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4 U.S. Funding for the PEPFAR Initiative
Pages 93-156

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From page 93...
... It also represents a critical input for answering the questions pertaining to PEPFAR's effects that were considered in the evaluation of programmatic areas using the program impact pathway framework described in Chapter 2. The distribution of PEPFAR funding over time can provide insight into HIV prevention, treatment, and care programs as well as into additional broader goals, such as country ownership, sustainability, and the strengthening of health systems.
From page 94...
... . This chapter begins with a brief discussion of the broader global funding environment for HIV/AIDS within which PEPFAR operates as a reflection of the context in which PEPFAR contributes to the HIV response in partner countries.
From page 95...
... PEPFAR'S CONTRIBUTION RELATIVE TO OTHER DONORS In most countries PEPFAR is situated within a broader landscape of global funding for HIV/AIDS, which includes partner country governments; other donor governments; the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund) ; the World Bank; and other multilateral institutions.3 The committee sought data on other sources of funding for HIV/AIDS in order to understand the context in which PEPFAR is implemented and to contribute to an assessment of the USG's relative HIV/AIDS investment.
From page 96...
... SOURCE: OECD, 2012b. bilateral funding for PEPFAR, the Global Fund, other bilateral government donors, and other multilateral organizations.5 The largest proportion of donor funding over this period was provided by the USG through bilateral funding for PEPFAR, followed by the Global Fund, for which the USG is the largest contributor (Goosby et al., 2012)
From page 97...
... Private Sector; USACA = U.S. 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.
From page 98...
... Most OGAC funding is transferred to the USG agencies responsible for implemenƟng PEPFAR USAID acƟviƟes in partner countries. Peace DOD DOL Spending authority for Corps PEPFAR funding may be transferred to PEPFAR mission teams in countries or remain at USG agency USG Agency HQ/PEPFAR Mission Team headquarters.
From page 99...
... Planned/Approved Funding: How OGAC and PEPFAR mission teams plan to obligate and outlay funds, documented in annual operational plans.
From page 100...
... The PEPFAR Operational Plan provides information about the planned distribution of congressionally appropriated funding to USG agencies for PEPFAR activities as well as details about how the funding that remains at OGAC is used for central programs, oversight, and administration. COPs provide further information about which USG agencies will receive funding for implementation of specific activities and the mechanisms for disbursing that funding to implementing partners.
From page 101...
... Prime partners may be nonprofit organizations, academic institutions, for-profit firms, multilateral organizations, partner country governments, or USG agencies. PEPFAR funding is obligated when a USG agency enters into a legally binding agreement (also known as an implementing mechanism)
From page 102...
... From 2004 to 2011, more than $38 billion (current USD) was appropriated to USG agencies for PEPFAR programs and the Global Fund (OGAC, 2011a)
From page 103...
... Cumulative Obligations and Outlays To understand the level of PEPFAR investment intended by Congress that has been spent to support PEPFAR activities over time, the committee first assessed how appropriated funds have been obligated and outlaid over time. Figure 4-4 summarizes the cumulative funds made available, obligated, and outlaid for PEPFAR programs in all partner countries.
From page 104...
... . Global AIDS Coordinator Eric Goosby has explained that a 12- to 18-month funding reserve is reasonable because it allows services to continue in the case of a delay in congressional appropriations (Donnelly, 2012b)
From page 105...
... . There are several factors related to partner countries, USG contracting processes, and implementing partners that may contribute to the increasing size of the pipeline.
From page 106...
... . During interviews conducted by the IOM committee, interviewees from PEPFAR mission teams and implementing partners identified challenges or barriers to obligating and outlaying money in a manner that would facilitate a steady and timely funding flow.
From page 107...
... To achieve this, the ideal approach would have been to access the best possible estimate of the actual financial input toward activities in each year, with a breakdown by country, by partner, and by programmatic area; this corresponds to the first step in the program impact pathway framework described in Chapter 2. However, it is difficult to follow the funding actually spent in a given year because PEPFAR mission teams can simultaneously spend funding that was originally made available in multiple prior fiscal years (NCV-1-USG)
From page 108...
... First, the data were harmonized across all 78 spreadsheets into a single dataset to ensure that the data could be used together to comprehensively represent PEPFAR spending across agencies, in total and by country. Second, cumulative expenditures were converted into annual expenditures.
From page 109...
... (in Current USD Millions) Reporting Year Budget Year FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2004 <$0.1a $231.0 $10.9 $536.8 –$2.3b $5.9 $16.5 $8.3 FY 2005 $151.2 $234.1 $805.9 $53.3 $28.2 $19.7 $18.3 FY 2006 $124.8 $907.7 $409.4 $86.4 $109.9 $26.2 FY 2007 $224.9 $1,242.9 $688.6 $447.7 $36.9 FY 2008 $246.4 $1,649.9 $1,436.1 $451.2 FY 2009 $181.6 $1,700.4 $1,484.3 FY 2010 $275.5 $1,100.5 FY 2011 $176.4 Total outlays for <$0.1 $382.2 $369.9 $2,475.4 $1,949.6 $2,640.5 $5,005.7 $3,302.2 reporting year Total outlays for FY 2004-FY 2011:            $15,125.6 NOTE: Funding presented in current USD millions.
From page 110...
... The original focus countries and the additional COP countries that are the focus of this evaluation represent most of the PEPFAR expenditures over time. Although the committee recognizes the complexity and the burden of tracking expenditures across multiple USG agencies and hundreds of diverse implementing partners, the lack of accessible data on actual annual expenditures, regardless of the year in which the money was appropriated or obligated, represents a significant data gap for PEPFAR.
From page 111...
... a All countries <$0.1c $375.3 $363.1 $2,336.8 $1,906.8 $2,605.5 $3,969.4 $3,244.2 $14,801.1 All countries and <$0.1c $382.2 $369.9 $2,475.4 $1,949.6 $2,640.5 $4,005.7 $3,302.2 $15,125.6 regionsb Total outlays for all countries and regions, FY 2004–FY 2011: $15,125.6 NOTE: Funding presented in current USD millions. Each row is inclusive of the preceding rows.
From page 112...
... . Planned/approved funding reflects how OGAC and PEPFAR mission teams plan to obligate and outlay funds.
From page 113...
... Funding for field programs represents the planned/approved funding for activities planned by mission teams in COPs or regional operational plans; other country programs is funding for programs in those countries that do not prepare COPs or regional operational plans. Central programs are funded and managed centrally by agency HQ yet implemented in partner countries (usually by large nongovernmental organizations, faith-based organizations, and academic institutions)
From page 114...
... SOURCES: OGAC, 2005, 2006b, 2007c, 2008c, 2010e, 2011c,d. 7% 3% Country Activities: Field Programs Country Activities: Central 18% Programs Country Activities: Other Country Programs Multilateral Partners 2% HQ Programs: Technical Oversight and Management 1% 69% HQ Programs: Technical Leadership and Support FIGURE 4-8 FY 2011 PEPFAR operational plan program funding summary.
From page 115...
... . While programs implemented in partner countries have consistently represented the largest share of PEPFAR's funding, the way in which pro 13  From FY 2005 to FY 2008, OGAC classified the following as central programs within country activities: New Partner Initiative, Supply Chain Management, Technical Leadership Support, and Twinning.
From page 116...
... The category of technical oversight and management captures administrative costs for each of the USG agencies responsible for implementing PEPFAR, such as salary, benefits, travel, supplies, professional services, and equipment. The technical leadership and support category includes funding for technical assistance at all levels (e.g., USG agencies, implementing partners, and partner country governments)
From page 117...
... Most funding in the category of multilateral support has been directed to the Global Fund, which channels international financing for efforts against AIDS, tuberculosis, and malaria. The Leader $900 12% Percentage of Total Planned/Approved Funding $800 10% $700 Current USD Millions $600 8% Technical Leadership and Support $500 Technical Oversight and 6% Management $400 Technical Leadership and Support (%)
From page 118...
... SOURCES: OGAC, 2005, 2006b, 2007c, 2008c, 2010e, 2011c,d. ship Act and the Lantos-Hyde Act authorized the use of PEPFAR funds for the USG contribution to the Global Fund, provided that USG contributions not exceed 33 percent of total contributions to the Global Fund.14 Also represented in this category is funding for the Joint United Nations Program on HIV/AIDS (UNAIDS)
From page 119...
... The PEPFAR operational plans report planned/approved funding for four technical areas that correspond with the primary categories of HIV/AIDS services and systems strengthening efforts: prevention, care, treatment, and other. These data, disaggregated by technical area, represent funding for country activities in countries that prepare COPs or regional operational plans, including the field and central programs described in the previous section.
From page 120...
... . NOTE: The totals were calculated by retroactively categorizing budget codes as reported in FY 2011 to ensure consistency.
From page 121...
... As a result of the changing definitions, shifts in the way funding was programmed, and variability in how country programs interpreted the budget codes, PEPFAR's budget codes do not necessarily track funding consistently across countries and over time. This limited the committee's ability to draw major conclusions about the distribution of PEPFAR funding beyond descriptive findings; the limitations in tracking funding over time will also be discussed, where relevant, when funding for specific budget codes are presented and discussed in the subsequent chapters of this report.
From page 122...
... Please refer to the July 2010 Revised Guidance on Comprehensive HIV Prevention for People Who Inject Drugs for more information. [This budget code was adopted in FY 2009.]
From page 123...
... Funding for these activities, including commodities and laboratory, should be in cluded in the TB/HIV budget code rather than other budget codes. The location of HIV/TB activities can include general medical settings, HIV/ AIDS clinics, home-based care and traditional TB clinics and hospitals.
From page 124...
... Distribution/supply chain/ logistics, pharmaceutical management and related systems strengthen ing inputs, including training, are to be included in the Health Systems Strengthening section. Adult Treatment: including infrastructure, training clinicians and other providers, exams, clinical monitoring, related laboratory services, and community-adherence activities.
From page 125...
... , human resources for health, institutional capac ity building, supply chain or procurement systems, information systems, Global Fund programs and donor coordination. The HSS Steering Com mittee has identified the following areas for current emphasis: (1)
From page 126...
... , for-profit firms or organizations, academic institutions, and partner country governments. Although in some cases USG agencies implement activities directly, for most PEPFAR-supported activities prime partners receive PEPFAR funding from USG agencies through grants, contracts, or cooperative agreements.
From page 127...
... NOTE: These data represent, based on the available sources, the proportion of PEPFAR funding directed to prime partners based in the United States, partner countries, other countries, or multilateral organizations. SOURCE: Select country data extracted by IOM from PEPFAR Country Operational Plans, PEPFAR partner lists, and the Center for Global Development PEPFAR funding dataset (CGD, 2008; OGAC, 2012a)
From page 128...
... . In Figure 4-14, types of partners are not disaggregated by origin; for example, the category of government prime partners includes partner country governments, USG agencies such as CDC and USAID (when these agencies are directly responsible for delivering technical assistance or implementing activities)
From page 129...
... NOTE: Other prime partners include prime partners that are based in the United States or other countries as well as multilateral organizations. SOURCE: Select country data extracted by the IOM from PEPFAR Country Operational Plans, PEPFAR partner lists, and the Center for Global Development PEPFAR funding dataset (CGD, 2008; OGAC, 2012a)
From page 130...
... Even within this planned/approved funding, there are limitations to matching the data in the reported budget codes to the program's activities, and data are limited on the types of partners that ultimately receive the funding. Until recently, OGAC has been unable to track and assess how PEPFAR funds have moved from congressional appropriations to OGAC to the implementing agencies to prime partners to subcontractors, because USG implementing agencies were not required to report on expenditures at all levels of the program (Donnelly, 2012b)
From page 131...
... To this end, the committee, while acknowledging the realities of the additional reporting burden, supports OGAC's request to collect more information from implementing partners on PEPFAR pro gram expenditures. PEPFAR FUNDING BY COUNTRY CHARACTERISTICS As described above, most PEPFAR funding is appropriated and budgeted for activities within partner countries.
From page 132...
... To gain a more detailed understanding of the characteristics of these countries, the committee chose to examine how PEPFAR funding, as reflected in the total annual planned/approved funding reported by OGAC in the annual PEPFAR Operational Plans, is distributed using specific metrics for these 31 partner countries. As described in the sections that follow, in order to examine PEPFAR funding by the severity of the epidemic, the committee calculated summary statistics for three groups of countries based on HIV prevalence in 2009 as well as average PEPFAR funding per person living with HIV (PLHIV)
From page 133...
... . Globally, there were nine countries with HIV prevalence rates greater than $4,500 $4,000 Current USD Millions $3,500 $3,000 $2,500 >10% $2,000 1% to 10% <1% $1,500 $1,000 $500 $0 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FIGURE 4-16 PEPFAR planned/approved funding by 2009 prevalence groupings in 31 PEPFAR partner countries (current USD millions)
From page 134...
... ($4.0, $590.9) Total funding $22,205.4 NOTE: Funding data are presented in current USD millions.
From page 135...
... 2009 HIV Average PEPFAR Funding per Population Prevalence Estimated PLHIV Size Grouping (FY 2005–FY 2011) Guyana 753,013 1-10% $3,842.7 Greater than $250 per Haiti 9,864,241 1-10% $806.5 PLHIV Rwanda 10,311,275 1-10% $632.8 Namibia 2,242,078 >10% $469.2 Ethiopia 81,187,751 1-10% $368.3 Cambodia 13,977,903 <1% $275.4 Kenya 39,462,188 1-10% $270.8 Vietnam 86,901,173 <1% $252.4 Botswana 1,981,576 >10% $242.7 Between $100 and $250 per Zambia 12,723,746 >10% $224.7 PLHIV Uganda 32,367,909 1-10% $206.2 Côte d'Ivoire 19,350,026 1-10% $186.2 Dominican Republic 9,796,852 <1% $173.7 Tanzania 43,524,738 1-10% $173.1 Mozambique 22,858,607 >10% $132.4 Nigeria 154,488,072 1-10% $99.4 Between $20 and $100 per Swaziland 1,168,345 >10% $99.2 PLHIV South Africa 49,751,503 >10% $73.8 Lesotho 2,149,201 >10% $55.3 Angola 18,555,115 1-10% $51.1 Indonesia 237,414,495 <1% $42.0 Ghana 23,824,402 1-10% $37.9 Dem.
From page 136...
... Lower-prevalence countries may receive high levels of funding per PLHIV for various reasons, including political or foreign policy considerations; availability of other external donor and country resources for the HIV/AIDS response, which in some cases may be influenced by how active a role the country government takes in the response; lack of economies of scale for service delivery; and initial or existing capacity levels and infrastructure development that affect the costs of service delivery.
From page 137...
... Four other countries that receive funding but are not in the lowest income grouping (Namibia, Swaziland, South Africa, and Botswana) are priority partner countries for investment because of their very high prevalence of HIV.
From page 138...
... ($4.0, $590.9) Total funding $22,205.4 NOTE: Funding data are presented in current USD millions.
From page 139...
... for Partner Countries Grouped by Income and HIV Prevalence Income Level Low Income Lower-middle Income Upper-middle Income <1% India $12.1 China $13.8     Vietnam* $252.4 Indonesia $42.0     Cambodia $275.4 Dominican Republic $173.7     1-10% Nigeria*
From page 140...
... . This plan calls for the generation and use of economic and financial data; the allocation of resources based on their anticipated impact; collaboration with governments, the Global Fund, and others to align programs; and streamlining of business processes to maximize the impact of PEPFAR resources.
From page 141...
... Allocation of Resources Based on Anticipated Impact In addition to understanding program costs, OGAC calls on PEPFAR mission teams and partners to use scientific evidence as a guide for allocating resources to the interventions that will have the most impact within each country (Goosby, 2012b)
From page 142...
... Collaboration with Governments, Other Donors, and the Global Fund to Align Programs OGAC has also identified the importance of working with partner country governments, the Global Fund, other donors, and other stakeholders involved in the HIV/AIDS response to ensure that PEPFAR resources complement funding from domestic and external sources and that interventions are aligned with partner country HIV/AIDS strategies (Goosby, 2012b)
From page 143...
... . Collaboration with Partner Country Governments OGAC has instructed PEPFAR mission teams to align and harmonize PEPFAR planning processes with national planning for the HIV/AIDS response.
From page 144...
... . These coordination efforts can be led by external donors, by multilateral organizations such as UNAIDS, by Global Fund Country Coordinating Mechanisms, or by the partner country government.
From page 145...
... Collaboration with Global Fund In some countries, PEPFAR and the Global Fund provide 90 percent of total funding for HIV/AIDS responses, yet the planning and implementation processes of the two donors are not always aligned. Recently, PEPFAR has started planning country programs in greater coordination with the Global Fund, and Ambassador Goosby has stated that he foresees significant cost savings as the two donors become more aligned (Donnelly, 2012b)
From page 146...
... . Within PEPFAR mission teams, OGAC has mandated that all USG agencies be involved in the annual COP process (described briefly above)
From page 147...
... . Many interviewees from PEPFAR mission teams described challenges with interagency coordination (240-3-USG; 272-1-USG; 272-36-USG; 461-4-USG; 935-17-USG)
From page 148...
... . Coordination of Implementing Partners Another ongoing approach or future opportunity for more strategic and effective use of resources that emerged from country visit interviews is improving coordination among PEPFAR implementing partners.
From page 149...
... . Several PEPFAR mission teams described various reasons for choosing to fund multiple implementing partners for related activities, such as having different partners provide comprehensive services within certain geographic regions (935-2-USG; 461-18-USG)
From page 150...
... . Conclusion: PEPFAR is increasingly emphasizing a range of efforts to use its resources more strategically and efficiently through the generation and use of economic and financial data; the allocation of resources based on anticipated impact; improved collaboration with partner country governments, other donors, and the Global Fund to align priorities and programs; and the streamlining of busi ness processes.
From page 151...
... Because of limitations in the available financial data, it is difficult to fully describe the distribution of the annual direct investment of PEPFAR in partner countries, to match the accounting budget codes to programmatic activities, and to follow the types of partners that ultimately receive the funding and implement PEPFAR-supported activities. This led the committee to conclude that PEPFAR would benefit from the collection and reporting of financial data that not only serve an accounting purpose but also are more closely aligned with programmatic data and program implementation.
From page 152...
... 2012. The United States President's Emergency Plan for AIDS Relief: A story of partnerships and smart investments to turn the tide of the global AIDS pandemic.
From page 153...
... 2008b. The President's Emergency Plan for AIDS Relief: FY 2009 country operational plan guidance.
From page 154...
... 2010d. The President's Emergency Plan for AIDS Relief: FY 2011 country operational plan guidance appendices.
From page 155...
... 2003. Fact sheet: The President's Emergency Plan for AIDS Relief.


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