PEPFAR was designed as an emergency prevention, care, and treatment response to the global HIV/AIDS epidemic. However, the work that is being done through PEPFAR can and should support advances in research. It must be systematically studied and analyzed to help inform public health and clinical practice. PEPFAR is improving efforts to contribute to the evidence base around HIV prevention, care, and treatment, as well as broader HSS and integration.

Types of Data Use Supported by PEPFAR

Key components of data use supported by PEPFAR include the following:

• Monitoring: Monitoring involves the routine collection and analysis of data to ensure that programs are on track to meet goals.
• Program Evaluation (PE): PE is a systematic and practical process of examining program implementation and outcomes in both the short and long term to improve and inform further development of the program.
• Special Studies: Special studies are driven by the specific and ad hoc needs for information not available from routine sources.
• Operations Research (OR): OR involves systematic and objective assessment of the availability, accessibility, quality, or sustainability of services, and is designed to improve service delivery. It assesses only factors that are under the control of program or project managers, such as improving the quality of services, increasing training and supervision of staff, and adding new service components. It may also compare effectiveness of delivery models and relative costs in achieving a desired program impact.
  
  PEPFAR’s OR refers to studies that guide PEPFAR partner country program and policy development, inform service delivery, and identify areas where further evaluation and research may be needed. These activities answer key questions, build knowledge applicable across the range of PEPFAR-funded sites, and assess the impact of PEPFAR programs on the population being served.

Information Utilization

At the outset of PEPFAR’s emergency response, information use and knowledge management targeted immediate returns in the forms of relatively simple output data. This focus reflected the program’s overall emphasis on rapid scale-up of services. While PEPFAR’s goal was to support national efforts to build information systems, the acceleration of service delivery sometimes resulted in parallel data systems. In the next phase of PEPFAR, the program is expanding tracking of quality, outcomes, cost-effectiveness, innovation, and impacts in both the short- and long-term. It is also continuing to monitor the scale-up and maintenance of prevention, care, and treatment programs.

In keeping with both PEPFAR’s focus on sustainability and the principles of the GHI, PEPFAR is reorienting away from parallel systems to more concerted support for national systems. Information is critical to all aspects of a health system; strengthening the national system for access to and use of data requires a unified and focused approach. PEPFAR is better integrating its own activities in monitoring and evaluation, survey and surveillance, health management information systems, and OR. Doing so supports a more uniform approach in providing guidance and assistance to partner countries. The primary goal of PEPFAR’s programming in this area is to build the country capacity necessary to implement and maintain a fully comprehensive data use strategy.

Indicators and Monitoring

PEPFAR released its Next Generation Indicators (NGI) in 2009. In conjunction with the shift from an emergency response to country capacity and sustainability, the NGI reflects emphasis on efforts to reconsider how to track and account for PEPFAR’s work. Use of improved and new indicators allows PEPFAR to strengthen the tracking and reporting of the full spectrum of work conducted in country programs. These indicators were developed in close consultation with other donors, multilaterals, and civil society to ensure the greatest degree of harmonization, and are designed to refine data collection around quality and coverage of service delivery and around data regarding PEPFAR’s support for capacity-building, policy development, and systems strengthening. Through these, PEPFAR increases streamlined support to a single national monitoring and evaluation system.

The NGI advanced PEPFAR’s progress in support of the UNAIDS Monitoring and Evaluation Reference Group (MERG) goal to harmonize indicators across governments and donors alike. Thirty-four percent of the NGI are fully harmonized across all MERG member organizations. Seventy-four percent of the NGI are partially or fully harmonized with at least one multilateral organization (WHO, UNAIDS, UNICEF, World Bank, or Global Fund). As additional indicators are developed to measure items like HSS, integration, and progress on gender, PEPFAR will continue to work with its international partners to use the same benchmarks in measurement and monitoring. Using common indicators allows for comparison across PEPFAR countries and programs.

Data Collection and Analysis

During the first five years of PEPFAR, the program’s focus on accountability and results meant that country teams collected a substantial quantity of data. Data included program outputs, documentation of demographics, and behavioral patterns of populations and sub-populations. In its next phase, PEPFAR is working with country counterparts to define broad “data-use frameworks.” These can help to determine data needs and strengthen processes for data collection, management, and analysis, allowing countries to better translate data for use within decision-making structures.

PEPFAR is assisting countries to engage in the targeted data collection and mapping necessary to define need for services. To do so, countries need trained personnel to engage in data collection and OR. PEPFAR’s larger training goals for both health workers and broader health systems professionals will help countries expand this capacity. More information about PEPFAR’s data collection can be found at www.pepfar.gov/2009results/.

PEPFAR Operations Research

Operations research, a term which has been used interchangeably with public health evaluation (PHE) for most of PEPFAR, is a mechanism through which to assess the effectiveness or impact of a program. Through OR, PEPFAR can compare program models, answer questions related to program implementation, and seek evidence in support of innovation. With OR, PEPFAR, at the individual or multi-country level, continually collects data and evaluates implementation in an objective manner, thus identifying best practices that should be scaled up. Such evaluation contributes to improvement of programs globally and informs decisions about future resource allocations. The feedback loop of OR is distinct from, and does not replace, ongoing program monitoring or basic program evaluation. It also does not encompass clinical or basic medical research.

These studies may be proposed by country teams working in collaboration with local scientists and governments, promoting the development of local capacity in evaluation and the local use of data to guide programs. In addition, involvement of government entities, PLWHA, local universities, and other key stakeholders in the oversight and implementation of OR helps to support an expansion of national research capacity.

PEPFAR’s OR process will be improved to contribute to more effective implementation. In previous OR efforts, many proposed country-level studies addressed similar questions, and a lack of coordination limited comparability of results. There was a lack of uniformity regarding quality or applicability of results. Some PEPFAR studies replicated or did not take into account similar research being funded by other organizations. In order to address these concerns, PEPFAR implemented a full review and revision of the process in 2008.

In the future, priority will be given to OR studies that:

• focus on improving program delivery,
• ask and answer questions that PEPFAR is uniquely poised to research, and
• provide clear answers about the efficiency, effectiveness, and impact of programs in a timely manner.

PEPFAR is also encouraging OR studies that involve multiple countries and coordinated methodologies. These studies will be rigorously managed to meet the highest quality assurance standards.

Transparency, Dissemination and Use

To maximize benefits from a more expansive and coherent monitoring, evaluation, and OR agenda, PEPFAR is placing greater emphasis on the dissemination and use of the results of its work. PEPFAR is organizing a process to identify monitoring and evaluation reports and make these data accessible to expand learning opportunities. A corollary to the dissemination of reports and publications is the accessibility of data for additional research. PEPFAR is working within the context of the OR process to include a requirement to make data publically available.

Innovation

When it was created, PEPFAR represented an innovative model for providing foreign assistance. In turn, PEPFAR has worked to support innovative methods of service delivery in its programming, from public-private partnerships that utilize cell phones and video games in HIV programming, to supporting promising pilot initiatives like the use of electronic medical records. PEPFAR is expanding its efforts to support promising interventions and expand the capacity of local organizations within partner countries to create and support such interventions. Activities supported include the following:

• Expanding linkages between implementers and scientists to support identification and scale-up of promising practices across health and development sectors;
• Creating better collaboration and country support for public-private partnerships to increase public health system awareness and use of groundbreaking technologies that are common in the private sector; and
• Supporting innovative multisectoral linkages to address the structural interventions that contribute to HIV transmission.

More information on PEPFAR’s work to support innovation with public-private partnerships can be found in additional annex documents available at www.pepfar. gov/strategy/.

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