Global Health:

U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment but Others Remain

GAO-04-784: Published: Jul 12, 2004. Publicly Released: Jul 12, 2004.

Additional Materials:

Contact:

David B. Gootnick
(202) 512-3000
contact@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

The President's Emergency Plan for AIDS Relief (PEPFAR), announced January 2003, aims to provide 2 million people with anti-retroviral (ARV) treatment in 14 of the world's most severely affected countries. In May 2003 legislation established the position of the U.S. Global AIDS Coordinator in the State Department. GAO was asked to (1) identify major challenges to U.S. efforts to expand ARV treatment in resource-poor settings and (2) assess the Global AIDS Coordinator's response to these challenges.

GAO interviewed 28 field staff from the U.S. Agency for International Development (USAID) and the Department of Health and Human Services (HHS), who most frequently cited the following five challenges to implementing and expanding ARV treatment in resource-poor settings: (1) coordination difficulties among both U.S. and non-U.S. entities; (2) U.S. government policy constraints; (3) shortages of qualified host country health workers; (4) host government constraints; and (5) weak infrastructure, including data collection and reporting systems and drug supply systems. These challenges were also highlighted by numerous experts GAO interviewed and in documents GAO reviewed. Although the Global AIDS Coordinator's Office has begun to address these challenges, resolving some challenges requires additional effort, longer-term solutions, and the support of others involved in providing ARV treatment. First, the Office has taken steps to improve U.S. coordination and acknowledged the need to collaborate with others, but it is too soon to tell whether these efforts will be effective. Second, to address policy constraints, U.S. agencies are working to enhance contracting capacity in the field and resolve differences on procurement, foreign taxation of U.S. assistance, and auditing of non-U.S. grantees. However, the Office's guidance did not address key issues related to the use of PEPFAR funds to buy certain ARV drugs. Third, the Office has proposed short-term solutions to the health worker shortage, such as using U.S. and other international volunteers for training and technical assistance; however, agency field officials said that using such volunteers is not cost effective. The Office is discussing with other donors certain longer-term interventions. Fourth, the Office has taken steps to encourage host countries' commitment to fight HIV/AIDS, but it is not addressing systemic challenges outside its authority, such as poor delineation of roles among government bodies. Finally, the Office is taking steps to improve data collection and reporting and better manage drug supplies.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: The Office of the Global AIDS Coordinator has taken action to render this recommendation moot. Specifically, PEPFAR is now funding many of the generic ARV drugs that the Coordinator's Office had previously not approved. These generic drugs, many of which are fixed-dose combination pills, are much less expensive than the innovator (brand name) drugs PEPFAR had restricted its funding to earlier, and are also an easier regimen for patients to follow, since they only have to be taken once or twice a day. As of fiscal year 2007, over half of the drugs PEPFAR was supplying, both by volume and by cost, were generic.

    Recommendation: To improve the U.S. Global AIDS Coordinator's ability to address challenges in expanding AIDS treatment in PEPFAR focus countries, the Secretary of State should direct the Coordinator to specify the activities that PEPFAR can fund and support in national treatment programs that use ARV drugs not approved for purchase by the Coordinator's Office.

    Agency Affected: Department of State

  2. Status: Closed - Implemented

    Comments: In July 2004, GAO reported in Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment, but Others Remain (GAO-04-784) on the challenges facing the U.S. Global AIDS Coordinator in expanding anti-retroviral treatment in resource-poor settings. The report identified several challenges, including inadequate contracting capacity in the field and other U.S. government administrative constraints. GAO recommended that the U.S. Global AIDS Coordinator collaborate with the Administrator of the U.S. Agency for International Development (USAID) and the Secretary of Health and Human Services (HHS) to address contracting capacity constraints in the field and resolve any negative effects resulting from the differing laws governing the funds appropriated to these agencies in the areas of procurement and foreign taxation of U.S. assistance, as well as, differing requirements for auditing non-U.S. grantees. In response, in September 2004, the Coordinator's Office established an interagency Procurement and Assistance Working Group to vet and disseminate guidance on procurement and assistance policy. An updated draft of this charter was circulated in 2005 and the final version was adopted in March 2008; the group includes, among others, HHS' directors for grants and acquisition policy in addition to HHS' Centers for Disease Control and Prevention's (CDC) Procurement and Grants Office. In addition, procurement and assistance experts from Washington and field missions in Africa met for the first time in the Fall of 2007 to discuss challenges, recommend solutions, and share new approaches. They laid out a number of actions to address capacity constraints in the field, including CDC sending a contracting officer and a grants management officer to South Africa in fiscal year 2008 on a pilot basis to remedy the fact that CDC has no acquisition or assistance officers overseas; USAID identifying acquisitions and assistance staffing needs in headquarters and the field and developing commensurate staffing plans; facilitating and increasing hiring of acquisitions and assistance staff, especially among potential employees already in-country; integrating acquisitions and assistance staff into the annual Country Operational Plan planning and staffing exercises; implementing cross-agency staffing rotations; and ensuring that all President's Emergency Plan for AIDS Relief (PEPFAR) Cognizant Technical Officers attend new training, scheduled to commence in 2008. Also, to date, USAID and HHS/CDC have added a total of 49 new procurement and legal staff. As for the differing laws governing the funds appropriated to PEPFAR implementing agencies, appropriations for all PEPFAR implementing agencies are increasingly coming to USAID and State from the same account - the 150 Foreign Operations Account. This percentage has steadily increased from 66 percent in fiscal year 2004 to 87 percent in fiscal year 2008.

    Recommendation: To improve the U.S. Global AIDS Coordinator's ability to address challenges in expanding AIDS treatment in PEPFAR focus countries, the Secretary of State should direct the Coordinator to collaborate with the Administrator of USAID and the Secretary of HHS to address contracting capacity constraints in the field and resolve any negative effects resulting from the differing laws governing the funds appropriated to these agencies in the areas of procurement and foreign taxation of U.S. assistance, as well as differing requirements for auditing non-U.S. grantees.

    Agency Affected: Department of State

  3. Status: Closed - Implemented

    Comments: In July 2004, GAO reported in Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment, but Others Remain (GAO-04-784) on the challenges facing the U.S. Global AIDS Coordinator in expanding anti-retroviral (ARV) treatment in resource-poor settings. The report identified several challenges, including difficulties coordinating with other stakeholders, particularly host governments, in providing treatment. GAO recommended that the U.S. Global AIDS Coordinator monitor implementing agencies' efforts to coordinate President's Emergency Plan for AIDS Relief (PEPFAR) activities with stakeholders involved in ARV treatment, including taking adequate steps to actively solicit the input of host government officials and respond to their input. In April 2008, the Coordinator's Office developed a framework for "partnership compacts" with host governments. These compacts represent a new operational concept for PEPFAR, replacing a donor-recipient paradigm relationship with a more consultative process. In addition, in 3 interviews GAO conducted with host government officials in January 2008 as part of a subsequent PEPFAR-related engagement (320504), the consensus was that PEPFAR has improved its efforts to work with host governments. The fiscal year 2008 Country Operational Plan (COP) guidance states that, as they develop their 2008 plans, PEPFAR staff "should include time in the schedule for active participation and review by the Host Country Government" and that "no COP should be submitted without host country concurrence." In addition, the fiscal year 2008 COP guidance encourages "wrap-around programming," in which PEPFAR activities complement those funded by other donors, e.g., by collaborating with the World Food Program to provide food and nutritional assistance for people receiving antiretroviral therapy. Furthermore, The COP reporting system now integrates U.S. government support to HIV/AIDS efforts through U.S. bilateral programs (e.g. U.S. Agency for International Development's Child and Maternal Health Program) and U.S. assistance to multilateral initiatives, such as the Global Fund; this helps coordinate PEPFAR activities with other U.S. government and global programs in country.

    Recommendation: To improve the U.S. Global AIDS Coordinator's ability to address challenges in expanding AIDS treatment in PEPFAR focus countries, the Secretary of State should direct the Coordinator to monitor implementing agencies' efforts to coordinate PEPFAR activities with stakeholders involved in ARV treatment, including taking adequate steps to actively solicit the input of host government officials and respond to their input.

    Agency Affected: Department of State

  4. Status: Closed - Implemented

    Comments: In July 2004, GAO reported in Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment, but Others Remain (GAO-04-784) on the challenges facing the U.S. Global AIDS Coordinator in expanding anti-retroviral treatment in resource-poor settings. The report identified several challenges, including shortages of qualified health workers in host countries. GAO recommended that the U.S. Global AIDS Coordinator work with national governments and international partners to address the underlying economic and policy factors creating the crisis in human resources for health care. In response to our work, on April 17, 2008, shortly before the G-8 summit, the United States and the United Kingdom announced a joint effort to strengthen health care systems and support health workers in four African countries. Toward this end, the United States is planning to invest at least $1.2 billion over five years on health workforce development through the President's Emergency Plan for AIDS Relief (PEPFAR), with the aim of approaching the World Health Organization's (WHO) goal of at least 2.3 health workers per 1,000 people. The Coordinator's Office is also working with WHO to address the crisis in human resources for health care through a new initiative called "task shifting." In a December 2007 article in the New England Journal of Medicine, experts from WHO and PEPFAR argued that this policy of shifting certain health care tasks from more specialized to less specialized health workers is the one strategy that will have the most immediate effect on increasing the pool of health workers in resource-limited settings. The first guidelines for task shifting were developed by WHO with PEPFAR support and released in January 2008. Examples of task shifting include training nurses to initiate antiretroviral therapy, thus freeing up doctors to address more complicated issues such as treatment failure, and training patients to deliver some of the services currently undertaken by nurses, such as routine follow up and counseling. PEPFAR's new framework for improving working relationships with host country governments through "partnership compacts," drafted in April 2008, calls for promote task shifting as well. Additionally, PEPFAR country teams in the 15 focus countries plan to support nearly 2.7 million training encounters in fiscal year 2008 - including training in task shifting - more than the cumulative total in the preceding four years. PEPFAR is also addressing the health worker crisis by supporting the salaries for an increasing number of health care workers - nearly 105,000 in fiscal year 2008. The fiscal year 2009 Country Operational Plan (COP) provides continued backing for salary support, and task-shifting training for lay and community health workers. It also backs retention strategies for health workers by encouraging PEPFAR to work with host government health ministries to develop non-financial incentives, such as housing support in rural areas, to keep these workers from leaving the often impoverished communities they serve.

    Recommendation: To improve the U.S. Global AIDS Coordinator's ability to address challenges in expanding AIDS treatment in PEPFAR focus countries, the Secretary of State should direct the Coordinator to work with national governments and international partners to address the underlying economic and policy factors creating the crisis in human resources for health care.

    Agency Affected: Department of State

 

Explore the full database of GAO's Open Recommendations »

Sep 24, 2014

Sep 10, 2014

Sep 9, 2014

Aug 28, 2014

Jul 24, 2014

Jul 21, 2014

Jul 9, 2014

Looking for more? Browse all our products here