ORGANIZATION OF PEPFAR AT THE CENTRAL/HEADQUARTERS LEVEL

Office of the U.S. Global AIDS Coordinator

The formal organizational unit for PEPFAR is OGAC at the Department of State. OGAC is overseen by the Coordinator, an appointed position at the level of ambassador who reports directly to the U.S. Secretary of State. OGAC serves as the administrative office for PEPFAR and directs and coordinates activities at both the headquarters level in Washington, DC, and at the country level, where PEPFAR operates under the additional oversight of the U.S. ambassador of the country. OGAC staff members, including detailees from other USG agencies, coordinate administrative, financial, and programmatic implementation, oversight, and guidance. OGAC also has country support team leaders who serve as the principal point of contact and liaison to in-country PEPFAR mission teams (IOM, 2007; PEPFAR, 2013a). The organizational structure of OGAC has changed over time; the current structure at the time of this evaluation is shown in Figure 3-2.

FIGURE 3-2

Organizational structure of OGAC(last updated November 14, 2011). SOURCE: PEPFAR, 2011.

In addition, the Coordinator and other OGAC staff represent the United States on global bodies responding to the HIV/AIDS pandemic and participate with multinational organizations, including the Joint United Nations Programme on HIV and AIDS (UNAIDS), the Global Fund, the World Health Organization (WHO), and the United Nations Children's Fund (UNICEF), on a range of aspects of the global HIV response, such as developing normative technical guidelines and conferring with other donors and institutions with respect to global priorities and harmonizing elements of the global response (IOM, 2007; PEPFAR, 2013b).

ORGANIZATION OF PEPFAR AT THE COUNTRY LEVEL

PEPFAR country programs that submit a Country Operational Plan (COP) to OGAC typically have an interagency U.S. mission team made up of representatives of all implementing departments and agencies working in the country (see Figure 3-3 for an illustration of a mission team). U.S. ambassadors or chiefs of mission are the leaders of interagency PEPFAR teams, ultimately responsible for ensuring that policies and programs are coordinated at the highest levels, accounting for all plans and reports submitted to OGAC, and engaging with partner-country leadership. Mission teams coordinate all of the program activities in the country and are almost all anchored by a country coordinator. The members of the mission teams work with implementing partners, other international organizations and donors, and partner country governments and nongovernmental entities to implement programs and services, develop partnerships, participate in coordination and planning processes, and support policies that contribute to an effective response to HIV and ensure that more attention and resources are put toward HIV/AIDS. Mission team staff members also participate in joint planning committees or working groups organized by the partner country government or by multilateral organizations. In addition members of the interagency mission team also work with the Global Fund's local committee, known as the Country Coordinating Mechanism, to improve implementation of Global Fund grants programs and to facilitate coordination between the Global Fund and USG programs (240-2-USG; 331-3-USG; 587-2-USG; 196-6-USG; 196-26-USG; 636-3-USG; 116-4-USG; 166-4-USG; 166-31-USG; 272-2-USG; 935-2-USG; 461-4-USG; 542-3-USG; 396-2-USG; 396-39-USG; 934-2-USG; NCV-20-USG) (IOM, 2007; IOM and NRC, 2010; USG, 2011).

FIGURE 3-3

Example structure of PEPFAR mission team. NOTE: The structure of each team will vary by country. Different TWGs are present in different countries; this figure includes an illustrative example. CDC = U.S. Centers for Disease Control and Prevention; DoD (more...)

Although some PEPFAR-supported activities are implemented directly by members of the mission team, most PEPFAR-supported programs and services within countries are implemented by a variety of different partners, including international and partner country nongovernmental organizations, academic institutions, partner country governments, private-sector entities, civil society organizations, and faith-based organizations. Most of the activities that PEPFAR supports and implements in partner countries are determined by and contracted through the in-country mission teams, although some programs and initiatives are funded and managed at the central, headquarters level. Chapter 4 describes in more detail the different ways in which programs are funded and implemented.

Activities are expected to aim toward performance targets and goals in areas such as prevention, care, treatment, monitoring and evaluation, Partnership Framework development, capacity building, and health systems strengthening (the process for setting program targets is discussed further in Chapter 11, Knowledge Management) (OGAC, 2004, 2009b). Specific activities supported and implemented by PEPFAR will be described and documented in more detail throughout this report. Therefore, the following is not a comprehensive list but rather examples drawn from those chapters of the types of activities that are supported and implemented through PEPFAR. In supporting the scale-up of HIV-related services, PEPFAR has supported the direct provision of services. This has included clinical, nonclinical, and laboratory services in public (government) and non–public health facilities as well as in community facilities and home-based services. In addition to supporting providers and providing commodities required to deliver these services, PEPFAR has supported the strengthening of infrastructure, such as equipment and facilities. Beyond supporting the direct provision of services, PEPFAR has supported partners in the provision of training, mentoring, technical assistance, and other capacity building for not only service delivery but also program management, leadership, and governance. PEPFAR has also supported policy development at the level of national and sub-national management of the HIV response. In addition, PEPFAR also has supported routine data collection, surveillance, special studies, and evaluation and research activities.

Although the general structure is similar across countries, the model of implementation and types of activities vary, ranging from direct support for service delivery to primary technical assistance. The balance and combination among the different activities and approaches to implementation vary according to the country's needs, resources, capacity, and infrastructure (USG, 2012). The implementation of these different models is discussed further in Chapter 4 and Chapter 10.

PERSPECTIVES ON INTERAGENCY IMPLEMENTATION

PEPFAR is the largest bilateral global health program in history, and in order to implement such large amounts of foreign assistance for such a range of activities in such a short time, the operational structure of PEPFAR was strategically designed to use a number of existing USG agencies in a whole-of-government approach (Simonds, 2012). In the course of collecting data about the implementation and effects of PEPFAR-supported programs in partner countries, the committee learned about some of the advantages and challenges of the interagency implementation approach. These perspectives are reflected in a brief summary here; this is not a comprehensive assessment of this topic because the committee was not charged nor was this study designed to carry out an assessment of the organizational infrastructure and operational management of PEPFAR, areas which fall under the scope and mandate of other organizations external to PEPFAR that have issued reports of their assessments, such as the Government Accountability Office and the Office of Inspector General (GAO, 2009; OIG, 2008, 2009, 2010).

To be able to administer the large amounts of funding and the diverse programs that characterize PEPFAR, USG agencies had to go through a ‘maturation process’⁶ (NCV-4-USACA). CDC, for example, had an administrative framework for grants primarily with a U.S. domestic focus, and initially it experienced challenges in devising ways to manage large international grants (NCV-4-USACA; 272-34-USG). In addition, different agencies already had different approaches, systems, and mechanisms for contracting or granting funds to partners (396-ES; 240-ES; 272-34-USG). These varied in the degree to which the involvement of the agency headquarters was required and in what kinds of partners were typically funded, including whether agencies provided funds directly to partner country governments and public-sector facilities or used funds to pay salaries directly for staff working in partner country facilities and ministries (IOM, 2007; IOM and NRC, 2010; USAID, 2009).

Interviewees across countries and stakeholder types described several challenges in the implementation of PEPFAR programs through a whole-of-government, interagency model; this process was a notable source of tension in several countries. The challenges included the large amount of time spent on coordination; inefficiencies or non-optimal use of resources, particularly due to the duplication of programs and services; tensions among staff members around budget decisions and competition for funds, activities, and partners; a lack of clarity about the role and affiliation of the Country Coordinator position; communication and information-sharing challenges within the USG and between the USG and implementing partners and partner country stakeholders; and the extra administrative burden that implementing partners faced in dealing with multiple agencies (NCV-6-USNGO; NCV-11-USG; 934-ES; 461-ES; 272-ES; 166-ES; 116-ES; 396-47-USNGO; 396-57-USG; 935-17-USG; 240-3-USG; 934-40-ML; 461-4-USG; 272-1-USG; 272-36-USG; 166-4-USG; 331-3-USG; 587-25-ML). In a number of countries, PEPFAR mission teams described their efforts to identify the comparative advantages of each USG agency and to assign responsibility for projects accordingly. This process was a considerable challenge in some countries where mission teams have struggled to reduce duplication and overlap of activities by USG agencies, and some interviewees described a lack of clarity or agreement among the agencies, either in the country or from headquarters, on which agencies were better at which types of activities or working with which types of partners (272-ES; 331-2-USG; 587-2-USG; 240-3-USG; 240-8-USG; 240-ES; 272-1-USG; 272-33-USG). One interviewee asserted, ‘OGAC does not promote interagency cooperation, no leadership in this area’ (331-3-USG). Another described the “one USG” philosophy as ‘theoretical’ (587-2-USG).

In contrast, some interviewees described the interagency approach and collaboration among agencies as a success (116-27-USG; 396-23-USG; 331-ES; 542-ES; 166-ES; 636-16-USG; 461-19-USG; 935-10-USG; 935-28-USG). They emphasized, for example, the critical role that the interagency approach played in achieving initial rapid scale-up of services and the value of having multiple agencies with diverse capacities and expertise working together to contribute to the country program, in some cases describing this as an advantage compared to single-agency development assistance programs (396-23-USG; 935-10-USG; 461-4-USG; 331-ES; 542-ES; 272-34-USG; 166-ES). Interviewees also identified factors and efforts that have contributed to reducing interagency tensions and creating more functional interagency operations. These included revisiting and refining strategies and processes for decision making and program management, including streamlining responsibility for potentially difficult decisions such as budget allocations and strategic planning; empowering foreign service nationals to take leadership roles in the interagency team and technical working groups; and having strong leadership from the chief of mission that values and facilitates a more positive interagency process (461-ES; 935-ES; 331-ES; 587-ES). Some PEPFAR mission teams successfully conducted, either internally or with external involvement, a review of the PEPFAR portfolio to identify areas of overlap and opportunities to reduce duplication as well as, in several countries, a rationalization process of services and programs by agency, by region, and by partner (461-ES; 935-ES; 240-ES; 587-2-USG). One mission team mentioned that the Partnership Framework process helped its program identify what each agency was doing (116-7-USG).

Chapter 4 further discusses the topic of making more strategic and efficient use of resources by reducing duplication and overlap.

PEPFAR IMPLEMENTATION IN THE CONTEXT OF THE HIV EPIDEMIC IN PARTNER COUNTRIES

The diverse nature of the HIV epidemic in the various partner countries where PEPFAR supports programs brings with it key contextual aspects that are not specific to PEPFAR but that affect its implementation; among the most influential of these are factors that relate to risk and vulnerability—the risk of HIV infection and transmission and vulnerability to poor health and other adverse outcomes. Understanding the many complex factors that contribute to risk and vulnerability is critical to understanding the nature of the epidemic and to the planning and implementing of an effective response to HIV; this principle is often articulated as “Know your epidemic, know your response” (UNAIDS, 2007). While there may be general agreement on this principle, in practice applying it is often difficult. Some of the key factors that contribute to the epidemic and to some of the difficulty in implementing a response are discussed here from a broad perspective as context for this report because they apply to the whole of the response to HIV and not just to specific technical areas; these issues are also discussed in more depth in various sections of the report where they intersect with specific areas of PEPFAR-supported programs and other PEPFAR activities, especially in the chapters on prevention (Chapter 5), children and adolescents (Chapter 7), and gender (Chapter 8).

Although HIV continues to affect all regions of the world, the burden of HIV is not equally distributed among or within countries and populations. Certain populations are disproportionately vulnerable as a result of biological, behavioral, social, cultural, economic, and political factors that can contribute to high rates of HIV infection. These factors include poverty, a lack of access to education, low access to and utilization of health care, gender-based violence, the effects of humanitarian crises, stigma, discrimination, social and cultural marginalization, and criminalization of behaviors and activities that affects some populations at elevated risk. In addition to increasing the risk of HIV infection and transmission, many of these same factors contribute to vulnerability to poor health and other adverse outcomes directly as well as indirectly, through, for example, barriers to accessing health care and other support services. For many populations and individuals, various of these factors intersect. Taken together, in different parts of the world they have facilitated particularly high rates of HIV infection among men who have sex with men, sex workers, people who inject drugs, and, particularly in southern Africa, young women (Gouws et al., 2008; IOM, 2007; UNAIDS, 2012). The relative influence of factors that contribute to vulnerability and that drive the HIV epidemic varies by country and by region within countries. In some cases the epidemic has a relatively low prevalence in the total population and is concentrated among specific populations; in others with a high overall prevalence the risk of transmission is high for broad segments of the general population, while rates of infection are typically still disproportionately high in some specific populations (IOM, 2007; UNAIDS, 2012).

It became clear during the committee's assessment of PEPFAR that perspectives on which populations are most vulnerable and most in need of support and services vary widely by country and type of stakeholder, influenced both by the available data and by the stakeholders' experiences in implementing HIV programs (240-ES; 331-ES; 587-ES; 196-ES; 636-ES; 116-ES; 166-ES; 272-ES; 935-ES; 461-ES; 542-ES; 396-ES; 934-ES). These varying perspectives reflected many of the intersecting factors described previously. Although not a comprehensive listing, the wide range of populations identified as “vulnerable” or “most in need” by interviewees in PEPFAR partner countries is illustrated in Box 3-1. The populations identified as key populations at elevated risk in HIV programming were consistently among those identified as vulnerable, including people who inject drugs, men who have sex with men, and people who engage in sex work. Women and children as well as serodiscordant couples and people with multiple concurrent sexual partners were also commonly identified as vulnerable. Many interviewees also characterized populations as vulnerable because of such factors as life-stage, geographical region, socioeconomic status, occupation, and ability to access services. In many cases, interviewees described those most vulnerable and most in need of services simply as those who were already HIV-positive (240-ES; 331-ES; 587-ES; 196-ES; 636-ES; 116-ES; 166-ES; 272-ES; 935-ES; 461-ES; 542-ES; 396-ES; 934-ES).

BOX 3-1

Examples of Vulnerable Populations Identified from Country Visit Interview Data. Women Children (in general as well as specifically infants exposed to HIV through maternal transmission; orphans; HIV-positive children; children with disabilities; immigrant (more...)

This wide range of identified needs and perspectives on vulnerability can pose a challenge in trying to plan strategically for a response to HIV that is prioritized according to the drivers of the epidemic and the populations most in need of services. An overarching challenge described by interviewees was the need to allocate limited resources among a range of types of identified needs and available services. Indeed, in some cases there was a lack of alignment and at times contention among stakeholders about how to target and prioritize the response (240-ES; 587-ES; 461-ES; 331-ES; 166-ES; 196-ES; 935-ES). Another commonly expressed challenge was a lack of data on population size, baseline HIV prevalence and other factors for specific populations that are vulnerable or at elevated risk, which made it difficult to fully understand the epidemic and the performance of the ongoing response and therefore to have a well-informed process for setting priorities (166-5-USG; 396-24-USNGO; 240-9-USG; 331-7-PCNGO; 396-37-USNGO; 396-39-USG; 636-6-USG; 166-19-PCGOV; 116-15-USNGO; 461-ES). In some cases it was noted by U.S. mission team members, civil society groups, and stakeholders within partner country governments that achieving a shift in priorities can require a great deal of evidence and effort, especially if there are social, political, policy, or cultural barriers to implementing certain intervention approaches or focusing on certain marginalized populations. Examples of such barriers perceived by interviewees included a lack of government commitment to specific populations or programs, restrictive or punitive national policies, governmental resistance to acknowledging some populations at elevated risk as part of their epidemic, and the criminalization of some behaviors or practices associated with these populations (240-ES; 396-ES; 461-ES; 166-ES; 270-ES; 240-ES; 542-ES; 331-ES; 935-ES).

Interviewees in many countries credited PEPFAR for playing a facilitative role in acknowledging, addressing, and including in the country's HIV response the needs of populations that are vulnerable or at elevated risk, in particular through PEPFAR's support for the generation and use of epidemiological data, surveys, and special studies to better understand and respond to the specific drivers of epidemics (396-6-PCGOV; 934-24-PCGOV; 196-1-USG; 196-8-ML; 196-10-PCGOV; 196-11-USNGO; 196-13-OGOV; 116-1-USG; 116-4-USG; 166-4-USG; 240-9-USG; 240-12-USG; 272-13-USG; 331-3-USG; 331-10-PCGOV; 331-14-USG; 331-15-USG; 331-24-PCGOV; 587-9-USG; 636-1-USG; 934-21-USG; 461-1-USG; 396-1920-USG; 396-53-USNGO; 272-22-USG; 272-25-USG; 166-23-USG). This support for generating data and encouraging its use to inform planning for the response is discussed further in Chapter 9 in the section on information systems in partner countries and in Chapter 11 on PEPFAR's knowledge management efforts.

In addition to supporting the generation of data, PEPFAR has both field- and headquarters-level efforts to review COPs to ensure that PEPFAR's planned prevention and other programmatic activities align with the available epidemiological data in that country and to promulgate a response that addresses the specific drivers of the epidemics (Ryan, 2010). At the same time PEPFAR also has the articulated goal of working to better harmonize its efforts with national priorities and the national response.⁷ These two goals are sometimes in conflict. For example, even where epidemiological data exist or had been produced through PEPFAR support, PEPFAR and partner countries sometimes experienced conflict about the translation of epidemiological data and other information about the response into aligned program priorities. In undertaking targeted prevention efforts, PEPFAR and partner country stakeholders, particularly partner country governments, disagreed in some cases about the populations to be targeted. While PEPFAR might have put forth the need to address specific populations at elevated risk, some partner country stakeholders preferred instead to focus on, for example, the general population or on children and youth (542-9-PCGOV; 587-ES; 166-5-USG; 240-8-USG; 331-18-USNGO; 587-7-PCGOV; 587-12-USG).

PEPFAR's role in the process of aligning its contribution to the HIV response with partner country government priorities and with the available evidence on the HIV epidemic in partner countries is a critical topic that is also discussed in the following section and in more depth throughout this report where it intersects with specific aspects of PEPFAR-supported efforts.

PEPFAR IMPLEMENTATION AND THE POLICY ENVIRONMENT

Since its creation, PEPFAR has operated in the context of domestic, global, and partner country policy environments, each of which introduces factors that can either facilitate or constrain PEPFAR's priorities and actions as well as the effectiveness of its efforts. Thus, in addition to attempting to implement well-established practices and interventions and to incorporate scientific advances, PEPFAR has also had to navigate diverse political pressures while developing its priorities, guidance, and programming. Within the United States, PEPFAR's efforts must contend with pressures coming from the U.S. Congress, advocacy groups, the media, and the general public. The United States' domestic policy environment influences what PEPFAR is authorized to undertake or address for the U.S. response to global HIV as well as how PEPFAR-supported programs and activities are implemented. In addition, PEPFAR is influenced by its inherent role as a part of the diplomatic and foreign relations mission of the United States. Finally, PEPFAR must also navigate its relationship with global bodies, other donors, and, as discussed in the preceding section, the governments and other stakeholders in the countries where it works. Situated within this larger political environment, PEPFAR has played a key role at the global level and within countries in influencing HIV policy. This section is a brief overview that synthesizes some key general aspects of PEPFAR's relationship with and role in the policy environment; this overview is linked to the committee's assessment of specific policy issues that intersect with specific programmatic areas, which are discussed in more depth in the pertinent chapters of the report.

There are several related but distinct ways that PEPFAR interacts with policy formulation and implementation. One is the development of PEPFAR's own guidance to set general policy and programmatic direction for PEPFAR's activities within partner countries, alluded to earlier in this chapter (PEPFAR, 2013c). This affects how PEPFAR money will be spent and what aspects of the HIV response will be prioritized, and often the effects are not limited to PEPFAR-supported activities but also influence activities that are supported through other resources (IOM, 2007). The other two primary pathways are through PEPFAR's relationship with the policy context in partner countries and PEPFAR's relationship with the broader global policy environment.

SUMMATION

PEPFAR is large, multifaceted, and complex, supporting a wide range of activities that are carried out by many different partners in a diverse group of countries. PEPFAR-supported programs operate alongside programs supported through other external and partner country funding sources, other funders that share the same ultimate aim as PEPFAR. In addition, health outcomes are also influenced by cultural, societal, geographical, and political factors and influences that vary by country and are not within the control of PEPFAR-supported programs. As PEPFAR increasingly emphasizes country ownership and alignment with national plans, the extent to which the USG directly influences all levels of priority setting, decision making, and implementation can be quite limited.

As discussed in depth in the description of the evaluation approach in Chapter 2, the committee endeavored to conduct a rigorous evaluation of PEPFAR that took into account the complexities of implementation in order to develop a credible assessment of the contribution of PEPFAR to changes in health outcomes and health impact within the landscape of other funding sources, other HIV programs, and other factors that affect health.

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Footnotes

1

United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, P. L. 108-25, 108th Cong., 1st sess. (May 27, 2003).

2

Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, P.L. 110-293, 110th Cong., 2nd sess. (July 30, 2008).

3

In general when this report refers to activities that are carried out by OGAC or actions that are recommended to be taken by OGAC, the activities and actions should be understood to be carried out by the USG implementing agencies through PEPFAR's interagency mechanisms, coordinated by OGAC.

4

OGAC operates the following TWGs (by program area): Prevention of Sexual Transmission in the General Population (Including Youth); Prevention of HIV in Persons Engaged in High-Risk Behaviors; Medical Transmission; Counseling and Testing; Prevention with Positives Taskforce; Male Circumcision Taskforce; Care and Treatment Steering Committee; Adult Treatment; PMTCT/Pediatric AIDS; Tuberculosis (TB) and HIV/AIDS; Care and Support; Orphans and Vulnerable Children; Community/Faith Based Organizations, Food, Nutrition, and HIV/AIDS; Gender; Public–Private Partnerships; Health Systems Strengthening; Human Resources for Health; Laboratory; Finance and Economics; Strategic Information Steering Committee; Monitoring and Evaluation; Surveillance and Survey; Health Management Information Systems. Staff from USG agencies, USG-funded partners, and non-USG-funded partners may participate in each TWG (OGAC, 2012).

5

For citations of interview data:

Country Visit Exit Synthesis Key: Country # + ES Country Visit Interview Citation Key: Country # + Interview # + Organization Type Non-Country Visit Interview Citation Key: “NCV” + Interview # + Organization Type Organization Types: United States: USG = U.S. Government; USNGO = U.S. Nongovernmental Organization; USPS = U.S. Private Sector; USACA = U.S. Academia; Partner Country: PCGOV = Partner Country Government; PCNGO = Partner Country NGO; PCPS = Partner Country Private Sector; PCACA = Partner Country Academia; Other: CCM = Country Coordinating Mechanism; ML = Multilateral Organization; OBL = Other (non-U.S. and non-Partner Country) Bilateral; OGOV = Other Government; ONGO = Other Country NGO.

6

Single quotations denote an interviewee's perspective with wording extracted from transcribed notes written during the interview. Double quotations denote an exact quote from an interviewee either confirmed by listening to the audio-recording of the interview or extracted from a full transcript of the audio-recording.

7

Supra, note 2.