This is a joint post with Jenny Ottenhoff.

Looming budget cuts for FY2012 and recent reports about the decline in AIDS funding from the USG in FY2010 relative to FY2009 have triggered the classic Washington, D.C. tug-of-war;  global health and development advocates are pushing to maintain funding levels, if not to increase them, and the U.S.  Congress is looking for ways to increase oversight and management of taxpayer dollars. Advocates are rightly pointing out what would happen if we don’t have the money and Congress is rightly signaling that the party is over.  What’s new? Nothing.

But lost in this old push and pull battle is a pragmatic and productive way forward, particularly for programs like PEPFAR.  Since its creation in 2003, the President’s Emergency Plan for AIDS Relief (PEPFAR) has received relatively unfettered political backing in the United States (by global health standards); enjoying bi-partisan support, full funding in annual appropriations and re-authorization in 2008.  It’s clear this kind of support will be increasingly difficult to maintain in the current political and fiscal climate which is why now, more than ever, PEPFAR needs to better demonstrate the effectiveness and value of its programs.  So here are my thoughts on why PEPFAR needs a Value for Money Plan and some steps towards creating that plan.

Why PEPFAR Needs a Value for Money Plan

PEPFAR’s efforts to combat the global HIV/AIDS epidemic have achieved impressive results.  But results data that are publically available are largely reported through program anecdotes and measures of people impacted by PEPFAR programs.  PEPFAR disaggregates results by country and program area (prevention, treatment and care), but does not tie data to specific activities.  From these data, we can make general observations about PEPFARs impact in FY2010, such as:

  • PEPFAR directly supported antiretroviral treatment for more than 3.2 million men, women and children worldwide.
  • PEPFAR directly supported antiretroviral prophylaxis to prevent mother-to-child HIV transmission for more than 600,000 HIV-positive pregnant women, and averted an estimated 114,000 infant HIV infections.
  • PEPFAR directly supported 11 million people with care and support, including nearly 3.8 million orphans and vulnerable children.

These publically available data illustrate important gains PEPFAR is making in the global fight against HIV/AIDS, but they stop short of permitting assessment of outcomes and impact of PEPFAR programs, robust cost-effectiveness analyses and comparisons of investments with results.  After 8 years of an unprecedented multi-billion dollar foreign aid program, it’s time to know more.

What Should the U.S. Congress Do?

As congress considered measures for increased oversight of PEPFAR, they shouldn’t make the best (expenditure data) the enemy of the good (strengthening information systems for better monitoring and evaluation of programs).  While ideal, chasing expenditure data at the country level is impractical in a developing country context where strong fiduciary systems often don’t exist.  After interacting with PEPFAR recipients in Mozambique, Uganda, and Zambia for CGD’s HIV/AIDS Monitor initiative research, it is clear to me that information systems are dysfunctional and/or overwhelmed, whether for financial or program data reporting. This is not to say that expenditure data isn’t important, but good expenditure data may only be generated when strong financial management and information systems are in place.

The World Bank has spent years trying to get countries to develop better fiduciary systems and report expenditures but it’s still unclear if this has led to better development outcomes.  Continuing to invest increasingly scarce resources to produce bad or fake expenditure data won’t help Congress decide if PEPFAR dollars are having an impact.  Isn't it time for us to develop information systems to learn how and which programs work to achieve a stated set of objectives instead of obsessively trying to capture elusive expenditure data? I think so.

What Should OGAC Do?

1.    Share Existing Data

PEPFAR implementers collect a wide range of valuable financial and related data on its programs but do not make this detailed information publically available.  Financial data that are publically available are largely planned and obligated funding, and only illustrate broadly where funds are being directed in terms of priority disease and program areas.   Data are also available on the cumulative obligations and outlays spread among the various implementing agencies and the three relevant appropriations bills (Foreign Ops, Labor-HHS-Education, and DoD).  From these data, we can infer that of the $6.9 billion appropriated for PEPFAR in FY 2011:

  • $5.6 billion (81%) is for HIV, $243 million (4%) for TB, and $1.050 billion (15%) for the Global Fund.
  • The largest share of planned funding in FY2010 is for treatment (37.6%), followed by prevention (35.9%) and care (26.5%). Funding for OVCs is part of care funding, and totaled 10.3% of approved funding in FY 2010.

But, that’s all we can really tell. A 2008 CGD HIV/AIDS Monitor Analysis and a memo to the then incoming President Obama recommended that PEPFAR make spending data publically available, specifically highlighting official data on obligations to prime- and sub-recipients. OGAC has since released data on obligations and outlays to each prime recipient, though data for sub-recipients is still not publically available.  In addition, PEPFAR recently reported they are strengthening their use of economic and financial data and moving towards routine implementation of expenditure tracking in some country programs and issued specific indicator guidance in 2009 that emphasizes a greater focus on outcome measures of program coverage and quality.

Providing access to a disaggregated country breakdown of PEPFAR funding activities and increasing investments in better reporting systems for outcomes measures would improve transparency and help to measure impact, optimize resource allocation, and clarify important policy debates.  The challenges of attributing results in the field directly to PEPFAR support, including weak fiduciary and information systems, should also be recognized and taken into account when considering ways to improve data collection and reporting. Making this data publically available will make funding decisions more transparent, and could reward effective programs and incentivize poor performers to improve (read more on how PEPFAR could better link funding decisions to performance here).

2.    Develop Meaningful Metrics of Success to prioritize data collection and reporting

PEPFAR should report results that go beyond  outputs (counts of people treated and cared for, and counts of HIV infections averted) and show us what has happened, for example, as a result of enrolling people into treatment programs. For example, of all the people who require ART in say, the catchment area of a PEPFAR supported program in Ethiopia, what proportion are actually receiving ARTs? Or of the people who are receiving ART, how many have been able to go back to work, or to school in the case of children?  Spending some time and money, after 8 years of learning from PEPFAR, to develop strong and meaningful outcome measures is long overdue. Knowing what one’s measures are BEFORE projects are funded may also assist in prioritizing data collection and could prove to be a better investment for the USG than trying to set up impossible oversight processes that yield little and low quality expenditure data.

Next month, Congress will begin making critical decisions about the allocation of future spending – including for PEPFAR – and unfortunately in this political and fiscally constrained climate, the current metrics aren’t going to cut it.   With 20 percent cuts already on the table for the international affairs budget, PEPFAR is in for a tough fight in the fall and it’s more critical than ever to demonstrate how effective its programs are.   What do you think PEPFAR’s leaders can do to successfully implement a value for money plan?