What do the US Congress, the US Senate and the White House have in common? (This isn’t a trick question). Both the House and the Senate matched the President’s FY14 request for global AIDS spending, including $4.02 billion for the President’s Emergency Plan for AIDS Relief (PEPFAR) and $1.65 for the Global Fund – marking a rare sweet spot where the executive and legislative branches agree.
This harmonious moment came when the House and Senate Appropriations Committees approved their respective State and Foreign Operations (SFOPs) appropriation bills for FY2014 last week. The agreed-upon allocation of $4.02 billion for PEPFAR is the lowest in four years (dropping from $4.24 billion in FY 2012 and $4.067 billion under the FY 2013 continuing resolution). But the absence of deeper cuts is good news in the current budget climate.
Beyond the top-line numbers, both bills commend the Global Fund for its progress on ongoing programmatic and fiduciary reforms. They also signal strong support for PEPFAR – a particularly significant development, given that formal reauthorization looks unlikely this year.
The House report also included a few notable calls for PEPFAR to increase its efficiency and effectiveness. First, the report directs the Global AIDS Coordinator to “consult with interested stakeholders such as the PEPFAR Scientific Advisory Board in determining the appropriate priorities for operations research and impact evaluation research.” I’m pleased to see this call for more research with an explicit emphasis on impact, and was thrilled to note a shout-out to the Scientific Advisory Board, on which CGD’s own Mead Over sits (read about the SAB’s recent work on data management and disclosure here).
The report also calls for the Global AIDS Coordinator to consult with the Appropriations Committee on PEPFAR’s efforts to reduce per-patient costs for treatment, an issue that Mead Over has worked on extensively with the Clinton Health Access Initiative, and which we discuss in an upcoming CGD report “More Health for the Money”. Understanding the per-patient costs of treatment is critical to getting value for money, and can help programs identify waste and streamline country-level program expenditures. PEPFAR has already taken concrete steps towards tracking the costs of treatment through expenditure analysis and is working to institutionalize the process across all of its programs. Still, more could be done to streamline efforts in this area, particularly in harmonizing expenditure tracking between PEPFAR and the Global Fund. I hope congressional attention will serve to highlight and bolster this good work.
Unfortunately, not everything in the two spending bills proved as unifying as global AIDS. Overall, the House bill comes in $10 billion below the Senate bill – due largely to dramatic reductions elsewhere in international aid. Global health writ large fared relatively well, but there was still some level of discord between the House and Senate bills for most programs.
The House bill slates $236 million for USAID’s tuberculosis program, which matches FY12 levels and far surpasses the $225 million proposed by the Senate and the $191 million requested by the President. The House bill also holds malaria funding at the FY12 level of $650 million, falling short of the Senate and the Presidential requests ($667 million and $670 million, respectively). The Senate bill requests more for pandemic influenza, NTDs, and family planning and reproductive health – including $40 million for UNFPA, which the House is positioned to defund completely.
For more in-depth analysis of how all global health programs fared, check out the Kaiser Family Foundation’s policy tracker on the House and Senate bills.
So what’s next? Both bills won approval by their respective committees. But the $10 billion chasm between the House and the Senate, paired with a minefield of divisive policy issues, suggest that the bills likely won’t be reconciled. Instead, they will probably be rolled into a continuing resolution (CR) – a temporary measure to hold current funding levels steady and provide more time for Congress to work out a longer-term spending plan. Under a CR, most elements of these two bills – both good and bad – will be null. But they may still have potential to inform the funding levels and policy provisions in a final FY14 appropriations bill down the line -- if and when one materializes. Hey, a girl can hope!