Since its launch in 2003, the President’s Emergency Plan for AIDS Relief (PEPFAR) has saved more than 20 million lives and has helped to prevent many partner countries from collapsing, as HIV/AIDS ravaged the African continent. It has been a win both for the countries it serves and for U.S. foreign policy. The Congress and the American people should continue to support its lifesaving mission and current structure.
PEPFAR isn’t a democracy program, nor should it be. In his June 22 American Purpose article, “Fight AIDS in Africa, Not Democracy,” Jon Temin recognizes that PEPFAR has saved lives, but he ignores its other positive impact—the six transformative ways PEPFAR has changed how citizens interact with each other and their government in the countries in which the program invests.
First, PEPFAR has improved equity across the countries in which it works by spurring the realignment of funding and programming. PEPFAR collects granular, disaggregated data down to the particular site and community level and then makes this information available and fully transparent to both governments and communities, so that it’s harder for those in power to allocate health resources only to their supporters. PEPFAR has also successfully encouraged governments “to invest much more substantially in their own HIV and broader health responses,” according to the Bipartisan Policy Center. That government money now follows epidemiology, not political trends.
Second, PEPFAR has increased accountability. The program and its partners, including government ministries, use PEPFAR’s open and accessible data in real time to guide decision-making and to improve outcomes and impact. This culture of data utilization ensures that people can hold both host governments and PEPFAR accountable for results. In fact, a higher level of PEPFAR funding in a country has been associated with improved government effectiveness, regulatory quality, and rule of law in the World Bank’s indicators of governance.
Third, PEPFAR has nurtured and expanded civil society by championing the development and direct funding of grassroots, community- and faith-based groups across sub-Saharan Africa. Local nongovernmental organizations now receive more than 60 percent of PEPFAR’s bilateral funding. That’s crucial for both program management and democratic strengthening, because NGOs are vehicles for citizens to express their views and defend their rights. Despite Temin’s implications, in fact governments directly channel very little PEPFAR funding. No PEPFAR money at all goes through autocratic regimes like Zimbabwe’s, while 15 percent or less of PEPFAR’s country budgets are channeled by ministries in other countries. The remainder, PEPFAR invests through international NGOs.
Fourth, PEPFAR has given ordinary people a clear voice in how their nations manage health care—often for the first time. The program launched regular quarterly and annual planning and programmatic reviews in each country, which bring community representatives and advocacy organizations to the table along with government officials to chart their country’s response to HIV together.
Fifth, PEPFAR has brought reform in its wake. Working through U.S. ambassadors, the program has pushed successfully for policy and implementation changes that have increased access and transparency and improved performance. PEPFAR has prompted government leaders to expand the availability of prevention and treatment, to secure human rights and access for LGBTQ populations, and to eliminate informal and formal health fees for the poor. These changes have improved overall health as well; the Kaiser Family Foundation found “PEPFAR has had positive health spillover effects beyond just HIV, with no negative, ‘crowding-out’ effects.”
Finally, PEPFAR is helping to create the next generation of democratic leaders, particularly women leaders. The grassroots DREAMS (Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe) program helps adolescents and young women overcome the structural barriers and issues that put them at higher risk of acquiring HIV than their male peers. DREAMS keeps girls in school (especially high school), prevents child marriage, provides bridges to private employment, and builds leadership skills. DREAMS is also democracy in action: Many of the young women involved are now community leaders who are holding their governments to account.
PEPFAR has evolved from an early focus on urgent medical care to cut the dramatic HIV/AIDS death rate among adults in sub-Saharan Africa to comprehensive programming both to prevent HIV and to improve health care delivery and management. While PEPFAR hasn’t magically eliminated one-party states in Africa, its model has brought revolutionary change to the nexus of democracy and governance: community engagement and empowerment.
The fact that PEPFAR and its leader, the ambassadorial-level U.S. Global AIDS Coordinator, report directly to the Secretary of State ensures the highest level of accountability, impact, and coordination with other foreign policy efforts. It also enhances PEPFAR’s ability to work horizontally across the federal government and in many countries.
As the United States rightly focuses on supporting democracy and human rights around the world, we should recognize PEPFAR’s contributions and look to it as a model for effective foreign assistance. PEPFAR not only saves lives, but lifts up communities and promotes democracy and human rights.
Deborah L. Birx is a senior fellow of the George W. Bush Institute. She is the former U.S. Global AIDS Coordinator and former White House Coronavirus Response Coordinator.
William R. Steiger is a global health consultant for the George W. Bush Institute. He is the former chief of staff for USAID, and former director of the Office of Global Health Affairs at the U.S. Department of Health and Human Services (HHS) and Special Assistant for International Affairs to the Secretary of HHS.
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