Governance and transparency at PEPFAR

Originally printed in The Lancet: Global Health, January, 2014.

by Matthew Kavanagh and Brook K Baker, Health GAP Senior Policy Analysts

The US President's Emergency Plan for AIDS Relief (PEPFAR) has been one of the most effective foreign aid programmes in history. It reached 6·7 million people with antiretroviral therapy in 2013,1 and has also strengthened country health systems, provided billions of dollars in aid to biomedical and behavioural prevention programmes, and helped to drive declines in morbidity and mortality in many countries in sub-Saharan Africa.2 PEPFAR began as an emergency response, after relative inaction by wealthy nations, and rapidly built disease-response capacity by funding non-governmental organisations. Although PEPFAR, even in the early years, helped to strengthen health systems,34 it also faced criticism that it created parallel structures;5 criticism the programme has responded to in recent years by shifting much of its clinical funding to local partners. The programme has increasingly emphasised country ownership and has responded to aid effectiveness concerns, creating innovative shared governance structures, such as those in South Africa. Similarly, PEPFAR's recent structured coordination with the Global Fund to Fight AIDS, Tuberculosis, and Malaria is a laudable effort to harmonise bilateral and multilateral health programming.

However, transparency has declined rather than improved. A recent analysis in the Aid Transparency Index ranked PEPFAR as very poor—50th of 67 aid agencies worldwide.6 The report noted that, “PEPFAR does not disclose information on contracts to prime partners and sub-partners in a machine-readable and open format consistent with the US Open Data Policy.”

Just a few years ago, countries met after the Paris Declaration on Aid Effectiveness and agreed to an Accra Agenda for Action6 that put public transparency at the centre of the global aid effectiveness project:

“Donors will publicly disclose regular, detailed and timely information on volume, allocation and, when available, results of development expenditure to enable more accurate budget, accounting and audit by developing countries” (section 24).

It is striking that there is probably more data for the planning, spending, and outcomes of PEPFAR programmes than for any other aid programme in the world. PEPFAR undertakes a careful and detailed planning process every year for every country that receives aid—a process of creating Country Operational Plans that includes consultation with governments and detailed interagency priority setting. PEPFAR has also done expenditure analyses that show, in detail, what the provision of specific AIDS-related services cost in various geographical and implementation settings.

However, PEPFAR refuses to make data fully public in a timely manner. Country Operational Plans are published only many months after the year's programming has already finished, and then with unexplained redactions of nearly all relevant data. Programmatic goals and targets for each country are inexplicably missing, making the published plans largely useless to increase understanding of the successes or failures of the programme. In a departure from the early years of the programme, the most recent reports to the US Congress do not contain even the most basic data about how programme funds are allocated to programmatic areas.

It is time for PEPFAR to become a leader in transparency, to share its data in the service of its mission to end the AIDS crisis, and to expand real country ownership. If published as soon as they are approved for the coming year, with details about the interventions funded, geographic areas of activity, and specific goals and targets, then Country Operational Plans could be important instruments for partner governments and civil society. Knowledge of exactly what PEFPAR-funded non-governmental organisation are doing, what gaps they are filling, and what outcomes they are expected to achieve should be central to the planning of the AIDS response in these countries. Civil society in countries that receive PEPFAR funding could be mobilised to help to monitor the effectiveness of PEPFAR programmes, as well as their own government's efforts alongside donor-funded efforts. Meanwhile, PEPFAR costing studies could be crucial for national programme planners—how much the delivery of antiretroviral therapy costs in a given region should be essential information to be shared with the world. A bill recently passed by US Congress will require greater PEPFAR reporting,8 but is unlikely to change practice for the Country Operational Plans, which is a missed opportunity.

Even more importantly, PEPFAR can engage in a planning process that is itself transparent and consultative. Global health initiatives miss important opportunities to strengthen public health systems and civil society capacity when they do not structure governance mechanisms for substantive engagement with the organised end-users of their programmes.9 When PEPFAR supports a major portion of AIDS services in a country, lack of knowledge of and ability to affect allocation decisions results in a major democratic deficit. A recent diplomatic cable instructed PEPFAR teams to begin engaging civil society,10 but there is a danger it will be simply be a pro forma exercise. If, instead, engagement is substantive, and Country Operational Plans and costing studies are made public, PEPFAR could use its data and planning processes to drive not only AIDS objectives, but democracy-strengthening too.

We declare that we have no conflicts of interest.


1 The White House. Fact sheet: shared responsibility to strengthen results for an AIDS-free generation. Office of the Press Secretary, Dec 2, 2013 Dec 4, 2013).

2 US Department of StateBlueprint for Creating an AIDS-free GenerationAvailable from: Oct 28, 2013).

3 Kruk MEJakubowski ARabkin MElul BFriedman MEl-Sadr WPEPFAR programs linked to more deliveries in health facilities by African women who are not infected with HIVHealth Aff (Millwood) 2012; 311478-1488CrossRef | PubMed

4 Kiwanuka NStover BLim T, et alDid PEPFAR funding affect non-HIV health indicators? Longitudinal study of facility-based baby deliveries in Uganda, 2005—10Lancet 2013; 381S74Summary | PDF(42KB) | CrossRef | PubMed

5 Biesma RGBrugha RHarmer AWalsh ASpicer NWalt GThe effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS controlHealth Policy Plan 2009; 24239-252CrossRef | PubMed

6 Publish What You FundAid Transparency Index 2013 for PEPFAR Nov 24, 2013).

8 Menendez R. PEPFAR Stewardship and Oversight Act of 2013: 113th Congress, Sept 18, 2013.

9 Cohn JRussell ABaker BKayongo AWanjiku EDavis PUsing global health initiatives to strengthen health systems: a civil society perspectiveGlob Public Health 2011; 6687-702CrossRef | PubMed

10 US Department of StateUnclassified cable to all diplomatic and consular posts: involving civil society as part of country-level planning. Washington DC Oct 28, 2013).

Uncited Reference

7 Accra Agenda for Action. Accra: Organisation for Economic Co-operation and Development, 2008.

a University of Pennsylvania and Health Global Access Project, Philadelphia, PA 19104, USA

b Northeastern University School of Law and Health Global Access Project, Boston, MA, USA

Access this article on ScienceDirect


Donate Stay Connected