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Evaluation of PEPFAR (2013) / Chapter Skim
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7 Children and Adolescents
Pages 347-390

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From page 347...
... . Defined age ranges for children and adolescents also vary by programmatic area within PEPFAR, which uses ages 0 to 17 years for orphans and 347
From page 348...
... The population of children and adolescents affected by HIV varies by geographic, demographic, social, and cultural factors, and their needs and the responses to these needs vary according to these factors as well as to their developmental stage and gender. Globally, approximately 3.3 million children younger than 15 years of age were living with HIV in 2011, and 330,000 children acquired new HIV infections that year vulnerable children (OVC)
From page 349...
... . Children and adolescents living within communities that experience a high HIV burden are also at a greater risk of homelessness, of exposure to HIV, and of physical and sexual abuse and exploitation (UNAIDS et al., 2002, 2004)
From page 350...
... . The Committee on the Rights of the Child monitors the progress of countries in achieving standards and goals.5 Multilateral and bilateral stakeholders who support efforts and policies for OVC affected by HIV/AIDS have developed the Framework for the Protection, Care, and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS.
From page 351...
... It also stated that PEPFARsupported programs need to "provide care and treatment services to children with HIV in proportion to their percentage within the HIV-infected population of a given partner country."7 Additionally, PEPFAR II performance targets for the care and support of people living with HIV include the specific target of providing care and support for 5 million children and adolescents orphaned or made otherwise vulnerable by HIV/AIDS.8 The committee's assessment of prevention, care, and treatment, including for children and adolescents, were covered in more detail in Chapters 5 and 6. In brief, PEPFAR support has made a major contribution to meeting the need in partner countries for prevention of mother-to-child transmission 6  For the purpose of brevity, the acronym OVC will be used to describe programs or pro gramming targeting eligible children and adolescents under PEPFAR's programs for orphan and vulnerable children.
From page 352...
... The total planned/approved funding that can be documented from these budget codes as explicit support for services for children and adolescents includes a total from FY 2005 to FY 2011 of $2.3 billion, including $1.7 billion for OVC programs, as well as at least $160 million for pediatric HIV care and $405 million for pediatric treatment. Although these data give a general sense of the funding history and provide an approximation of PEPFAR's overall investment in children and adolescents, it is important to note that it is difficult to compile an entirely accurate accounting over time of the total investment that has gone to serve this population of beneficiaries.
From page 353...
... Finally, some PEPFAR supported services for this population are not included in these codes but instead are in budget codes that are not tracked separately by age, such as prevention services for youth when not explicitly a part of OVC programs (OGAC, 2011b)
From page 354...
... . for HIV/AIDS assistance for each such fiscal year shall be expended for assistance for orphans and vulnerable children."9 This earmark was preserved when the Lantos-Hyde Act of 2008 reauthorized PEPFAR.10 PEPFAR's policy for implementing this budgetary requirement is provided in the instructions to country programs on planning and budgeting for OVC programming through Country Operational Plan (COP)
From page 355...
... . Given these complications, in order to reasonably and comparably approximate the compliance with the legislative earmark across PEPFAR partner countries and over time, the committee chose to assess the available planned/approved funding data reported through the OVC budget code, compiling the totals for prevention, care, and treatment program resources as the denominator using the FY 2011 definition retrospectively for all years (therefore excluding the laboratory infrastructure budget code)
From page 356...
... OVC as % of Total 8% 9% 10% 10% 11% 11% 10% 10% Program Resources NOTES: This table represents funding for all PEPFAR countries as planned/approved through PEPFAR's budget codes. The budget codes are the only available source of funding information disaggregated by type of activity and are therefore used in this report as the most reasonable and reliable approximation of PEPFAR investment by programmatic area.
From page 357...
... . PEPFAR'S PROGRAMS AND SERVICES FOR ORPHANS AND VULNERABLE CHILDREN OVC Program Guidance and Supported Activities PEPFAR provides guidance for programs aimed at meeting the needs of children and adolescents living with and affected by HIV through programming guidance documents, "Technical Considerations" provided by headquarters-level technical working groups, and the COP guidance, which is released annually at the beginning of the country planning process.
From page 358...
... identifies important elements of child and adolescent well-being in seven core areas that are based on the principles of the Framework for the Protection, Care, and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS (UNICEF, 2004)
From page 359...
... . Further, PEPFAR-supported activities under OVC programs include not only services that directly support orphans and vulnerable children and adolescents but also those that support their caregivers, families, and community structures (OGAC, 2009b)
From page 360...
... . Protection  PEPFAR OVC programs that address the protection of orphans and vulnerable children and adolescents may focus on interventions such as health care and social services that facilitate birth registration and identification, community-based assistance to orphans and vulnerable children who need to make inheritance claims, the removal of children from abusive situations and their placement in safe temporary or permanent living situations, and the strengthening of community structures that are responsible for monitoring and protecting orphans and vulnerable children (OGAC, 2006b)
From page 361...
... These activities include microfinance programs for the caregivers of orphans and vulnerable children, small business development, and community-based asset building. Programs also provide orphans and vulnerable children and adolescents with training and other skills that can improve their economic opportunities in the future (OGAC, 2006b)
From page 362...
... . OVC = orphans and vulnerable children a Results and targets for FY 2004-FY 2009 correspond to OGAC indicator 8.1 (direct)
From page 363...
... Academia; Partner Country: PCGOV = Partner Country Government; PCNGO = Partner Country NGO; PCPS = Partner Country Private Sector; PCACA = Partner Country Academia; Other: CCM = Country Coordinating Mechanism; ML = Multilateral Organization; OBL = Other (non-U.S. and non-Partner Country)
From page 364...
... . 16 As described by an interviewee in one country, ‘Support for orphans and vulnerable children has [positively]
From page 365...
... . In another, a PEPFAR-supported partner country nongovernmental organization designed a model to keep children from going into residential care by strategically building capacity and integrating early intervention, prevention, and child protection (272-11-PCNGO; 116-15-USNGO)
From page 366...
... . In one partner country, PEPFAR added resources to work with OVC by using Title 2 for food commodities to buy food for HIV-positive families (240-3-USG)
From page 367...
... . Adolescents in transition  Adolescents affected by HIV face many challenges as they navigate this developmental stage and, later, as they face aging out of the services directed toward orphans and vulnerable children, despite their continuing need for support.
From page 368...
... . As one interviewee observed, ‘Teenage pregnancy rates are high, which leads to more vulnerable children' (272-32/35-PCNGO)
From page 369...
... . An interviewee affiliated with a partner country nongovernmental organization indicated a desire to continue to care for children who were no longer eligible for services because of PEPFAR-imposed age limits (272-18-PCNGO)
From page 370...
... Some examples exist of explicit efforts to improve integration and linkages, such as integration of care for orphans and vulnerable children with treatment programs, adult clinics, family clinics, and maternal and child health programs (116-7-USG; 396-21-USG; 240-24-USG) , integration of HIV education into the school curriculum (587-6-CCM; 196-20-PCNGO; 331-24-PCGOV; 587-10-USG)
From page 371...
... ' (461-3-USG) ‘There are many more vulnerable children than they are able to reach, and so the concern is that the programs might not be reach ing the most critically vulnerable children.' (461-19-USG)
From page 372...
... One interviewee described the following interpretation issue for PEPFAR indicators to track targets for OVC care and support: "In the current generation of PEPFAR indicators, there are still areas that people still do not actually understand [.
From page 373...
... The ability of partner countries to continue the successes they have realized in addressing the needs of OVC, to sustain existing programs over time, and to meet the remaining gaps in coverage and in needed services, as described in the preceding section, remains a continuing challenge and an unanswered question in the face of expected future reductions or cessation of donor support (272-32/35-PCNGO; 461-4-USG)
From page 374...
... The toll that HIV has taken on families in some partner countries will be magnified with the eventual loss of grandparent caregivers: ‘There is going to be a big gap when an older generation dies, be cause there are places where the middle generation (30- to 50-year olds) doesn't exist anymore or have HIV and will not be there to care for their children.
From page 375...
... reviewed findings from five studies -- four effectiveness studies of OVC programs in Zambia, Namibia, South Africa, Tanzania, and Kenya and one baseline data collection study for new OVC programs in Mozambique. A third review of existing program evaluations was part of a multi-faceted USAID review of the PEPFAR OVC portfolio that included background data and literature review, an analysis of data from surveys received from USG staff in 17 partner countries and OVC Task Force staff in 3 countries, and interviews with various stakeholders in 3 countries (Malawi, Tanzania, and South Africa)
From page 376...
... In addition to the interventions already described, the USAID review found that good maternal and young child health programs have had some of the most cost-effective and posi
From page 377...
... . Finally, from the USAID review of the PEPFAR OVC portfolio it can be concluded that PEPFAR has been in the forefront of OVC programming, leading the way in terms of financing, capacity building, and human resources development for OVC well-being (Yates et al., 2011)
From page 378...
... As described previously, in addition to the new OVC programming guidance, PEPFAR has recently spearheaded an effort to develop, field test, and pilot program-evaluation methods that can be disseminated and implemented in OVC programs (MEASURE Evaluation, 2012b)
From page 379...
... Therefore, the committee was not able to draw definitive conclusions about the direct effects of PEPFAR on child mortality rates. However, the committee did review trends in estimated child mortality due to all causes and due to AIDS using data on AIDS deaths from HIV prevalence and on prevention and treatment coverage (Liu et al., 2012)
From page 380...
... 380 EVALUATION OF PEPFAR Botswana 1000 2000 3000 4000 5000 Number of deaths among children < 5 years 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year All causes AIDS Kenya 150000 Number of deaths among children < 5 years 0 50000 100000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year All causes AIDS Lesotho 8000 Number of deaths among children < 5 years 0 2000 4000 6000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year All causes AIDS FIGURE 7-2 All-cause and AIDS deaths for children under 5 years, in select high-childmortality-burden PEPFAR countries.
From page 381...
... CHILDREN AND ADOLESCENTS 381 Malawi 80000 Number of deaths among children < 5 years 0 20000 40000 60000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year All causes AIDS Namibia Number of deaths among children < 5 years 0 1000 2000 3000 4000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year All causes AIDS South Africa 80000 100000 Number of deaths among children < 5 years 20000 40000 60000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year All causes AIDS FIGURE 7-2 (Continued) All-cause and AIDS deaths for children under 5 years, in select high-child-mortality-burden PEPFAR countries.
From page 382...
... 382 EVALUATION OF PEPFAR Swaziland 4000 Number of deaths among children < 5 years 0 1000 2000 3000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year All causes AIDS Zambia 80000 Number of deaths among children < 5 years 0 20000 40000 60000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year All causes AIDS Zimbabwe 10000 20000 30000 40000 50000 Number of deaths among children < 5 years 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year All causes AIDS FIGURE 7-2 (Continued) All-cause and AIDS deaths for children under 5 years, in select high-child-mortality-burden PEPFAR countries.
From page 383...
... . With its explicit focus on orphans and vulnerable children, PEPFAR has elevated attention to and investment in meeting the needs of this population through programs and services that are informed by evidence.
From page 384...
... . Recommendation 7-1: To improve the implementation and assess ment of nonclinical care and support programs for adults17 and children, including programs for orphans and vulnerable children, the Office of the U.S.
From page 385...
... • The core key outcomes should also include quality of ser vices and measures to reflect the potential sustainability of programs. • A shift to a more outcomes-oriented implementation model will require that partner countries receive support to define their prioritized outcomes and their target population and then to conduct baseline assessments so that progress toward outcomes can be measured.
From page 386...
... • To improve the targeted coverage and sustainability for chil dren and adolescents, PEPFAR and its implementing partners should continue to enhance services through existing systems and infrastructure and to support national governments in ex panding social support services and the workforce to meet the health, education, and psychosocial needs of affected children and adolescents. • OGAC should provide general guidance for country programs on continuous program evaluation and quality improvement in order to measure and monitor the achievement of key out comes.
From page 387...
... 2009. Child status index a tool for assessing the well-being of orphans and vulnerable children -- manual.
From page 388...
... 2006b. Orphans and other vulnerable children programming guidance for United States government in-country staff and implementing partners.
From page 389...
... 2012. Guidance for orphans and vulnerable children programming.
From page 390...
... 2011. PEPFAR HKID portfolio review: Children in the HIV/AIDS epidemic.


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