Assessing PEPFAR’s Impact: Analysis of Maternal and Child Health Spillover Effects in PEPFAR Countries

Issue Brief
  1. State Department, PEPFAR Global Stakeholders Briefing, November 23, 2021.

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  2. See, for example: Shiffman J, “Has donor prioritization of HIV/AIDS displaced aid for other health issues?” Health Policy Plan, 2008 Mar, 23(2): 95-100; Lordan G, Tang KK, Carmignani F, “Has HIV/AIDS displaced other health funding priorities? Evidence from a new dataset of development aid for health,” Soc Sci Med, 2011 Aug, 73(3): 351-355; Barbiero VK, “Fulfilling the PEPFAR mandate: a more equitable use of PEPFAR resources across global health”, Glob Health Sci Pract, 2013 Nov 14,1(3): 289-293.

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  3. See, for example: Embrey M, Hoos D, Quick J, “How AIDS funding strengthens health systems: progress in pharmaceutical management”, J Acquir Immune Defic Syndr, 2009 Nov, 52 Suppl 1: S34-37. Walensky RP, Kuritzkes DR, “The impact of the President's Emergency Plan for AIDS Relief (PEPFAR) beyond HIV and why it remains essential”, Clin Infect Dis, 2010 Jan 15, 50(2): 272-275; Rasschaert F, Pirard M, Philips MP, Atun R, Wouters E, Assefa Y, Criel B, Schouten EJ, Van Damme W, “Positive spill-over effects of ART scale up on wider health systems development: evidence from Ethiopia and Malawi”, J Int AIDS Soc, 2011 Jul 6,14 Suppl 1: S3. Bendavid E, Holmes CB, Bhattacharya J, Miller G, “HIV Development Assistance and Adult Mortality in Africa”, JAMA, 2012, 307(19): 2060-2067.

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  4. Kates J, Nandakumar A, Gaumer G, Hariharan D, Crown W , Wexler A, Oum S, Rouw A, Assessing PEPFAR’s Impact: Analysis of Mortality in PEPFAR Countries, KFF, 2021. Available at: https://www.kff.org/global-health-policy/issue-brief/assessing-pepfars-impact-analysis-of-mortality-in-pepfar-countries/.

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  5. See, for example: Brugha R, Simbaya J, Walsh A, Dicker P, Ndubani P, “How HIV/AIDS scale-up has impacted on non-HIV priority services in Zambia”, BMC Public Health, 2010,10: 540; Kruk ME, Jakubowski A, Rabkin M, Elul B, Friedman M, El-Sadr W, “PEPFAR programs linked to more deliveries in health facilities by African women who are not infected with HIV”, Health Aff (Millwood), 2012 Jul 31(7): 1478-1488; Grépin KA, “HIV donor funding has both boosted and curbed the delivery of different non-HIV health services in sub-Saharan Africa”, Health Aff (Millwood), 2012 Jul 31(7):1406-1414; Luboga SA, Stover B, Lim TW, Makumbi F, Kiwanuka N, Lubega F, Ndizihiwe A, Mukooyo E, Hurley EK, Borse N, Wood A, Bernhardt J, Lohman N, Sheppard L, Barnhart S, Hagopian A, “Did PEPFAR investments result in health system strengthening? A retrospective longitudinal study measuring non-HIV health service utilization at the district level.” Health Policy Pla, 2016 Sep 31(7).

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  6. KFF, The U.S. Government and Global Maternal and Child Health Efforts, July 2021. Available at: https://www.kff.org/global-health-policy/fact-sheet/the-u-s-government-and-global-maternal-and-child-health-efforts/

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  7. PEPFAR, Leveraging American Rescue Plan Act Funding to Support HIV and COVID-19 Responses, January 2022. Available at: https://www.state.gov/wp-content/uploads/2022/01/PEPFAR-ARPA-Funding-Fact-Sheet_2022.pdf.

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  8. The program’s 2003 authorizing legislation states that the “magnitude and scope of the HIV/AIDS crisis demands a comprehensive, long-term, international response focused upon addressing the causes, reducing the spread, and ameliorating the consequences of the HIV/AIDS pandemic, including…. development of health care infrastructure and delivery systems through cooperative and coordinated public efforts and public and private partnerships”. See, Public Law 108–25—May 27, 2003, 117 STAT. 715. Available at: https://www.kff.org/wp-content/uploads/2021/12/PEPFAR-Original-Legislation-2003-PL-108-25.pdf

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  9. The first strategy states that, “While mobilizing rapid scale-up for treatment availability, the Emergency Plan will also lay the foundation for sustainable high-quality treatment programs. This will be accomplished by: Strengthening national human resource capacity through health care worker recruitment and retention strategies, longer-term training, and technical assistance; Establishing, disseminating, and implementing treatment protocols; Developing the capacity of new partners; and Developing and strengthening health infrastructure.  See, President’s Emergency Plan for AIDS Relief: U.S. Five-Year Global AIDS Strategy, 2004. Available at: https://www.kff.org/wp-content/uploads/2021/12/PEPFAR-Original-5-Year-Strategy-2004.pdf.

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  10. The 2008 reauthorization of PEPFAR added a new section on health systems strengthening. See, Public Law 110–293—JULY 30, 2008, section 204, 122 STAT. 2942. Available at: https://www.kff.org/wp-content/uploads/2021/12/PEPFAR-Reauthorization-2008-PL-110-293.pdf.

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  11. State Department, PEPFAR 2009 Country Operational Guidance, May 2008. Available at: https://www.kff.org/wp-content/uploads/2021/12/PEPFAR-FY2009-COP-Guidance-Final.pdf.

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  12. State Department, PEPFAR 2022 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR-Supported Countries, January 2022. Available at: https://www.state.gov/wp-content/uploads/2022/01/COP22-Guidance-Final_508-Compliant.pdf.

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  13. State Department, PEPFAR 2022 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR-Supported Countries, January 2022. Available at: https://www.state.gov/wp-content/uploads/2022/01/COP22-Guidance-Final_508-Compliant.pdf.

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  14. PEPFAR Solutions Platform, CFM: Improving mother-baby pair retention in integrated maternal and child health and HIV services in Eswatini, December 2018. Available at: https://www.pepfarsolutions.org/solutions/2018/12/19/cfm-improving-mother-baby-pair-retention-in-interated-maternal-and-child-health-and-hiv-services-in-eswatini?rq=eswatini.

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  15. State Department, Guidance for United States Government In-Country Staff and Implementing Partners for a Preventive Care Package for Children Aged 0-14 Years Old Born to HIV-Infected Mothers, #1, April 2006. Available at: https://web.archive.org/web/20070719203347/http://www.pepfar.gov/documents/organization/77005.pdf.

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  16. We examined two other maternal and child health measures for potential inclusion (receipt of prenatal care and modern contraceptive prevalence) but these did not meet the difference-in-difference parallel trend assumption (that in the absence of an intervention, the difference between the treatment and comparison group is constant over time) and therefore were not included in our final selection.

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  17. A subset of PEPFAR countries prepare annual Country Operational Plans (COPs). COPs are developed through a multi-stakeholder planning process, document planned investments and results, and serve as a basis for approval of final PEPFAR funding.

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  18. As measured by percentage point difference, see Table 6.

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  19. Analysis of data from the Institute for Health Metrics and Evaluation (IHME), GHDx, VizHub. Available at: https://vizhub.healthdata.org/gbd-compare/. Accessed February 17, 2022.

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  20. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, Gülmezoglu AM, Temmerman M, Alkema L. “Global causes of maternal death: a WHO systematic analysis.” Lancet Glob Health. 2014 Jun;2(6):e323-33.

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  21. Gertler, Paul J., Sebastian Martinez, Patrick Premand, Laura B. Rawlings, and Christel M. J. Vermeersch. 2016. Impact Evaluation in Practice, second edition. Washington, DC: Inter-American Development Bank and World Bank. Available at: https://openknowledge.worldbank.org/handle/10986/25030.

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