Interactive: Dissecting PEPFAR's country operational plans

When the U.S. President’s Emergency Plan for AIDS Relief initially began its operations in sub-Saharan Africa in 2003, only half a million people in the region were receiving lifesaving antiretroviral treatment. Today, PEPFAR is working in more than 50 countries and supporting more than 14 million people with treatment, making it the biggest player in the HIV/AIDS funding landscape. In the past 16 years, PEPFAR has changed and evolved as both politics and the HIV epidemic have shifted. In recent months, as the Trump administration has sought to exert greater influence over U.S. global health policy, the initiative has faced new demands and challenges. PEPFAR released a new strategy focusing resources on 13 high-priority countries, an expansion of the "global gag rule" created new oversight and ethical dilemmas for PEPFAR's implementing partners, and U.S. Global AIDS Coordinator Deborah Birx has driven a push to direct 70% of PEPFAR's funding to "indigenous organizations.” Despite repeated White House proposals to slash PEPFAR’s budget, its mandate has been extended through 2023, meaning the largest funder of HIV/AIDS projects worldwide is here to stay — at least for the next few years. With these developments in mind, Devex has analyzed publicly available data published by PEPFAR. The data is drawn from PEPFAR’s annual country operational plans, or COPs, which outline critical funding flows to countries, partners, and HIV/AIDS sectors. As part of this analysis, Devex has produced an interactive visualization, which allows users to explore the data in-depth and dig deeper into specific areas of interest. Key geographies of investment According to the COPs’ data, PEPFAR allocated $47 billion between 2005-2018. Since 2008, the total contribution per year has remained relatively stable, averaging around $3.8 billion. For COP18 — which is being implemented in U.S. fiscal year 2019 — PEPFAR has allocated $3.9 billion. Out of these flows, the list of top recipient countries with the largest volume of funding has also been relatively stable over the years. Since 2005, South Africa has been allocated the most funding, around $5.9 billion in total, and has been the top recipient country nine out of 14 years. In COP18 alone, South Africa received almost $600 million. Trailing behind, Kenya, Nigeria, Uganda, and Tanzania are the other top recipient countries between 2005-2018. These five countries together constitute more than half of all PEPFAR allocations for that period. Though PEPFAR’s primary focus is on sub-Saharan Africa, it also operates in countries outside that region. For Asia, the top three recipient countries since 2005 are Vietnam, India, and Cambodia, with total allocations of around $790 million, $400 million, and $190 million, respectively. In the Americas, Haiti ($1.5 billion), Guyana ($180 million), and the Dominican Republic ($130 million) have received the most funding, though Guyana’s last recorded funding flows were in 2015. According to the COPs, Ukraine is the only country in Europe receiving PEPFAR support since 2007, worth around $220 million. Beyond bilateral allocations, there are four regions through which PEPFAR channels its funding: the Caribbean region (with total allocations of $220 million), Central America region ($150 million), Central Asia region ($90 million), and Asia regional program ($80 million). Due to the nature of these flows, they have not been taken into account in this analysis, nor the interactive visualization. Top priorities COPs divide HIV/AIDS projects into higher level strategic areas and specific programming areas. The higher level strategic areas include care; governance and systems; management and operations; prevention; testing; and treatment. Historically, treatment has been the strategic area with the highest investments, followed by care and prevention. For COP18, PEPFAR has allocated $1.7 billion for treatment, compared to around $600 million for prevention. Under each strategic area, there are a number of areas of HIV/AIDS programming. For instance, the strategic area of care includes care for orphans and vulnerable children; adults; tuberculosis and HIV; and pediatric care. The strategic area of management and operations contains the highest number of areas of HIV/AIDS programming, including administrative costs, salaries, and office space expenses, among others. Looking at the areas of HIV/AIDS programming specifically, the area with highest funding is adult treatment, which includes infrastructure, training for clinicians, clinical monitoring, related laboratory services, and community-adherence activities. In COP18, PEPFAR allocated more than $1 billion to adult treatment. Anti-retroviral, or ARV, treatment-related costs are the second highest expense ($500 million for COP18), followed by care of orphans and vulnerable children ($300 million), who either lost a parent to HIV/AIDS or live in areas of high HIV/AIDS prevalence. Localization agenda Though PEPFAR is still currently operating on COP18, by this time next year it should reach 40% of its funding directed to local organizations. The COPs themselves do not provide a classification taking into account local and international status of the awarded organization, but the COP data website hosted by the Foundation for AIDS Research, or amfAR, includes necessary classifications to make this analysis. It is worth noting, however, that local branches of international organizations have been classified as ‘international.’ According to amfAR data, the share of funding channeled to local entities is at around 23% as of COP18, compared to 28.5% during COP17. The share of funding to international organizations has fluctuated between 46%-48% during COPs in 2016-2018. The N/A category comprises a large share of total funding, which makes it more difficult to estimate the actual share of local and international organization funding flows. The upcoming COP19 will have to substantially increase the flows to local organizations if PEPFAR is to meet the first target in its localization agenda. The share of funding channeled to local partners differs from country to country. Kenya is the only country where 40% of PEPFAR’s funding is already directed to local organizations. South Africa, Uganda, Rwanda, Ethiopia, and Cameroon are all past the 30% threshold and are close to reaching the goal. Tanzania, Lesotho, Botswana, eSwatini, and the Democratic Republic of the Congo, however, are trailing behind with less than 10% of their total funding channeled to local partners for COP18 and COP17. Top partners For COP18 alone, PEPFAR has allocated funds to 237 organizations. While international organizations dominate the overall amount of funding, local organizations make up a larger share of the recipient pool, with 131 organizations classified as local, and only 88 as international. Not surprisingly, local organizations are more likely to win smaller awards focusing on grassroots activities in one country, which make up a smaller share of PEPFAR funding than larger, regional contracts. The top partner according to COP18 is Chemonics International, an international organization that supplies a large portion of ARV drugs across 22 PEPFAR-supported countries. The top local partner is Kenya Medical Supplies Agency, which also works primarily on ARV drugs, but only in Kenya. Within the most-funded area of HIV/AIDS programming for COP18, adult treatment, the top three partners are all international: Chemonics International, Elizabeth Glaser Pediatric AIDS Foundation and FHI 360. Blood safety is one of the few areas of HIV/AIDS programming where the top recipients are local organizations — including, for example, the National Blood Transfusion Service in Kenya and Malawi Blood Transfusion Service. A larger share of PEPFAR's funding was allocated to NGOs (more than $1 billion) than to private contractors (around $730 million) in COP18. The funding for NGOs was split between 110 different organizations. The top-funded international NGO was Elizabeth Glaser Pediatric AIDS Foundation and the top local one was Medical Access Uganda Limited. Funding to private contractors, such as Chemonics, went to only 20 organizations, which explains why some of these contractors are listed as top partners in the overall rankings. Nearly half a million dollars has also been allocated to universities and $100 million to faith-based organizations, including Catholic Relief Services. Devex Analytics is a team of analysts, data scientists, and engineers delivering actionable solutions on development issues through structured datasets, official reports, press releases, and community-sourced information. Do you have questions about our methodology or analysis? 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