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*This post is co-authored by Michael Bernstein

With a contribution to date of almost $13 billion, PEPFAR is the largest foreign aid program ever dedicated to a particular disease. Impressive results are documented regularly on PEPFAR's website detailing partners supported, numbers of people treated, cared for and infections prevented to name a few accomplishments of this mammoth and unparalleled program. These results alone don't tell us whether the program is doing its best or could do better to stop the epidemic. While it may be too early to estimate the impact of PEPFAR, a short-term evaluation could certainly tell us if the program is heading in the right direction. So how is PEPFAR doing?

That is the question that the Institute of Medicine (IOM) has tried to address in its long awaited evaluation report released Friday morning. The evaluation team of experts examined the first 2 years (2004-2006 for the evaluation period) of PEPFAR's implementation progress and makes recommendations to improve PEPFAR going forward. The report is 420 pages long and valued at ~$40 for a download or a hard copy, so our initial analysis is based on the IOM briefing yesterday morning and from our quick reading of sections of the report, which is now available for free to read on the website.

The overarching theme of the evaluation, as explained by chair Dr. Jaime Sepulveda, is that "PEPFAR will need to make the transition from an emergency plan to a sustained effort that invests in building the capacity within countries to eventually take full responsibility for responding to their epidemics." A number of recommendations labeled as "opportunities" for improvement of PEPFAR that would support this transition have been identified by the evaluators and resonate strongly with the widely held view that things have gotta change for longer term success! Details of these opportunities are discussed at length in the main report, but here are some key highlights:

What Stands Out? Why?

Giving more attention to sustainability makes good sense, but it is unclear what this will mean in practice. The report emphasizes that an essential part of the way forward is to make large new investments in training more health workers, program managers, and other "human capacity." Easier said than done - recruiting and retaining health workers in the system is often more of a challenge than training them. As our CGD colleague Michael Clemens found in his analysis of the migration of health professionals out of Africa, that health care worker shortage is less about migration than it is about incentives for health workers to take these jobs in many of the countries supported by PEPFAR. So, how exactly will PEPFAR tackle this and other key issues? Should PEPFAR be giving more money directly to governments vs. non-governmental organizations? What effects are PEPFAR programs themselves having on the workforce? And how can PEPFAR programs be used to strengthen national health systems, since the report notes that "PEPFAR is a vertical program"? These are some questions among many that we are examining in our ongoing country-level research.

The most important recommendation in the report could prove to be the call for Congress to remove all funding earmarks (i.e. 55% of funding should go for treatment, 20% for prevention, etc.) when it passes legislation to "reauthorize" PEPFAR in the coming months. Again, another check on our wish list! Earmarks are an unnecessary constraint to programming, since we have seen that the allocations have become targets themselves. The report frames the problem well: "contrary to basic principles of good management and accountability, the budget allocations have made spending money in a particular way an end in itself rather than a means to end - in this instance, the vitally important end of saving lives today and in the future."

There is also a tension between imposing universal rules on how money can be allocated, while trying to implement a program that is responsive to each country's priorities. As Dr. Sepulveda noted, earmarks have "limited PEPFAR's ability to tailor their approach to countries, and adjust to national plans." He went on to say that there was "no logic to having earmarks for 15 different countries." Let's hope Congress sees it the same way, and decides to remove any funding restrictions when it drafts the new PEPFAR law. Early legislative endeavors such as the recent PATHWAY Bill re-introduced in the House by Reps. Lee and Shays last week are bolstered by these IOM recommendations and perhaps will allow for earlier legislation to remove the 1/3 abstinence only earmark and establish a comprehensive and integrated HIV prevention strategy to address the vulnerabilities of women and girls in countries.

The recommendation to PEPFAR to boost funding for prevention (which could be facilitated by removing funding earmarks) presents a critical opportunity to PEPFAR. Dr. Sulpuveda's emphatic words on this point say it all - "we need more prevention efforts and better prevention efforts, with a larger profile...without prevention, the epidemic will never end." Improving prevention activities, he said, would require larger investments in epidemiological and behavioral research. (Dr. Sulpuveda was asked about the ABC approach, but skillfully managed to avoid a direct answer on that one.) Our colleague Mead Over will be tackling the re-focus on prevention in a soon to be released brief. Stay tuned!

What's Next?

"Better late than never" truly applies to the IOM evaluation report, given the repeated delays in completion. The IOM committee deserves much credit, not only for taking on this enormous task but also for calling for improvements in the PEPFAR program that seem Appropriate, Beneficial, and Concrete (ABC, if you will!). The focus should now shift to the actors who can take these recommendations to action - Congress and the Office of the US Global AIDS Coordinator. Decision makers from both bodies are reading the report closely, and we'll be waiting to hear if, and how, they intend to act on the report's key recommendations.

A very good first step would be for OGAC to issue an official response to the IOM report, and feature the response on its website so that an open public dialogue can occur on how to best improve PEPFAR going forward.

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CGD blog posts reflect the views of the authors drawing on prior research and experience in their areas of expertise. CGD does not take institutional positions.