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PART I Introduction and Background

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INTRODUCTION Epidemiology of the Pandemic Since the first case was recognized in the early 1980’s, the spread of the human immunodeficiency virus (HIV), which causes acquired immune deficiency syndrome (AIDS), has achieved pandemic proportions (CDC, 1981; UNAIDS, 2006). According to the latest report from the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) (2009), HIV/AIDS continues to be a major global health priority. In 2008, the number of people living with HIV worldwide reached an estimated 33 million, an increase of more than 20 percent since 2000 (UNAIDS and WHO, 2009). The number of new HIV infections in 2008 was estimated to be nearly 3 million, which is approximately 30 percent lower than at the pandemic’s peak in 1996—with 84 percent of the new HIV infections occurring among people aged 15–49 years old (UNAIDS and WHO, 2009). Sub-Saharan Africa accounts for 67 percent of people (approximately 22 million) living globally with HIV and continues to experience the greatest burden of the disease, including the largest proportion of new HIV infections in 2008. Asia follows with nearly 15 percent (approximately 5 million people) of adults and children living with HIV (UNAIDS and WHO, 2009). The Caribbean has the second highest adult HIV prevalence of 1 percent (UNAIDS and WHO, 2009). Worldwide, the prevalence of HIV reached peaks in the 1990s and early 2000s. The timing of peaks in incidence varied considerably, from the early 1980s to the mid 1990s, indicating that the peaks in incidence preceded those in prevalence by nearly a decade. This implies that prevalence continued to rise for a number of years after the incidence rate had begun to decline (UNAIDS and WHO, 2009). The HIV pandemic is having an impact in every region of the world; some populations, however, demonstrate greater vulnerability to HIV infection. Several factors associated with this phenomenon are the major risks of drug use and sexual risk-taking behavior. These are also associated with poverty (or wealth in some countries), gender-based violence, access to health and education, culture and awareness about HIV, and stigma and discrimination. Discrimination and criminalization of behavior, for instance, may prevent groups such as men who have sex with men (MSM), injection drug users (IDU), and commercial sex workers (CSW) from accessing health care and other services in certain countries. Additional vulnerable sub- populations are women and girls, young people and children, out-of-school youth, and people affected or displaced by humanitarian crises (UNAIDS, 2010b). In sub-Saharan Africa, women and children are among the most vulnerable groups of the epidemic (WHO et al., 2009). Women account for nearly 60 percent of the estimated HIV infections in the region (UNAIDS, 2008), while young women aged 15–24 years old show on average three times the prevalence of their male counterparts in countries most affected by HIV/AIDS in southern Africa (Gouws et al., 2008). Despite the recent increase of antiretroviral therapy (ART) availability and coverage, HIV/AIDS remains a major cause of death worldwide—an estimated 2 million people died from AIDS in 2008—and AIDS remains a leading cause of death for people aged 15–49 years old in sub-Saharan Africa (UNAIDS and WHO, 2009). Furthermore, HIV/AIDS is the leading cause of death worldwide among women of reproductive age (WHO, 2009d)—globally there were approximately 16 million women living with HIV at the end of 2008 (UNAIDS and WHO, 2009). 7

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8 STRATEGIC APPROACH TO THE EVALUATION OF U.S. GLOBAL HIV/AIDS PROGRAMS To some extent, successful scale-up of ART has prolonged survival and resulted in growing numbers of people living with HIV infection (WHO et al., 2009). However, for every person placed on ART, even more people are becoming newly infected who need care and who may be potentially spreading infection. This leads to the concurrence that incident infections are outpacing the number of people placed on ART (Zachariah et al., 2010) and that implementation of effective prevention lags considerably. Behind these numbers lies the broader impact of AIDS and associated diseases on populations and societies: plummeting life expectancy, changing population demographics (including a large impact in the working-age population group), and overloaded health systems. For instance, Swaziland experienced a dramatic reduction by half in average life expectancy between 1990 and 2007 (UNAIDS and WHO, 2009). Despite the expanded availability of HIV/AIDS services, the pandemic continues to affect the socioeconomic conditions of many of the least developed countries and requires continued commitment and support from not only the international community, but also the national governments of the affected countries (OGAC, 2009g). The primary challenges—and opportunities—facing the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in its current and future phases of operation are to facilitate sustainable country-driven responses to the pandemic that reduce HIV incidence, are commensurate with the needs of people living with HIV, and strengthen health systems to better address HIV-related health needs. Organization of the Report This report is organized into three principal parts. Part I describes the epidemiology of the HIV/AIDS pandemic, key information from the original and reauthorizing legislation for the U.S. global HIV/AIDS initiative, the strategies for program implementation under this U.S. initiative, and some organizational information for the office that administers these HIV/AIDS programs. It also describes the first congressionally mandated study for the U.S. Institute of Medicine (IOM) to evaluate the implementation of the HIV/AIDS programs under the initiative. Following the introduction and background, Part II describes the proposed evaluation approach, including methodologies and data sources, for the new congressionally mandated IOM evaluation of the same programs from 2004–2011. In particular, the evaluation approach is organized around a program impact pathway based on a theory of change model that identifies the intermediate steps between the inputs invested in the program and the ultimate impact on health. Part III applies this model of change to specific parts of PEPFAR in response to the legislative directive for the evaluation. It provides descriptions and presents illustrative evaluation questions that will be used to guide the evaluation of the performance and impact of specific programmatic areas as well as other key systems level goals such as health systems strengthening and transitioning to sustainability BACKGROUND The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act In his 2003 State of the Union address, President Bush proposed that the U.S. Congress authorize $15 billion, over 5 years, to globally address HIV/AIDS—making the proposed health initiative the largest single donor investment for a single disease in U.S. history (Bush, 2003).

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9 INTRODUCTION AND BACKGROUND The U.S. Congress’ authorization of the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (the Leadership Act) 1 marked an important contribution to the global response to HIV/AIDS, including the commitment of significant new funding and attention. Before the establishment of the PEPFAR program, however, the U.S. Government (USG) was already making significant investments to combat HIV and AIDS in developing countries. The United States Agency for International Development’s (USAID) HIV/AIDS funding grew from $1.1 million in fiscal year (FY) 1986 to $433 million in FY2001 (USAID, 2009b). On July 19, 1999, the Clinton Administration launched a $100 million initiative called Leadership and Investment in Fighting an Epidemic. This initiative supported the increase of funding to address the global AIDS pandemic by focusing on primary prevention, care and treatment, as well as capacity and infrastructure development (USAID, 2000). A Kaiser Family Foundation report on bilateral donations from 15 donor countries in 1996 and 1997 placed the United States as the largest donor of HIV/AIDS official donor assistance, contributing 49 percent of the total amount (Alagiri et al., 2001). In 2002, President Bush launched the $500 million International Mother and Child HIV Prevention Initiative with a goal of preventing mother-to-child transmission by up to 40 percent. Activities were directed to support expansion of national prevention of mother- to-child transmission (PMTCT) programs and linkage of PMTCT services with ART and care for mothers, infants, and family members, with a target of reaching up to 1 million women annually in 12 African and 2 Caribbean countries with high rates of HIV/AIDS. These activities and countries, which were to become the “focus countries” (Vietnam was later added), were subsumed as a major activity under PEPFAR and were coordinated across several USG agencies including the Centers for Disease Control and Prevention (CDC) and USAID (CRS, 2003; KFF, 2009; Shaffer et al., 2004). The Leadership Act required (1) the President to establish a comprehensive, integrated Five-Year Strategy to combat global HIV/AIDS focusing on prevention, treatment and care strategies; (2) the assignment of priorities for pertinent executive branches; (3) better coordination mechanisms among such agencies; (4) the provision of the resources needed to achieve the projected goals; and (5) the coordination of provided resources with related assistance from multilateral organizations, other international organizations, governments of foreign countries, and appropriate governmental and non-governmental organizations (NGO). A specific emphasis was given to programs based on women and children’s vulnerabilities, to support the development of countries’ health care infrastructure and human resources, and to periodic monitoring and evaluation (M&E). In addition, the legislation created the position of the U.S. Global AIDS Coordinator (the Coordinator) within the U.S. Department of State (DoS) with the rank of ambassador. The Coordinator would be appointed by the President, with advice and consent of the Senate, and would be accountable for the oversight and coordination of all U.S. international resources and efforts to fight the HIV/AIDS pandemic. Ambassador Randall Tobias was sworn in as the first Coordinator (2003–2006) and presented the first required Five-Year Global HIV/AIDS Strategy to Congress on February 2004. Ambassador Mark R. Dybul succeeded Tobias (2006–2009), and currently Ambassador Eric Goosby serves as the Coordinator. 1 United States Leadership against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, P.L.108-25, 108th Cong.,1st Sess. (May 27, 2003).

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10 STRATEGIC APPROACH TO THE EVALUATION OF U.S. GLOBAL HIV/AIDS PROGRAMS The President’s Emergency Plan for AIDS Relief The title given to the U.S. Five-Year Global HIV/AIDS Strategy, “The U.S. President’s Emergency Plan for AIDS Relief,” or PEPFAR, became the common name for the program (hereinafter referred to as PEPFAR I). PEPFAR I’s strategy established three overarching goals to guide the development of the initiative: (1) to encourage bold leadership at every level to fight HIV/AIDS; (2) to apply best practices within bilateral HIV/AIDS prevention, treatment, and care programs, in concert with the objectives and policies of partner governments’ national HIV/AIDS strategies; and (3) to encourage partners, including multilateral organizations and other partner governments, to coordinate at all levels to strengthen response efforts, to embrace best practices, to adhere to principles of sound management, and to harmonize monitoring M&E efforts to ensure the most effective and efficient use of resources (IOM, 2007). The principles for achieving the stated goals were emphasized in the initial strategy as well, including responding with urgency to the crisis; seeking new approaches; establishing and ensuring accountability for measurable goals; harmonizing program development and implementation with the partner countries; integrating prevention, treatment, and care programs; and building national capacity (OGAC, 2004). PEPFAR I’s funding (from 2004 to 2008) was focused on establishing and scaling up prevention, care, and treatment programs, and reaching specific performance targets of preventing 7 million new HIV infections by 2010, treating 2 million HIV-infected people with antiretroviral (ARV) drugs by 2008, and providing care for 10 million people infected with and affected by HIV/AIDS (including orphans and vulnerable children) by 2008. Two-thirds of the originally funded $15 billion was directed to be appropriated to 15 “focus” countries,2 selected because their HIV/AIDS burden represented, at the time, at least 50 percent of global HIV prevalence. Budgetary targets for the program included 55 percent to be spent on treatment for individuals with HIV/AIDS, 20 percent for the prevention of HIV/AIDS (with at least a third of that money going to programs that promoted only abstinence and being faithful), 15 percent for palliative care of infected individuals, and 10 percent for orphans and vulnerable children (IOM, 2007). Less intense activities were also performed in more than 120 countries with the remainder of the funding (IOM, 2007). The Office of the U.S. Global AIDS Coordinator Headquarters Level The administrative office and formal organizational unit for PEPFAR is the Office of the Global AIDS Coordinator (OGAC) at the DoS. Overseen by the Coordinator, it directs activities at both the headquarters level in Washington, DC, and at the country level in the designated PEPFAR countries 3 under the additional oversight of the U.S. Ambassador of the country. 2 The 15 focus countries included Botswana, Republic of Côte d’Ivoire, Federal Democratic Republic of Ethiopia, Cooperative Republic of Guyana, Republic of Haiti, Republic of Kenya, Republic of Mozambique, Republic of Namibia, Federal Republic of Nigeria, Republic of Rwanda, Republic of South Africa, United Republic of Tanzania, Republic of Uganda, Socialist Republic of Vietnam, and Republic of Zambia. 3 The current PEPFAR countries include the following additions to the original 15 focus countries: Republic of Angola, Kingdom of Cambodia, People's Republic of China, Democratic Republic of the Congo, Dominican Republic, Republic of Ghana, Republic of India, Republic of Indonesia, Kingdom of Lesotho, Republic of Malawi,

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11 INTRODUCTION AND BACKGROUND OGAC staff, including detailees of other USG agencies, are organized into numerous divisions including Executive Director, Management and Budget, New Partner Outreach, Public-Private Partnerships, Strategic Information, Multilateral Diplomacy, and Program Services. OGAC also has a Chief of Staff and Legal Advisor, as well as liaisons for Congressional Relations, and Public Affairs and Public Diplomacy (see Figure 1). FIGURE 1 Organizational structure of OGAC (last updated October 16, 2007). SOURCE: PEPFAR (2007). Guidance also is provided by the Agency Principals and the administrative heads of the agencies involved in implementing PEPFAR programs. 4 Additional advisory bodies and processes provide assistance to OGAC for information sharing and decision making for programmatic activities. For example, USG agency program directors form the Deputy Principals, who advise political appointees in the Principals group and the AIDS Coordinator on programmatic and policy guidance. There are Country and Regional Support Teams. Other technical advisory bodies for headquarters include the Technical Working Groups (TWGs) 5 that Russian Federation, Republic of the Sudan, Kingdom of Swaziland, Kingdom of Thailand, and the Ukraine (personal communication from OGAC, June 16, 2009). 4 The Department of Defense; Department of Health and Human Services including CDC, Health Resources and Services Administration, Food and Drug Administration, National Institutes of Health, Substance Abuse and Mental Health Services Administration; Department of Labor; Department of Commerce; DoS; the Peace Corps; and USAID (IOM, 2007). 5 OGAC operates the following TWGs (by program area): General population sexual prevention, Most-At-Risk Persons, Medical Transmission, Counseling and Testing, Prevention with Positives, Male Circumcision Taskforce, Human Resources for Health, Adult Treatment, PMTCT/Pediatric AIDS, Community/Faith Based Organizations, Tuberculosis (TB) and HIV/AIDS, Orphans and Vulnerable Children, Care and Support, Food and Nutrition, Public- Private Partnerships, Strategic Information, Gender, Laboratory. Staff from USG agencies, USG-funded partners, and non-USG-funded partners may participate in each TWG (Personal communication from OGAC, June 16, 2009).

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12 STRATEGIC APPROACH TO THE EVALUATION OF U.S. GLOBAL HIV/AIDS PROGRAMS provide programmatic guidance by service area and topic, the USG Global Fund Technical Support Advisory Panel, and the Technical Advisory Board (TAB). The TAB was instituted by the Deputy Principals to support their work with the TWGs, provide technical assistance and policy recommendations to the Deputy Principals, and provide overarching coordination and function of the TWGs. In 2009, the TAB presented its analysis of the work of the TWGs called the State of the Program Areas, in which it identified promising practices, gaps in programming, and accomplishments of the TWGs (Stanton, 2009). The primary function of the TAB is to inform the Deputy Principals of policy considerations for upcoming program planning. Country Level At the country level, each country that was formerly a focus country has a U.S. Country Team, which coordinates all the program activities. By 2009, the 16 additional countries and regions were also building interagency HIV/AIDS teams and submitting a country operational plan (COP) to OGAC. Although implementation may vary depending on the needs and capacity of the country, the general structure of the program is intended to be similar across countries. The U.S. Ambassador ensures policy and program coordination at the highest levels and assures accountability for all reports and plans submitted to OGAC. The staff of the Country Teams include representatives from all the implementing departments and agencies. Each Team is anchored by a Country Coordinator located within the U.S. embassy (see Figure 2). Chiefs of Mission provide essential leadership to interagency HIV/AIDS teams and, along with other U.S. officials, engage in policy discussions with partner-country leaders to generate additional attention and resources for the pandemic and ensure strong partner coordination. The activities support the performance targets in prevention, treatment, and care, as well as other areas, such as M&E, capacity building, developing partnership frameworks, and health systems strengthening.

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13 INTRODUCTION AND BACKGROUND FIGURE 2 Model structure of PEPFAR Country Teams. NOTE: The structure of each team will vary by country. Different TWGs are present in different countries, and this figure includes an illustrative example. CDC = U.S. Centers for Disease Control and Prevention, DoD = U.S. Department of Defense, HHS = U.S. Department of Health and Human Services, OVC = orphans and vulnerable children, PMTCT = prevention of mother-to-child transmission, TWG = technical working groups, USAID = United States Agency for International Development. SOURCE: Adapted from personal communications from OGAC (June 16, 2009). IOM’s First Evaluation of PEPFAR: “PEPFAR Implementation: Progress and Promise” In accordance with the Leadership Act mandate, the IOM evaluated the implementation of PEPFAR three years after the program’s authorization to provide a final report in 2007 as guidance for Congress for its consideration of reauthorization of the program. The IOM focused this evaluation on the initial implementation of PEPFAR in the 15 focus countries. The evaluation, due to logistical constraints, was not an impact assessment and did not include the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) (IOM, 2005). The study was planned, designed, and conducted by an independent expert committee with three subcommittees convened by the IOM and several consultants (IOM, 2007). The framework developed for the first evaluation set the concept of “harmonization” at the center of the plan, focusing the evaluation on the contribution of PEPFAR I to the development of countries’ capacity to address their HIV/AIDS epidemics. This was based on the “Three Ones,” principles endorsed by many international donors and United Nations agencies. These guiding principles of harmonization—one agreed HIV/AIDS Action Framework, one National HIV/AIDS Coordinating Authority, and one agreed HIV/AIDS country-level M&E system—were intended to improve the country-level HIV/AIDS response, and reduce the transactional costs of business between countries and multiple donors (UNAIDS, 2004).

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14 STRATEGIC APPROACH TO THE EVALUATION OF U.S. GLOBAL HIV/AIDS PROGRAMS A wide range of methods was used, including six information-gathering and deliberative meetings; review of the scientific and other literature; review of PEPFAR and other documentation; and discussions with PEPFAR staff, in-country implementation partners, and other donors and stakeholders. The committee also analyzed PEPFAR I’s budget and program performance data. Although it did not independently audit or verify these data, it did some checks for internal consistency as well as congruence with external sources (IOM, 2007). The committee visited 13 of the 15 focus countries in small delegations between late October of 2005 and late February of 2006. Due to security concerns, the committee was unable to visit Côte d’Ivoire and Haiti, but conducted several conference calls with the Country Teams and implementing partners (IOM, 2007). The country visits were used to directly observe implementation activities, but did not review the details of all the programs funded by PEPFAR I. Each IOM country team rendered a report with the summary of the consensus on the key observations, findings, and conclusions about PEPFAR I activities in that particular country. This information was also used to reach conclusions across the focus countries using several types of analyses. The committee “triangulated” these syntheses of information from the focus countries with other sources of information—including documentation and other interviews—to reach conclusions about key aspects of PEPFAR I implementation, such as harmonization (IOM, 2007). According to the first IOM evaluation, PEPFAR made progress toward meeting the performance targets of PEPFAR I in the first 2 years and established a foundation for achieving the broader, longer-term goals of the Leadership Act. The committee placed emphasis on the need to transition from an emergency response to one of sustainability to achieve these longer- term goals. PEPFAR was also identified as a functioning learning organization in many areas, including research efforts, communications, knowledge dissemination and contributions to the global evidence base to address HIV/AIDS, and quality improvement to facilitate building capacity to support the transition. The committee stated that PEPFAR would benefit from developing a detailed strategy to institutionalize the concept of being a learning organization that would also enable tracking and reporting of progress toward goals of the strategy (IOM, 2007). However, that report also identified the continuing challenge of supporting a substantial expansion of HIV/AIDS services, while placing greater efforts on long-term strategic planning and the development of countries’ capacity building for sustainability (IOM, 2007). The main recommendations from the first IOM evaluation were categorized in three groups: (1) the need to address long-term factors, such as expanding prevention strategies, improving the status of vulnerable groups such as women and girls, building workforce capacity, and increasing the knowledge base by means of publishing research conducted; (2) the need to improve harmonization with international and national stakeholders, providing support to the WHO on their drug prequalification process, and removing budget allocations or “earmarks” associated with performance targets; and (3) the need to expand, improve, and integrate services based on evidence-based strategies and exhausting the existing local capacity, providing adequate medications for treatment, using community-based care, establishing performance targets for orphans and vulnerable children and addressing the needs of marginalized populations.

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15 INTRODUCTION AND BACKGROUND Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 On July 30, 2008, the U.S. Congress passed the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (hereinafter, the Lantos–Hyde Act of 2008). 6 The primary goal of this reauthorization legislation was to continue the USG commitment to the program for 5 additional years, from 2009 through 2013 (hereinafter referred to as PEPFAR II), authorizing up to $39 billion exclusively for PEPFAR bilateral HIV/AIDS programs and U.S. contributions to the Global Fund. New cumulative performance targets for 2013 under the Lantos–Hyde Act of 2008 include preventing 12 million new infections worldwide (without a proportional goal stated for women or children), providing care for 12 million people living with or affected by HIV/AIDS including 5 million orphans and other children made vulnerable due to HIV/AIDS, and training and retaining at least 140,000 new health care workers. 7 In addition, the reauthorization legislation supports the increase in the number of individuals with HIV/AIDS receiving ART above two million people, which was the initial goal under the Leadership Act of 2003. The Lantos–Hyde Act of 2008 also eliminated nearly all of the fiscal benchmarks established in the original legislation, with the exception of the 10 percent target for orphans and vulnerable children and the treatment earmark directing that at least half of funds must be spent on ART and other treatment services. Additionally, there are new programmatic requirements, many related to prevention activities, which are discussed in the section on prevention in Part III of this report. In December 2009, Ambassador Goosby issued a new PEPFAR Five-Year Strategy, which includes the targets in the reauthorization legislation, but specified the treatment target of providing direct support for more than 4 million people (OGAC, 2009g). However, different from the legislation, the strategic plan extends the time frame of these cumulative performance targets through FY2014 (OGAC, 2009g). Furthermore, the new PEPFAR Five-Year Strategy defined the future direction of PEPFAR II and clearly established the need to (1) transition from an emergency response to promoting sustainable country programs; (2) strengthen partner government capacity to lead the response to this epidemic and other health demands; (3) expand prevention, care, and treatment in both concentrated and generalized epidemics; (4) integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems; and (5) invest in innovation and operations research to evaluate impact, improve service delivery, and maximize outcomes (OGAC, 2009g). This strategy also describes how PEPFAR can help leverage additional investments in global health as a part of the Obama Administration’s new $63 billion, 8 6-year Global Health Initiative (GHI) (OGAC, 2009h). The Initiative’s consultation document indicates how it will incorporate PEPFAR’s strategic cumulative goals within a comprehensive U.S. global health policy approach that will focus attention on broader global health challenges (DoS, 2010b). Although this evaluation will not focus on the targets or activities for the GHI beyond PEPFAR, summary information on the initiative is in Box 1. 6 Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, Public Law 110-293, 110th Cong., 2nd sess. (July 30, 2008). 7 Ibid., §301(a)(2), 22 U.S.C. §2151b-2(b)(1)(A). 8 This amount includes the funds for the second operational phase of PEPFAR (2009–2013) and other international health programs.

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16 STRATEGIC APPROACH TO THE EVALUATION OF U.S. GLOBAL HIV/AIDS PROGRAMS BOX 1 PEPFAR and the U.S. Global Health Initiative In May 2009, President Barack Obama announced a new U.S. government (USG) Global Health Initiative (GHI). In February 2010, an implementation plan was published as a consultation document to outline a core focus to improve health outcomes in low-income countries through strengthened platforms and systems and utilization of a new business model for USG global health assistance. The GHI expands beyond HIV/AIDS to enhance the focus on other areas, particularly maternal and child health, family planning and reproductive health, and neglected tropical diseases. As the largest bilateral health assistance program of the USG, PEPFAR is expected to be an integral foundation for the GHI. As with PEPFAR, the transition to strengthened, integrated, and sustained health systems owned and driven by country priorities is considered a centerpiece. This will necessitate a re-orientation “away from parallel systems to more concerted support for national health systems” (OGAC, 2009h, p. 27). Commitment is also signalled for short- and long-term measurement of quality, outcomes, cost-effectiveness, innovation, and impact. The need to improve government accountability and to provide financial and program management technical assistance to support these activities is acknowledged. Human resource planning and health professional pre-service education, task-shifting, retention, and re- employment models also are essential components of the GHI. In its most recent budget request for fiscal year (FY) 2011, the Administration proposed to designate $200 million in funding for up to 20 “GHI Plus” country partners (10 in FY2011–2012 and 10 in FY2013) of which $100 million is slated to come from Department of State funding (the other $100 million will come from other United States Agency for International Development (USAID) global health programs). The GHI will encourage operational research, considering evaluation, program learning, innovation, and dissemination as key to the Initiative‘s success. SOURCES: DoS (2010a, 2010b); OGAC (2009h).