Overview of the President’s Emergency Plan for AIDS Relief (PEPFAR)
By Myra Sessions[1]Full text PDF available(155, KB)
I. IntroductionThe President's Emergency Plan for AIDS Relief, also called PEPFAR or the Emergency Plan, is a five-year bilateral commitment by the United States Government to support HIV/AIDS prevention, care and treatment programs in developing countries. Authorized to spend $15 billion in five years (fiscal years 2004-2008), PEPFAR is the largest-ever global health initiative dedicated to a single disease. PEPFAR employs a unique model of aid delivery that emphasizes concentrating resources in a few countries to rapidly scale-up proven interventions.[2] This approach seeks to maximize impact and reach pre-determined, program-wide targets, including providing ARV treatment to 2 million people, preventing 7 million new infections, and caring for 10 million of those infected (these are sometimes called the 2-7-10 targets). This paper provides a general overview of PEPFAR policies and programs. More information can be found on the website of the Office of the Global AIDS Coordinator.
II. History and Political FrameworkPEPFAR was first announced by President George W. Bush during his 2003 State of the Union Address. In May 2003, Congress enacted and the president signed the "U.S. Leadership Against AIDS, Tuberculosis and Malaria Act of 2003" (P.L. 108-25). The law authorized spending of up to $15 billion over 5 years and created the Office of the Global AIDS Coordinator (OGAC) to manage and coordinate U.S. Government-supported HIV/AIDS programs in developing countries. The law also mandated that the executive branch develop a "comprehensive, integrated, five-year strategy to combat HIV/AIDS that strengthens the capacity of the United States to be an effective leader in the international campaign against AIDS."[3] Besides providing the general policy framework, the law outlines PEPFAR funding priorities, including:
These percentages served as a guideline for the first two years of the initiative, 2004-2005. However, for 2006-2008 the law stipulates that "not less than 55 percent" of the appropriation "shall be expended for therapeutic medical care of individuals infected with HIV, of which 75 percent should be expended for the purchase and distribution of anti-retroviral pharmaceuticals."[4] Congress endorsed the president’s proposal of 14 focus countries for concentrated PEPFAR resources: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda and Zambia and later added a fifteenth country: Vietnam. As outlined by Congress, OGAC performs three distinct roles in the implementation of PEPFAR:
In all focus countries except Vietnam, and to a lesser extent Guyana, PEPFAR represents a rapid scale-up and expansion of existing bilateral HIV/AIDS program support. US Government agencies have been supporting HIV/AIDS programs in developing countries since 1986, although before the advent of PEPFAR, these resources were relatively limited.
III. Structure of the OrganizationPEPFAR is centrally managed by OGAC in conjunction with other United States Government (USG) agencies and is implemented by US Embassies and US Government Agency offices in developing countries.
Field: In focus countries, PEPFAR is administered by the US ambassador who reports (on these issues) to the Global AIDS Coordinator and has the responsibility to sign-off on all planning and reporting documents submitted to OGAC. The day-to-day implementation and management of the programs, however, is conducted by the in-country staff of the USG agencies, primarily USAID and the CDC. In some countries, these agencies collaborate with other USG institutions including the Department of Defense, the Department of Labor, the Peace Corps, and the US Embassy who all support programs among their respective constituencies. All USG agencies collaborate to plan programming at the beginning of each fiscal year (called a "Country Operational Plan") and for periodic results report to OGAC. This cross-agency collaboration and unification, meant to capitalize on each institutions’ comparative advantages and reduce duplication, is a new model for USG development assistance. Although not exclusive, the general division of implementation and management responsibilities between the different USG agencies can be described as below. More information can also be found at: http://www.state.gov/s/gac/agencies/.
IV. Available FundingThe Office of the Global AIDS Coordinator receives an annual appropriation from the US Congress for PEPFAR programming. Although divided between two different appropriations bills (Foreign Operations and Health and Human Services) the total appropriation for fiscal year 2006 was $3.2 billion. This is an increase from $2.8 billion in fiscal year 2005 and $2.4 billion in fiscal year 2004. [9] For fiscal year 2007, President Bush requested a total of approximately $4 billion for PEPFAR programs. The majority of the PEPFAR resources are dedicated to focus-country programs. Although the size of focus-country programs differs widely based on population, in-country capacity and other factors, all countries receive sizable levels of funding. As shown in Table 1, in fiscal year 2005, Guyana had the smallest total budget at $19 million; Uganda had the largest budget at $148 million. [10] Six focus countries (Kenya, Nigeria, South Africa, Tanzania, Uganda and Zambia) had annual budgets of greater than $100 million. [11] Table 1: Annual Appropriations for PEPFAR Focus Countries, FY 2004-2005
In fiscal year 2005, $293 million of the total resources were dedicated to non-focus country bilateral programs in 108 countries.[12] Of these resources, five nations (Malawi, Zimbabwe, India, China and Russia) received more than $10 million each, 13 countries received between $5 million and $10 million, and an additional 20 received between $1 million and $5 million. The remaining 70 countries received less $1 million each.[13] The PEPFAR appropriation also includes the United States' contribution to the Global Fund for AIDS, Tuberculosis and Malaria, worth $414 million in 2005.[14] Although Congress has granted PEPFAR some flexibility in budgeting by allowing annual funding to remain "available until expended,"[15] the vast majority of the annual allotment is obligated to partner organizations before the end of the fiscal year. However, delays in the Congressional appropriations process as well as the lengthy in-country planning and OGAC approval procedures, fiscal year activities are often not launched until at least April (and run for 12-18 months).
V. What PEPFAR SupportsIn all 15 focus countries, PEPFAR supports a comprehensive program in HIV/AIDS prevention, care and treatment, as well as limited activities in health system strengthening as it relates to HIV/AIDS, monitoring and evaluation and policy reform. Not being an implementing agency itself, the USG provides grants to implementing organizations to perform activities according to the USG comprehensive strategy and country targets. To date, many of the direct grants have been made to international NGOs and host-country government agencies, with sub-contracts to local organizations, although there is new emphasis placed on building local capacity to the point that local organizations will be able to compete for and receive grants directly from USG agencies. In fiscal year 2005, 53% of all prime partners and 93% of sub-partners were local organizations or governments.[16] In non-focus countries, the US bilateral programs often do not have sufficient resources to support fully comprehensive HIV/AIDS programs. Instead, USG resources are often leveraged with resources from other donors to provide funding for prevention, care and/or treatment. PEPFAR only supports programs that are directly related to HIV/AIDS prevention, care and treatment, although they will leverage resources from other USG development assistance programs (i.e. P.L. 480 food assistance and USAID development assistance programs) where necessary. In some cases, OGAC has issued specific guidance about how resources may be used. This guidance includes, most notably, the guidance on PEPFAR-supported ABC activities for prevention.
VI. How PEPFAR Funds ProgramsAlthough loosely organized around the themes of prevention, care and treatment, OGAC has developed a system of 13 program areas around which focus-country programs are planned and funded. These program areas also form the framework for reporting results to OGAC. Before each fiscal year (the US fiscal year begins October 1), the USG agencies meet with partners and the host-country government to plan and budget activities. This plan, the USG Country Operational Plan (COP), is approved by the host-country government and then sent to OGAC for approval. OGAC has the authority to approve or reject any PEPFAR-supported activities. A compilation of all focus-country activities for fiscal year 2005 can be found in the Emergency Plan for AIDS Relief Fiscal Year 2005 Country Operational Plan (PDF). All PEPFAR-supported programs are implemented through partner organizations, often international NGOs, which receive direct grants from the USG agencies in order to perform specific project activities. Often these grantees will sub-grant funding to smaller, local or community-based organizations that perform a defined set of activities that contribute to the project goal. In selecting partner institutions to implement programs, PEPFAR teams in host countries have three broad options that differ in terms of the management burden as well as local control over design. All focus-country programs are comprised of a mix of all three types of management approaches: Country Managed, Country Funded Programs: These programs are funded and managed by the USG team in the focus countries. Although many of these grants are direct agreements between the USG and the host-country governments, as PEPFAR matures there are increasing numbers of locally designed and procured contracts for NGOs. These openly competed contract mechanisms are often used when there situations, gaps or needs particular to the host-country, or as a way to engage more local organizations as prime partners. Centrally Managed, Country Funded: Accounting for the majority of PEPFAR funding, these are mechanisms that in-country teams choose to support. These contracts are either pre-existing (prior to PEPFAR) agreements between USG agencies and international NGOs, or new projects that have been designed centrally to meet the perceived needs of PEPFAR focus-countries. The central agencies provide minimal funding to these projects for management, and all programmatic funding comes from in-country offices. By buying into these pre-existing, multi-country projects, the focus-country teams retain control over the budget and activities conducted by the partners, but without the additional management burden. The new Supply Chain Management System contract is an example of a centrally managed, country funded project. Centrally Managed, Centrally Funded: Also referred to as "track 1" grants, this mechanism of funding programs was used frequently in fiscal year 2004 to initiate programs and achieve rapid scale-up of prevention, care and treatment programs in focus countries. These programs were designed by OGAC and competed by one of the central USG agencies. Track 1 grants are on-going throughout the life of PEPFAR in countries that opted to welcome them. Since these partners are centrally funded, their work does not count against the budgets of the focus-countries, although they are expected to report to both the in-country and central offices.
VII. How Results Are Measured and ReportedUSG teams in focus countries submit two result reports to OGAC annually: a semi-annual report covering the first six months of the fiscal year is submitted in May, and an annual report covering the entire fiscal year is reported in November. Data for the program level indicators reported in these two results reports are collected from implementing partners and are reported in all 13 program areas. Generally, the indicators provide data on:
In addition, with the annual report in November, USG teams submit data on impact- or outcome-level indicators (such as HIV prevalence, high risk sexual behavior, access to ARV treatment, proportion of deaths attributed to HIV, capacity of health care centers, etc.) when relevant data have been collected. These outcome- and impact-level indicators are measured in conjunction with other international health and HIV/AIDS entities, such as the Global Fund, UNAIDS and the WHO, and are meant to move PEPFAR toward the “three-ones” goal of one unified monitoring and evaluation plan. More information and definition of all PEPFAR focus-country indicators can be found in the Indicators, Reporting Requirements and Guidelines for Focus Countries (pdf-revised for FY2006 reporting). In addition, OGAC has issued specific guidance on reporting requirements for non-focus countries (pdf) that receive more than $10 million annually and for countries that receive between $1 million and $10 million annually (pdf). The requirements for these smaller programs include a subset of the required program-, outcome- and impact-level indicators, although there are distinctions made between countries with generalized epidemics and those with concentrated epidemics. To capture the full reach of programs in terms of the 2-7-10 targets, PEPFAR has defined a system of results reporting that includes people reached by both direct, “downstream” assistance as well as more indirect, or “upstream” assistance, including system strengthening, training etc. More information about downstream and upstream reporting can be found in the PEPFAR Reporting guidance (pdf).
VIII. Analyses that have been written about PEPFARTo date, there have been few if any comprehensive analyses written about PEPFAR. However, there are numerous assessments and information sources about PEPFAR programming, priorities and implementation from various perspectives. Advocacy and Research Organizations:
Formal Evaluations and Internal Audits The Inspector General of the USG Agencies have conducted several audits of the implementation of PEPFAR activities in several focus countries, with more to be completed in fiscal year 2006.[17] These include the USAID Inspector General's reports on audits of the participation of USAID/Rwanda (pdf) and USAID/Ethiopia (pdf) in the implementation of PEPFAR. Government Accounting Office (GAO)
IX. Useful links
[1] The author benefited from the contributions of Celina Schocken and Nandini Oomman, both of the Center for Global Development. [2] Since the advent of PEPFAR, other USG foreign assistance programs, notably the President’s Malaria Initiative, have followed a similar model. [3] P.L. 108-25, The US Leadership against AIDS, Tuberculosis and Malaria Act of 2003 http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=108_cong_bills&docid=f:h1298enr.txt.pdf The PEPFAR Five-Year Strategy can be found at: http://www.state.gov/documents/organization/29831.pdf [4] P.L. 108-25. [5] P.L. 108-25 dictates the United States’ contribution to the Global Fund, including language limiting the US contribution to not more than one-third all contributions to the Global Fund from all sources for any given year. [6] "Implementing Agencies" OGAC website. http://www.state.gov/s/gac/agencies/53564.htm [7] These countries include Malawi, Zimbabwe, India, China and Russia. All five programs receive more than $10 million annually from the USG for HIV/AIDS programs. [8] See OGAC Organization Chart, found at: http://www.state.gov/documents/organization/57731.pdf [9] Action Today, A Foundation for Tomorrow: Second Annual Report to Congress on the President’s Emergency Plan for AIDS Relief; p. 9. Accessed at: http://www.state.gov/s/gac/rl/c16742.htm [10] These figures include centrally funded programs (see section V. for explanation). Without centrally-funded programs, Guyana received $15.7 million and Uganda received $132 million. [11] Action Today, A Foundation for Tomorrow; Annex III “Allocation of Funding to Focus Countries.” [12] In some of these countries, there is no USG presence. HIV/AIDS activities in these contexts are managed through regional programs. [13] Action Today, A Foundation for Tomorrow; p. 14. [14] This is the amount actually contributed to the Global Fund, which can be lower that the appropriation for a particular year for several reasons. From “Financing the Global Fund to Fight AIDS, TB and Malaria in 2007,” Friends of the Global Fight Fact Sheet, February 2006. http://www.theglobalfight.org/downloads/Fact_Sheets/FY07_Financing_Global_Fund.pdf [15] P.L. 108-25 [16] Website of the Office of the Global AIDS Coordinator, “Partners” section: http://www.state.gov/s/gac/progress/other/data/partners/60363.htm [17] Action Today, A Foundation for Tomorrow; p. 142 |