In just over 20 years, the President’s Emergency Plan for AIDS Relief (PEPFAR) has saved 26 million lives and prevented over 7.8 million babies from contracting HIV. Today, the program works alongside host-country governments, communities, and other partners to provide life-saving antiretroviral medication for over 20 million people living with HIV.
Despite conflict, natural disasters, inflation, and pandemics like COVID-19 and Ebola, PEPFAR’s budget has gone virtually unchanged since 2009. Strategic partnerships, data-driven programming, and interagency collaboration have ensured the program continues to succeed despite flat funding for over a decade.
But HIV/AIDS is not a one-size-fits-all epidemic. Progress in controlling HIV/AIDS differs across and within countries, communities, and populations. While some are on the right track, others face significant challenges.
With a flat budget and unequal progress across countries, PEPFAR has had to use innovative techniques to ensure taxpayer dollars have the greatest impact. Senior Bush Institute Fellow Deborah L. Birx, M.D., and Global Health Advisor Dr. William R. Steiger outlined this in their 2022 report – PEPFAR and the Geolocation Revolution: Using Site-Level Data to Drive Transparency and Equity in Programming.
PEPFAR’s use of site-level data to drive transparency, accountability, and equal access
Most international assistance programs use global data or country-by-country comparisons to measure progress. But even country-level data do not show the whole picture and can hide communities that require greater attention.
PEPFAR goes a step further by using data down to the site level to identify progress in specific geographic communities so the program can direct funding and services toward those who need it most. Partners must provide the GPS coordinates of the sites they support, which PEPFAR then cross-references with demographic and other information.
Based on the data, every year PEPFAR identifies sites that do not need resources because of changes in the local epidemic and redirects funding from them to sites that address underserved and underfunded population areas that could add greater risk to addressing HIV globally.
Over time, PEPFAR has evolved these methods to prevent and root out fraud in reporting by adopting Ronald Reagan’s “trust but verify” approach to foreign relationships. PEPFAR has implemented a two-pronged approach to validate data and hold itself, communities, national governments, and other partners accountable.
First, PEPFAR implements comprehensive, community-level surveys to validate the number of people living with HIV/AIDS and verifies service-level data on testing, treatment, and prevention knowledge among clients.
Second, PEPFAR revamped its internal policies and systems for quality control and assurance. The result was the Site Improvement Through Monitoring System (SIMS) – the most extensive push to improve the quality of site-level data by any U.S. international assistance program in history. Through programmatic site visits, SIMS provides a more streamlined and comprehensive process of assessing whether in-country providers follow worldwide and national quality standards, not only for services but also for data collected.
These visits have been critical in spotting waste, fraud, abuse, and inefficiencies. The SIMS teams supervise providers and check on the status of infrastructure and stocks of medicines, health supplies, and equipment in communities. They also look for innovative clinical and managerial practices they can take to other sites to improve their performance. These close examinations have led PEPFAR to adjust payments to implementers or even switch partners if poor performance persists.
What’s next
Despite a waiver exempting PEPFAR-specific programming from a 90-day pause in foreign assistance, many PEPFAR partners have reported challenges in resuming the implementation of approved programming. People living with HIV now face significant barriers to accessing life-saving, time-sensitive care. The Department of State must work with PEPFAR partners to resume programming immediately.
PEPFAR – like all federal programs – should be subject to regular review to ensure taxpayer dollars are having the greatest possible impact, to incorporate innovative reforms, and to provide oversight that leads to greater efficiencies and effectiveness. The U.S. Government has an opportunity to learn from PEPFAR’s successful, real-time data-driven model to improve international assistance by having all U.S. federal departments and agencies focused on global health and development take the following steps:
- Update their regulations and internal policies to mandate clear, site-level metrics to track results and impact, rather than inputs;
- Prioritize field visits in their plans for monitoring and evaluating all site-based activities and create standardized systems like SIMS for doing so; and
- Support regular, independent, community-level surveys to ensure the validity of programmatic data and prevent fraud, waste, and abuse.
Through these methods, the United States can continue to work alongside communities, governments, and other partners to save lives, strengthen economies, combat authoritarian adversaries, and prevent extremism.
