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Highlights

The President's Emergency Plan for AIDS Relief (PEPFAR), first authorized in 2003 at $15 billion for 5 years, was reauthorized in 2008 at $48 billion through 2013. PEPFAR supports HIV/AIDS prevention, treatment, and care services, primarily in Africa as well as in Asia and the Caribbean. The Office of the U.S. Global AIDS Coordinator (OGAC) leads implementation of PEPFAR. The Department of Health and Human Services' Centers for Disease Control and Prevention (CDC) and the U.S. Agency for International Development (USAID) are among PEPFAR's primary implementing agencies. In this report, responding to a legislative directive, GAO examined practices used in (1) selecting organizations to implement PEPFAR activities and (2) overseeing these organizations' PEPFAR activities. GAO interviewed agency and implementing organization officials; reviewed key agency guidance; analyzed PEPFAR awards for fiscal years 2007 and 2008; and observed PEPFAR activities in Namibia, South Africa, and Zambia.

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Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of State To strengthen CDC's and USAID's ability to accomplish PEPFAR goals and ensure accountability for PEPFAR funds, the Secretary of State should direct OGAC to improve the process of partner selection by ensuring that the annual guidance on preparing the country operation plan (COPs) addresses the need to involve assistance and acquisition officials.
Closed - Implemented
In a May 2010 letter to Congressional committees about its actions related to the report, State agreed that assistance and acquisition officials need to be included in the preparation of country operation plans (COP). In its FY 2010 COP guidance, issued June 29, 2009 (shortly before the report was published), the Office of the Global Aids Coordinator (OGAC) cited the GAO report and stated the need to consult with all relevant agencies when preparing country plans. The FY 2010 COP guidance contained language specifying that acquisition and assistance officials who are part of country teams are to participate in planning and drafting of annual COPs and a section for acquisition and assistance officials emphasizing the importance of their participation throughout the funding year, for example, for the purposes of both changing existing contracts or awards in addition to planning new procurements for the following fiscal year. Similar language was contained in the FY 2011 COP guidance. We consider these actions to be responsive to the recommendation.
Department of State To strengthen CDC's and USAID's ability to accomplish PEPFAR goals and ensure accountability for PEPFAR funds, the Secretary of State should direct OGAC to improve the process of partner selection by working with Department of Health and Human Services (HHS) and USAID to clarify the relation between PEPFAR guidance on COP preparation and the agencies' guidance on assistance and acquisition awards.
Closed - Implemented
In August 2013, State provided GAO a document describing the actions it has taken, in coordination with CDC and USAID, to improve the guidance on COP development process, the COP guidance, and partner selection and rationalization, including the following. OGAC and the PEPFAR Deputy Principals have made improvements to the annual planning guidance and processes that emphasize the importance of the interagency country-level planning, including partner performance reviews and partner consultation during COP deliberations. Furthermore, for USAID at both the field and headquarters levels, many operating units have updated their annual portfolio review processes to align procurement planning more systematically with PEPFAR guidance on COP preparation. In addition, since 2009, HHS/CDC has worked to include assistance and acquisition staff in funding planning discussions at the headquarters level. Furthermore, the next evolution in this process will be implemented in fall 2013 in which HHS/CDC will include CDC Program and Grants Office acquisition and assistance officials in individual country meetings to review and plan the agency's expected FY 2014 extramural funding portfolio, according to State.
Department of State To strengthen CDC's and USAID's ability to accomplish PEPFAR goals and ensure accountability for PEPFAR funds, the Secretary of State should direct OGAC to strengthen oversight of PEPFAR implementing partners by working with CDC and USAID to develop a strategy to address staffing shortages identified by OGAC, CDC, and USAID.
Closed - Implemented
In August 2013, State provided a document describing a wide variety of actions it has taken with implementing agencies to address PEPFAR staffing shortages, including the following. In 2008, an interagency technical working group within OGAC began working on standardized framework job descriptions in order to harmonize and expedite hiring of core positions for locally-employed staff within agency offices. Since 2009, 26 framework job descriptions have been developed and approved, providing core position description elements that can be supplemented with country-specific elements. This effort has expedited the end-to-end process of requesting and filling a position vacancy, as well as ensuring that position descriptions for similar positions were consistent across countries and across agencies to ensure that similar positions across agencies were announced at the same pay grade. For several years pre-dating this effort, grade disparities across agencies for similar positions had been contributing to staff attrition. In 2011, CDC established and expanded a separate overseas hiring team within its Human Capital and Resources Management Office which solely focused on hiring and benefits for overseas staff. Concurrently, a CDC contractor assessed its overseas hiring to review the hiring process, from identification of a vacancy to the selected employee arriving for duty in country. According to State, this assessment quantified the timeframes for key steps in the process, identified bottlenecks and made a number of recommendations for improvement which are being addressed and reported in monthly meetings of the Center for Global Health's Global Staffing Group. CDC has established metrics and conducts ongoing data analysis to ensure timelines for the process are improving. One key recommendation of the assessment is to more actively use CDC's biennial Global Staffing Plan exercise, which reviews tour end dates for all overseas staff, as a planning tool for hiring. These efforts are expected to minimize gaps between an employee and his or her eventual successor and to ensure continuity of operations. Overall, according to State, the PEPFAR field vacancy rate dropped from 15.3% to 11.6% on average from FY 2011 to FY 2013.
Department of State To strengthen CDC's and USAID's ability to accomplish PEPFAR goals and ensure accountability for PEPFAR funds, the Secretary of State should direct OGAC to strengthen oversight of PEPFAR implementing partners by working with implementing agencies to develop a plan to reduce PEPFAR country teams' reporting burden through better alignment of OGAC and agency reporting time frames.
Closed - Implemented
In August 2013, State provided a detailed description of the actions it has taken with implementing agencies to better align OGAC and agency reporting time frames. In particular, as part of a State/USAID Streamlining Initiative begun in 2010, OGAC moved the COP submission date from October to March of each year in order to align with the State and USAID annual planning cycles. The change in submission date provided an opportunity for PEPFAR country teams to better interact, align with and integrate program planning and implementation with non-HIV health programs, according to State.
Department of State To strengthen CDC's and USAID's ability to accomplish PEPFAR goals and ensure accountability for PEPFAR funds, the Secretary of State should direct OGAC to strengthen oversight of PEPFAR implementing partners by assessing and addressing the degree to which weaknesses in PEPFAR partners' and subpartners' implementation of financial controls negatively affect CDC's and USAID's ability to ensure that program funds are used for their intended purposes.
Closed - Implemented
In August 2013, State provided a detailed description of the actions it has taken with implementing agencies to strengthen financial controls for partners and subpartners, including the following. In FY 2011, CDC established a Technical Assistance contract to improve business systems for partners that are determined to have weak financial controls. This contract has been used to provide specific technical assistance for Ministries of Health in the field upon request of the program office to CDC headquarters. The request could be triggered by site visit observations, Project Officer review of documentation, or a request from the partner for assistance in a specific area. The technical assistance contract reviews and assesses the partner's standard operating procedures, provides a recommended improvement plan, and assists the partner with correcting issues as they relate to cooperative agreement management, according to State.
Department of State To strengthen CDC's and USAID's ability to accomplish PEPFAR goals and ensure accountability for PEPFAR funds, the Secretary of State should direct OGAC to strengthen oversight of PEPFAR implementing partners by working with CDC to establish procedures for collecting PEPFAR implementing partners' audit information and addressing audit findings.
Closed - Implemented
In a letter to Congress following the report's issuance, State indicated that OGAC would work with CDC to further develop procedures for collecting audit information and addressing audit findings. During a meeting on June 7, 2012, a CDC official stated that CDC had addressed GAO's recommendation about audit collection procedures by collecting the audits that were outstanding at the time of GAO's 2009 report and developing a standard operating procedure (SOP) for receipt, tracking, and retention of CDC foreign and international audit documents. The official also noted that GAO's recommendation influenced CDC's decision to establish the SOP. Among other things, the SOP requires foreign entities to submit audits to CDC for review and to resolve audit findings within a specified period of time. CDC approved and implemented the SOP, and provided GAO a copy. As such, we consider CDC?s actions to be responsive to our recommendation.

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