The persistent shortchanging of PEPFAR, the President’s Emergency Plan for AIDS Relief, is one of the more significant and perplexing trends in America’s global health policy. Funding for PEPFAR (America’s bilateral global AIDS program) has been falling consistently from its peak in fiscal year 2010. In fiscal year 2012, $250 million was transferred out of the program to the Global Fund to Fight AIDS, Tuberculosis and Malaria. For fiscal year 2013, the White House proposed cutting PEPFAR by $550 million (11 percent) and in March of this year Congress went part way, taking $176 million from the program in the Continuing Resolution.
Funding for PEPFAR has fallen 12 percent since 2010 in the State Department HIV bilateral budget line. Last week, the White House proposed an additional $50 million cut for 2014. When the mandated sequestration cut is taken into account, the program is now at its lowest funding level since 2007.
This downward funding spiral might make sense if there was a consensus that tackling AIDS has become less important, or if PEPFAR was not producing results. But the opposite is true. In November 2011, Secretary of State Hillary Clinton announced that achieving an AIDS-free generation was a "policy priority" for the U.S. government. President Obama went on to set bold new targets for AIDS treatment and other services through PEPFAR. In November 2012, the Administration released a PEPFAR Blueprint lauding the program’s accomplishments and affirming the need to "rapidly scale-up core … interventions." Doing so, the Blueprint argued, would accelerate declines in HIV incidence globally.
In February of this year, President Obama inspired all those engaged in the response to AIDS when, in his State of the Union address, he reaffirmed his commitment to the goal of an AIDS-free generation. The same month, the Institute of Medicine (IOM) weighed in with their assessment of PEPFAR, four years in the making. It concluded that the program has been "globally transformative" and has "had major positive effects on the health and well-being of individual beneficiaries, on institutions and systems in partner countries, and the overall global response to AIDS."
Why the mismatch between results, rhetoric, and financing? Budget deficit pressures do not explain it: total U.S. global health spending is just a quarter of one percent of the federal budget. Politics doesn’t explain it either, with PEPFAR maintaining a unique level of bipartisan Congressional support.
The more likely reason for steady reductions in PEPFAR funding is an Administration decision to gradually de-emphasize bilateral AIDS investments in favor of multilateral institutions and multiyear commitments to these institutions. Increased investments in the Global Fund and other multilateral health organizations are a badge of honor for President Obama. These institutions have demonstrated clear results in countries around the world, and U.S. funding leverages investments from others.
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