Chapter 9 -- Improving Accountability and Programming

The President's Emergency Plan for AIDS Relief: First Annual Report to Congress
Released by the Office of the U.S. Global AIDS Coordinator
May 23, 2005

Chapter 9 -- Improving Accountability and Programming

Chapter 9 header -- With support from the Emergency Plan, Namibia is developing the technological infrastructure necessary to support a comprehensive health management information system.

Accountability for results is a cornerstone of the President’s Emergency Plan for AIDS Relief (PEPFAR/Emergency Plan) and serves as the basis for program and policy development, implementation, and improvement. Fiscal year 2004 program accomplishments in prevention, capacity building, care, and treatment provide critical information for future funding cycles, mid-course program adjustments, and the identification of best practices in the field.

Collecting and analyzing HIV/AIDS data for program accountability and improvement in the developing world poses certain strategic information challenges. Tracking patients and maintaining records is particularly difficult in under-resourced settings. Often, over-extended physicians and other health practitioners focus on delivering the best quality services as quickly as possible, with little time to focus on patient record-keeping. A key contributor to patient record-keeping and timely information-sharing is a robust health management information system infrastructure. In many of the focus countries, lack of such an infrastructure presents a challenge to both routine monitoring and program evaluation efforts.

In response to these challenges, the Emergency Plan has begun implementation of key strategic information systems identified in the U.S. Five-Year Global HIV/AIDS Strategy. Such strategies include the improvement of surveillance activities to ensure a clearer understanding of the epidemic; accurate reporting to enhance program accountability; design and upgrade of information management systems to support patient tracking and program monitoring activities; and prioritization and coordination of special studies across countries. In addition, the Office of the U.S. Global AIDS Coordinator (OGAC) has engaged in a number of activities to build country capacity for strategic information and to enhance coordination and cooperation across U.S. Government agencies and external donor organizations, such as UNAIDS, WHO, and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Surveillance Information to Track HIV Incidence, Prevalence, and Mortality
Enhanced surveillance efforts improve our understanding of the epidemic. Surveillance provides knowledge of where cases are concentrated, and among whom, and allows tracking of program impacts and outcomes. For example, in Guyana, uncertainty remains about important aspects of the epidemic, such as prevalence, both overall and among certain high-risk groups. To address this, complementary data collection efforts are under way, including behavioral surveillance surveys, AIDS indicator surveys, antenatal clinic surveillance, and most-at-risk population surveys. Survey results will be used to help target future funding and make midcourse program shifts.

Surveillance efforts are also providing improved information for Emergency Plan programs in Botswana. One effort focuses on improving the tracking of TB cases through an electronic TB register. This system has been successful and Botswana reported more than 10,000 HIV-positive individuals receiving TB care and treatment in an AIDS palliative care setting during fiscal year 2004.

Key fiscal year 2004 outcomes of HIV surveillance efforts also include improved methods for estimating and projecting HIV prevalence and incidence, an improved definition for AIDS case reporting, and development of methods for antiretroviral drug resistance surveillance. A number of baseline data collection activities were undertaken, establishing baselines for measuring changes in the pandemic over time.

Program Reporting and Monitoring Mechanisms
In fiscal year 2004, each focus country followed OGAC’s newly established central reporting process. Components include five-year strategic plans to set long-range vision, annual country operational plans to map out specific program activities and related budgets, and biannual and annual reports to document program results. In a number of countries, the Emergency Plan has organized monitoring and evaluation coordinating committees to ensure coordination of the planning and implementation of country HIV reporting systems with existing health information efforts. For example, in Botswana, the United States supports the HIV Response Information Management System to enhance monitoring, reporting, and use of data in decision-making. Such data will help target use of U.S. funds and measure progress toward the 2-7-10 goals in the 15 focus countries. By mid-2004, all U.S. missions allocated resources to enable them toreport first-year treatment accomplishments.

Health Management Information Systems
The emphasis on health management information systems (HMIS) in the Emergency Plan has a threefold purpose: 1) to assist in the collection of core indicator data; 2) to improve country capacity to collect client-level and clinical service information that will assist in daily management of individual patient care; and 3) to improve capacity to collect facility-, district-, and country-level information that will assist with clinic and program management. Emergency Plan HMIS activities are spearheaded by a multi-agency workgroup that facilitates the design of country-level management information systems. These integrate separate HIV information systems (including patient management, laboratory services, logistics management, program indicators, and HIV facil-ity-based management information systems) into broader regional or national health information systems. The HMIS workgroup helps improve the quality and capacity of data storage systems, data flow, and use of data for decision-making.

A number of countries have already seen improvements in their information systems. In Ethiopia, for example, Emergency Plan funding is facilitating the adoption of a national monitoring and evaluation plan and framework in site-level database systems for prevention of mother-to-child HIV transmission, TB, antiretroviral treatment, and counseling and testing, and is also expanding public health information systems to all Ministry of Health offices. To begin this work, U.S.-supported program staff created operations manuals for implementers, developed database formats, and trained information officers, 400 to 600 of whom will be trained by early 2005.

This computer is part of a site-level database system in an Ethiopian counseling and testing site. With Emergency Plan support, the system will help ensure the accuracy and accessibility of patient records. In Namibia, the Emergency Plan is also working with the National Planning Commission, the Ministry of Health, the United Nations Development Program, and others to improve reporting of estimates and projections on the impact of HIV/AIDS on key demographic and health indicators. The Emergency Plan is providing technical assistance to the central statistics office and the monitoring and evaluation unit in the Ministry of Health.

In Botswana, the President, his cabinet, and other stakeholders have advocated a centralized computer-based information management system. The current system produces quarterly paper-based reports on program implementation at the national and district levels. It is highly dependent on information inputs from sources such as government and private health sectors, institutions, individuals, and financiers and donors across Botswana. U.S. support will allow for further development of the framework and full implementation of monitoring and evaluation services for all sectors by 2006.

An example of how focus countries are benefiting from tools developed in the United States comes from Uganda, where Emergency Plan funds are being used to adapt and test the U.S. Health Resources and Services Administration’s CAREWare, an electronic medical record and reporting system first developed to track HIV patients in the United States.

Key accomplishments in fiscal year 2004 included publication in May of a concept paper, Developing Facility-Based Management Information Systems, which describes the strategy for achieving Emergency Plan HMIS objectives. Three countries -- Haiti, Côte d’Ivoire, and Mozambique -- initiated HMIS planning and assessment in fiscal year 2004. Recommendations and action steps were developed for each country and are in various stages of implementation. Five additional U.S. missions are anticipated to participate in the HMIS planning and assessment process in fiscal year 2005. An HMIS Assessment Guide has been developed to assist U.S. missions that have not yet initiated an HMIS assessment. An inventory was also developed to support U.S. missions that plan to use software in the management of patients receiving ART. This inventory describes about a dozen software packages, including their functions, system specifications, availability, and suitability to various settings. Two of the software tools, the CAREWare tool for patient care and management and the Epi-Info data analysis tool of the Centers for Disease Control and Prevention (CDC), were modified to make them more suitable for Emergency Plan requirements. In fiscal year 2005, a new area of focus for the inventory will be laboratory information systems. Additionally, software packages currently supported by Emergency Plan funds, including CAREWare and the UNAIDS Country Response Information System, will be updated and/or enhanced. Enhanced support and management of geographical information systems activities is anticipated, as well as support to WHO for its HealthMapper and Service Availability Mapping projects.

Identifying Best Practices
Identifying evidence-based best practices is a core principle of the Emergency Plan. Through determining key evaluation questions, monitoring methods and results, and evaluating programs and activities on the ground, the Emergency Plan is ensuring program reliability, determining critical areas of program success, and seeking opportunities for program improvement.

In 2004, OGAC convened a standing subcommittee on targeted evaluations under its Scientific Steering Committee. This group of U.S. Government program implementers, evaluators, and research scientists has agreed upon critical evaluation questions for the first year of Emergency Plan implementation and conducted a technical review for proposed targeted evaluation activities in the fiscal year 2005 country operational plans. Based on input from this technical review, OGAC will determine the need for centralized mechanisms for technical assistance to countries implementing studies and address gaps in the evaluation agenda.

Joint U.S. Government Planning
Strategic information staff at U.S. Government agencies, including the U.S. Agency for International Development (USAID), the Department of Health and Human Services, the Department of Defense, the Census Bureau, and the Peace Corps have worked together to transform their formerly disparate surveillance, HMIS, targeted evaluation, and monitoring and evaluation activities. They have produced an annual joint activity plan and budget focused on improving strategic information capacity in both Emergency Plan focus countries and other countries. Through this effort, U.S. Government agencies have combined complementary strengths, such as CDC’s HIV surveillance experience and USAID’s population survey experience, to update HIV epidemic impact and outcome information, provide technical assistance, and build capacity in the field.

Through coordinated strategic information planning, in fiscal year 2004 U.S. Government agency headquarters and country teams achieved the following:

Substantially contributed to international efforts to coordinate the monitoring and evaluation objective under the "Three Ones" strategy (see chapter 7) by establishing one country monitoring and evaluation effort.
Participated in UNAIDS strategic information reference groups and hosted a meeting in Washington to harmonize 2004 program reporting information. The reference groups coordinated data measurement definitions and common support of management information systems and related standards. They also harmonized the interpretation of the quality of international treatment numbers.
Partnered with WHO, UNAIDS, the World Bank, and the Global Fund in the effort to improve the quality of HIV/AIDS strategic information. The results of these partnerships include harmonizing 2004 country treatment numbers, expanding HIV surveillance guidelines, and agreeing to draft common HIV management information standards in 2005.
Established an annual planning and results reporting system for use within the U.S. Government - the Country Operational Plan and Reporting System. This Web-based information system allows for the annual entry and updating of Emergency Plan country operational plans, semiannual reports, and budget information by the focus country teams. Information is now available and can be rapidly searched and reported by key factors and areas of interest to the program, including partner and partner type, program area, geographic coverage, women’s issues, indicator targets, and budget.
Took a leadership role in planning, funding, and participating in a number of joint international donor-sponsored training and capacity building efforts, including in-depth strategic information staff training in Atlanta, surveillance training in Ethiopia, and a joint HMIS country planning meeting in Tanzania.

In addition, U.S. missions in focus countries have established strategic information functions with staff for program reporting and gathering surveillance impact and outcome information.

Table 9.1 -- Strategic Information: FY04 Capacity Building Results Table 9.1 summarizes the results of capacity building efforts for strategic information in Emergency Plan focus countries during 2004.

International Coordination
The Emergency Plan’s strategic information system is being guided by internationally agreed indicators developed by WHO, UNAIDS, and the United States. Such worldwide coordination is part of ongoing efforts to harmonize data and reporting systems across donors. Donors are working together to streamline how they require affected nations to submit proposals, manage programs, and report strategic information. Ensuring compatibility among donor requirements enables recipient nations to face fewer burdens. With the United States in a leadership role, donors are working to come up with better systems to collect high-quality data.

Beginning in 2004 and continuing into 2005, OGAC pursued harmonization efforts with WHO, UNAIDS, and the Global Fund. In late 2004, senior strategic information managers from the Global Fund and Emergency Plan drafted plans for coordination in four new systems areas - joint monitoring and evaluation systems (to be created in 2005); a central technical support body for monitoring and evaluation; jointly developed estimation methods and data release dates; and coordinated evaluation plans. Additionally, data confidentiality and international data collection protocols were discussed and are now being established and reinforced. To ensure that data systems are suited to resource-poor settings and enable easy data sharing, in 2005 the Global Fund and OGAC have agreed to:

Communicate system guidelines to grantees and countries
Develop guidance on data storage, confidentiality, and transmission standards based on initial guidelines
Coordinate with WHO on national estimates
Share data on subrecipients and assess overlap

The Emergency Plan, the Global Fund, WHO, and UNAIDS have also agreed to an ongoing dialogue with regard to study results and epidemiologic estimates. Donors saw a need to coordinate national WHO and UNAIDS epidemiologic estimates to enhance consistency in reporting, with attention to clarifying what the estimates can include and how they relate to Emergency Plan and Global Fund epidemiologic data. Among the needs are consistent estimates of people on ART and how to attribute the contributions of various donors.

Donors also recognized a need for coordination on information collected about funded programs. Plans for the future include:

Sharing of common data on focus countries
Comparing subrecipients in focus countries
Meeting with WHO/UNAIDS to specify content and dates for national estimates
Jointly analyzing reported Emergency Plan/Global Fund data
Analyzing and issuing a joint statement on high-level results
Preparing a comparative article on figures, problems with data, data comparison challenges, and estimates

Multiple evaluators across donor organizations are working to better determine what evaluations to undertake and how to conduct them. Areas for coordination to be worked out include development of baselines against historical data, the potential impact of interventions on infections averted, and mortality and disease outcomes.

Key Challenges and Future Directions
The future of HIV strategic information systems holds many challenges, particularly in countries that lack basic transmission and storage capacity for health information, have few trained strategic information personnel, and must cope with the operations and demands of multiple donors. Major Emergency Plan efforts in 2005 will focus first on building U.S. Government systems within countries for monitoring partner accountability and reporting. Headquarters workgroups will assist missions in the Emergency Plan’s focus countries as they issue reporting guidelines and audit and store program and budget data from partners. Discussions are also under way among U.S. agencies to explore harmonizing their existing HIV reporting systems in other nations where the Emergency Plan is at work. As it pursues these activities, the United States will also continue and expand its coordination of strategic information with other donors.

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