PEPFAR in Africa: Success or Failure?

My friend and co-author, Melissa Lee, is presenting our paper, “PEPFAR in Africa: Beyond HIV/AIDS”, today at the 2011 American Political Science Association annual conference. I have long wondered whether such a huge influx of health aid targeting a particular disease has a negative effect on the rest of the health sector. So, sometime earlier this year, Melissa and I decided to try to find out!

In our paper, we find that immunization and under-5 mortality rates in African PEPFAR recipient countries improved significantly less than in African non-recipient countries with HIV epidemics. The paper has not been uploaded yet, but I will share the link as soon as it is available.

The President’s Emergency Fund for AIDS Relief (PEPFAR) was initiated by President Bush in 2003, and is the largest bilateral aid program in the world that targets a single disease. By 2011, the U.S. government had committed $39 billion to the program, which often constitutes a large percentage, if not the majority, of health funding in PEPFAR recipient countries.

PEPFAR’s initial goals focused on prevention and treatment of HIV/AIDS, although they have recently expanded their strategy to include integrating PEPFAR into more general health programs. How successful has PEPFAR been in achieving these goals? They have helped provide anti-retroviral treatment to 3.2 million people, prophylaxis for 600,000 HIV+ pregnant women to prevent mother-to-child transmission, and supported 11 million people through other activities.

But a real evaluation of how well PEPFAR has performed must include a comparison to how well PEPFAR recipient countries would have performed in the absence of PEPFAR. Of course there is no way to go back in time and re-do history, but Eran Bendavid and Jay Bhattacharya in their 2009 paper use a difference-in-difference approach (as do Melissa and I) to evaluate the effect of PEPFAR on HIV outcomes such as HIV deaths, HIV prevalence, and the number of people living with HIV among African countries with an HIV epidemic. They find that while PEPFAR appears to have reduced deaths due to HIV/AIDS, HIV prevalence did not improve significantly in PEPFAR recipient countries when compared to non-recipient countries.

All told, the evidence on the effect of PEPFAR on both HIV and non-HIV health outcomes is mixed. Much more work needs to be done to determine why PEPFAR has been unable to reduce the prevalence of HIV, and the channels through which it negatively affects non-HIV related health outcomes such as child mortality and immunization rates.