The Institute of Medicine (IOM) will soon release its much anticipated report evaluating the implementation of the President’s Emergency Plan for AIDS Relief (PEPFAR). Conducted at the request of Congress, the forthcoming report should follow up on points raised by a previous IOM report (2007), which provided a “short-term evaluation” of implementation after PEPFAR’s first three years, and which was soon followed by PEPFAR’s Congressional reauthorization in 2008. The new report is expected to broadly assess the cumulative performance of US HIV/AIDS programs, with two main tasks:

“(i) an assessment of the performance of United States-assisted global HIV/AIDS programs; and

(ii) an evaluation of the impact on health of prevention, treatment, and care efforts that are supported by United States funding, including multilateral and bilateral programs involving joint operations.

Source: Appendix A, National Academy of Sciences 2010”

As the IOM hasn’t given a preview of its findings, we (along with everyone else) eagerly await tomorrow’s release. But based on our own work-in-progress on PEPFAR’s value for money and data management, we’ve flagged two focus areas that we hope the report will address – and which are the subject of a forthcoming CGD policy paper on PEPFAR’s financial flows.

1. Institutional Arrangements of Implementation (The Nitty Gritty)

PEPFAR’s massive scale-up between its launch (2003) and its first reauthorization (2008) was an extraordinary achievement, enabling a true “emergency response” to the global AIDS epidemic. United under the leadership of the Office of the Global AIDS Coordinator (OGAC), USAID, the U.S. Centers for Disease Control and Prevention (CDC), and other USG implementing agencies achieved an unprecedented level of interagency cooperation to meet the challenge of AIDS. Within this context, rapid scale-up, by necessity, was achieved through the deployment of US-based NGOs and contractors with existing expertise, both in program implementation and compliance with USG fiscal and legal standards.

It is widely acknowledged that there was a trade-off between rapid scale-up and long-term sustainability, both for AIDS-specific programs and global health more broadly. Given the large and sudden influx of international (earmarked) AIDS funding (of which PEPFAR is a major contributor), countries may have shifted their own resources for health – either to complement AIDS funding or to address issues other than AIDS – with varying effects on health systems. New research, for example, has found that international AIDS financing has reduced childhood vaccination rates in some countries, although it may have also increased the provision of some maternal health services; these results indicate that the effects of AIDS funding on health systems may be mixed and/or highly contextual.

One such contextual factor with potentially high importance is the mode of financing and service delivery, which, in PEPFAR’s case, includes heavy utilization of US contractors. For example, private contractors or NGOs could lure health workers away from the public sector, but the existence of parallel systems and facilities could also help insulate government-run clinics from focusing too much on HIV patients at the expense of other constituencies.

In recognition of some of these challenges, PEPFAR’s current 5-year strategy, adopted in 2009, aims to achieve a “transition from an emergency response to promotion of sustainable country programs,” including through the eventual transition of implementation responsibility to country governments. Within this broader push towards country ownership, in 2011 the USG identified “working to increase the number and types of local partners…and strengthening the capacity of partner countries…” as a core component.

Over the past year, we at the Center for Global Development have analyzed PEPFAR data using a dataset compiled from PEPFAR documents under the leadership of Nandini Oomman, previously director of the HIV/AIDS Monitor. Our forthcoming paper finds that in 2008, 477 contractors received PEPFAR financing totaling $3.56 billion; the average organization received a reported $7.5 million and the median was $1.5 million. In this 2008 dataset, more than $2 billion (about 58% of the total) was concentrated in 25 contractors (or 5% of all 477 contractors). Nearly all of these 25 contractors were based in the US and included for-profits, non-profits, faith-based organizations, universities, and others. While $686 million was spent through academic institutions, $301 million was allocated to developing-country governments as prime partners who represented 8% of all contractors. In line with PEPFAR’s 5-year strategy, we might expect that this proportion to have increased substantially in the interim.

So, we are eager to see the IOM’s findings on PEPFAR’s implementation arrangements: How have they changed over time? How has PEPFAR progressed towards its goal of country-led implementation – and where countries have taken over responsibility, have they maintained high-quality service delivery? Are different implementation arrangements more or less effective for program success, and more or less conducive to strengthened health systems more broadly? How can PEPFAR best maintain its scale and success while transitioning towards a more sustainable model?  We hope the report gives us some insight on how implementation arrangements may be evolving to meet the challenges of long-term sustainability.

2. Investing for Impact (The Big Picture)

At its launch, PEPFAR’s allocation decisions were heavily shaped by the legal requirements of its Congressional authorization, including strict guidelines for the distribution of funds to different interventions, and the selection of 14 “focus countries” which were to receive concentrated PEPFAR funding (a 15^th country, Vietnam, was formally added in the 2008 reauthorization). Some of the more controversial earmarks (i.e. abstinence-based prevention) have been relaxed over time, and PEPFAR no longer uses the “focus country” designation. Still, there are clear legacy effects of PEPFAR’s earlier incarnation, likely due, at least in part, to the moral entitlement created by putting a person on life-saving treatment. In our forthcoming study, we find that after controlling for disease burden, GDP per capita, and governance effectiveness, countries previously designated as “focus countries” each received roughly $591 million in additional funding (cumulative) between FY2004 and FY2011.

So with this increased flexibility, how has PEPFAR made the most of its money through strategic allocation? Has PEPFAR used a clear rationing mechanism to distribute scare funds between countries, interventions, and target populations within countries? Is resource allocation explicit, efficient, equitable, and ethical – and how does PEPFAR approach tough funding trade-offs?

We hope that the IOM report will provide insight into how PEPFAR is adapting to and addressing these difficult issues – and that our upcoming paper can supplement those findings.  Stay tuned!

In mid-2011, one of the biggest developments in HIV/AIDS research took place. The HPTN 052 study found that early antiretroviral therapy treatment could reduce HIV transmission by 96% in couples where one partner is HIV positive and the other is HIV negative. The study was heralded as the breakthrough of 2011 by Science, and was hailed as a game changer by many others, including UNAIDS, The Economist and The Lancet. The World Health Organization wrote a comprehensive guideline for TasP, or treatment as prevention, in June 2012, asserting that “TasP needs to be considered as a key element of combination HIV prevention and as a major part of the solution to ending the HIV epidemic.”

Further, at the 2012 AIDS conference, the HPTN052 team presented their models assessing TasP in India and South Africa as “very cost-effective” as compared to delayed ART or no ART, using the WHO “rule of thumb” for cost-effectiveness (<1x or <3x an average GDP per capita). The strategy is already gaining traction on the ground: the Clinton Health Access Initiative announced plans to scale up TasP to 90% of the relevant population in Swaziland.

Yet even if TasP is cost-effective according to the GDP per capita rules of thumb, is it the most cost-effective use of resources to combat HIV/AIDS? When and how much TasP versus other interventions are needed? These critical policy questions can only be answered by mathematical models that optimize the mix of interventions and their coverage for HIV prevention for a given budget, not models that compare the cost-effectiveness of a new intervention to no intervention (no ART) or the status quo (delayed ART) with no budget constraint.

Till Barninghausen, David Bloom and Salal Humair have recently published the results of such a modeling exercise for South Africa, assessing “whether TasP is indeed a game changer or if comparable benefits are obtainable at similar or lower cost by increasing coverage of medical male circumcision (MMC) and antiretroviral treatment (ART) at CD4 <350/microliter” (see here, gated). The authors find that MMC is significantly cheaper than TasP in terms of cost per infections averted – $1,096 versus $6,790. Further, they find that most benefits result from high levels of ART coverage using the CD4 <350/microliter criteria.

Barninghausen et al conclude that the most cost-effective HIV prevention strategy in South Africa is first to increase MMC coverage, and then to scale up ART: this strategy would achieve comparable incidence reductions to TasP and cost $5 billion less, a figure comparable to total Global Fund expenditures on AIDS over a five year period.

While the Barninghausen et al study looks at all the benefits of TasP, there are certain benefits and costs they overlook. There are significant differences of benefits across different risk groups:  for example, if MMC is targeted to the most at-risk men, including soldiers, policemen, truck drivers and MSM, it would yield higher benefits (for more on this by Mead Over and others, see here and here). Similarly, for costs, there are issues of diseconomies of scale in the production of TasP (South Africa; here). There are also certain tradeoffs, or production synergies, that have not received sufficient attention: a study from Burkina Faso shows that adding ART to existing health services did not increase the waiting time for non-ART services in Burkina Faso. Finally, there could be diminishing returns to program scale up due to the saturation of groups most willing to receive and use the intervention – this could apply both to TasP and MMC.

All in all, this evaluation shows that as new interventions become available, the need to assess and invest in the most cost-effective mix and coverage of interventions becomes more relevant. The UNAIDS investment framework is a start. However, if we want to get the most done with the money that we have available, reaching an AIDS-free generation, we need to maximize our impact on HIV incidence reduction – getting to the intervention mix and coverage levels that are optimal for that purpose, given resources available.

The Barninghausen et al approach is the way to go for the future. To maximize value for money, global health funders and technical agencies should support the development of these models –in close collaboration with country officials- for all of their major recipients.

The objective proposed by the new PEPFAR blueprint is to reduce new infections below the number of people newly added to treatment in a given year. But this isn’t good enough, because the total number of people in low and middle income countries who are living with HIV/AIDS and dependent on the US and other donors for their daily medication would continue to grow – along with the moral entitlement to support these people on treatment.

Moving forward, I suggest that the US should figure out how to convert the moral entitlements it has already granted into credible long-term enforceable commitments which are more analogous to the commitments it makes to Social Security beneficiaries in the US.  My logic is that unless there is a lower bound to the US commitment in an individual recipient country, the recipient government will have little financial incentive to contribute its own scarce resources to AIDS treatment, because every penny it contributes might well be offset by the withdrawal of US resources.  (Even if the Obama administration means to continue funding this treatment, future administrations are entirely too free to renege.)  But just as the US must reform Social Security and Medicare to clearly establish a more sustainable upper bound for future payments, the US should clearly establish and communicate an upper bound to the US commitment to AIDS treatment in every beneficiary country.  The combination of the long-term commitments to a lower and upper bound on US contributions will change the incentive structure in recipient countries, establishing that the recipient country is responsible for the balance of the treatment need – and that the country has much to gain financially as well as through improved health of its citizens by implementing effective HIV prevention as rapidly as possible.

The recommendation in my book, “Achieving an AIDS transition,” is that, in addition to all the patients the US has started supporting, the US should commit to support a fixed percentage of the new treatment need in each recipient country, which might vary from 20% to 80% depending on the country.  The US government would have to plan how much would be required to meet each percentage point of need in each country and choose what percentage it intends to finance in every country to fit within the US’s projected future budget for AIDS treatment overseas.  But such an arrangement would assure continued US support and generate strong incentives for the country and its citizens to improve their HIV prevention efforts.

The pressure is on for the US government to cut spending.  In this environment, vague statements of administration support for meeting its moral commitments to AIDS patients in other countries provide unfair and perverse incentives to recipient government partners and provide insufficient guidance to Congressional and Administration budget cutters.  The White House should append the blueprint just released with a firm multi-year commitment to AIDS treatment specific to every recipient country.

Graph above is created from UNAIDS data accessed on December 3^rd, 2012 from the AIDSinfo database. Here is the Stata code to replicate the graph.

Secretary Clinton to Global Health community – Science and evidence must continue to guide our work. 

Around this time last year, world leaders called for “the beginning of the end of AIDS” and an “AIDS-free generation”, and committed to reaching the ambitious disease-specific targets for HIV/AIDS: the virtual elimination of mother-to-child transmission; 15 million people on treatment and a reduction in new adult and adolescent HIV infections — all by a rapidly approaching 2015.  And this year, US Secretary of State Hillary Clinton recommitted to these ambitious goals in the release of the PEPFAR Blueprint, saying “An AIDS-free generation is not just a rallying cry — it is a goal that is within our reach”.  While the overarching World AIDS Day message remains clear – we have made tremendous progress thus far, and there is still a long way to go in the fight against AIDS – one question remains:  is this really the beginning of the end of AIDS?

To answer these questions, we have to define what the “end” is. A recent report by the ONE Campaign, titled “The Beginning of the End? Tracking Global Commitments on AIDS,” highlights that we are off-track to meet the 2015 goals unless commitments by countries are scaled up tremendously. The report defines the “beginning of the end” as the point where the number of people newly added to treatment surpasses the number of people newly infected with AIDS.  On the other hand, our colleague Mead Over would suggest aiming instead for the point when the number of new infections falls below the number of deaths so that the number of people living with AIDS, and the associated cost and dependency, stops growing – an objective he calls the AIDS transition.

But by either definition, we haven’t yet reached the beginning of the end. There are still 7 million eligible people who don’t receive treatment, 2.5 million new infections every year, and a $7 billion funding gap.  And to reach the 2015 goals, 140,000 additional people have to be added to treatment and new HIV infections will have to decrease by 200,000 annually for the next three years (see figure below from the ONE Report).

This is not to say there is no progress. The latest UNAIDS report shows that for the first time, a majority of people eligible for antiretroviral therapy (8 million) are receiving it, and in 25 low- and middle-income countries HIV infections have declined by 50 percent in the past decade, resulting in 700,000 fewer new infections.  These declines were achieved in part due to increased commitments by low- and middle-income country governments — domestic investments rose from $4 billion in 2005 to $9 billion in 2011 and now make up over half of the total funds against AIDS.

So, how do we capitalize on these gains and truly reach the beginning of the end?

The ONE report outlines three areas critical to achieving maximum impact: eliminating mother-to-child transmission (PMTCT), ensuring access to treatment for 15 million individuals, and reducing new HIV infections to 1.1 million annually, by 2015.  In order to reach these targets, the report highlights strengthened health systems as the key to addressing PMTCT, scaling up the pace of initiating treatment, and increasing focus on effective interventions. Combination prevention strategies, for example, have proven to be effective, but certain components such as circumcision are not scaled up in many settings.

Of course, all of this is largely contingent upon one input: money. The ONE report shows how much  bilateral and multilateral donors have committed thus far to the fight against AIDS, and concludes that all must ramp up their spending until 2015 – surely a tough message to convey in today’s fiscal climate. ONE recommends that both traditional and new actors must scale up their contributions to fighting HIV/AIDS, and maximize their impact through accountable planning and reporting.

While more money is important, it is not enough. We must increase the value for money of existing investments and leverage more impact for each dollar spent. If global health funders coordinate to increase their commitments to proven interventions, and ensure their funds go to where they can leverage the highest impact, we might really reach the beginning of the end of AIDS by 2015 and have the data to prove it.

The authors thank Jenny Ottenhoff for her contributions to this blog.

Background

Since January, 2011, I have served on two of the working groups of PEPFAR’s Scientific Advisory Board , those on data and key populations.    As I described in a previous post, Ambassador Goosby formally constituted this board in January, 2011 under the auspices of the Federal Advisory Committee Act and requested it to advise him and PEPFAR “concerning scientific, implementation and policy issues related to the global response to HIV/AIDS.”  [From the SAB’s charter.]  PEPFAR has recently posted the 22 presentations from the recent meeting as a downloadable 28 MB zip file.  For those who are following the progress of PEPFAR, the US’s most prominent, most frequently praised and most costly foreign assistance effort, these presentations provide a wealth of fascinating perspective, information, opinion and advise.  Because of the packed agenda, the SAB as a whole had little opportunity to review all of the material or to discuss each of the topics in the depth they deserved.  Hopefully many of the issues raised will receive a fuller discussion in the public arena, including on blogs such as this one.

The Data Working Group

Since January, 2011, I have served on two of the working groups, the ones on data and on key populations.  While I have long had an interest in improving the global response to the epidemic in key populations (an interest that was inspired by my early collaboration on an article with Peter Piot here and ungated here), my interest in data has only been instrumental.   I have appreciated data not for their own sake but only as a means to an analytical end.  But serving on the Data Working Group has opened my eyes to both the opportunities and the challenges that PEPFAR faces in the arena of data collection, management and disclosure.  In a series of meetings and conference calls over the past two years with other members of the DWG and with US government staff of PEPFAR and other agencies, I have learned that PEPFAR and its contractors are spending a great deal of money, perhaps $500 million per year or even more, collecting and managing data, but neither the intended beneficiaries (the AIDS patients and vulnerable populations of recipient countries) nor the US taxpayer is benefitting as much as they could from this effort.

In our group deliberations, the members of the DWG based our recommendations on a set of “principles of data collection and management”:

1. Data should strengthen US government program management
2. Data are a public good (i.e. the consumption of data is neither “excludable” nor “rivalrous” and therefore its production and distribution require government support)
3. Data should further transparency and accountability of government programs
4. Data should be standardized for comparability through a common data “platform”
5. Data based analyses of the progress or problems of a US government program should be replicable by members of the public, who can also be a source of independent ideas (“Crowd sourcing”)

How do you, the readers of this blog, feel about these principles?

The DWG’s Recommendations to PEPFAAR

Proceeding from these principles, the Data Working Group arrived at a set of four recommendations which we delivered to Ambassador Goosby (the US’s Global AIDS Coordinator) in the form of a presentation that I presented at the recent October meeting.  These were that PEPFAR should:

1. Establish and maintain a PEPFAR public access knowledge portal
2. Strengthen, streamline and publicly disclose PEPFAR’s collection and management of key program indicators
3. Establish, collect and publicly disclose activity-based budget, expenditure and cost data
4. Require each future grantee and contractor to submit a “Data Management Plan”

Since PEPFAR already has a website and collects indicators, the first two of these recommendations may seem anodyne.  However, those who have attempted to retrieve more detailed quantitative information from the PEPFAR website already know how frustrating such an effort has been.  PEPFAR does well on collecting its mandated indicators, but lags behind other US agencies both in the scope of its reports to Congress and in its  ranking on the 2012 Aid Transparency Index.  PEPFAR’s indicators also need to be strengthened (e.g. to better capture the retention as well as the enrollment of AIDS patients) and also streamlined (to minimize the collection and reporting of unusable indicators).  See the full presentation for more details on both the strengths and the weaknesses of PEPFAR’s current efforts.

Recommendation 3, the collection and disclosure of activity-based budget and expenditure data, may be the most surprising recommendation to the average US taxpayer, who wants to be sure US foreign assistance is wisely spent.  The taxpayer might well ask, “Aren’t the budget, expenditure and cost of PEPFAR funded activities already fully disclosed?”   Unfortunately long before PEPFAR was created the US government ceded to its contractors the “right” to declare their detailed activity-based budgets and expenditure reports to be, get this, “trade secrets”, which the contractors can refuse to divulge to the public.  These data that would intuitively seem to be the property of the citizens of any democratic country, are hidden behind so many layers of protection that sometimes even PEPFAR staff cannot access them.  See this enlightening blog post by Till Bruckner who attempted to extract such information from US aid contractors using a Freedom of Information Act request.

The good news is that PEPFAR has taken aggressive steps to better understand the cost-effectiveness of its programs, but has not yet disclosed the underlying data to the public.  The DWG recommended that PEPFAR build on its recent progress in this area by:

1. Regularly repeating its surveys of the activity-linked unit cost of anti-retroviral treatment and disclose the properly anonymized underlying data
2. Expanding its activity-linked unit cost analysis to other PEPFAR supported HIV/AIDS services
3. Releasing the properly anonymized activity-linked budget, expenditure and  cost data at the unit of observation, which is the partner or program
4. Disclosing the anonymized activity-linked financial data on PEPFAR’s open web portal, freely browsable by the public

Recommendation 4 will be the most controversial in the PEPFAR research community.  Researchers have many reasons, both good and bad, for preferring not to share their data.  The good reasons are to protect the privacy of their patients or subjects and to respect the sovereignty of host countries (although one must ask whether the host countries preferences for data control should trump those of the American taxpayer and the global community in every case).  The bad reasons have to do with researchers’ ambitions to squeeze out all of the possible publications from the data before releasing them for use by other researchrs.  (As a researcher I have not been immune to this temptation.)  Unfortunately, the two sets of reasons can become easily confounded, since a researcher wishing to retain private use of data over a longer time can often persuade the host country government to request the data not be shared.

Although I empathize with the researchers’ desire to have privileged access to data they have collected, at least for a while, as an economist I am aware that private incentives will always be slanted against optimal public disclosure of data.  In this fourth recommendation, we on the DWG advise PEPFAR to represent the public interest as a counterweight to the various private interests of host countries and researchers and support the principle that publicly funded data should eventually enter the public domain and that US government contractors must establish an approved timetable for archiving their properly anonymized data for public use.

An opportunity for some quick progress.

Assembled in a blog post by CGD’s Lawrence MacDonald, four colleagues and I propose that those in the Obama administration with attention to spare from the task of avoiding the fiscal cliff could make a few immediate, low cost or free changes that would substantially improve US policy support for poverty reduction in poor countries for years to come.  Building on what I’ve learned on PEPFAR’s SAB, my contribution to this list is to suggest that Ambassador Goosby and his staff move forward quickly towards greater public disclosure of existing data (DWG Recommendation #1) and towards mandating the Data Management Plans for contractors (DWG Recommendation #4).  Looking forward to 2013, we can all hope and expect that further improvements in PEPFAR’s collection, management and disclosure of key program data will support continued improvement in the quality, efficiency and accountability of PEPFAR’s efforts against the AIDS epidemic.

UNITAID: maybe you’ve heard of it, or maybe not. Launched in 2006, UNITAID has lived in the shadow of its older and bigger global-health siblings (the Global Fund, GAVI, and PEPFAR, to name a few). Perhaps due to its relative obscurity and late entry to a crowded global-health field, UNITAID has proactively worked to differentiate itself through a focus on commodities, market shaping, novel funding sources, and innovation. To wit, UNITAID’s stated mission is “to contribute to scale up access to treatment for HIV/AIDS, malaria and tuberculosis for the people in developing countries by leveraging price reductions of quality drugs and diagnostics, which currently are unaffordable for most developing countries, and to accelerate the pace at which they are made available.”

But today, as UNITAID celebrates its sixth birthday (happy birthday UNITAID!), it stands at a potential crossroads. Last year, UNITAID’s Executive Board commissioned a five-year evaluation, requesting a “high quality, forward-looking report relevant to the future of UNITAID” with a final report expected in August 2012 – any day now. The evaluation will consider a broad range of core questions that may influence UNITAID’s future directions. For example: Where does UNITAID add value, and to what extent has UNITAID successfully complemented the roles of its older global health siblings? Can UNITAID’s “catalytic funding approach” achieve long-term market and public health impacts? To what extent has UNITAID exerted a positive influence on health commodity markets, addressing market inefficiencies in line with its market-oriented core mandate? (Hat tip to Marco Schäferhoff of SEEK Development)

In light of UNITAID’s forthcoming evaluation report and its upcoming strategy for 2013 to 2015, we too examined UNITAID’s role within the global-health financing architecture. Is UNITAID’s mandate still appropriate or relevant? UNITAID tries to support the movement to scale-up access to treatment through its constitutional focus on commodities and price reductions – is this the most value-added approach? How can a commodity-centric approach respond to recent global-health trends and priorities, including country ownership, health-systems strengthening, and sustainability? More provocatively: has UNITAID’s approach of using “innovation [to] make markets work for the neediest ” devolved into a hammer in search of an innovative, market-based nail?

In our paper (see consultative draft here) we outline some contradictions and limitations of UNITAID’s current approach. We worry that UNITAID’s approach to value for money “measures its success based on its impact on the markets for medicines, diagnostics and related products” – potentially conflating strategy with mission. Further, UNITAID’s focus on market-shaping and price reductions leads it to choose small, niche markets that are neglected by other donors, i.e. pediatric formulations and second-line drugs. But is this the right priority? For example, second-line TB drugs cost up to 120 times as much as first-line medications. It may not necessarily be ethical or smart to provide a single patient with second-line TB drugs instead of treating up to 120 patients with first-line drugs, all for the same cost (see table below), and especially when many people still lack first-line treatment for non-drug resistant tuberculosis. That said, there may well be good reasons for UNITAID to focus on small, niche commodities, e.g., basic arguments of fairness and justice to reach populations that would otherwise be unable to receive second-line treatment; or because children should not be born condemned to a preventable death sentence; or as part of a broader strategy to stem drug-resistant epidemics (a very worrying development, particularly for TB). But in its available documents UNITAID does not appeal to these real concerns, instead emphasizing instrumental arguments in justifying its intervention choices, where funding decisions are made because of the potential to drive price reductions or other market impact in selected commodities. This argument is analogous to purchasing something on sale because it is on sale (or purchasing something expensive because it is expensive).

We hope that the imminent evaluation provides the impetus for UNITAID to turn inward and do something truly innovative: buck institutional inertia, change course as necessary, and reinvent itself as the solution to 2012’s biggest global health challenges. One very specific recommendation: UNITAID should reframe its rhetoric away from market-based jargon, and instead appeal to arguments of fairness, justice, and health impact in justifying its intervention choices.

Read the whole thing  for our full take; comments below or by e-mail are welcome as always.

The authors thank Amanda Glassman for excellent comments. 

There’s an AIDS spending cliff in Ethiopia and the government is already in free fall. Next year, Ethiopia will experience a 79% reduction in US HIV financing from PEPFAR. The announcement of these cuts came with an explanation that PEPFAR was “free(ing) up resources by reducing programs in lower HIV prevalence countries” (see blog). Further, Global Fund monies have gone almost completely undisbursed in 2012. These cuts in spending might be warranted due to epidemiological trends and improved efficiency, or might cripple progress as health programs dependent on external donors are cut back. The truth is, with the current poor status of basic information on beneficiaries and costs, it’s difficult to judge whether these cuts are good or bad.

The US$191 million decline of PEPFAR funding from 2012 to 2013 is part of a broader trend of decreasing funding in recent years. With its dynamic and popular minister of health, Dr. Tedros Ghebreyesus, Ethiopia had long been a donor darling. Cumulatively, PEPFAR contributed more than $1.4 billion to Ethiopia, and, between 2006 and 2011, PEPFAR’s annual contribution to Ethiopia more than doubled. Ethiopia received more funding from the Global Fund than any other country—with total disbursements of $1.16 billion. In 2008, AIDS spending accounted from more than 20% of total spending on health, of which 84% was externally funded.

Yet, as shown in the chart below, total funding from PEPFAR-Global Fund peaked in 2010, and has since decreased by almost 50 percent as of 2012. The Global Fund has yet to disclose how much of two newly signed grants (US$424 million designed to span 5 years) will be disbursed in 2013. But even if the full amount of these new grants were to be spent during 2013, this hypothetical PEPFAR-Global Fund total wouldn’t get close to matching Ethiopia’s total annual funding from these two sources in 2010.

Increased government spending might be one reaction to donor cuts. However, the Ministry of Finance publicly reported expenditure for the last time in 2009 and the most recent round of National Health Accounts is from 2007/8, so what fiscal adjustments have been made are yet to be seen. Even with increasing public spending associated with several years of positive economic growth, Ethiopia has always had an extremely low revenue to GDP ratio and high inflation (and associated tight cash controls on government expenditure), making substantial new public funding to health unlikely. A new factor in the equation is the political instability following the death of Prime Minister Meles Zenawi that may also compromise the size and speed of disbursements.

Increasing amounts of funding up to 2010 may have resulted in the peak number of individuals that received ART in 2011 as well as other effects, but will the funding crash of 2012/13 affect these gains? Can the same or better be provided with much less? In other words, could the backlog of funding and efficiency improvements make it possible to provide more with less in Ethiopia?

Sources:

PEPFAR, PEPFAR, PEPFAR Funding Allocations, Global Fund, PEPFAR, UNAIDS

*Note: Global Fund Disbursements for 2012 are to-date. 2013 figures for PEPFAR are included in the Administration’s budget request to Congress. 2013 figures for the Global Fund are approved disbursements from grants round 10 and lower.

A recent CSIS paper suggests that Ethiopia should still be on track to achieve universal coverage of ART in 2014 despite reduced HIV funding. Unfortunately, it’s very difficult for external commentators to assess this possibility. We don’t know exactly what interventions PEPFAR, the Global Fund and -perhaps most importantly- the Government of Ethiopia are currently financing and for whom, and we don’t know the actual cost of these interventions in Ethiopia. Therefore, we can’t link spending to enrolled patients or disease results. It’s possible that PEPFAR and the Global Fund have this analysis in their pocket? I hope so, since without this link, even a well-intentioned donor or Minister of Finance can’t understand or plan for the programmatic and human impact of cuts, or assess the potential for savings and reallocation via improved efficiency.

The AIDS spending cliff in Ethiopia also raises issues on likely funding cuts and new eligibility and allocation policies in general. It’s a great idea to reallocate monies to more affected, more impoverished countries, or countries that can spend monies more efficiently. Yet when you’re funding life-saving care for a defined population and you’re not able to connect money to patients, cutting abruptly is a terrible idea. Transitioning to a new allocation requires a basic set of information on expenditure and its uses –ideally connected to patients themselves, and it requires dialogue with country governments and other donor partners to smooth any cliffs into gentle slopes.

Two messages reigned supreme at last month’s International AIDS Conference (IAC) in Washington DC:  1) that there should be universal coverage of HIV/AIDS treatment and 2) that international funding for HIV/AIDS has been flat-lining recently and may even shrink. The most optimistic scenario to reach universal coverage will cost $22 billion dollars annually, which means raising an additional $6 billion per year. Clearly, the goal to provide treatment to the 34 million people currently living with AIDS, and the approximately 2.5 million newly infected each year, conflicts with the reality of shrinking aid budgets.

Indeed, an IAC session titled Show Me the Money: Political Commitment, Resources and Pricing made it clear that there was no question of abandoning the agenda for universal coverage of HIV/AIDS treatment – rather the challenge moving forward would be to secure financing. To this end, there were several creative solutions put forth in sessions at the conference and at satellite sessions throughout DC.

Denis Broun of UNITAID suggested using financial securities transaction taxes to address the funding gap in HIV/AIDS. A tax of 0.0005% levied on products of globalization such as international trade, transportation, finance, internet and telecommunications could raise $300 billion a year. A similar tax that has already been implemented on air tickets has raised $9 billion in the last five years.  Seems like a quick and painless way to raise more than enough to cover the gap, and the success of the air ticket levy suggests that this is a politically feasible solution. But most of the revenues would come from transactions in the developed world, whose governments may wish to allocate money to their own pressing issues (Medicare and Social Security in the US?).  Perhaps a tax to prevent about 2 million deaths each year would be much more popular than taxes to increase defense budgets. Either way, financing universal treatment of HIV/AIDS through a transaction tax will prolong the dependence of AIDS budgets on donors.

Another intriguing option from Gorik Ooms from Georgetown Law School is to capitalize on the fundraising potential of the Millennium Development Goals by proposing universal health coverage as a new goal to rally around when the current goals expire in 2015. It would mean a shift from the primarily vertical approach that the AIDS community has taken to combat the epidemic, to a more holistic approach where HIV/AIDS prevention and treatment is synonymous with health systems. Ooms rightly pointed out that the AIDS response stands to gain by working for Universal Health Coverage, and making it their own from the very beginning to ensure that AIDS treatment does not get left behind.  The right to health as a development goal, ratified by the majority of countries would create a truly shared, global responsibility and a means to hold world leaders accountable for sustaining health programs. In this scenario, the financial securities transaction tax and allocation of the resulting revenues to global health and HIV/AIDS would be more of a political reality.

At a slightly hyperbolic debate at the World Bank, Jeffery Sachs of The Earth Institute argued that there are more than enough funds in-hand to treat everyone in need if we are able to achieve a more equitable taxation system, a budget focused on building a healthier, more productive, global population (instead of arms driven), and continued investment by the wealthy – as seen by the likes of Bill Gates, Warren Buffet, and Raymond Chambers. But accessing these funds in the current market, where people are afraid of market failure and savings are at an all-time high, is a herculean task. Perhaps this option would be more feasible in the future, but unfortunately now is the time when people need treatment.

All of these ideas are worth considering given the challenge of closing the funding gap for HIV/AIDS in the coming years.  But allocative efficiency of both domestic and international health funding must also be considered in a resource constrained environment if donors and countries want to continue to save the lives of people in need – not just people with HIV. As Mead Over, senior fellow at CGD, questioned during the World Bank debate: why should we focus constrained resources on HIV when we could instead save the lives of millions of additional children with more cost-effective treatments for diarrheal diseases or one of the other diseases on the long list of child killers. This balancing of program funds and priority setting are at the crux of more than just AIDS funding, it is at the heart of international health in the coming years. The path we choose to take will determine not only the focus of the next International AIDS Conference in 2014 in Melbourne, but how the global community will help shape donor and domestic budgets and more importantly the lives of millions of people around the world.

In 2009, Michelle Adato and a co-author pointed out that cash transfers could add value to the HIV response, by reaching the poorest households relatively quickly. Now, a new generation of cash transfer programs in sub-Saharan Africa is reducing new infections and HIV-related risky behavior—and documenting the gains—while also providing consumption, nutrition, education, and mental health benefits to the orphans and vulnerable children who are the primary targets of some programs.

The first study to show an impact of cash transfers on risky sexual behavior comes from the now-discontinued Zomba program in Malawi, where Baird and co-authors found a 64% reduction in HIV risk as a result of a cash transfer that targets girls. The unconditional arm of the program was more successful in reducing pregnancy and marriage rates, whereas the conditional arm was more successful in increasing school enrolment. The study estimates a cost of $5,000 per HIV infection averted. Another study from another program in Malawi by Kohler and Thornton finds that the conditional arm reduced risky sex for women but not for men.  In addition to having HIV-related impacts, the program decreased child labor and increased agricultural asset accumulation as well as participation in skilled labor.

Damien de Walque and co-authors evaluate the one-year-long RESPECT program in Tanzania, which pays $10 or $20 every four months if an individual tests negatively for various sexually transmitted infections. The study finds that after a year, there is a significant reduction in new infections for the group that got $20, but not $10. An early draft of a follow-up study presented at the IAEN Conference found that two years after the inception of the program, the effects were sustained for men but not for women.

The Malawi and Tanzania programs were small, short-lived, and NGO-run. The first evidence of whether a large-scale national cash transfer program can reduce HIV-related risky behavior among young people comes from the government-run Kenya Cash Transfer for Orphans and Vulnerable Children (CT-OVC) program.  The program provides an unconditional $20 monthly transfer targeting 135,000 ultra-poor households and 360,000 orphans. In results from a cluster randomized longitudinal design study presented at the recent IAS meeting, Ashu Handa and co-authors find a 30% reduction in sexual debut among program beneficiaries between 15 and 20 years old (who were between 11 and 16 years old at baseline). The evaluation also found fewer occurrences of unprotected sex and fewer sexual partners for women. In addition to all these effects, the program increased secondary school enrollment to a level comparable to conditional cash transfer programs from around the world (by 8%). Similar large-scale national “unconditional” or “social” transfer programs exist in Malawi, Mozambique, South Africa, Zambia, and Zimbabwe.

Are cash transfers cost-effective? It depends on your objective. STRIVE, a consortium that investigates the structural drivers of the HIV/AIDS epidemic, evaluates the Malawi program, finding that in terms of the cost per HIV infection averted, the program is not cost-effective, as its price tag of $5,000 is significantly above $181 for male circumcision, or $1,315 for voluntary counseling and testing. However, if additional benefits generated by the program are taken into account, the price tag falls to $996 per HIV DALY averted, which makes it a better investment.

Both the Global Fund and PEPFAR spend considerable amounts on prevention, health systems strengthening, and orphans and vulnerable children: the Global Fund, from 2002-2011, has spent 29% of its funding on prevention and 3% on orphans and vulnerable children. Similarly, PEPFAR, last year, spent 29% of its overall funding on prevention and 8% on orphans and vulnerable children.  So far, neither agency has provided significant funding to cash transfer programs, even while allocating funds to interventions that have been shown to be ineffective or for which there is no rigorous evaluation evidence.

With the new batch of evaluation results on cash transfers, there may be more reasons to invest in these kinds of programs, particularly the at-scale national programs targeted to the poor.

Note: A recent special issue of the Journal of Development Effectiveness reports on other effects of cash transfer programs in sub-Saharan Africa. A recent review of cash transfer programs in Africa by Pettifor et al aggregates evidence from 10 studies, finding promise for cash transfers in changing risky sexual behaviors. 

This month, both Health Affairs and the Journal of Acquired Immune Deficiency Syndrome (JAIDS) released special thematic issues on the US President’s Emergency Plan for AIDS Relief (PEPFAR) in which the articles – mainly commentaries but some analyses – provide an exceptionally positive readout on PEPFAR’s past performance and future direction. In principle, this is great – any insights into PEPFAR are always welcome, and it’s clearly valuable to discuss and disseminate lessons learned from the program. If these articles were posted on the PEPFAR website, or released as official PEPFAR reports, we wouldn’t bat an eye. But within scientific, peer-reviewed journals, the articles read more like PEPFAR PR rather than commentary and analysis from independent, third-party observers and stakeholders. A quick skim of the titles in the table of contents illustrates this point (see word cloud of selected title excerpts), and a closer look at the contributors sheds some light on why this may be the case: most authors of the articles are somehow affiliated with PEPFAR or with organizations that have received money from the program.

For how many authors in these two issues did this hold true?  To find out, we compiled a list of all the authors who contributed to either issue, and noted their affiliations as described in the articles. If an author had multiple affiliations, we made a judgment call as to his or her primary affiliation. Next, we cross-checked the list of affiliated institutions against a list of organizations receiving PEPFAR funding in FY2008, compiled from country operational plans (COPs). We also used internet research to check for more recent funding. You can see all of our work in an excel file here, as well as notes on data cleaning. Here’s a summary of our findings (which should be treated as estimates):

Table. Numbers of authors in Health Affairs and JAIDS special PEPFAR issues working for PEPFAR or organizations that have received funding from PEPFAR

It’s a great thing to see PEPFAR and their affiliates writing and publishing about the program, as it brings much needed discussion of issues that will undoubtedly improve the quality of programs, policy, and advocacy. But the dearth of independent voices on the program is concerning. More generally, we wonder: To what extent can researchers maintain independence and scientific integrity in assessing and evaluating a program if they are also salaried by the program?

Every single article in the JAIDS supplement included at least one co-author who was employed by the Office of the Global AIDS Coordinator, or by PEPFAR’s other implementing agencies within the US government.  Health Affairs was substantially more balanced by this measure; only a third of its pieces included an author directly employed by the US government, and most of those articles were commentaries (full disclosure – Health Affairs also asked CGDs very own Mead Over to write a more critical piece on PEPFAR for the issue, but he was unable to do so).  In addition, the Health Affairs special issue received direct financial support from PEPFAR. It also received funding from two of PEPFAR’s private-sector implementing partners: Merck, a leading provider of ARV medicines, and BD, a global medical technology company. It’s not clear whether JAIDS received any external financial support for its supplement.

A second related concern is on the role of journals in countering bias. According to the International Committee of Medial Journal Editors, authors are responsible for explicitly disclosing any conflicts of interest, including financial and personal relationships, that might bias their work. JAIDS articles disclose that “various authors have professional relationships with PEPFAR (either as employees of PEPFAR-supported US Government agencies or as grantees/contractors)” Most of the articles in the Health Affairs special issue do not include an explicit disclaimer for conflicts of interest, though some (roughly half) disclose at least some funding sources and/or affiliations. But when over 80 percent of the authors work for PEPFAR or an institution funded by or affiliated with PEPFAR, it begs the question: can the journals themselves experience conflicts of interest, and further exacerbate them? And is full disclosure, when it happens, sufficient to overcome such bias?

With PEPFAR, the close ties between analysts and implementers may be unavoidable, as the most knowledgeable experts on the subject are also likely to be working closely with the program, and to have exclusive access to unpublished program data. Still, there may be ways to mitigate bias, and to foster broader participation and analysis. One idea: journals could adopt a policy on full data disclosure, as we have done at CGD. Full disclosure of the underlying program data behind these articles would allow for duplication and verification of their results, and invite further analysis by a broader pool of stakeholders.

We have only kind words for the PEPFAR-affiliated contributors, and the insider-perspectives they’ve brought to the issues. And we recognize that global health, and the AIDS community more narrowly, is a small and interconnected network, making some kind of association between PEPFAR and experts inevitable. But it is the responsibility of journals to ensure balanced content that clearly discloses conflicts of interest and maintains scientific integrity.

What do you think?

The authors thank Mead Over and Jenny Ottenhoff for their helpful comments.