President's Emergency Plan for AIDS Relief: Program Planning and Reporting
Published: 2011-07-29T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: U.S. assistance through the President's Emergency Plan for AIDS Relief (PEPFAR) has helped provide treatment, care, and prevention services overseas to millions affected by HIV/AIDS. In 2008, Congress reauthorized PEPFAR with the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (2008 Leadership Act). The act requires the Department of State's Office of the U.S. Global AIDS Coordinator (OGAC) to report to Congress annually on PEPFAR performance. The U.S. Agency for International Development (USAID) and the Health and Human Services (HHS) Centers for Disease Control and Prevention (CDC) also report on PEPFAR program performance. Responding to legislative directives, GAO (1) described key procedures for planning and reporting on PEPFAR performance and (2) examined published PEPFAR performance plans and reports. GAO analyzed performance management documents and interviewed officials at OGAC, USAID, and CDC.
section_title: What GAO Found
paragraphs: Officials in several offices and divisions in OGAC, USAID, and CDC coordinate and manage PEPFAR program planning and reporting procedures at headquarters and in PEPFAR countries and regions. These procedures, which include PEPFAR-wide annual operational planning and periodic results reporting, support internal agency-specific program management as well as provide information for external reporting on PEPFAR results. OGAC, USAID, and CDC publicly issued plans and reports on PEPFAR performance in recent years consistent with 2008 Leadership Act requirements and GPRA practices; however, two key elements are lacking. First, although OGAC has internally specified annual performance targets, its most recent annual reports to Congress did not identify these targets or compare annual results with them. According to the 2008 Leadership Act, OGAC's annual reports on PEPFAR program results must include an assessment of progress toward annual goals and reasons for any failure to meet these goals. In addition, the Government Performance and Results Act (GPRA) of 1993 calls for federal agency performance reports to compare program results with established targets. Performance documents published by USAID, jointly with State, and by CDC report program targets and results for two and four PEPFAR indicators, respectively. Second, OGAC's most recently published performance plans and reports do not provide information on efforts to validate and verify reported data, while USAID's and CDC's published performance documents cite such efforts by OGAC. In addition, none of the plans or reports refers to noted data reliability weaknesses or efforts to address these weaknesses. GPRA and prior GAO work emphasize the importance of providing information in public performance documents on data verification and other efforts to address identified weaknesses.
section_title: What GAO Recommends
paragraphs: GAO recommends that OGAC include in its annual report to Congress (1) comparisons of annual PEPFAR results with established targets and (2) information on efforts to verify and validate PEPFAR performance data and address data limitations. OGAC partially agreed with the first recommendation, pending discussions with stakeholders about implementation issues and consequences, and agreed with the second recommendation.

section_title: Letter
paragraphs: U.S. foreign assistance through the President’s Emergency Plan for AIDS  Relief (PEPFAR) has helped to provide treatment to millions of people  worldwide infected with HIV, prevent mother-to-infant transmission of the  virus, and provide care and assistance to millions of adults and children  affected by HIV/AIDS. In fiscal years 2004 through 2008—the first 5 years  of PEPFAR—the U.S. government directed more than $18 billion to  PEPFAR implementing agencies and the Global Fund to Fight AIDS,  Tuberculosis and Malaria. Seeking to continue and expand past efforts,  Congress reauthorized PEPFAR in 2008 through passage of the Tom  Lantos and Henry J. Hyde United States Global Leadership Against  HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (2008  Leadership Act), authorizing $48 billion to continue and expand U.S.- funded HIV/AIDS and other programs through fiscal year 2013. The 2008  Leadership Act includes U.S. government multiyear targets for  prevention, treatment, care, and health-systems-strengthening programs  supported through PEPFAR. The act also calls on the U.S. Global AIDS  Coordinator to produce a plan for program monitoring and regularly report  on PEPFAR program activities and performance. The Office of the U.S.  Global AIDS Coordinator (OGAC) establishes overall PEPFAR policy and  program strategies; coordinates PEPFAR programs; and allocates  PEPFAR resources from the Global Health and Child Survival account to  U.S. implementing agencies—primarily the U.S. Agency for International  Responding to directives in the Consolidated Appropriations Act of 2008  and the 2008 Leadership Act to review global HIV/AIDS program  monitoring, this report (1) describes OGAC’s, USAID’s, and CDC’s key  procedures for planning and reporting on PEPFAR program performance  and (2) examines published PEPFAR performance plans and reports.
We analyzed the most recent publicly available OGAC, CDC, and USAID  performance plans and reports, as well as relevant PEPFAR and agency- specific guidance and reports. We drew on our prior work and guidance  on the Government Performance and Results Act of 1993 (GPRA), as  well as the 2008 Leadership Act, to identify elements and practices of  program performance planning and reporting. We also analyzed USAID  Office of Inspector General (OIG) reports and categorized report  recommendations using monitoring and evaluation categories established  by the Joint United Nations Programme on HIV/AIDS (UNAIDS) (see app.  II for more information on these categories). We interviewed OGAC,  USAID, and HHS officials in Washington, D.C.; CDC officials in Atlanta,  Georgia; and USAID OIG officials in Washington, D.C.; Dakar, Senegal;  and Pretoria, South Africa. (See app. I for further details of our scope and  methodology.)
We conducted this performance audit from October 2010 to July 2011 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence we obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: The 2008 Leadership Act called on the U.S. Global AIDS Coordinator to  develop a 5-year strategy to combat global HIV/AIDS, including a plan to  achieve a number of prevention, treatment, and care program goals. The  5-year PEPFAR strategy, which OGAC released in December 2009,  specifies multiyear program goals and outlines multiyear targets including  those listed in the Leadership Act. The 2008 Leadership Act, which  amends the 2003 Leadership Act, requires that OGAC submit an annual  report to Congress, including an assessment of progress toward the  achievement of annual goals. If annual goals are not being met, the 2008  Leadership Act states that the report should identify the reasons for such  failure.
GPRA and our prior work identify practices related to performance  planning and reporting. GPRA calls for the use of several performance  management practices intended to improve federal program  effectiveness, accountability, and service delivery and to enhance  congressional decision making by requiring federal agencies to provide  more objective information on program performance. In addition, our  prior work suggests the use of a practice to bolster program performance  reporting. These practices include the following, among others:    Performance planning. GPRA calls for preparation of public annual  performance plans that articulate goals for the upcoming fiscal year.  These plans should link annual program goals to program activities,  include indicators that will be used to measure performance, provide  information on the operational processes and resources required to  meet the performance goals, and identify the procedures that will be  used to verify and validate performance information.   Performance reporting. GPRA calls for annual performance reports  reviewing the success of achieving the performance goals of the fiscal  year. The reports are to describe and review results compared with  performance goals, provide explanations for any unmet goals and  actions needed to address them, and include summaries of completed  program evaluations. In addition, our prior work found that explaining  any limitations of performance information can provide context for  understanding and assessing program performance and the costs and  challenges faced in gathering, processing, and analyzing data. This  practice can help identify the actions needed to address any  inadequacies in the completeness and reliability of performance data  and thereby improve program performance reporting.
In August 2009, OGAC issued its Next Generation Indicators Reference  Guide, providing an updated list of indicators for establishing targets and  reporting on results of PEPFAR prevention, care, treatment, and health  systems strengthening programs. The guidance classifies 32 indicators  as essential and reported—that is, indicators that PEPFAR country or  regional teams must use in submitting data on program results to OGAC.  (See app. III for a list of the 32 essential reported PEPFAR indicators.)  The guidance advises PEPFAR country and regional teams to require  PEPFAR implementing partners to submit data for an additional set of  indicators, if applicable, but does not require country and regional teams  to submit these data to OGAC. The guidance also provides a list of  recommended indicators for implementing partners and PEPFAR  program managers who need additional information for program  management. The guidance states that PEPFAR interagency country or  regional teams determine how to collect data from PEPFAR implementing  partners and relevant national systems, as well as how to aggregate,  store, and use the PEPFAR program monitoring indicators in country.
section_title: OGAC, USAID, and CDC Have Procedures for PEPFAR Performance Planning and Reporting
paragraphs: OGAC, USAID, and CDC officials share responsibility for PEPFAR  planning and reporting activities—including developing and approving  PEPFAR operational plans and reports—and conduct agency-specific  planning and reporting procedures. The procedures support agencies’  internal program management and provide data for external reporting on  PEPFAR results.
OGAC’s Strategic Information (SI) office guides and coordinates  PEPFAR performance planning and reporting for countries and regions  receiving U.S. HIV/AIDS assistance. SI advisors—as of July 2011, 20  CDC and USAID officials—provide technical support and assistance to  country and regional teams for developing annual operational plans for  PEPFAR programs. In helping to develop the country-level and regional  operational plans, when requested, SI advisors work with the country and  regional teams to describe partner-level PEPFAR activities during the  preceding fiscal year and establish country-level and regional targets for  the coming year. When OGAC receives the operational plans (typically in  October), SI advisors review the performance targets. After the plans  are approved by the U.S. Global AIDS Coordinator, OGAC aggregates  budget, program activity, and planned performance information in the  plans to create an annual PEPFAR operational plan to be submitted to  Congress.
When requested, OGAC’s SI office also guides and assists PEPFAR  teams in preparing and submitting data on program results to the U.S.  Global AIDS Coordinator. SI advisors work with PEPFAR country and  regional teams to submit data on program results semi-annually (typically  in May) and annually (typically in November). The semi-annual data  consist of targets and results for a subset of eight PEPFAR essential  indicators; the annual data consist of targets and results for all 32  essential reported PEPFAR indicators. SI advisors review the submitted  data, and SI office staff further review and reconcile treatment data with  data from the Global Fund, UNAIDS, and the World Health Organization.  Once the data are confirmed, OGAC considers them to be PEPFAR’s  final results for the year. These data, which OGAC maintains internally,  are intended to support PEPFAR program monitoring, midcourse  correction, and planning for subsequent fiscal years. PEPFAR program  results data also supply information for public reports and other  documents, including OGAC’s annual report to Congress on PEPFAR  performance, typically published in February, as well as a World AIDS  Day (December 1) press release on PEPFAR results.
USAID’s Office of HIV/AIDS, in Washington, D.C., and USAID officials in  regional and country missions share responsibility for global HIV/AIDS  performance planning and reporting, including oversight of USAID  implementing partners. The Office of HIV/AIDS comprises four divisions,  two of which—the Implementation Support Division and the Strategic  Planning, Evaluation, and Reporting Division—provide assistance to the  agency and field missions in managing programs and incorporating  programmatic best practices.
USAID uses PEPFAR program results data for its annual performance  plans and reports. USAID also conducts foreign assistance performance  planning and reporting jointly with State’s Office of the Director of U.S.  Foreign Assistance, using State’s and USAID’s Foreign Assistance  Framework. In addition to producing multiyear country assistance  strategies and mission strategic plans, USAID country or regional  missions complete annual operational plans and annual performance  plans and reports for monitoring, evaluating, and reporting progress in  achieving the agency’s foreign assistance objectives. USAID guidance  further specifies required elements of mission performance management  plans, including indicators, baseline values and targets, data sources, any  known data limitations, and data quality assessment procedures. State’s  and USAID’s master list of standard indicators specifies 46 HIV/AIDS- related indicators for setting targets and reporting results. According to  USAID officials, the HIV/AIDS-related indicator descriptions are aligned  with those for PEPFAR.
Through its audits of USAID’s global HIV/AIDS program activities, from  fiscal year 2008 to 2011, USAID’s OIG has made recommendations  related to performance planning and reporting. We identified 130 USAID  OIG recommendations regarding performance monitoring of USAID- administered PEPFAR activities for fiscal years 2008 to 2011, which we  categorized using 12 components of HIV/AIDS program monitoring and  evaluations systems, as defined by UNAIDS. Of these  recommendations, 94 recommendations, or 72 percent, are related to  routine program monitoring or data quality—specifically, 39 percent are  related to routine program monitoring (producing timely and high-quality  program monitoring data); 11 percent are related to supportive  supervision and data auditing (monitoring data quality periodically and  addressing any obstacles to producing high-quality data); and 22 percent  are related to both routine program monitoring and supportive supervision  and data auditing. (See fig. 1.) For example, the OIG reported in 2009  that the USAID mission in one country did not sufficiently verify and  validate implementing partner performance data and, as a result,  recommended that the mission establish procedures, including site visits,  for validating these data. (We categorized this recommendation as  relating to both routine program monitoring and supportive supervision  and data auditing.) In addition, we found that a number of  recommendations related to human capacity for monitoring and  evaluation, often in combination with recommendations for improving  program monitoring. For example, a 2010 audit of another USAID country  mission’s PEPFAR program found that inadequate training of  implementing partner staff resulted in weak data collection methods and  reporting of inaccurate performance data. The OIG recommended that  the mission develop a training plan for implementing partner staff in  charge of data collection and reporting.
Routine program monitoring (51 recommendations)
Routine program monitoring and    supportive supervision and data auditing  (29 recommendations)
Supportive supervision and data auditing  (14 recommendations)
Supportive supervision and data auditing and  human capacity (10 recommendations)
Human capacity (5 recommendations)
Human capacity and   routine program monitoring (6 recommendations)
Partnerships for monitoring and evaluation   (3 recommendations)
Routine program monitoring and   partnerships for monitoring and evaluation (2 recommendations)
Organizational structures and   routine program monitoring (2 recommendations)
According to data provided by USAID, as of June 2011, the agency had  implemented about two-thirds (65 percent) of USAID OIG report  recommendations related to program performance monitoring and  evaluation; about a third (35 percent) of the remaining recommendations  are due for final action by December 2011. (See fig. 2.)
CDC’s Division of Global HIV/AIDS (DGHA), in Atlanta, Georgia, is  responsible, along with CDC officials in 41 overseas offices, for global  HIV/AIDS programs in more than 75 countries. DGHA comprises a  regional and country management office and eight headquarters-based  technical and operational branches, including epidemiology and strategic  information; health economics, systems, and integration; and country  operations. These offices and branches manage and provide technical  assistance and support to CDC country teams and partner governments,  coordinate DGHA involvement in PEPFAR interagency activities and  partnerships with international organizations, and support regional and  country offices with implementing partner selection and performance  monitoring.
CDC uses PEPFAR program results data for its annual performance  plans and reports. In addition, in 2010, CDC instituted quarterly program  reviews for all CDC divisions, and DGHA underwent its first quarterly  program review in November 2010. For these CDC management reviews,  DGHA selected 16 1-year and 14 4-year goals under four priority  strategies: strengthen public health systems globally; scale up  combination prevention programs and treat HIV globally in a cost- effective manner; transition HIV/AIDS treatment programs to host-country  governments; and support the Global Health Initiative. DGHA reports  quarterly to the Office of the Associate Director for Program on eight  PEPFAR indicators, representing 31 PEPFAR countries and three  regions. According to CDC officials, the quarterly program review is  intended to inform CDC’s annual performance plan and report.
Beginning in February 2011, DGHA officials initiated a series of in-country  reviews—called country management and support visits—of CDC country  office management of global HIV/AIDS programs. DGHA officials  completed eight visits by the end of June 2011 and planned to complete  up to 17 additional visits over the next several months, with up to 34  country visits being completed by the end of fiscal year 2012. DGHA  plans to make summaries of the country visits available to the public. In  addition, CDC develops annual interagency programmatic planning and  monitoring documents called country assistance plans. In February 2010,  CDC technical and budget officials and senior management reviewed  country assistance plans for seven countries: Afghanistan, Brazil, Laos,  Mali, Papua New Guinea, Senegal, and Sierra Leone. These plans  provide information on planned activities and country targets and results,  among other things. CDC’s country assistance plan guidance  recommends that CDC country offices refer to PEPFAR indicators in the  plans, as appropriate, when reporting results.
During a pilot project for assessing the quality of treatment program data,  CDC found that data quality varied across CDC-funded treatment sites.  CDC examined the reliability of the numbers of patients reported as  currently on treatment at 31 CDC-funded PEPFAR treatment sites in  Mozambique, Tanzania, and Côte d’Ivoire. CDC found that counting  actual patient visit or drug pickup data at the 31 sites yielded a lower total  than the method used by some implementing partners (39,577 patients  versus 48,796 patients, respectively). The implementing partners  sometimes summed the number of people who ever started treatment  and subtracted those known to have left the program, resulting in  misclassification of patients’ treatment status and inflation of reported  results. Based on these assessments, CDC recommended (1) refining  definitions of indicators and acceptable methods for deriving the  information; (2) developing a data quality assessment program with a  standardized protocol for evaluating data; (3) completing the treatment  data quality assessment at all PEPFAR-supported sites; and (4) sharing  the assessments’ findings with all PEPFAR country teams, implementing  partners, and ministries of health.
section_title: OGAC, USAID, and CDC Documented Performance Management, but Published Plans and Reports Lack Two Key Elements
subsections: section_title: Several Documents Have Been Issued to Meet Planning and Reporting Requirements
paragraphs: OGAC, USAID, and CDC have issued several performance management  planning and reporting documents in response to the requirements  included in the 2008 Leadership Act and practices specified in GPRA.  (See app. IV for a list of targets and results reported by OGAC, USAID,  and CDC.)    OGAC. OGAC has issued annual PEPFAR operational plans for fiscal  years 2009 and 2010. According to OGAC officials, the PEPFAR  operational plan—which aggregates information from country and  regional operational plans—serves as its annual performance plan.  OGAC also issues an annual PEPFAR performance report to  Congress. OGAC’s most recent annual report to Congress, for fiscal  year 2010, includes a series of tables showing programwide PEPFAR  results for prevention, treatment, and care indicators; the annual  report for fiscal year 2009 also includes results for health systems  strengthening indicators. In most cases, these results are also  displayed by country or region.    USAID. In March 2011, USAID issued, jointly with State, the “Foreign  Operations FY 2010 Performance Report, FY 2012 Performance  Plan” (State-USAID APR/APP) as part of State’s and USAID’s  congressional budget justification for fiscal year 2012. The document  provides, among other things, information on 2010 targets and results  for two PEPFAR indicators: (1) number of individuals receiving  antiretroviral treatment, and (2) number of individuals infected or  affected by HIV/AIDS, including orphans and vulnerable children, who  were receiving care and support services. The State-USAID APR/APP  cites PEPFAR’s 5-year target for number of HIV infections averted  and provides an annual target for 2010 but does not report on annual  results.   CDC. CDC’s “Fiscal Year 2012 Justification of Estimates for  Appropriation Committees” and “FY 2012 Online Performance  Appendix” constitute its performance report and performance plan for  fiscal years 2010 and 2012, respectively. In these documents, CDC  reports on 2010 targets and results using four PEPFAR indicators: (1)  number of individuals receiving antiretroviral treatment; (2) number of  individuals infected and affected by HIV/AIDS, including orphans and  vulnerable children, receiving care and support services; (3) number  of pregnant women receiving HIV counseling and testing; and (4)  number of HIV-positive pregnant women receiving antiretroviral  prophylaxis.
section_title: OGAC’s Annual Reports Do Not Compare Annual Results with Targets as Required
paragraphs: OGAC’s most recent annual performance documents do not provide  information related to annual targets, as required by the 2008 Leadership  Act and consistent with GPRA. (See fig. 3.) PEPFAR country and regional  operational plans contain country-level and regional targets for the  coming year and data showing program targets and results, measured by  PEPFAR indicators. However, the annual PEPFAR operational plans and  reports that OGAC submitted to Congress for fiscal years 2009 and 2010  do not contain any information on annual targets. Moreover, OGAC’s  annual reports to Congress for fiscal years 2009 and 2010 do not  compare annual results with annual targets. According to the 2008  Leadership Act, these reports are to include an assessment of progress  toward the achievement of annual goals and, if annual goals are not  being met, the reasons for such failures. In addition, GPRA calls for  annual performance reports to compare results with previously  established targets.
State-USAID’s and CDC’s annual performance documents present some  information on PEPFAR targets and results (see fig. 3). The State-USAID  APR/APP cites two targets for treatment and care programs for fiscal year  2010. CDC’s fiscal year 2010 performance report and fiscal year 2012  performance plan cite four fiscal year targets—two for prevention, and  one each for treatment and care programs. Both agencies’ performance  documents compare PEPFAR 2010 results with targets set for the same  year and rate PEPFAR’s performance against those targets. For  example, the documents report that PEPFAR exceeded its 2010 target for  number of individuals on antiretroviral treatment but did not meet its target  for number of individuals receiving care and support services. The State- USAID APR/APP states that the reason for the shortfall is being  evaluated, while CDC’s fiscal year 2010 performance report and fiscal  year 2012 performance plan states that trend analysis shows constant  progress in expanding care with significant increases each year. In  addition, CDC reports that PEPFAR exceeded its 2010 targets for number  of pregnant women receiving counseling and testing and number of  pregnant women receiving antiretrovirals. For the 2010 PEPFAR  prevention target reported in the State-USAID APR/APP, the document  states that data are not available for the indicator. Further, the document  states that, because an infection averted is a nonevent, this estimate  needs to be modeled based on surveillance reports and that the estimate  of impact through 2010 is expected to be available in 2012 at the earliest.
section_title: Limited Information Is Available on Efforts to Validate PEPFAR Data and Address Data Limitations
paragraphs: OGAC has not publicly provided, consistent with GPRA practices,  information on efforts to verify and validate reported performance data.  However, State-USAID’s and CDC’s annual performance documents cite  OGAC efforts to verify and validate some PEPFAR performance data.     OGAC. Although OGAC internal guidance summarizes PEPFAR  country teams’ and OGAC’s roles in verifying and validating reported  data, OGAC’s two most recent PEPFAR operational plans and annual  reports to Congress, covering fiscal years 2009 and 2010, contain no  information on these efforts.   USAID. The State-USAID APR/APP states that the results data  reported for the two PEPFAR indicators are corroborated with data  from other sources. The document also notes that OGAC expects to  report the estimated number of HIV infections averted using a U.S.  Census Bureau model.   CDC. CDC’s fiscal year 2010 performance report and fiscal year 2012  performance plan sources the data it reports to PEPFAR annual  program results data, noting that OGAC manages and validates  results data at the headquarters level.
Moreover, even with the data reliability weaknesses noted by USAID OIG  reviews and CDC’s treatment program data quality pilot project, OGAC’s,  USAID’s, and CDC’s performance reports do not contain information on  these weaknesses or on steps taken to address the weaknesses.  Credible performance information is essential for accurately assessing  agencies’ progress toward the achievement of their goals and, in cases  where goals are not met, identifying opportunities for improvement or  whether goals need to be adjusted. As we have reported previously,  without such information, and absent strategies to address identified  limitations, Congress and other decision makers cannot assess the  validity and reliability of reported performance information.
section_title: Conclusions
paragraphs: PEPFAR’s commitment to transparent reporting of program results,  clearly stated in its 5-year strategy, is also reflected in OGAC planning,  reporting, and indicator guidance to PEPFAR country teams. In addition,  OGAC, USAID, and CDC procedures for program performance planning  and reporting are intended to help a broad range of stakeholders— including PEPFAR implementing agency headquarters and country team  officials, partner country governments, and Congress—manage and  oversee PEPFAR programs and demonstrate the U.S. government’s  contribution to the global fight against HIV/AIDS. OGAC, USAID, and  CDC performance plans and reports serve as key sources of public  information on their efforts to monitor PEPFAR program performance.  However, OGAC can improve its annual performance planning and  reporting. First, by discussing annual results alongside established  targets in its annual report to Congress, OGAC would provide important  context for understanding PEPFAR’s annual achievements and areas  needing attention. Second, by providing information on its own and  implementing agencies’ efforts to ensure the quality of their performance  data, OGAC would give decision makers greater insight into the quality  and value of the reported performance information.
section_title: Recommendations for Executive Action
paragraphs: In accordance with requirements and practices set forth in the 2008  Leadership Act and GPRA, and to improve transparency and  accountability, we recommend that the Secretary of State direct the U.S.  Global AIDS Coordinator to modify the annual report to Congress on  PEPFAR performance in the following two ways:   (1) include comparisons of annual PEPFAR results with previously  established annual targets and   (2) include information on efforts to verify and validate PEPFAR  performance data and address data limitations.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to State, USAID, and HHS for comment.  Responding jointly with HHS and USAID, OGAC provided written  comments (see app. V for a copy of these comments). OGAC agreed with  our second recommendation to include in PEPFAR’s annual report to  Congress information on efforts to verify and validate PEPFAR  performance data and address data limitations, and stated that PEPFAR  will provide this information in future annual reports and on its Web site.  Citing the need to consider various related issues and their   consequences in consultation with Congress and other stakeholders,  OGAC partially agreed with our first recommendation to include in  PEPFAR’s annual report to Congress comparisons of annual PEPFAR  results with previously established targets, consistent with a 2008  Leadership Act requirement and a key GPRA practice. OGAC’s  comments suggested that specific action in response to this  recommendation would be contingent on the outcome of these  discussions. OGAC also provided additional background information on  PEPFAR indicators and data validation efforts. Finally, OGAC, in  coordination with HHS and USAID, provided technical comments, which  we incorporated as appropriate.
We are sending copies of this report to the Secretary of State, the Office  of the U.S. Global AIDS Coordinator, USAID Office of HIV/AIDS, HHS  Office of Global Affairs, CDC Division of Global HIV/AIDS, and  appropriate congressional committees. In addition, the report will be  available at no charge on GAO’s Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-3149 or gootnickd@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made major contributions to  this report are listed in appendix VI.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: In response to directives in the Consolidated Appropriations Act of 2008  and the Tom Lantos and Henry J. Hyde United States Global Leadership  Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008  (2008 Leadership Act) to review global HIV/AIDS program monitoring,  this report (1) describes the Office of the U.S. Global AIDS Coordinator’s  (OGAC), U.S. Agency for International Development’s (USAID), and the  Centers for Disease Control and Prevention’s (CDC) key procedures for  planning and reporting on the President’s Emergency Plan for AIDS  Relief (PEPFAR) program performance and (2) examines published  PEPFAR performance plans and reports.
To describe OGAC, USAID, and CDC procedures for planning for, and  reporting on, PEPFAR program performance, we reviewed PEPFAR and  agency-specific guidance documents such as PEPFAR country  operational plan guidance for fiscal years 2009 and 2010, Next  Generation Indicators guidance, and semi-annual and annual program  results guidance; USAID’s Automated Directives System guidance; and  CDC’s quarterly program measures guidance. We also reviewed  documents provided by OGAC, USAID, and CDC to describe their  organizational structures and procedures, and we interviewed OGAC and  USAID officials in Washington, D.C., as well as CDC officials in Atlanta,  Georgia.
To categorize USAID Office of Inspector General (OIG) audit report  recommendations related to program performance planning and  reporting, we identified 24 USAID OIG reports from fiscal years 2008  through 2011 published on USAID’s Web site. We also interviewed  cognizant USAID OIG officials in Washington, D.C., and two regional  offices in Africa (Pretoria, South Africa, and Dakar, Senegal) to gain  additional information on past and current USAID OIG audit work on  PEPFAR. We identified the countries and programs covered by each  report and found that the 24 reports covered prevention, treatment, and  care programs in 19 PEPFAR countries: Botswana, Cambodia, Côte  d’Ivoire (two reports), Dominican Republic, Ethiopia, Ghana, Guyana,  Haiti, Kenya (two reports), Mozambique (two reports), Namibia, Nigeria,  Rwanda, South Africa, Tanzania, Uganda, Vietnam, Zambia (two reports),  and Zimbabwe. In addition, one USAID OIG report reviewed USAID’s  implementation of PEPFAR’s New Partners Initiative. We identified the  recommendations in these reports and entered this information into a  spreadsheet database. To identify and describe types of performance  management-related themes, we utilized the Joint United Nations  Programme on HIV/AIDS (UNAIDS) 12 components of a national HIV  monitoring and evaluation system as categories. (See app. II for a list of  these categories and their definitions.) Two analysts independently  assigned each recommendation to not more than two of these categories.  The two analysts then met to discuss the results of their analysis; in  cases where the analysts’ categorizations differed, the analysts discussed  and came to agreement on final categories. We determined that 74  recommendations addressed one category, and 56 addressed two of the  categories—totaling 130 recommendations. We also determined that 43  recommendations—related, for example, to disposal of expired  medications and to requirements for USAID branding and marking—did  not fall into any of the categories. Furthermore, three of the 12  categories—national multisectoral monitoring and evaluation plan; annual  costed national monitoring and evaluation workplan; and advocacy,  communication, and culture for monitoring and evaluation—were not used  to categorize any of the recommendations. To determine the extent to  which USAID has taken steps to implement the recommendations, we  interviewed cognizant USAID OIG officials in Washington, D.C., to gain  understanding of recommendation tracking, and we analyzed data  provided by USAID specifying dates for final action, target dates for final  action, and target dates for management decisions.
To examine published PEPFAR performance plans and reports and the  extent to which they adhere to established practices, we identified  OGAC’s, USAID’s, and CDC’s most recent publicly available annual  performance plans and reports: for OGAC, the PEPFAR annual  operational plans and annual reports to Congress for fiscal years 2009  and 2010; for USAID, the “Foreign Operations FY 2010 Performance  Report, FY 2012 Performance Plan” that it issued with the Department of  State as part of their joint congressional budget justification for fiscal year  2012; and for CDC, the “Fiscal Year 2012 Justification of Estimates for  Appropriation Committees” and “FY 2012 Online Performance  Appendix.” We systematically reviewed these documents using a matrix  with a series of questions about key performance management practices,  as defined by the 2008 Leadership Act, the Government Performance  and Results Act of 1993, and previous GAO work. We also interviewed  OGAC, USAID, and CDC officials in Washington, D.C., and Atlanta,  Georgia, regarding the information contained in these documents and the  procedures they followed to produce them.
We conducted this performance audit from October 2010 to July 2011 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
section_title: Appendix II: UNAIDS Components
paragraphs: To identify and describe types of performance management-related  themes in our analysis of USAID OIG report recommendations (see app.  I), we used as categories 12 components of a national HIV monitoring  and evaluation system established by UNAIDS. Table 1 provides a list of  these categories and their descriptions.
section_title: Appendix III: PEPFAR Indicators
paragraphs: According to OGAC’s Next Generation Indicators guidance and OGAC  officials, PEPFAR country and regional teams are to use 32 essential  indicators for annual target setting and regular reporting to OGAC. The  guidance distinguishes between direct and national indicators. National  indicators are intended to measure the collective achievements of all  contributors (i.e., host country government, donors, and civil society) to a  program or project, while direct indicators are intended to measure results  attributable to PEPFAR alone. Table 2 provides a list of these indicators.
section_title: Appendix IV: PEPFAR Program Performance Results Reported by OGAC, USAID, and CDC for Fiscal Year 2010
paragraphs: OGAC provides information on PEPFAR program results in its annual  reports to Congress, which are typically published in February. USAID  reports on PEPFAR program results in the “Foreign Operations FY 2010  Performance Report FY 2012 Performance Plan” that it issued with the  Department of State as part of their joint congressional budget  justification for fiscal year 2012 (State-USAID APR/APP). CDC reports on  PEPFAR program results in its “Fiscal Year 2012 Justification of  Estimates for Appropriation Committees” and “FY 2012 Online  Performance Appendix.” The indicators used to report on PEPFAR results  are a subset of the 32 essential reported indicators listed in appendix III.
Table 3 summarizes PEPFAR results for fiscal year 2010 reported by  OGAC, USAID, and CDC in their most recent performance reports.
section_title: Appendix V: Comments from the U.S Department of State, Office of the U.S. Global AIDS Coordinator
section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Audrey Solis (Assistant Director),  Todd M. Anderson, David Dornisch, Lorraine Ettaro, Brian Hackney, Fang  He, Reid Lowe, Grace Lui, and Reina Nuñez made key contributions to  this report. Lisa Helmer and Keesha Egebrecht provided technical  assistance.
section_title: Related GAO Products
paragraphs: Global Health: Trends in U.S. Spending for Global HIV/AIDS and Other  Health Assistance in Fiscal Years 2001-2008. GAO-11-64. Washington,  D.C.: October 8, 2010.
President’s Emergency Plan for AIDS Relief: Efforts to Align Programs  with Partner Countries’ HIV/AIDS Strategies and Promote Partner  Country Ownership. GAO-10-836. Washington, D.C.: September 20,  2010.
President’s Emergency Plan for AIDS Relief: Partner Selection and  Oversight Follow Accepted Practices but Would Benefit from Enhanced  Planning and Accountability. GAO-09-666. Washington, D.C.: July 15,  2009.
Global HIV/AIDS: A More Country-Based Approach Could Improve  Allocation of PEPFAR Funding. GAO-08-480. Washington, D.C.: April 2,  2008.
Global Health: Global Fund to Fight AIDS, TB and Malaria Has Improved  Its Documentation of Funding Decisions but Needs Standardized  Oversight Expectations and Assessments. GAO-07-627. Washington,  D.C.: May 7, 2007.
Global Health: Spending Requirement Presents Challenges for Allocating  Prevention Funding under the President’s Emergency Plan for AIDS  Relief. GAO-06-395. Washington, D.C.: April 4, 2006.
Global Health: The Global Fund to Fight AIDS, TB and Malaria Is  Responding to Challenges but Needs Better Information and  Documentation for Performance-Based Funding. GAO-05-639.  Washington, D.C.: June 10, 2005.
Global HIV/AIDS Epidemic: Selection of Antiretroviral Medications  Provided Under U.S. Emergency Plan is Limited. GAO-05-133.  Washington, D.C.: January 11, 2005.
Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges  to Expanding Treatment, but Others Remain. GAO-04-784. Washington,  D.C.: June 12, 2004.
Global Health: Global Fund to Fight AIDS, TB, and Malaria Has Advanced  in Key Areas, but Difficult Challenges Remain. GAO-03-601. Washington,  D.C.: May 7, 2003.