What happened with PEPFAR's faith-based initiative?

U.S. Vice President Mike Pence. Photo by: Michael Gross

WASHINGTON — On World AIDS Day in 2018, Vice President Mike Pence announced a new U.S. President’s Emergency Plan for AIDS Relief initiative that would provide an additional $100 million to faith-based organizations. It was a flashy announcement that raised concerns over where the funding would come from and whether it would be politics or evidence that determined the initiative’s direction.

Nearly two years later, all of the funding has been quietly distributed — but concerns linger about a PEPFAR push for more faith-based funding at the potential expense of other communities.

The PEPFAR Faith and Community Initiative was designed to “address key gaps toward achieving HIV epidemic control and ensuring justice for children, including by leveraging the unique capacities and compassion of faith-based organizations and communities,” a PEPFAR spokesperson told Devex via email.

Faith-based organizations, particularly Christian organizations, have been a key part of PEPFAR delivery since it was founded in 2003 under then-President George W. Bush’s administration, but the push to increase funding to those organizations raised a number of questions, in part due to the increased politicization of aid funding under the President Donald Trump administration, several experts told Devex.

Focus on: Faith and Development

This series illuminates the role faith actors and their communities play in strengthening global development outcomes.

PEPFAR chose 10 countries to receive funding as part of the initiative in 2019: Botswana, Eswatini, Haiti, Kenya, Lesotho, Malawi, Tanzania, Uganda, Zambia, and Zimbabwe.

The funding was provided both to prime partners and subpartners, which — along with recent changes in PEPFAR’s database system and reporting — makes some of it difficult to track through publicly available data. PEPFAR funding to faith-based organizations appears to have increased in 2019, up about $64 million from 2018 to a total of about $160 million. That accounts for about 4% of total PEPFAR funding, according to the database of amfAR, The Foundation for AIDS Research, which reflects prime contracts.

The full $100 million has been distributed, according to PEPFAR, and it all came from unallocated prior-year PEPFAR funding with no funds redirected to the initiative, according to the PEPFAR spokesperson.

A long history and a unique role

In some sub-Saharan African countries, faith-based organizations provide nearly half of all health services. In Kenya, about 40% of health services across the country are provided by FBOs, according to the country’s 2019 PEPFAR country operational plan.

With a wide reach, faith-based organizations are often key partners for reaching the “last mile,” said Doug Fountain, executive director of Christian Connections for International Health, a forum for Christians working in global health. PEPFAR funding to FBOs had declined in recent years, having peaked late in the first decade of the 21st century, and this initiative was merely restoring funding to a valuable group of partners, rather than some new “windfall,” Fountain said.

“[Faith-based and community organizations] bring to bear unique service delivery capacities as well as positions of access and trust in the communities where PEPFAR works.”

— A PEPFAR spokesperson

There are a number of robust local faith-based health networks, including the Christian Health Association of Malawi and the Christian Health Association of Kenya, that have handled multimillion-dollar U.S.-funded programs in the past and have the capacity to deliver, but local faith-based organizations do often need capacity-building support, which is part of what CCIH does, in part through U.S.-funded efforts, Fountain said.

The faith initiative is “great in the sense [that] it is supporting new local faith-based organizations and is helping existing ones strengthen their work,” said Bill O’Keefe, executive vice president for mission, mobilization, and advocacy at Catholic Relief Services, which is one of the top recipients of PEPFAR faith-based funding.

CRS received nearly $52 million in funding from PEPFAR in 2019, according to amfAR, but O’Keefe said that while funding increased, it was largely as part of the ebb and flow of ongoing programs rather than new funding through initiative.

Faith-based and community organizations are also essential partners as a greater proportion of people living with HIV, such as men and children, feel healthy and might not access a clinic for testing or treatment, according to PEPFAR. Programs must find new ways to reach them, and that is where these organizations are needed, the PEPFAR spokesperson said.

“They bring to bear unique service delivery capacities as well as positions of access and trust in the communities where PEPFAR works,” the spokesperson said.

Skepticism and politicization

Despite the often important role of faith-based organizations, however, the initiative raised a number of concerns about the types of interventions and how partners were chosen.

“FBOs can play a very valuable role. They do have contacts other groups don’t have,” Justin Fugle, head of policy at Plan International, told Devex. “The problem here is they politicized something that has a reasonable basis.”

The faith-based initiative came on the heels of Trump’s 2017 expansion of the Mexico City Policy, or “global gag rule,” which states that foreign NGOs receiving any U.S. global health funding are prohibited from engaging in abortion-related activities, including providing counseling or education. The ideologically driven policy has hampered sexual and reproductive health services around the world.

With the vice president making the announcement and an administration that has sometimes let politics dictate aid, one of the concerns is whether this initiative would be directed by Washington or be part of a “sound technical process” with missions having control and the ability to identify organizations that have credibility, Fugle said.

PEPFAR told Devex that all of the initiative’s implementing partners were chosen based on their ability to provide evidence-based interventions to address key gaps in HIV epidemic control and that the programs are evaluated using the standard PEPFAR reporting mechanisms.

Another concern is whether FBOs are providing science-based information for HIV prevention “that includes internal and external condoms and are they providing services to all individuals without discrimination and stigma, especially for LGBTQ individuals, women and adolescent girls who are not married, among others,” said Beirne Roose-Snyder, director of public policy at the Center for Health and Gender Equity, in an email to Devex.

PEPFAR’s faith-based initiative “supports evidence based programming through partnership with faith communities and other traditional community organizations in these countries, with a focus on two over-arching priorities: 1) to help find men, youth, and children living with HIV and link them into continuing care; and 2) to prevent sexual violence among children and accelerate justice for children who have suffered from it,” the PEPFAR spokesperson wrote.

FBOs have been behind the curve on evidence and accountability, and they need to work to “reframe the discussion” and prove that they can “demonstrate impact,” Fountain said. Otherwise, they are going to lose out competitively, he added.

Another concern is that with an emphasis on faith-based organizations, some populations might be discriminated against or could lose out, several experts told Devex. Notably, while the initiative targets faith-based organizations, the top 20 FBOs receiving funding from PEPFAR are all Christian organizations.

Faith has sometimes been used “as an excuse to spread misinformation or anti-LGBT or homophobic rhetoric” that fuels discrimination, said Keifer Buckingham, senior policy adviser at the Open Society Foundations.

The worry is that LGBT individuals, transgender people, drug users, or sex workers will not effectively be reached through PEPFAR programs, Buckingham said.

“Playing favorites with FBOs is risky,” Roose-Snyder wrote. “A reliance on FBOs puts communities at increased risk when they are the sole service provider in a community and do not provide the full range of evidence-based interventions, withhold services, or cannot abide by the stigma and discrimination-free services required for a roboust public health response.”

While some of the concerns about the initiative, particularly around the politicization of foreign assistance, are understandable, the initiative should ultimately be judged by how the money is spent, its objectives, and its design. And the initiative is trying to achieve “what all of us are trying to do, so I think it stands muster in terms of the content,” O’Keefe said.

While the initiative was a one-time commitment with the goal of starting new partnerships and collaborations and identifying new solutions to achieve and sustain epidemic control, PEPFAR is encouraging continued support for models and programs that were identified through the initiative, the spokesperson said.

Devex, with support from our partner GHR Foundation, is exploring the intersection between faith and development. Visit the Focus on: Faith and Development page for more. Disclaimer: The views in this article do not necessarily represent the views of GHR Foundation.

About the author

  • Adva Saldinger

    Adva Saldinger is a Senior Reporter at Devex, where she covers the intersection of business and international development, as well as U.S. foreign aid policy. From partnerships to trade and social entrepreneurship to impact investing, Adva explores the role the private sector and private capital play in development. A journalist with more than 10 years of experience, she has worked at several newspapers in the U.S. and lived in both Ghana and South Africa.