PEPFAR Reauthorization Responds to Some Evidence from First Five Years

March 19, 2008
Last week, Congress took a major step towards re-authorizing PEPFAR, and global malaria and TB programs, for another five years. A congressional press release explains:
Legislation sponsored by the Chairman of the Senate Foreign Relations Committee Joseph R. Biden, Jr. (D-DE) and Ranking Member Richard G. Lugar (R-IN) authorizing $50 billion for global HIV/AIDS, malaria and tuberculosis programs for the next five fiscal years was approved by the Senate Foreign Relations Committee today. This legislation closely mirrors a bipartisan reauthorization bill approved by the House Committee on Foreign Affairs late last month, which will facilitate a prompt conference with the House.
Great news, of course, that the process is well on its way, with a hefty tab of $50 billion ($9 billion of which is for malaria and TB) that should build on the accomplishments of the first five years of PEPFAR and strengthen its performance in the global fight against HIV/AIDS. A quick scan of the House and Senate bills and various analyses that have followed suggest one major accomplishment in the reauthorization process - that our legislators and their incredibly dedicated staff have looked closely at the evidence, and in large part, have responded to the lessons learned in the emergency phase of the last 5 years. In particular, we are encouraged by the following highlights of the legislation (and pleased that the HIV/AIDS Monitor's research and the work of other CGD colleagues have contributed to the growing body of evidence about these issues): Removal of Most Earmarks The removal of almost all earmarks - funding restrictions that mandate how PEPFAR can spend money - is a very encouraging sign that has clearly responded to evidence from various sources, including the IOM and the GAO, that flexibility in funding is a must for countries to respond to their national priorities. Our own findings - including a forthcoming analysis of PEPFAR funding data - shows that the way PEPFAR allocated money across and within prevention, treatment and care closely mirrored the global-level earmarks imposed by Congress. This unduly limited PEPFAR's flexibility because every country's funding needs are different - some countries might need PEPFAR to spend more on prevention, and others might need more money for treatment - but PEPFAR's program could not easily respond to these differences. While the new legislative language does not stipulate any AB (Abstinence and Being Faithful) spending requirements it does require that countries receiving PEPFAR funds explain their reasons for using less than 50% of their funds on abstinence and being faithful. What is NOT clear in both the bills is the process of approval for a country that does not spend in the A and B categories as required and the ramifications for not doing so. Some clarity on this process before the final bill is passed is a MUST to avoid confusion and the possibility of blindly following the requirements because the consequences of non-compliance are not clear. Building Local Capacity Since large sums of AIDS money began flowing from PEPFAR and other sources in 2003, it has become apparent that the money cannot be used effectively unless we build "in-country capacity" - a broadly used term that refers to both adequate numbers of competent staff to manage and implement AIDS programs, and appropriate systems to manage the flow of goods, people, and information. PEPFAR has often skirted the capacity problem by setting up their own systems and channeling large shares of funding to international NGOs. But this approach is not sustainable in the long-term if the systems are not local, and the new reauthorization bill takes a number of key steps to ensuring that each country will be able to fight the long battle needed against the epidemic, including: (i) Increasing the number of African health workers - The continent is desperately short of health workers, from doctors to nurses to medical assistants that are needed to win the fight against AIDS. The House bill sets a concrete target of 144,000 health workers that will be trained over the next five years using U.S. government funds. There is some uncertainty about what type of health workers would be included as part of this target and whether these would be additional and/or include the training of existing workers - we believe these should be a range of health workers from doctors to nurses and community health workers. The effort to increase the number of trained health workers is undoubtedly a good move but this may not solve the real shortage problems. As my colleague Michael Clemens' research showed, shortages in many countries in Africa are less related to brain-drain and the emigration of workers, and more to do with the rural/urban and private/public distribution of health professionals, the skill mix of the health work force and the lack of incentives for health professionals within the current public sector systems. Donor supported and national efforts to mitigate the health care worker shortages should surely address some of these issues and not focus only on training. (ii) Improving financial management, inside and outside government - Our paper on "Following the Funding" showed that many local recipients, and especially governments, do not have the systems needed to manage and report on large sums of AIDS money. The reauthorization bills calls specifically for PEPFAR to work with governments and other local recipients to strengthen their financial management capabilities. (iii) Giving government oversight of PEPFAR programs - National governments in each country act as the steward of the AIDS response, helping to coordinate the myriad actors responding to the AIDS crisis. But national governments have limited input into PEPFAR programs and are thus constrained in performing their stewardship role. The new PEPFAR bill would aim to change this. As Senator Biden's press release states, the bill aims to "push the U.S. government to plan for a sustainable long-term effort, to help local governments take over the fight against HIV/AIDS with our technical assistance." (iv) Assessing the capacity development initiatives undertaken by the countries - The new legislation calls for an assessment of countries holding them accountable to their commitments to the Abuja Declaration (to invest in the development of human resources and health systems by motivating existing personnel by upgrading skills and through improvement of condition of services including the use of incentives to prevent brain-drain). Despite all good intentions to increase the incentives for health sector staff the new legislation acknowledges the impact of the IMF's macroeconomic and fiscal policies on national and donor investments in health and also calls for a review of this policy in each country. Findings from a working paper by my colleague David Goldsborough on the IMF's constraints on health spending suggest that the IMF has overused the wage bill ceilings in the health sector and could restrict the capacity development efforts of a particular country. This type of an assessment would help situate a country's particular commitment and ability to invest in building capacity in the health sector. Balancing Prevention and Treatment PEPFAR has been widely praised for quickly putting well over a million people on treatment, but prevention programs seemed to take a backseat in the first phase of PEPFAR. Forthcoming analysis by my colleague Mead Over and by the HIV/AIDS Monitor team shows that in the average focus country PEPFAR spent nearly twice as much on treatment as prevention. Yet, for every person put on treatment, there are five or six new HIV infections. Recognizing these facts, the new PEPFAR bills emphasize the importance of prevention. They state that PEPFAR should spend no less than 20% of its money on prevention activities - we hope PEPFAR will spend much more than the 20% figure as each country identifies their prevention priorities. The bills have also increased the prevention target - which has gone from preventing 7 million infections to preventing 12 million infections - more significant than the treatment target - which has changed from treating 2 million people to 3 million people. Behavior change to reduce risk also features prominently in both bills as a new focus in prevention efforts. Better late than never - the realization that prevention along with treatment is paramount for an effective response is long overdue. While PEPFAR I focused on the "emergency" of getting treatment to the heavily affected countries and giving people hope, the efforts to support comprehensive prevention efforts and provide people with a greater sense of hope that they can prevent themselves and others from getting infected have been less than optimal and the step up to increase these efforts is welcome. Addressing the Vulnerabilities of Women and Girls Several recent reports, including CGD's Girls Count have showed the unique vulnerabilities faced by women and girls to HIV. The epidemic is not gender neutral and the new bills recognize this by calling for gender to be a high priority in all aspects of PEPFAR, from the five-year strategy to the evaluation that will be conducted during its fourth year. With the overall PEPFAR strategy, the Senate bill asks for "a description of the specific targets, goals and strategies developed to address the needs and vulnerabilities of women and girls to HIV/AIDS." In addition, the proposed legislation authorizes that a new evaluation report include an assessment of gender specific aspects, including the constraints to accessing services and underlying social and economic vulnerabilities. For a more detailed and interesting analysis of the Senate and House bills and the current law, and their relative emphasis on women and girls and related gender issues in prevention, prostitution, family planning and microbicides see a chart by Kathy Selvaggio at ICRW. Monitoring AND Impact Evaluation The Senate bill stands out for its effort to ensure that PEPFAR II captures both, the monitoring of programs including operations research AND the impact of its efforts by preparing these activities at the outset of the program. By including operations research in the strategy, Congress will ensure that PEPFAR will learn while it is implementing and using these data to "improve program quality and efficiency...and optimize the delivery of services." The bill also includes language that requires the Global AIDS Coordinator to contract the IOM to produce, in the first 18 months of PEPFAR II, a "design plan and budget for the evaluation and collection of baseline and subsequent data." CGD's work on impact evaluation led by Bill Savedoff and my colleague Ruth Levine, points the U.S. government in the direction of making evaluation an imperative in its global AIDS efforts so that the U.S. can account for the billions of dollars spent and assess whether or not PEPFAR actually made a measurable difference in the reduction of incidence. This will be an important step to supplement the evidence that OGAC already reports to Congress on the absolute targets for treatment, prevention and care--2, 7, 10 goals to the new 3, 12, 12 goals--with rigorous evidence about what has changed because of this remarkable effort. A set of “before and after” PEPFAR measures will tell us whether the program is working relative to its investments and demonstrated priorities and needs in each country. The absence of this evidence will place future funding for HIV/AIDS in jeopardy and will deny countries the much needed support to keep their citizens free from preventable infections and from dying. We strongly support the inclusion of this provision in the final bill. Advanced Market Commitments for Vaccines Good news on the development of new vaccines from our policy makers! Senator John Kerry introduced an amendment (Download file) to the Senate bill that will "promote participation by the United States in negotiations on Advanced Market Commitments (AMC) to develop key vaccines, and strengthen efforts to provide technical assistance for the creation of vaccines in developing countries." CGD's Michael Kremer and Ruth Levine, co-chaired a working group on AMCs in 2005 that concluded that an advance commitment on the part of donors could effectively stimulate greater private sector investment in the development of new vaccines appropriate for use in poor countries, and accelerate their adoption. We are encouraged by the U.S. response to this call to donors and its potential participation in an advance commitment to buy vaccines if and when they are developed for AIDS, TB, Malaria and other infectious diseases. With other donors, the U.S. will create incentives for industry to increase investment in research and development and spur commercial investment in the development of vital new vaccines for the developing world. The Sticking Issues Anti-prostitution pledge: Both versions of the bill propose no changes from the current law. The confusion caused by the current law about what PEPFAR implementers and their sub-recipients can and cannot do with sex workers still persists. Clarifying the language in the new bill may be helpful to recipients and sub-recipients to understand how one can effectively prevent infections from being transmitted to and from women in sex work and their clients. Family planning: The Senate bill makes no reference to the family planning issues in the current law, while the House bill adds another layer of restriction to the use of PEPFAR funds for family planning activities. It authorizes family planning organizations to conduct HIV testing and counseling, but there is some uncertainty over whether organizations will have to comply with the Mexico City policy. This is a step backwards and any negotiation to better include family planning as an integral component of PEPFAR prevention programs may be a deal breaker. So it looks more and more like this issue will at best use the current House language to restrict the effective provision (and use) of family planning services and HIV/AIDS services where needed, a policy that will limit the effectiveness of the PEPFAR program in its prevention efforts. The HIV/AIDS Monitor will have field-based data on this topic later in the year to add to the ongoing debate about better linkages between HIV/AIDS programs and other health service delivery programs. Wrap-Up There is a lot of good stuff in these bills and because they more or less mirror each other, the chances are that most of these changes from the current law will get through with ease. That is largely a good thing, but in agreeing to a final bill, the House and Senate should clarify some of the key points of uncertainty that linger, so that a lack of clarity does not constrain the important work of fighting the pandemic effectively.


CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.