Evaluation of PEPFAR (2013) / Chapter Skim
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Pages 1-16
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From page 1... ...
PEPFAR is a large, multifaceted, and complex initiative that is implemented in the cultural, social, economic, and political landscapes of each partner country as well as in the presence of HIV and health programs supported by other funding sources. Working through many implementing partners, PEPFAR supports a range of activities for all aspects of the HIV response, including direct service provision, programmatic support, technical assistance, and policy facilitation.
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To conduct a rigorous assessment that took into account PEPFAR's complexity and varied contexts, the IOM committee employed a mix of methods using financial data, program monitoring indicators and clinical data, extensive document review, and primary data collection carried out through more than 400 semi-structured interviews and site visits. A range of stakeholders were interviewed in 13 PEPFAR partner countries, at the U.S.
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They appear below in bold text, each followed by an indication of the chapter in the report in which it appears, and where additional considerations for its implementation are also described.3,4 The recommendations are presented in this summary in four main areas: scaling up HIV programs, strengthening systems for the HIV response in partner countries, transitioning to a sustainable response in partner countries, and transforming knowledge management to improve effectiveness. Scaling Up HIV Programs PEPFAR has provided a "proof of principle" that HIV services can be successfully delivered on a large scale in countries with a high burden of disease and limited available resources and infrastructure.
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Global AIDS Coordinator5 should support an enhanced, nested program monitoring effort in which additional longitudinal data on core outcomes for HIV-positive adults and children enrolled in care and treatment are collected and centrally reported from a coordinated representative sample across multiple countries and implementing partners. (Chapter 6)
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While services for people living with HIV are one foundation for the sustainable management of an HIV response, prevention is also paramount as part of a balanced attempt to change the trajectory of the HIV epidemic. PEPFAR's support for the scale-up of HIV prevention activities has been a valuable contribution to the HIV response in partner countries.
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An effective response requires responsiveness not only to the available evidence on intervention effectiveness, but also to the epidemiological evidence about the drivers of the epidemic. Given that behavioral and structural drivers will not be addressed through biomedical approaches alone, PEPFAR can contribute to a more effective HIV response by serving as a platform for innovation to help fill this gap in the availability of effective interventions and of appropriate approaches to assess prevention interventions.
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PEPFAR's efforts have evolved from a focus on the HIV-related needs and vulnerabilities of women and girls to a more comprehensive focus that aims to also address the vulnerabilities of men and boys that arise as a result of social and cultural norms in partner countries about gender and sexuality. PEPFAR's gender efforts have scaled up slowly over time, in an ad hoc fashion, with little strategic guidance to facilitate comprehensive country portfolios that address gender norms and inequities and that incorporate gender-focused objectives within prevention, care, and treatment programs to improve service access, coverage, and quality for both men and women.
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PEPFAR has expanded the health workforce with the capacity to provide HIV services in partner countries; these contributions are now transitioning appropriately to more pre-service education and training, including initiatives for strengthening academic institutions, degree programs, and long-course trainings in countries. PEPFAR has also supported individual and organizational capacity building for leadership and for program and financial management across the governmental, private, and civil society sectors.
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Enhancing service delivery through existing local systems and longterm infrastructure development will continue to strengthen and expand the capacity of health and other systems to provide the services that are fundamental to an effective response to HIV, one that can meet the current and future trajectory of need. There is a need for future U.S.
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In addition, transitioning to new models of PEPFAR support, including less direct support for service delivery and more technical assistance and systems strengthening, is part of a reasonable strategy for achieving sustainable management, but it also carries the inherent risks that in the transition period the same level of targets and access to services will not be achievable and that the quality of services, programs, and data may diminish. At the same time, greater embedding of HIV services in national health systems may offer opportunities for better integration of care, greater efficiencies, and broader health benefits.
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From page 11... ...
Transforming Knowledge Management to Improve Effectiveness PEPFAR's ability to generate, use, and disseminate knowledge is fundamental for program management and improvement and, ultimately, for the sustainability of PEPFAR's efforts. PEPFAR has made strong efforts in this area, often at levels not seen in other development initiatives, by creating a program monitoring data collection system to track activities and program results; supporting epidemiologic and surveillance activities; strengthening partner country health information systems; implementing various program evaluation approaches; and supporting some research across a wide range of technical areas.
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From page 12... ...
PEPFAR will need to transform its approach to knowledge management in order to adapt to a transition from direct support for delivery of services and programs to increased support and technical assistance for systems strengthening, capacity building, and sustainable management of the response by partner country stakeholders. An investment now to develop reliable, credible approaches to assess the effectiveness of these efforts will be needed to document future progress and to continually improve future efforts.
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From page 13... ...
To reduce duplicative efforts and investments in its evaluation portfolio, OGAC should coordinate among country programs to strategically plan and coordinate a subset of evaluations designed not only to be useful at the country level but also to enable comparability across programs and countries in order to assess performance and inform improvements across PEPFAR. B. contribute to filling critical knowledge gaps that impede ef To fective and sustainable HIV programs, OGAC should continue to redefine permitted research within PEPFAR by developing a prioritized portfolio with articulated activities and methods.
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From page 14... ...
In addition to the positive effects of PEPFAR's support for services, PEPFAR is generally recognized as providing good technical assistance; being a flexible donor that fills gaps and supports innovation within country structures; contributing to addressing the challenging nature of concentrated epidemics; advancing global expectations for performance measurement and accountability; and contributing to the global knowledge base. PEPFAR has also contributed to shaping global health policy and action for HIV and potentially other areas of health and development.
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This new era may not be one of rapid, dramatic results. Yet, if it is successful, then PEPFAR has the potential to again transform the way health assistance is envisioned and implemented, with ultimate long-term positive effects for health and well-being.
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