Issue 1: How do congressional funding restrictions (earmarks) influence PEPFAR allocations for prevention, treatment, and care?

The flexibility of PEPFAR funding is much debated, with particular attention to how congressionally mandated restrictions influence PEPFAR allocations to different program areas. Such legislative restrictions, or earmarks, now direct PEPFAR to spend 55% of its global funding on treatment, 20% on prevention, 15% on care, and 10% for orphans and vulnerable children.¹

An early evaluation of PEPFAR by the Institute of Medicine in 2007 found that the earmarks were unnecessarily constraining the flexibility of funds at the country level, and called for removing them when PEPFAR is reauthorized in 2008.² In contrast, PEPFAR officials have argued that the earmarks direct spending towards important program areas, such as orphans and vulnerable children, that otherwise would receive too little attention.³

The figures below offer a glance at what we can learn about this issue from the newly released data. See the new HIV/AIDS Monitor report "The Story Behind the Numbers: PEPFAR Funding for Fiscal Years 2004 to 2006" for further analysis.

View the raw data underlying these figures: View as web page | Download in Excel (19 KB)

¹ The earmarks for prevention and care are "soft" earmarks, meaning they are suggested. The earmarks for treatment and orphans and vulnerable children became mandatory in fiscal 2006. For details on the funding earmarks see Oomman, Bernstein and Rosenzweig (2007).

² Institute of Medicine (2007).

³ Personal communication with PEPFAR official, February 11, 2008.