This is the accessible text file for GAO report number GAO-10-836 entitled 'President's Emergency Plan For Aids Relief: Efforts to Align Programs with Partner Countries' HIV/AIDS Strategies and Promote Partner Country Ownership' which was released on September 20, 2010. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. 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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] GAO's Mission: The Government Accountability Office, the audit, evaluation and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. 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