This was originally posted on March 19th, 2008 in the Global Health Policy Blog from the Center for Global Development.

Last week, Congress took a major step towards re-authorizing PEPFAR, and global malaria and TB programs, for another five years. A congressional press release explains:

Legislation sponsored by the Chairman of the Senate Foreign Relations Committee Joseph R. Biden, Jr. (D-DE) and Ranking Member Richard G. Lugar (R-IN) authorizing $50 billion for global HIV/AIDS, malaria and tuberculosis programs for the next five fiscal years was approved by the Senate Foreign Relations Committee today. This legislation closely mirrors a bipartisan reauthorization bill approved by the House Committee on Foreign Affairs late last month, which will facilitate a prompt conference with the House.

Great news, of course, that the process is well on its way, with a hefty tab of $50 billion ($9 billion of which is for malaria and TB) that should build on the accomplishments of the first five years of PEPFAR and strengthen its performance in the global fight against HIV/AIDS. A quick scan of the House and Senate bills and various analyses that have followed suggest one major accomplishment in the reauthorization process - that our legislators and their incredibly dedicated staff have looked closely at the evidence, and in large part, have responded to the lessons learned in the emergency phase of the last 5 years. In particular, we are encouraged by the following highlights of the legislation (and pleased that the HIV/AIDS Monitor’s research and the work of other CGD colleagues have contributed to the growing body of evidence about these issues):

Removal of Most Earmarks
The removal of almost all earmarks - funding restrictions that mandate how PEPFAR can spend money - is a very encouraging sign that has clearly responded to evidence from various sources, including the IOM and the GAO, that flexibility in funding is a must for countries to respond to their national priorities. Our own findings - including a forthcoming analysis of PEPFAR funding data - shows that the way PEPFAR allocated money across and within prevention, treatment and care closely mirrored the global-level earmarks imposed by Congress. This unduly limited PEPFAR’s flexibility because every country’s funding needs are different - some countries might need PEPFAR to spend more on prevention, and others might need more money for treatment - but PEPFAR’s program could not easily respond to these differences.

While the new legislative language does not stipulate any AB (Abstinence and Being Faithful) spending requirements it does require that countries receiving PEPFAR funds explain their reasons for using less than 50% of their funds on abstinence and being faithful. What is NOT clear in both the bills is the process of approval for a country that does not spend in the A and B categories as required and the ramifications for not doing so. Some clarity on this process before the final bill is passed is a MUST to avoid confusion and the possibility of blindly following the requirements because the consequences of non-compliance are not clear.

Building Local Capacity
Since large sums of AIDS money began flowing from PEPFAR and other sources in 2003, it has become apparent that the money cannot be used effectively unless we build “in-country capacity” - a broadly used term that refers to both adequate numbers of competent staff to manage and implement AIDS programs, and appropriate systems to manage the flow of goods, people, and information. PEPFAR has often skirted the capacity problem by setting up their own systems and channeling large shares of funding to international NGOs. But this approach is not sustainable in the long-term if the systems are not local, and the new reauthorization bill takes a number of key steps to ensuring that each country will be able to fight the long battle needed against the epidemic, including:

(i) Increasing the number of African health workers - The continent is desperately short of health workers, from doctors to nurses to medical assistants that are needed to win the fight against AIDS. The House bill sets a concrete target of 144,000 health workers that will be trained over the next five years using U.S. government funds. There is some uncertainty about what type of health workers would be included as part of this target and whether these would be additional and/or include the training of existing workers - we believe these should be a range of health workers from doctors to nurses and community health workers. The effort to increase the number of trained health workers is undoubtedly a good move but this may not solve the real shortage problems. As my colleague Michael Clemens’ research showed, shortages in many countries in Africa are less related to brain-drain and the emigration of workers, and more to do with the rural/urban and private/public distribution of health professionals, the skill mix of the health work force and the lack of incentives for health professionals within the current public sector systems. Donor supported and national efforts to mitigate the health care worker shortages should surely address some of these issues and not focus only on training.

(ii) Improving financial management, inside and outside government - Our paper on “Following the Funding” showed that many local recipients, and especially governments, do not have the systems needed to manage and report on large sums of AIDS money. The reauthorization bills calls specifically for PEPFAR to work with governments and other local recipients to strengthen their financial management capabilities.

(iii) Giving government oversight of PEPFAR programs - National governments in each country act as the steward of the AIDS response, helping to coordinate the myriad actors responding to the AIDS crisis. But national governments have limited input into PEPFAR programs and are thus constrained in performing their stewardship role. The new PEPFAR bill would aim to change this. As Senator Biden’s press release states, the bill aims to “push the U.S. government to plan for a sustainable long-term effort, to help local governments take over the fight against HIV/AIDS with our technical assistance.”

(iv) Assessing the capacity development initiatives undertaken by the countries - The new legislation calls for an assessment of countries holding them accountable to their commitments to the Abuja Declaration (to invest in the development of human resources and health systems by motivating existing personnel by upgrading skills and through improvement of condition of services including the use of incentives to prevent brain-drain). Despite all good intentions to increase the incentives for health sector staff the new legislation acknowledges the impact of the IMF’s macroeconomic and fiscal policies on national and donor investments in health and also calls for a review of this policy in each country. Findings from a working paper by my colleague David Goldsborough on the IMF’s constraints on health spending suggest that the IMF has overused the wage bill ceilings in the health sector and could restrict the capacity development efforts of a particular country. This type of an assessment would help situate a country’s particular commitment and ability to invest in building capacity in the health sector.

Balancing Prevention and Treatment
PEPFAR has been widely praised for quickly putting well over a million people on treatment, but prevention programs seemed to take a backseat in the first phase of PEPFAR. Forthcoming analysis by my colleague Mead Over and by the HIV/AIDS Monitor team shows that in the average focus country PEPFAR spent nearly twice as much on treatment as prevention. Yet, for every person put on treatment, there are five or six new HIV infections. Recognizing these facts, the new PEPFAR bills emphasize the importance of prevention. They state that PEPFAR should spend no less than 20% of its money on prevention activities - we hope PEPFAR will spend much more than the 20% figure as each country identifies their prevention priorities. The bills have also increased the prevention target - which has gone from preventing 7 million infections to preventing 12 million infections - more significant than the treatment target - which has changed from treating 2 million people to 3 million people. Behavior change to reduce risk also features prominently in both bills as a new focus in prevention efforts.

Better late than never - the realization that prevention along with treatment is paramount for an effective response is long overdue. While PEPFAR I focused on the “emergency” of getting treatment to the heavily affected countries and giving people hope, the efforts to support comprehensive prevention efforts and provide people with a greater sense of hope that they can prevent themselves and others from getting infected have been less than optimal and the step up to increase these efforts is welcome.

Addressing the Vulnerabilities of Women and Girls
Several recent reports, including CGD’s Girls Count have showed the unique vulnerabilities faced by women and girls to HIV. The epidemic is not gender neutral and the new bills recognize this by calling for gender to be a high priority in all aspects of PEPFAR, from the five-year strategy to the evaluation that will be conducted during its fourth year. With the overall PEPFAR strategy, the Senate bill asks for “a description of the specific targets, goals and strategies developed to address the needs and vulnerabilities of women and girls to HIV/AIDS.” In addition, the proposed legislation authorizes that a new evaluation report include an assessment of gender specific aspects, including the constraints to accessing services and underlying social and economic vulnerabilities. For a more detailed and interesting analysis of the Senate and House bills and the current law, and their relative emphasis on women and girls and related gender issues in prevention, prostitution, family planning and microbicides see a chart by Kathy Selvaggio at ICRW.

Monitoring AND Impact Evaluation
The Senate bill stands out for its effort to ensure that PEPFAR II captures both, the monitoring of programs including operations research AND the impact of its efforts by preparing these activities at the outset of the program. By including operations research in the strategy, Congress will ensure that PEPFAR will learn while it is implementing and using these data to “improve program quality and efficiency…and optimize the delivery of services.”

The bill also includes language that requires the Global AIDS Coordinator to contract the IOM to produce, in the first 18 months of PEPFAR II, a “design plan and budget for the evaluation and collection of baseline and subsequent data.” CGD’s work on impact evaluation led by Bill Savedoff and my colleague Ruth Levine, points the U.S. government in the direction of making evaluation an imperative in its global AIDS efforts so that the U.S. can account for the billions of dollars spent and assess whether or not PEPFAR actually made a measurable difference in the reduction of incidence. This will be an important step to supplement the evidence that OGAC already reports to Congress on the absolute targets for treatment, prevention and care–2, 7, 10 goals to the new 3, 12, 12 goals–with rigorous evidence about what has changed because of this remarkable effort. A set of “before and after” PEPFAR measures will tell us whether the program is working relative to its investments and demonstrated priorities and needs in each country. The absence of this evidence will place future funding for HIV/AIDS in jeopardy and will deny countries the much needed support to keep their citizens free from preventable infections and from dying. We strongly support the inclusion of this provision in the final bill.

Advanced Market Commitments for Vaccines
Good news on the development of new vaccines from our policy makers! Senator John Kerry introduced an amendment (Download file) to the Senate bill that will “promote participation by the United States in negotiations on Advanced Market Commitments (AMC) to develop key vaccines, and strengthen efforts to provide technical assistance for the creation of vaccines in developing countries.” CGD’s Michael Kremer and Ruth Levine, co-chaired a working group on AMCs in 2005 that concluded that an advance commitment on the part of donors could effectively stimulate greater private sector investment in the development of new vaccines appropriate for use in poor countries, and accelerate their adoption. We are encouraged by the U.S. response to this call to donors and its potential participation in an advance commitment to buy vaccines if and when they are developed for AIDS, TB, Malaria and other infectious diseases. With other donors, the U.S. will create incentives for industry to increase investment in research and development and spur commercial investment in the development of vital new vaccines for the developing world.

The Sticking Issues
Anti-prostitution pledge: Both versions of the bill propose no changes from the current law. The confusion caused by the current law about what PEPFAR implementers and their sub-recipients can and cannot do with sex workers still persists. Clarifying the language in the new bill may be helpful to recipients and sub-recipients to understand how one can effectively prevent infections from being transmitted to and from women in sex work and their clients.

Family planning: The Senate bill makes no reference to the family planning issues in the current law, while the House bill adds another layer of restriction to the use of PEPFAR funds for family planning activities. It authorizes family planning organizations to conduct HIV testing and counseling, but there is some uncertainty over whether organizations will have to comply with the Mexico City policy. This is a step backwards and any negotiation to better include family planning as an integral component of PEPFAR prevention programs may be a deal breaker. So it looks more and more like this issue will at best use the current House language to restrict the effective provision (and use) of family planning services and HIV/AIDS services where needed, a policy that will limit the effectiveness of the PEPFAR program in its prevention efforts. The HIV/AIDS Monitor will have field-based data on this topic later in the year to add to the ongoing debate about better linkages between HIV/AIDS programs and other health service delivery programs.

Wrap-Up

There is a lot of good stuff in these bills and because they more or less mirror each other, the chances are that most of these changes from the current law will get through with ease. That is largely a good thing, but in agreeing to a final bill, the House and Senate should clarify some of the key points of uncertainty that linger, so that a lack of clarity does not constrain the important work of fighting the pandemic effectively.

This post originally appeared yesterday in the Center for Global Development’s blog, Views from the Center.

Yesterday President George Bush reported on his recent trip to Africa to members of the diplomatic corps, NGOs, and development policymakers at the Marriott Wardman Park Hotel in Washington, D.C. at an event hosted by the Leon H. Sullivan Foundation. President Bush relayed the details of what he called his “most exciting, exhilarating and uplifting trip” since becoming president and showed slides from his visits to Benin, Tanzania, Rwanda, Ghana and Liberia. He argued Americans should be “mighty proud” of the work the U.S. is doing in Africa and made a final plea for Congress to fully and promptly fund U.S. development programs and for presidential candidates of both parties to make engagement with Africa an enduring priority of the United States. (See full remarks and video)

As the president narrated the photos with anecdotes from his trip, there were mentions of the President’s Emergency Plan for AIDS Relief PEPFAR), malaria initiative and the Millennium Challenge Account (MCA) amidst commentary on the photos of the stuffed lion given to him by Tanzanian President Kikwete (Bush worried that his dog Barney might be “slightly intimidated”); the stylish dresses worn by several Tanzanian women (bearing images of George Bush); and how happy their audience in Accra was to see him (but, according to Bush, “even more excited to see [their] surprise guest, reigning American Idol Jordin Sparks”). All this made for an entertaining presentation but a major policy speech it was not.

When a U.S. president travels to Africa and then takes time to deliver a speech devoted entirely to U.S. relations with the continent, it somehow seems churlish to be critical. After all, this sort of prioritization of development issues is exactly what the development community would like to see.

Still, I suspect that, like me, many of the 400+ people who attended the speech left feeling ambivalent. On the one hand, it’s great that the president is talking about global development, the U.S. relationship with Africa and his signature assistance programs. No one doubts that these programs have significantly increased the flow of resources to Africa and provided opportunity for experiments with innovative delivery mechanisms. On the other hand, there was little if any new information or agenda and there was something vaguely unsettling about the broad brushstrokes and glossy pictures. Listening to the speech felt like looking over vacation photos with the president. I sensed that much of the audience, who were either from Africa or know the continent very well, appreciated the president’s attention but had been hoping for something more: a coherent vision of the reasons for U.S.engagement with Africa and the development process more broadly, and a clear sense of what should be done next.

Though few new announcements came out of the presentation, President Bush iterated his administration’s calls for Congress to:

Reauthorize PEPFAR and double the initial commitment to $30 billion over the next 5 years; Provide 5.2 million new insecticide-treated bednets to prevent malaria; Offer $100 million for “African nations willing to step forward and serve the cause of peace in Darfur”; Spend $350 million to target neglected tropical diseases like river blindness and hookworm; and Ensure full and prompt funding for U.S. development programs (in the FY09 budget).

President Bush also said that it is in the U.S. interest to “open up trade and deal with subsidies and trade-distorting tariffs” and that he is “firmly dedicated to coming up with a successful Doha Round to make trade freer and fairer.” He noted that Liberian President Ellen Johnson-Sirleaf had come to the U.S. for some of her schooling and that “the more people who come to get educated in the United States from abroad, the better off our country will be.” Again, while I am thrilled to see U.S. trade and migration policies raised as policies affecting global development, I was disappointed that there seemed to be an assumption that all our aid, trade, migration and other policies related to Africa automatically add up to one big good. In reality, the U.S. gives some assistance with one hand, takes some back with some trade policies, and does a little of both with migration policies. I left wanting a little more vision of how to make U.S. foreign assistance, trade, migration and other policies compliment each other and add up to a real development strategy.

For me it comes down to a question of how much expertise, nuance and leadership it is reasonable for an audience of development policymakers and practitioners to expect from a presidential speech. President Bush deserves credit for his work on Africa, the new programs created during his administration, and for raising other rich world policies like trade and migration that affect developing countries. But just as President Bush urged presidential candidates of both parties to make engagement with Africa an enduring priority of the United States, I urge them to take advantage of an audience that is eager for more substantive leadership on the complex and competing development policy issues, and for a more comprehensive approach to U.S. foreign assistance.

Clearly there are readers out there who are from, have lived in, or have worked with the African countries President Bush visited. You are doing the real work beyond the red carpets and greetings that accompany a presidential trip. How would you like to see the next American president make engagement with Africa and global development an enduring priority of the United States?

Yale University will be hosting a conference of interest to the global development community in April—the Unite For Sight Fifth Annual International Health & Development Conference: Building Global Health For Today and Tomorrow. The keynote speakers will be: Susan Blumenthal, Jim Yong Kim, Jeffrey Sachs, and Sonia Ehrlich Sachs. Find out more about the conference speakers here.

There will be over 180 speakers on topics such as: “Addressing Vitamin and Mineral Deficiencies is a Key Building Block to Achieve the Millennium Development Goals”, “Global Health and the Internet Panel”, and”Youth Engagement in Development Stategies.”

Early bird registration ends January 30th. You can learn more at Unite For Site’s conference page.

Public Radio International (PRI) just received a 3-year, $5 million grant from the Bill and Melinda Gates Foundation to produce and distribute content on global development and health topics. This is good news for people who care about global development—the more we talk about it (and our media talks about it), the more our future leaders will know that Global Development Matters to us, and will be able to shape US policy accordingly. PRI’s programming currently reaches around 11 million listeners each week.

PRI President and CEO Alisa Miller said, “This transformational grant will enable PRI to increase Americans’ understanding of the impact that global health and development issues have in today’s world….People and nations of the world are more interdependent than ever before, yet many media outlets continue to withdraw from international news. PRI is uniquely capable of aggressively developing compelling content, global reporting and interactive strategies to fill this urgent need.”

Stories on global development and health might focus on trade policy and how it affects developing countries’ food supplies, the effectiveness of development assistance, or personal stories of those with HIV/AIDS.

In addition to radio broadcast, coverage will also include online engagement tools through PRI’s website and other partner websites: blogs, podcasts, searchable transcripts, and mobile phone segments.

Read the press release to learn more.

Later this week, UN AIDS scientists will adjust their estimates of people infected with AIDS from 44 milion to 30 million. The new calculation is mainly due to improved methods of collecting data.

Some researchers worry that past funding decisions have been based on these faulty numbers. The revisions may have also clouded the lessons we take away on how to slow the disease.

Officials from UNAIDS, the United Nations AIDS Agency, don’t believe that the new estimates are a reason to slow support. UNAIDS Executive Director Dr. Peter Piot stated, “Unquestionably, we are beginning to see a return on investment — new HIV infections and mortality are declining and the prevalence of HIV leveling. But with more than 6,800 new infections and over 5,700 deaths each day due to AIDS, we must expand our efforts in order to significantly reduce the impact of AIDS worldwide.”

Decreased numbers of infections may also partially contribute to the new numbers.

The UNAIDS report said, “In both Kenya and Zimbabwe, there is increasing evidence that a proportion of the declines is due to a reduction of the number of new infections which is, in part due to a reduction in risky behaviors.”

Read the Washington Post or Reuters articles to learn more about the reassessment.

As you may know, HIV/AIDS is one of the largest challenges we face as a global community. It reduces life expectancy and decreases economic productivity—burdens that have an enormous impact on countries already struggling with poverty.

Today, Senator Clinton signed the “Presidential Pledge for Leadership on Global AIDS and Poverty.” She joined Bill Richardson as the only other presidential candidate to have signed the pledge.

Here are two main points to which Hillary commits if elected:

Give more money
She commits to set aside “at least $50 billion to the fight against AIDS by 2013,” and to “make significant progress toward providing an additional one percent of the U.S. budget to fighting poverty in impoverished countries.” In 2003, President Bush committed to provide $15 billion to AIDS relief over a five-year period through PEPFAR (The President’s Emergency Plan for AIDS Relief). Currently, we rank 14^th in the Center for Global Development’s “Commitment to Development Index” (CDI). America is a rich and generous country—but we give a low portion of our economy to help developing countries. Let’s help close the gap between what we have given and what is needed to fight this epidemic—and an extra one percent would be a big improvement.

Streamline the system
By adding her name to the pledge, Hillary also promises to look into the “creation of a cabinet-level poverty-focused development agency.” This would help us focus our global development efforts. Currently, more than 20 different U.S. government agencies are involved in global development. This means that our foreign assistance programs are frequently fragmented and uncoordinated. U.S. assistance programs could be far less expensive and more effective if we put someone in charge with direct access to the President.

We here at Global Development Matters hope all of the candidates put their names on the pledge. Let’s take more of a leadership role in the fight against HIV/AIDS and global poverty!

Read the full article to find out more about this Presidential Pledge.