$5.2 billion later, where have PEPFAR monies for health systems gone?

For more than a decade, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the world's largest AIDS assistance program, has allocated one-fifth of its budget, or $5.2 billion, strengthening health systems in poor countries that have high rates of AIDS.

Center Faculty Associate Corrina Moucheraud and coauthors analyze how much money each nation devotes to this segment of the program's investments in the May issue of Health Affairs, and found that the countries with the biggest PEPFAR budgets also had the smallest shares allocated to health systems -- and this relationship remained even controlling for a country's HIV burden.

The ambitious PEPFAR program was launched in 2003 in 15 AIDS-ravaged countries, now 35 countries. One goal was to strengthen the capacity of local public and private health systems to deliver AIDS and HIV services. Using PEPFAR budget data for 2004-2014, authors analyzed how PEPFAR funds were allocated in five program areas – prevention, care, treatment, management /operations, and governance/systems – focusing on the latter.

They found that budgets for countries in sub-Saharan Africa, primarily those with the biggest PEPFAR budgets, consistently had smaller allocations for health systems, which suggests a persisting gap in funds for health system strengthening in some of the countries where existing systems are weakest. The article reports a lack of consensus in what “strengthening a health system” means, which stymies effective assessment of the program.

Authors also discuss criticism that narrow disease-focused programs like PEPFAR have generally done too little for broad system strengthening in poor countries where donors substantially support the health sector -- so when a crisis like Ebola strikes, these chronically under-resourced health systems may struggle to respond effectively.