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: Published: Sep 20, 2010. Publicly Released: Sep 20, 2010.
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.
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. 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.
Recommendation for Executive Action
Status: Closed - Implemented
Comments: While commenting on the report, State concurred with GAO's recommendation. State subsequently indicated in its 60 day response letter that PEPFAR was responding to GAO's recommendation by working with McKinsey & Company to develop a framework that would permit measurement of country ownership. Briefing slides developed by PEPFAR and by McKinsey & Company in 2011, and PEPFAR FY 2012 Country Operational Plan (COP) guidance identified criteria, grouped as four "dimensions," to assess partner country ownership of PEPFAR programs. During a May 2012 meeting, an official from OGAC confirmed that OGAC had developed the four dimensions to assess country ownership, conducted pilots using the dimensions in two PEPFAR countries (South Africa and Botswana), and rolled out the assessment initiative to all PEPFAR country teams in PEPFAR FY 2012 COP Guidance issued by OGAC. The official also stated that GAO's report "absolutely" and "without a doubt" influenced the internal dialogue at OGAC about country ownership, and the decision to bring in McKinsey & Company to assist in developing the four dimensions. As such, we consider OGAC's actions to be responsive to our report.
Recommendation: To enhance PEPFAR country teams' ability to achieve the goal of promoting partner country ownership of U.S.-supported HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) activities, the Secretary of State should direct the Office of the U.S. Global AIDS Coordinator (OGAC) to develop and disseminate a methodology for establishing indicators needed for baseline measurements of country ownership prior to implementation of partnership frameworks.
Agency Affected: Department of State