Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment but Others Remain

In July 2004, GAO reported in Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment, but Others Remain (GAO-04-784) on the challenges facing the U.S. Global AIDS Coordinator in expanding anti-retroviral (ARV) treatment in resource-poor settings. The report identified several challenges, including difficulties coordinating with other stakeholders, particularly host governments, in providing treatment. GAO recommended that the U.S. Global AIDS Coordinator monitor implementing agencies' efforts to coordinate President's Emergency Plan for AIDS Relief (PEPFAR) activities with stakeholders involved in ARV treatment, including taking adequate steps to actively solicit the input of host government officials and respond to their input. In April 2008, the Coordinator's Office developed a framework for "partnership compacts" with host governments. These compacts represent a new operational concept for PEPFAR, replacing a donor-recipient paradigm relationship with a more consultative process. In addition, in 3 interviews GAO conducted with host government officials in January 2008 as part of a subsequent PEPFAR-related engagement (320504), the consensus was that PEPFAR has improved its efforts to work with host governments. The fiscal year 2008 Country Operational Plan (COP) guidance states that, as they develop their 2008 plans, PEPFAR staff "should include time in the schedule for active participation and review by the Host Country Government" and that "no COP should be submitted without host country concurrence." In addition, the fiscal year 2008 COP guidance encourages "wrap-around programming," in which PEPFAR activities complement those funded by other donors, e.g., by collaborating with the World Food Program to provide food and nutritional assistance for people receiving antiretroviral therapy. Furthermore, The COP reporting system now integrates U.S. government support to HIV/AIDS efforts through U.S. bilateral programs (e.g. U.S. Agency for International Development's Child and Maternal Health Program) and U.S. assistance to multilateral initiatives, such as the Global Fund; this helps coordinate PEPFAR activities with other U.S. government and global programs in country.

In July 2004, GAO reported in Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment, but Others Remain (GAO-04-784) on the challenges facing the U.S. Global AIDS Coordinator in expanding anti-retroviral treatment in resource-poor settings. The report identified several challenges, including inadequate contracting capacity in the field and other U.S. government administrative constraints. GAO recommended that the U.S. Global AIDS Coordinator collaborate with the Administrator of the U.S. Agency for International Development (USAID) and the Secretary of Health and Human Services (HHS) to address contracting capacity constraints in the field and resolve any negative effects resulting from the differing laws governing the funds appropriated to these agencies in the areas of procurement and foreign taxation of U.S. assistance, as well as, differing requirements for auditing non-U.S. grantees. In response, in September 2004, the Coordinator's Office established an interagency Procurement and Assistance Working Group to vet and disseminate guidance on procurement and assistance policy. An updated draft of this charter was circulated in 2005 and the final version was adopted in March 2008; the group includes, among others, HHS' directors for grants and acquisition policy in addition to HHS' Centers for Disease Control and Prevention's (CDC) Procurement and Grants Office. In addition, procurement and assistance experts from Washington and field missions in Africa met for the first time in the Fall of 2007 to discuss challenges, recommend solutions, and share new approaches. They laid out a number of actions to address capacity constraints in the field, including CDC sending a contracting officer and a grants management officer to South Africa in fiscal year 2008 on a pilot basis to remedy the fact that CDC has no acquisition or assistance officers overseas; USAID identifying acquisitions and assistance staffing needs in headquarters and the field and developing commensurate staffing plans; facilitating and increasing hiring of acquisitions and assistance staff, especially among potential employees already in-country; integrating acquisitions and assistance staff into the annual Country Operational Plan planning and staffing exercises; implementing cross-agency staffing rotations; and ensuring that all President's Emergency Plan for AIDS Relief (PEPFAR) Cognizant Technical Officers attend new training, scheduled to commence in 2008. Also, to date, USAID and HHS/CDC have added a total of 49 new procurement and legal staff. As for the differing laws governing the funds appropriated to PEPFAR implementing agencies, appropriations for all PEPFAR implementing agencies are increasingly coming to USAID and State from the same account - the 150 Foreign Operations Account. This percentage has steadily increased from 66 percent in fiscal year 2004 to 87 percent in fiscal year 2008.

The Office of the Global AIDS Coordinator has taken action to render this recommendation moot. Specifically, PEPFAR is now funding many of the generic ARV drugs that the Coordinator's Office had previously not approved. These generic drugs, many of which are fixed-dose combination pills, are much less expensive than the innovator (brand name) drugs PEPFAR had restricted its funding to earlier, and are also an easier regimen for patients to follow, since they only have to be taken once or twice a day. As of fiscal year 2007, over half of the drugs PEPFAR was supplying, both by volume and by cost, were generic.

In July 2004, GAO reported in Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment, but Others Remain (GAO-04-784) on the challenges facing the U.S. Global AIDS Coordinator in expanding anti-retroviral treatment in resource-poor settings. The report identified several challenges, including shortages of qualified health workers in host countries. GAO recommended that the U.S. Global AIDS Coordinator work with national governments and international partners to address the underlying economic and policy factors creating the crisis in human resources for health care. In response to our work, on April 17, 2008, shortly before the G-8 summit, the United States and the United Kingdom announced a joint effort to strengthen health care systems and support health workers in four African countries. Toward this end, the United States is planning to invest at least $1.2 billion over five years on health workforce development through the President's Emergency Plan for AIDS Relief (PEPFAR), with the aim of approaching the World Health Organization's (WHO) goal of at least 2.3 health workers per 1,000 people. The Coordinator's Office is also working with WHO to address the crisis in human resources for health care through a new initiative called "task shifting." In a December 2007 article in the New England Journal of Medicine, experts from WHO and PEPFAR argued that this policy of shifting certain health care tasks from more specialized to less specialized health workers is the one strategy that will have the most immediate effect on increasing the pool of health workers in resource-limited settings. The first guidelines for task shifting were developed by WHO with PEPFAR support and released in January 2008. Examples of task shifting include training nurses to initiate antiretroviral therapy, thus freeing up doctors to address more complicated issues such as treatment failure, and training patients to deliver some of the services currently undertaken by nurses, such as routine follow up and counseling. PEPFAR's new framework for improving working relationships with host country governments through "partnership compacts," drafted in April 2008, calls for promote task shifting as well. Additionally, PEPFAR country teams in the 15 focus countries plan to support nearly 2.7 million training encounters in fiscal year 2008 - including training in task shifting - more than the cumulative total in the preceding four years. PEPFAR is also addressing the health worker crisis by supporting the salaries for an increasing number of health care workers - nearly 105,000 in fiscal year 2008. The fiscal year 2009 Country Operational Plan (COP) provides continued backing for salary support, and task-shifting training for lay and community health workers. It also backs retention strategies for health workers by encouraging PEPFAR to work with host government health ministries to develop non-financial incentives, such as housing support in rural areas, to keep these workers from leaving the often impoverished communities they serve.