By most measures, the President’s Emergency Plan for AIDS Relief (PEPFAR), launched by President George W. Bush in 2003 to counter the HIV/AIDS epidemic, is a signal foreign policy achievement by the U.S. government. At more than $100 billion spent to date, PEPFAR is the largest investment ever made by a government to fight a disease on a global scale. Indeed, some estimates credit the program with having saved more than 20 million lives. Yet in some countries, PEPFAR is out of step with one of the Biden administration’s core foreign policy goals: reversing the world-wide trends of democratic backsliding and growing authoritarianism.
For one thing, PEPFAR has a messaging problem: Despite claims by American diplomats that the defense of democracy is a top priority, the program invests hundreds of millions of dollars a year in countries that have shown a weakening commitment to democratic governance. Thus, it risks legitimizing authoritarian regimes.
Moreover, the program’s annual injection of funds not only crowds out other types of development assistance but reduces pressure on the recipient states to deliver services, thereby creating opportunities for them to shift funds to projects that serve elite interests.
Consider some examples from Africa, where the bulk of PEPFAR investments are made. Over the past decade, arguably no country has seen a more rapid democratic decline than Tanzania, where politicians, journalists, and activists have been arrested and draconian legislation limits fundamental freedoms. Yet Tanzania is currently the world’s largest recipient of PEPFAR funds, receiving some $468 million over the last year.
Rapid democratic decline was also a hallmark of the regime of President Edward Lungu of Zambia, who served until August of 2021 and whose government used lethal force to subdue opposition demonstrations, restricted freedom of expression and independent media, and presided over large-scale corruption. Zambia’s most recent allotment of $420 million for one year made it the world’s fourth largest PEPFAR recipient.
In Uganda, President Yoweri Museveni, in office for 35 years, is now early in another five-year term, having overseen an election marred by violence and voter repression in January of 2021. His government is the world’s fifth-largest PEPFAR recipient, with $418 million in PEPFAR funds over the last year.
PEPFAR unquestionably saves lives in these countries, including lives of those in marginalized communities who are ignored or scapegoated by their governments. Still, the support can’t be isolated from political realities. Funding at these levels, for decades, is a type of American embrace. Diplomatic messaging may be critical of democratic conditions, but any good political analyst knows that budget is policy and words untethered to action can largely be ignored. Policymakers are in a bind: Any reduction in PEPFAR funds risks harming citizens who confront a deadly disease, especially those dependent on PEPFAR for their antiretroviral treatment. For just that reason, autocratic leaders think the chances slim that funding levels will be reduced, democratic backsliding or no. The result is that policymakers are massively constrained in their ability to align U.S. foreign aid with recipient countries’ commitments to democratic governance.
The perverse incentives continue. Leaders in recipient countries have little motivation to mobilize their countries’ own resources—through taxation, for instance—to provide health services if for 20 years much of their HIV/AIDS budget is externally funded, with no end in sight. Citizens are not inclined to press their own governments for health service delivery if they assume the donor commitment is open-ended. The ever-precarious feedback loop between citizens and their government is further disrupted.
As for displaced resource allocation, when the United States pays for a significant portion of a country’s health services, the host government can shift spending elsewhere, including to the pursuit of more narrow interests. In Uganda, according to the World Bank, the percentage of GDP spent on health went from 11.8 percent in 2006 to 6.5 percent in 2018. Over the same period, Tanzania’s percentage of GDP devoted to health declined from 7.6 percent to 3.6 percent; Zambia’s shrank from 6.9 percent to 4.9 percent.
Finally, massive spending on PEPFAR and other health initiatives risks crowding out other U.S. investments. For fiscal year 2021, 57 percent of the overall foreign assistance budget for Uganda was devoted to health programming; in Tanzania the figure was 79 percent and in Zambia 75 percent. Even with the life-saving impact of health interventions, surely these ratios are misaligned with U.S. goals, especially when compared to funding levels for democracy and governance programs. At the recent Summit for Democracy, President Biden announced $424 million for the high-profile Presidential Initiative for Democratic Renewal; this figure is roughly equivalent to Mozambique’s most recent PEPFAR allotment for a single year.
So, what can be done to close the gap between policy priorities and funding realities?
First, PEPFAR too often operates in a silo, narrowly focused on meeting its quantitative targets. The responsible U.S. officials face little pressure to consider democracy and governance issues. Country-level leadership—the ambassador and head of USAID —should have a greater say in how the funds at their disposal are divided by sector. In Washington, this is the type of messy issue, cutting across competing priorities, that should have National Security Council attention in order to implement the President’s priorities. If democracy promotion is important enough to merit a presidential summit, other efforts should also reflect that priority.
Other funding models take recipient governments’ performance into account. Consider the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has threatened to deny funding—and has actually done so—to press recipient governments to meet “co-financing” domestic spending targets to fight those diseases. PEPFAR could likewise condition continued support on increased domestic health spending.
For all of PEPFAR’s successes, there has been scant consideration of eventual off-ramps. Tying continued funding to increased domestic resource mobilization would help. Moreover, increased commitment to public health could start to mend the frayed relations between citizens and their governments.
Finally, Congress needs to cast a more critical eye on PEPFAR. The appropriators have the greatest leverage to compel reflection and reform. They need to use it more adeptly—not necessarily through budget reductions but by encouraging smarter spending more closely tied to democracy promotion goals, coupled with increased funding for democracy and governance investments.
John Nkengasong, who previously headed the Africa Centers for Disease Control and Prevention, recently assumed leadership of PEPFAR. He is no stranger to the complex interplay between health and democracy. Nkengasong should use the natural reset that occurs when a new leader takes the helm to start a dialogue on these issues within the U.S. government and with partners.
Overall, PEPFAR is an enormous success; but it is time to ask more probing questions about whether America’s flagship global public health program is making sound investments in countries that labor under authoritarian leadership, places where progress toward democracy could improve the lives of people living with HIV/AIDS. The Biden administration should acknowledge the tensions between PEPFAR and other goals and adapt its assistance so that the tools of American foreign policy work in concert, while maintaining life-saving support to people who remain vulnerable to a deadly epidemic.
Jon Temin is vice president for policy and programs at the Truman Center for National Policy and a former member of the Policy Planning Staff of the U.S. Department of State.
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