PEPFAR Shows Us What “Smart Investment” Looks Like

Margaret Reeves
Fellow, Global Health Policy Center

It’s an exciting, but trying time for development in Washington. A number of new initiatives have been launched by the White House including the Global Health Initiative and Feed the Future, but their fate is uncertain and much rests on their ability to demonstrate real impacts. The President’s Emergency Plan for AIDS Relief (PEPFAR) has made strong gains over the past seven years. As the program moves from an emergency response to a sustainable development effort, it has committed to changes to increase efficiencies, innovations and impact. On Thursday, February 10 PEPFAR hosted a day-long meeting to highlight some of the key approaches that will be implemented to ensure that PEPFAR’s new “Smart Investments” save as many lives as possible.

Promoting country ownership is one of the most important goals of PEPFAR moving forward. While country ownership is often cited as an important factor in sustainability and efficiency, it requires tradeoffs and compromises that in some cases could reduce U.S. control over program priorities and approaches. Impressively, according to the meeting’s presenters, PEPFAR’s Partnership Framework in South Africa provides a concrete example of true government-to-government coordination and the resulting increases in efficiency and impacts achieved when USG and host country priorities and efforts are aligned.

PEPFAR Partnership Frameworks provide a 5-year joint strategic framework for cooperation between the U.S. Government (USG), the partner government, and other partners to combat HIV/AIDS in the host country through service delivery, policy reform, and coordinated financial commitments. Dr. Yogan Pillay of South Africa’s Department of Health and Dr. Mark Blecher of the Ministry of Finance presented some of the early successes of the South Africa Partnership Framework signed in December 2010. With support from PEPFAR, the Ministry of Health has leveraged greatly reduced antiretroviral drug (ARV) pricing and reformed their procurement processes to achieve an estimated cost savings of $650m over the next two years. With recent changes in the CD4 threshold guidelines for treatment significantly increasing the number of individual eligible to receive ARVs, procurement reforms such as these help the Government of South Africa and PEPFAR treat more people with less money.

Additional efficiency measures taken by South Africa under the Partnership Framework include significant task shifting; this includes nurse initiated ARV treatment, drug distribution by pharmacy assistants and HIV counseling by volunteers. Efficiency gains have also been made by finding ways to reduce laboratory and diagnostic costs and aligning technical support with district health teams. A renewed commitment from both PEPFAR and South Africa to making funding and programmatic decisions based on program evaluations, scientific research, and accurate and timely financial data will further improve health outcomes.

This collaboration and coordination between PEPFAR and South Africa embodies the type of innovative approach that PEPFAR wants to build upon. PEPFAR describes seven principles that it hopes to introduce into its programs to save more lives:

  1. Strengthen use of economic and financial data to ensure efficient use of resources
  2. Incorporate innovations that promote efficiency and allocate resources based on impact
  3. Increase collaboration with governments, the Global Fund, and others to align programs and target investments
  4. Reduce costs by streamlining USG operations and supporting increased country ownership
  5. Achieve best all-inclusive commodity pricing
  6. Leverage creative mechanisms for healthcare finance to bring additional resources to bear
  7. Develop an evaluation and research agenda that will show how to improve efficiency and impact


Articulating these seven principles is important and provides a benchmark by which PEPFAR can measure its own efforts. They will also make it easier for stakeholders such as host countries and civil society to measure PEPFAR’s progress toward increased transparency, accountability and efficiency. However, while some points like number five provide clear actions, “achieve best all-inclusive commodity pricing”, others are less specific, such as numbers 2 and 6, which refer to “innovations” and “creative mechanisms”. One gets a general idea of what these points are getting at, but more specifics on how this is achieved and a clearer sense of what is considered innovative and creative is needed.

Some of the seven points touch on concepts that are acknowledged as important, but will take cooperation and effort from actors beyond the U.S. and PEPFAR. Point 3 on increasing collaboration with the Global Fund and other multilateral efforts, for example, is easy say on paper but difficult to implement. To truly coordinate efforts, leverage resources, align goals and approaches, minimize duplication and increase coverage, individuals at the country level need to be assigned to focus specifically on this kind of coordination. Achieving this is daunting, but highlighting it as one of seven discreet principles is an important step toward accountability and commitment.

More discussions, like the session convened last week by PEPFAR - that share real world successes as well as lessons learned - can convey what these seven principles look like in practice. These meetings, in and of themselves, would be a welcome and significant innovation.

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