PEPFAR and Maximizing the Effects of Global Health Assistance

Abstract

BETWEEN 1995 AND 2008, WORLDWIDE GLOBAL INvestment in improving health in developing countries increased from $8 billion to nearly $25 billion. A main reason for this substantial increase was the creation of new institutions including the Gates Foundation; the Global Fund to Fight AIDS, Tuberculosis and Malaria; the GAVI Alliance; and, most importantly, the President’s Emergency Plan for AIDS Relief (PEPFAR) program. Created by President George W. Bush in 2003, PEPFAR was, as its website says, “launched to combat HIV/AIDS.” The program targeted 15 “focus” countries, mostly chosen for their high rates of human immunodeficiency virus (HIV) and AIDS but also for their government’s willingness to address the problems of HIV/AIDS as well as larger US geopolitical strategic reasons. PEPFAR has been the largest financial commitment of any country to global health and to treatment of any specific disease worldwide. PEPFAR is widely considered President Bush’s greatest achievement. PEPFAR has shown that it is possible to deliver advanced care that includes massive screening programs, prevention education, combination drug therapies, CD4 counts, and the rest of modern AIDS care to millions of people in very poor countries. PEPFAR has built and significantly improved health facilities, trained tens of thousands of health care workers, and developed reliable supply chains of HIV drugs in numerous countries. In addition, as shown by the report by Bendavid et al in this issue of JAMA, PEPFAR demonstrates that global health programs can have substantial effects on health—significantly associated with lower morality rates among adults. Building on the success of PEPFAR, President Obama launched the Global Health Initiative (GHI). Overall, the GHI was intended to broaden the focus of US health assistance and to emphasize getting the maximum “bang for the buck” rather than just spending more. Two of the core principles guiding the GHI constituted important shifts of emphasis: from emergency programs to sustainable programs and from measuring the success of global health aid based on inputs to substantive and meaningful health outcomes. Measuring PEPFAR’s Success Since PEPFAR’s creation, advocates and others have largely measured its success on 2 metrics: the size of its budget and the number of infected individuals receiving antiretroviral therapy (ART). By those measures, PEPFAR has been successful. Under President Bush, the budget increased exponentially. Cumulatively from 2003 to 2008, $20.4 billion was spent on PEPFAR. By the end of 2008, 2 million people were receiving ART because of PEPFAR funding. Because of this initial success, Congress in 2008, through the HydeLantos Amendment, authorized—that is, it permitted the spending of but did not actually appropriate the money—up to $48 billion for PEPFAR over the next 5 years (ie, by 2014) .Thus far, spending on PEPFAR has remained robust and ART goals have been substantially exceeded: cumulatively between 2009 and 2011 in excess of $20 billion has been given to PEPFAR, and by the end of 2011—in just 3 years— PEPFAR has doubled the number of people receiving ART to more than 4 million—reaching the goal to be achieved by 2014, more than 2 years ahead of schedule. But in the end, how much is spent and how many pills PEPFAR distributes are largely irrelevant. These measures assume a fixed relationship between inputs and outputs but are not what are important. What is of most interest is whether PEPFAR is prolonging life; giving people higher quality of life; and allowing people to lead economically, socially, culturally, and personally productive lives—and doing so for the maximal number of people possible. These are the metrics that really matter. The article by Bendavid et al addressed one of these substantive outcomes: has the PEPFAR program actually decreased mortality and therefore prolonged lives? The analysis compared 9 of 15 PEPFAR focus countries, most of the ones in Africa, with 18 nonfocus African countries. The important finding was that implementation of PEPFAR was associated with a significant decrease in mortality among adults in the focus countries, from 8.3 to 4.1 per 1000 population, compared to a more modest 20% decline in nonfocus countries. Importantly, this decline involved all-cause mortality, not just a