AIDS Program Effort Index (API)
The API instrument is designed to measure the amount of effective effort put into national HIV/AIDS programs by domestic organizations and individuals and by international organizations (USAID et al., 2003). It measures the strength of effort for program inputs, as opposed to program outputs or results such as HIV prevalence or number of condoms distributed. The API contains ten components corresponding to the conceptual framework developed by UNAIDS, USAID, and the POLICY Project (2001). The index components are:
• Political support
• Policy and planning
• Organizational structure
• Program resources
• Evaluation, monitoring, and research
• Legal and regulatory environment
• Human rights
• Prevention programs
• Care and treatment services
• Mitigation programs
Note: Stover (2001) lists a slight variation on these components with an added eleventh category for the role of the United Nations.
The original 1998 API was redesigned in 2003 with the same ten components, but instead of asking respondents to rate the national policy on a scale of 0–5, the revised questionnaire asks for “Yes/No” responses to questions about the existence of a policy and characteristics of the policy. This approach removes some of the judgment from the scores and makes them more easily compared across countries. The revised questionnaire contains 167 of these specific items. Since the “Yes/No” items cannot capture all the elements of program effort, respondents are asked to provide a summary rating, on a scale of 0–10, for each of the ten components. The final score for each component is the average of the qualitative summary score and the quantitative item score. The qualitative summary score is divided by 10 to adjust the range to 0–1. The quantitative item score is the proportion of maximum possible score (for most components, this is the proportion of “Yes/No” questions answered “Yes”). For more details on the index and scoring for the revised 2003 index, see USAID et al. (2003).
National evaluators identify at least two respondents to be interviewed for each component in order to corroborate the answers. Evaluators are directed to conduct personal, individual, or small group interviews to ensure that the items on the questionnaire are well understood and to maximize accuracy and completeness. The average recommended interview time per respondent ranges from 30 to 60 minutes and responses are not linked to the individual respondents in order to maintain confidentiality. Expert respondents are encouraged to respond to only those items and components of the questionnaire about which they feel sufficiently knowledgeable. After completing all interviews for a country, each national evaluator combines the responses from all interviews into a single summary response and can use their discretion in recording majority, consensus responses or responses that best describe the national AIDS program.
Interviews with expert respondents who have been carefully selected for their professional and in-depth knowledge in the ten component areas.
Developed measure program effort in response to the HIV/AIDS epidemic, the API is designed to provide a current profile of national effort and a measure of change over time (UNAIDS/USAID/POLICY, 2001). The term ‘national’ refers to all domestic inputs including central, regional, and local by both government and NGOs. The API was applied to 40 countries in 2000 and a revised index was applied in 54 countries in early 2003 (USAID et al., 2003). At the global level, an effort score can be used to analyze the independent contribution of program effort to program success in a variety of social and cultural settings. At the country level, an effort score can be used as a diagnostic tool to indicate the strength and weaknesses of various program areas and to suggest corrective action. In terms of evaluation and impact, the API can be used to determine the effects of national and international efforts on outcomes. Although the API scores are not intended to rank or grade countries on their effort, the scores are useful as profiles, which can be used to indicate to international agencies and donors where past efforts have led to improvements and where greater emphasis may be required in the future.
A more recent composite index has been developed by UNAIDS, the National Composite Policy Index (NCPI) to measure progress toward specific goals of the Declaration of Commitment of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) (UNAIDS, 2003). The NCPI is included in the UNAIDS (2009) Guidelines on Construction of Core Indicators and UNAIDS provides online country reports from as recently as 2010 on its website.
The API is intended to measure the effort put into HIV prevention and care. It does not measure the socioeconomic context of the epidemic and response nor does it measure the outcomes. The API scores are based on responses that are a mixture of fact and subjective judgment. On the subjective items, respondent expectations may play a role in their assessments. The extent to which these expectations can vary across countries affect the usefulness of the scores for international comparisons. More objective scores could be developed from the subset of API items that are the least subject to respondent judgment, however, these scores would not provide a rich picture of overall program effort. The process of collecting and reporting the data for the API is very labor intensive, with only two primary rounds (1998-2000 and 2003) having been conducted to date.
index, management, health system strengthening (HSS), access, HIV/AIDS, policy
Global Health.Gov Website, 2008, National Composite Policy Index Questionnaire, Washington, D.C.: U.S. Department of Health and Human Services, PEPFAR, 2009, http://www.globalhealth.gov/news/news/072908b.html
Stover J., 2001, “Monitoring Political Commitment and Program Effort in HIV Prevention and AIDS Care: The AIDS Program Effort Index”, Monitoring Population and Health Program Efforts with Composite Indices, MEASURE Evaluation Bulletin, No. 3;p.17.
UNAIDS, USAID, and POLICY Project. 2001. Measuring the Level of Effort in the National and International Response to HIV/AIDS: The AIDS Program Effort Index (API). Geneva: UNAIDS.
UNAIDS, 2009, Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators, Geneva: UNAIDS. http://data.unaids.org/pub/Manual/2009/JC1676_Core_Indicators_2009_en.pdf
USAID, UNAIDS, WHO, POLICY Project, 2003, The Level of Effort in the National Response to HIV/AIDS: The AIDS Program Effort Index (API); 2003 Round, Washington, DC; USAID. http://www.policyproject.com/pubs/monographs/API2003.pdf