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Global Health Policy Blog


This is a joint post with Rachel Silverman.

The Institute of Medicine (IOM) will soon release its much anticipated report evaluating the implementation of the President’s Emergency Plan for AIDS Relief (PEPFAR). Conducted at the request of Congress, the forthcoming report should follow up on points raised by a previous IOM report (2007), which provided a “short-term evaluation” of implementation after PEPFAR’s first three years, and which was soon followed by PEPFAR’s Congressional reauthorization in 2008. The new report is expected to broadly assess the cumulative performance of US HIV/AIDS programs, with two main tasks:

“(i) an assessment of the performance of United States-assisted global HIV/AIDS programs; and

(ii) an evaluation of the impact on health of prevention, treatment, and care efforts that are supported by United States funding, including multilateral and bilateral programs involving joint operations.

Source: Appendix A, National Academy of Sciences 2010

As the IOM hasn’t given a preview of its findings, we (along with everyone else) eagerly await tomorrow’s release. But based on our own work-in-progress on PEPFAR’s value for money and data management, we’ve flagged two focus areas that we hope the report will address – and which are the subject of a forthcoming CGD policy paper on PEPFAR’s financial flows.

1. Institutional Arrangements of Implementation (The Nitty Gritty)

PEPFAR’s massive scale-up between its launch (2003) and its first reauthorization (2008) was an extraordinary achievement, enabling a true “emergency response” to the global AIDS epidemic. United under the leadership of the Office of the Global AIDS Coordinator (OGAC), USAID, the U.S. Centers for Disease Control and Prevention (CDC), and other USG implementing agencies achieved an unprecedented level of interagency cooperation to meet the challenge of AIDS. Within this context, rapid scale-up, by necessity, was achieved through the deployment of US-based NGOs and contractors with existing expertise, both in program implementation and compliance with USG fiscal and legal standards.

It is widely acknowledged that there was a trade-off between rapid scale-up and long-term sustainability, both for AIDS-specific programs and global health more broadly. Given the large and sudden influx of international (earmarked) AIDS funding (of which PEPFAR is a major contributor), countries may have shifted their own resources for health – either to complement AIDS funding or to address issues other than AIDS – with varying effects on health systems. New research, for example, has found that international AIDS financing has reduced childhood vaccination rates in some countries, although it may have also increased the provision of some maternal health services; these results indicate that the effects of AIDS funding on health systems may be mixed and/or highly contextual.

One such contextual factor with potentially high importance is the mode of financing and service delivery, which, in PEPFAR’s case, includes heavy utilization of US contractors. For example, private contractors or NGOs could lure health workers away from the public sector, but the existence of parallel systems and facilities could also help insulate government-run clinics from focusing too much on HIV patients at the expense of other constituencies.

In recognition of some of these challenges, PEPFAR’s current 5-year strategy, adopted in 2009, aims to achieve a “transition from an emergency response to promotion of sustainable country programs,” including through the eventual transition of implementation responsibility to country governments. Within this broader push towards country ownership, in 2011 the USG identified “working to increase the number and types of local partners…and strengthening the capacity of partner countries…” as a core component.

Over the past year, we at the Center for Global Development have analyzed PEPFAR data using a dataset compiled from PEPFAR documents under the leadership of Nandini Oomman, previously director of the HIV/AIDS Monitor. Our forthcoming paper finds that in 2008, 477 contractors received PEPFAR financing totaling $3.56 billion; the average organization received a reported $7.5 million and the median was $1.5 million. In this 2008 dataset, more than $2 billion (about 58% of the total) was concentrated in 25 contractors (or 5% of all 477 contractors). Nearly all of these 25 contractors were based in the US and included for-profits, non-profits, faith-based organizations, universities, and others. While $686 million was spent through academic institutions, $301 million was allocated to developing-country governments as prime partners who represented 8% of all contractors. In line with PEPFAR’s 5-year strategy, we might expect that this proportion to have increased substantially in the interim.

So, we are eager to see the IOM’s findings on PEPFAR’s implementation arrangements: How have they changed over time? How has PEPFAR progressed towards its goal of country-led implementation – and where countries have taken over responsibility, have they maintained high-quality service delivery? Are different implementation arrangements more or less effective for program success, and more or less conducive to strengthened health systems more broadly? How can PEPFAR best maintain its scale and success while transitioning towards a more sustainable model?  We hope the report gives us some insight on how implementation arrangements may be evolving to meet the challenges of long-term sustainability.

2. Investing for Impact (The Big Picture)

At its launch, PEPFAR’s allocation decisions were heavily shaped by the legal requirements of its Congressional authorization, including strict guidelines for the distribution of funds to different interventions, and the selection of 14 “focus countries” which were to receive concentrated PEPFAR funding (a 15th country, Vietnam, was formally added in the 2008 reauthorization). Some of the more controversial earmarks (i.e. abstinence-based prevention) have been relaxed over time, and PEPFAR no longer uses the “focus country” designation. Still, there are clear legacy effects of PEPFAR’s earlier incarnation, likely due, at least in part, to the moral entitlement created by putting a person on life-saving treatment. In our forthcoming study, we find that after controlling for disease burden, GDP per capita, and governance effectiveness, countries previously designated as “focus countries” each received roughly $591 million in additional funding (cumulative) between FY2004 and FY2011.

So with this increased flexibility, how has PEPFAR made the most of its money through strategic allocation? Has PEPFAR used a clear rationing mechanism to distribute scare funds between countries, interventions, and target populations within countries? Is resource allocation explicit, efficient, equitable, and ethical – and how does PEPFAR approach tough funding trade-offs?

We hope that the IOM report will provide insight into how PEPFAR is adapting to and addressing these difficult issues – and that our upcoming paper can supplement those findings.  Stay tuned!


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.