May 09, 2016
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Key component of PEPFAR’s budget drops 33% in 1 year

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A recent study from UCLA revealed that a crucial part of the budget for the President’s Emergency Plan for AIDS Relief, or PEPFAR, decreased 33% from 2013 to 2014. Researchers said the drop in funding calls into question whether the agency’s shift in policy to strengthen weak health systems abroad has been fully realized.

Launched in 2003, PEPFAR has five core activities — prevention, care, treatment, management and operations, and governance and systems. The latter activity, which focuses on strengthening health systems in countries heavily affected by HIV, receives approximately one-sixth of the agency’s overall funding, according to Corrina Moucheraud, ScD, MPH, assistant professor in the department of health policy and management at the UCLA Fielding School of Public Health. Although initially developed as an emergency response to the global HIV epidemic, PEPFAR has increasingly emphasized sustainability and systems strengthening, she said, which includes investments in laboratory infrastructure, information systems, the training of health care workers and other critical programs.

Corrina Moucheraud

Corrina Moucheraud

To analyze trends in these types of investments, Moucheraud and colleagues used data from the PEPFAR Dashboards — a data source made available to the public by the U.S. government on the agency’s budgets and expenditures.

“We looked into the budget data available on the PEPFAR Dashboards with an eye toward this question — whether this shift toward more emphasis on systems strengthening and sustainability was manifest in the budget numbers,” Moucheraud told Infectious Disease News.

Results of their analysis, published in Health Affairs, indicate that PEPFAR budgeted a total of $33.3 billion from 2004 to 2014. Of this, $5.2 billion was allocated for activities related to governance and systems. The share of PEPFAR funding for governance and systems increased from 14.9% in 2004 to 27.5% in 2013, but that budget item decreased 1 year later to 20.8%. By comparison, PEPFAR’s overall budget declined to $3.4 billion during the same time period — a 7% reduction.

Moucheraud said strong health systems are necessary to address the HIV epidemic, and stressed the importance of fully funding donor agencies like PEPFAR.

“Even though new HIV infections are declining, the absolute number of people living with HIV and AIDS is continuing to rise worldwide,” she said. “Particularly in low- and lower-middle–income countries that receive donor assistance, there is a need for continued funds to support prevention, testing and treatment.”

The researchers noted that the data used in the study pertained only to funding and not actual expenditures — a potential limitation. Moreover, the data were compiled by PEPFAR and may be subject to source bias.

“Since its inception, [PEPFAR] has made significant investments in partner country governance and health systems, strengthening their capacity to deliver lifesaving HIV/AIDS services for the people they serve and to address other health issues,” a PEPFAR spokesman told Infectious Disease News. “Unfortunately, the methodology used by the authors of the Health Affairs article does not fully capture PEPFAR’s investments in governance and health systems, as the authors readily admit in highlighting the limitations of their analysis.”

The spokesman said the study did not account for investments in health systems strengthening supported within other PEPFAR budget codes, such as for adult treatment. A more accurate reflection of PEPFAR’s spending on health systems can be found through an analysis of the agency’s publicly available expenditure data, he said.

As of Sept. 30, 2015, PEPFAR is supporting more than 9.5 million people on ART — a fourfold increase since 2008 — and the agency has provided approximately 9 million medical male circumcisions and training for more than 190,000 new health care workers, according to the spokesman.

Moucheraud said she wants to conduct additional analyses to assess the impact of PEPFAR spending on health systems in recipient countries.

“I think that’s an important question to look at,” she said. “It’s not one we looked at in this study.” – by John Schoen

Disclosure: The researchers report no relevant financial disclosures.