the general public.
[31] At the 2001 United Nations General Assembly Special Session on
HIV/AIDS (UNGASS), the General Assembly adopted the Declaration of
Commitment on HIV/AIDS. Under the Declaration, members committed to
"conduct national periodic reviews ... of progress achieved in
realizing these commitments ... and ensure wide dissemination of the
results of these reviews." A/RES/S-26/2, U.N. GAOR, 26th Special
Sess., 8th plen. mtg., Annex, Agenda Item 8, U.N. Doc. A/RES/S-26/2
(2001).
[32] Institute of Medicine of the National Academies, PEPFAR
Implementation: Progress and Promise.
[33] The Paris Declaration notes that partner country corruption and
lack of transparency remain a challenge in some countries. The
document also states that corruption in recipient countries inhibits
donors from relying on partner country systems.
[34] PEPFAR, Guidance for Partnership Frameworks and Partnership
Framework Implementation Plans, September 2009.
[35] The Paris Declaration states that demonstrating progress toward
shared goals at the country level is critical. As such, donors and
their partner countries are committed to periodically assessing,
qualitatively and quantitatively, mutual progress at country level,
using appropriate country-level mechanisms.
[36] At a workshop on country ownership organized as part of the
Organisation for Economic Co-operation and Development (OECD) Global
Forum on Development, a group of more than 30 experts from developing
countries, including representatives of governments, parliaments, and
a wide variety of civil society organizations, discussed the
difficulty in measuring country ownership. For more information see,
the OECD Development Centre, Ownership in Practice. Informal Experts'
Workshop Sèvres, September 27-28, 2007.
[37] See GAO, Executive Guide: Effectively Implementing the Government
Performance and Results Act, [hyperlink,
http://www.gao.gov/products/GAO/GGD-96-118] (Washington, D.C.: June
1996)
[38] Pub. L. No. 110-293, § 101(d).
[39] For the purposes of this report, alignment refers to the extent
to which PEPFAR programs support the goals and objectives laid out by
partner governments in their national strategy, while harmonization
refers to coordination among other development partners.
[40] PEPFAR guidance describes promotion of country ownership as
expanding partner governments' capacity to plan, oversee, manage,
deliver, and eventually finance national HIV/AIDS programs. See
Guidance for PEPFAR Partnership Frameworks and Partnership Framework
Implementation Plans, Version 2.0 (Washington, D.C.: 2009).
[41] Institute of Medicine of the National Academies, PEPFAR
Implementation: Progress and Promise, March 30, 2007.
[42] There are 14 PEPFAR technical areas outlined in the fiscal year
2010 COP guidance; Prevention of Mother to Child Transmission (PMTCT),
Sexual Prevention, Biomedical Prevention, Adult Care and Treatment,
Tuberculosis/HIV, Orphans and Vulnerable Children (OVC), Counseling
and Testing, Pediatric Care and Treatment, Antiretroviral Drugs (ARV),
Laboratory Infrastructure, Strategic Information, Health Systems
Strengthening, Human Resources for Health, and Gender.
[43] Vietnam was selected as the 15th focus country in 2004 and was
added to the list of designated countries in 2008 by the Leadership
Act. Pub. L. No. 110-293, § 102.
[End of section]
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