How America’s Global AIDS Program Spends Efficiently to Save Lives

As we stated today in our letter to the New York Times, PEPFAR’s work to prevent and treat H.I.V. and AIDS around the world has saved over 25 million lives, and should absolutely be reauthorized by Congress. For twenty years, it has set the global standard for fighting HIV and AIDS and won admirers for the United States around the world.

The reauthorization debate has focused mainly on abortion (PEPFAR does not fund abortion and is prohibited by law from doing so). Unfortunately, that debate has obscured one of PEPFAR’s signal, bipartisan achievements: its relentless focus on spending taxpayer dollars efficiently to save as many lives as possible. Lessons in efficiency learned from PEPFAR could do much to improve other U.S. government spending, overseas and here in America.

In the digital age, spending money efficiently means collecting, analyzing, and using data to monitor performance. Here, PEPFAR is in a class of its own among government programs. PEPFAR’s accountability standards require foreign governments and implementing NGOs to use data, evaluations (such as randomized control trials), and advanced analytics to measure results and demonstrate value for money. The result has been a revolution in global health that improves outcomes, saves lives, and protects taxpayer dollars.

As co-founders of a data-driven global health organization, we’ve seen this impact firsthand. A few years ago, we visited Luzi Orphan Care in rural Malawi. This small local charity is housed in several huts at the end of a long, dusty red-dirt road bordered by fields of maize. It gets around $500 a year from PEPFAR to care for children orphaned by AIDS.

Five hundred dollars goes a long way in Luzi’s hands. We know that because we saw their meticulous records: Binders of crisp white pages, filed neatly in boxes, recording how those $500 were spent and how many orphans received care.

When we asked whether they needed anything, they didn’t ask for more money. Instead, they asked for feedback on their performance: “How are we doing? How does our work compare to others? Are there things we could do better?” Good stewardship, they knew, would enable them to help more children.

That focus on accountability sets PEPFAR apart. For too long, foreign aid programs measured their success based on the size of their budget, not on the results they achieved. PEPFAR changed that culture. Instead of using last year’s funding amounts to justify budget requests, organizations as large as the U.S. government and as small as Luzi Orphan Care are now measured by whether they can achieve more with existing resources.

That means knowing how much an organization spends to save one life, prevent one infection, or achieve some other, specific goal: what PEPFAR calls “cost per result.” Since 2010, when PEPFAR’s funding began to plateau after years of rapid growth, its annual budget process has focused on costs per result, and how they differ across areas where the program works. That metric — how much organizations on the ground can achieve for a given amount of money — is then compared with estimates of HIV prevalence and unmet needs for HIV treatment and prevention.

The result: it now costs PEPFAR dramatically less to save each life. In 2014, it cost $327 to give lifesaving treatment to one person for one year. By 2022, that had fallen to $59.

PEPFAR’s focus on efficiency is echoing across the foreign-aid world. Countries are now using tactics developed by PEPFAR for other health programs, from disaster response to seasonal outbreaks. For example, when Malawi recently experienced its deadliest ever cholera outbreak, it used data from clinical monitoring and water-quality testing to allocate cholera vaccine where it was needed most. Thanks to this targeted response, Malawi declared the outbreak over last month.

That’s not to say PEPFAR is perfect. Any program at its scale can be improved, and there are ways to wring even greater efficiency from this well-functioning program. One promising policy is to move away from international NGOs as the primary implementers, instead relying more on local organizations. That shift could save money and build local governments’ capacity to provide for the health of their people.

PEPFAR has been enormously successful: in saving lives, in preventing the spread of HIV and AIDS, and in making global health systems more efficient. Letting PEPFAR lapse now would reverse that progress and squander the admiration PEPFAR has earned for the United States. With PEPFAR’s focus on efficiency and results, the American people can be confident that another five-year authorization would be money well spent.