�HIV/AIDS is a global health crisis and a constant struggle for many of our families, friends, and neighbors. On World AIDS Day, we underscore our commitment to fight the AIDS pandemic with compassion and decisive action.�
President George W. Bush
With the President�s Emergency Plan for AIDS Relief (Emergency Plan/PEPFAR), for the first time the U.S. Government (USG) has a unified, strategic approach to international development in order to ensure results. Rather than creating a new agency, PEPFAR established an innovative �virtual organization� model to create and implement a unified, USG-wide strategy on global HIV/AIDS.
During 2006, Ambassador Mark Dybul was sworn in as the second U.S. Global AIDS Coordinator, succeeding Ambassador Randall Tobias. The Coordinator, reporting directly to the Secretary of State, has primary responsibility for the oversight and coordination of all USG global HIV/AIDS spending, and strategically leverages the particular strengths of all USG agencies involved in HIV/AIDS interventions. These agencies are:
At its inception, PEPFAR�s imperative to embrace a �new way of doing business� created numerous implementation and management challenges. PEPFAR has instituted systems to learn from its implementation hurdles and successes, and translate those lessons learned into action. PEPFAR is focused on meeting challenges while continuing to evolve in order to address emerging needs. In light of the results PEPFAR has achieved, there is a broad recognition � within and beyond the USG � that the interagency PEPFAR model is effective and should be maintained. Credit for its success belongs to the people of PEPFAR�s primary implementing agencies � both in the field and in Washington � who have demonstrated the power of a unified USG response.
The Coordinator continues to chair a weekly meeting of the Policy Group, comprised of the principals at the lead implementing agencies and other key Executive Branch stakeholders. This group provides policy leadership, including approval of policy guidance for program implementation. In 2006, the Policy Group identified a number of key issues to target for improvement, including organizing procedures for systematically reviewing USG support for international HIV/AIDS efforts; USG interagency participation in international meetings; and the approval process for PEPFAR policy guidance.
Senior OGAC staff chair a weekly meeting of Deputy Principals from USG participating agencies, who focus on program management issues. The Deputy Principals develop and implement procedures to respond to policy requests, and they support a systematic decision-making process. In 2006, this group sought both field and headquarters reviews and recommendations for improving PEPFAR initiatives ranging from the Implementers� Meeting to Public Health Evaluations; Country Operational Plan (COP) reviews; and priorities for international HIV/AIDS coordination.
The Coordinator also holds quarterly coordination calls with the Chiefs of Mission (COMs) to PEPFAR countries. These calls provide an opportunity for OGAC to update the COMs on implementation, management, and budget issues, as well as discuss in-country issues and ways to improve PEPFAR implementation.
A Scientific Steering Committee meets regularly to ensure that PEPFAR programs are scientifically sound. In 2006, PEPFAR began transitioning from targeted evaluations to Public Health Evaluations (PHEs). A PEPFAR PHE strategy was approved and a new evaluation management structure was implemented. This strategy responds to USG staff recommendations for a more coordinated approach to program evaluations, and recognizes the needs and opportunities to systematically identify and answer critical questions across countries in order to facilitate the continued improvement in scope and quality of PEPFAR programs.
To oversee this new approach, a PHE Subcommittee was formed. The new Subcommittee has the authority to convene Evaluation Teams and is the focal point for the annual development of PEPFAR-wide evaluation priorities, based upon input from the broader PEPFAR community. Partners and USG staff, both in-country and at headquarters, have the opportunity to submit ideas for high-priority evaluation areas and studies; they also will be able to participate in the design and implementation of studies. The PHE Subcommittee is now developing a list of evaluation priorities for 2007.
Technical and Operational Working Groups � which are co-chaired by OGAC and agency personnel, with headquarters and field representation � formulate technical guidance and support implementation in the field. In 2006, PEPFAR�s interagency Technical Working Groups produced quality improvement measures that countries may use to monitor program quality.
Country-specific interagency Core Teams also continue to serve as a source of technical assistance, as well as a channel through which information can flow between the field and headquarters. In 2006, best practices in structuring and operating USG country teams were developed based on peer reviews and experience, and were disseminated to the field. These best practices include adding a PEPFAR Country Coordinator in focus countries, and scheduling country team and partner meetings. USG country management and staffing details are now included in COPs and reviewed by headquarters.
OGAC�s Program Management Systems division and the interagency Management and Staffing Technical Working Group address management issues that arise as part of PEPFAR implementation. They also troubleshoot issues and devise systematic solutions, which are then shared with relevant stakeholders. In order to evaluate staffing required to implement and manage PEPFAR, OGAC is examining current staffing requirements, both at headquarters and in the field. �Staffing for Results� is a key initiative that aims to improve in country management and staffing practices, with the goal of developing a long term USG staffing plan for implementation of HIV/AIDS programs. In 2006, interagency Deputy Principal teams visited five countries to promote this concept; further visits are planned for 2007. This initiative is leading to an innovative approach to staffing, using a single USG organizational chart for HIV/AIDS in-country rather than an agency-specific structure. The approach will be formalized and instituted in 2007.
In the focus countries where the interagency country team approach has been pioneered, the Staffing for Results model has sharpened the focus of programming, helping to ensure that decisions are made in a strategic fashion. This model has also helped to promote a unified voice and strategy for interacting with host governments and other partners.
The expansion of Staffing for Results to a growing number of countries is a PEPFAR priority. In the field, PEPFAR is also working to disseminate best practices developed in the focus countries to all PEPFAR countries. Increasingly, country teams are talking to each other in order to share concerns, successes, and lessons learned.
Country Operational Plans and Reporting
In keeping with the principles of the �Three Ones,� COPs are developed in close consultation with partners in-country, in particular the host country government, to:
Fiscal year 2007 is the fourth year for which COPs have been required in the focus countries, and both the COPs themselves and the process for their review continue to improve with each year of experience. After submission of the COPs to OGAC, interagency technical teams assessed the technical quality of proposed activities and management, as well as consistency with PEPFAR strategies. Programmatic teams then reviewed entire COPs from a more strategic perspective, incorporating the technical review findings. The findings then were discussed in detail with country teams. Program review teams submitted recommendations and comments to the interagency Policy Group, which is chaired by the Coordinator, who then made final funding decisions. In addition to technical reviews, in 2006, focus country management and staffing were also analyzed through the introduction of new country management and staffing charts in the COPs. Recommendations then were made in COP reviews for strengthening country staffing, including having teams of Deputy Principals visit those countries that had management and staffing challenges in order to help resolve issues.
The results reporting system is critical to PEPFAR accountability and is another key element of this country team approach. It is being expanded in stages to the bilateral programs outside of the focus countries. In fiscal year 2006, all bilateral programs that receive $1 million or more in USG HIV/AIDS funding reported their performance against a set of common PEPFAR indicators. Specific reporting requirements by country are determined by funding level and are detailed in the general policy guidance document for all bilateral programs (see the chapter on Strengthening Bilateral Programs).
For fiscal year 2006, OGAC expanded COP and reporting requirements to five other bilateral countries that are receiving more than $10 million in HIV/AIDS funding annually. Six countries that receive more than $5 million in HIV/AIDS funding annually completed five-year PEPFAR planning strategies. For fiscal year 2007, a total of 16 other bilateral countries (in addition to the 15 focus countries) completed mini-COPs, which are abbreviated versions of the full COPs.
Augmenting existing programs funded through the COP process, the New Partners Initiative (NPI) is increasing PEPFAR�s ability to reach people with needed services by identifying potential new partner organizations. Under the NPI, the Emergency Plan will award a series of grants totaling approximately $200 million for new partners to serve the Emergency Plan�s 15 focus countries. With NPI funding, these organizations will increase their capacity to provide prevention and care, strengthening capacity in host nations to address HIV/AIDS and thereby promoting the sustainability of future HIV/AIDS efforts. Eligible entities are non-governmental organizations working in any of the 15 Emergency Plan focus countries, with little or no experience working with the USG, defined as having received no more than $5 million in USG funding during the preceding five years, excluding disaster and emergency assistance or funding as a subcontractor. Announced on World AIDS Day, December 1, 2006, the first round of three-year NPI grants will award a total of up to $72 million to 22 recipient organizations.
Internal and External Communication
Program evaluations disseminated at the 2005 Annual Meeting indicated a need for better sharing of information about best practices in the field and improved technical assistance and peer-to-peer communications. In direct response to these expressed needs, OGAC established the PEPFAR Extranet in June 2006. The Extranet, which is open to all USG employees working on PEPFAR, contains country team sites, technical working group sites, News to the Field, and group spaces for policy and program operations program development. Use of the site is evaluated monthly, and more extensive user evaluations are conducted at regular intervals.
Weekly News to the Field email messages serve as a vehicle for dissemination of PEPFAR guidance, immediate answers to questions concerning PEPFAR policies and processes, and other information to the field. In December 2006, OGAC began a new series of monthly video conferences on implementation, management, and strategic information challenges and best practices. They provide regular opportunities for headquarters and country-based staff to present and exchange information.
In fiscal year 2006, an OGAC information technology (IT) strategic plan was researched, written, and implemented. Four goals and 19 initiatives support OGAC�s business plans and processes and address enhanced collaboration and knowledge management, improvements in the use of mobile computing and communication technologies, improvements in workforce IT skills and support, and improved data quality and data management processes. The 19 initiatives are completed or pending, and a continuing process for updating the plan is in place. This will promote use and dissemination of relevant PEPFAR information to the public and to personnel and partners in the field, as well as addressing the operational needs and data management issues of PEPFAR.
In response to requests for improved internal communications, OGAC organized monthly Executive Branch briefings, which are attended by USG employees from any agency who want to learn more about what PEPFAR is doing. At the request of participants, a �spotlight issue� segment recently was included in these meetings. After U.S.-based non-governmental organizations requested a forum for their questions, PEPFAR began holding quarterly meetings in Washington or New York City.
From its inception, PEPFAR has insisted on connecting funding to results. Decisions on funding and continuation of partnerships are tied to performance in terms of targets that have been set by country teams and partners and finalized in the COPs. In the field, country teams conduct annual reviews of partner performance prior to submitting COPs for the succeeding year. In 2005 and 2006, each focus country analyzed progress toward its targets in key areas such as treatment, care, counseling and testing, and prevention of mother-to-child transmission; these analyses enabled headquarters agencies to propose future budget requests and establish a set of budget allocations for 2006 and 2007 funding. The Principals� and Deputy Principals� planning groups used this information when making country comparisons of targets-to-results and results-to-costs in funding decisions.
PEPFAR has also developed valuable tools with which to strengthen this performance-based budgeting approach. Based on analysis conducted during fiscal year 2005, select high-performing countries received additional resources for fiscal year 2006, while others that performed below expectations were maintained at their base levels. In fiscal year 2007, PEPFAR will continue to apply and refine its tools for performance-based budgeting in order to ensure optimal use of prevention, treatment, and care resources.
In fiscal year 2007, PEPFAR country teams will report on their partners� programmatic and financial performance in the Semi Annual Program Results report. Country teams will assess how well partners are meeting their goals and maintaining good implementation practices. The reporting will formalize countries� ongoing �pipeline� analyses (which assess partner efficiency in putting funds to work), assessment of cost-effectiveness of partner activities, and review of partners� performance against targets established in the COPs.
PEPFAR also reports on its targets and results in a variety of strategic planning reports, including agency planning and results reports and OMB�s Performance Assessment Rating Tool (PART). In spring and fall PART updates, PEPFAR reports on progress in the focus countries and other bilateral countries, as well as progress of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).
PEPFAR Annual Meeting and 2006 HIV/AIDS Implementers� Meeting
The Annual Field Meeting included extensive programmatic presentations and papers. In addition, representatives of PEPFAR country teams � led by their Ambassadors � reported on their implementation challenges, successes, and lessons learned. This sharing of information generated invaluable dialogue among the country teams.
Representing more than 50 countries worldwide, over 1,000 people attended the 2006 HIV/AIDS Implementers� Meeting. They included implementers from selected PEPFAR partners, including host governments; indigenous community- and faith-based organizations; and organizations that are not USG partners. The vision for this meeting was to provide a forum for HIV/AIDS implementers worldwide to discuss the successes and challenges of bringing programs to scale and to share lessons learned. More than 500 oral and poster abstracts were presented during the Implementers� Meeting. Abstracts and presentations from the meeting are available on the conference website (http://www.blsmeetings.net/implementhiv2006).
Together, implementers will exchange lessons learned on building the capacity of local prevention, treatment, and care programs, maintaining quality control, and coordinating efforts. This forum will facilitate an open dialogue about future directions of HIV/AIDS programs, with a strong emphasis on best practices and implementation of PEPFAR and other programs.
Streamlining Reporting Requirements
Interruptions or disruptions in the supply of antiretroviral drugs can be disastrous for people receiving this life-saving treatment. PEPFAR is committed to supporting a supply system that prevents this from occurring. PEPFAR initiated the Partnership for Supply Chain Management in 2005, which manages the Supply Chain Management System (SCMS) project. SCMS, described in the chapters on Treatment and Building Capacity: Partnerships for Sustainability, will improve the supply chain in order to ensure an uninterrupted supply of high-quality, affordable products.
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