The PEPFAR legacy: Lessons for global health planning from 20 years of AIDS work

During the 2022 U.S. Global Leadership Summit, former President George W. Bush asked an audience of American changemakers to consider the following: “What’s the role of a great country in the world? Is it to look inward? Is it to think about how to solve big problems?”

Bush was speaking about the President’s Emergency Plan for AIDS Relief (PEPFAR) — landmark legislation crafted under his leadership by an unlikely coalition of partisans and idealists who believed the U.S. could change the face of global health. I was among them. As the deputy staff director of the House Foreign Affairs Committee, my job was to move the plan from principles to implementation, helping broker what has since become the largest commitment by any nation to address a single disease in history.

The legislation that led to PEPFAR was introduced into Congress 20 years ago this month. And as I reflect on its legacy, Bush’s questions resonate: How do countries think about — and solve — big problems? When it comes to global health, lessons learned from PEPFAR may answer those questions.

The impact of historic legislation

It’s no exaggeration to say that PEPFAR changed the global health landscape, providing treatment for 2 million people and care for 10 million worldwide, including 4 million orphans and children. Remarkably, the bill has garnered bipartisan support in Congress for each of the three reauthorizations since its initial passage in 2003, despite significant initial stigma surrounding HIV/AIDS and ongoing, widening political divisions that work against Congressional compromise.

While dollars apportioned for AIDS research were invested largely in domestic drug discovery and testing, the lion’s share of PEPFAR’s funds were channeled directly to the hardest-hit communities in the world, largely in Africa. So in addition to mobilizing funds, the U.S. required an infrastructure of willing, engaged, and culturally competent partners to ensure those funds were responsibly used.

I see five key ways that PEPFAR managed to accomplish so much, so quickly and still remains relevant and effective today:

Putting a stake in the ground. PEPFAR made the case for elevating global health as an essential domain for investment. By signing the plan into law, the U.S. defined health as a standalone sector for foreign aid — pushing health aid from $10 billion in 2000 to more than $25 billion by 2008. Over the same period, federal aid for HIV went from less than 1% to nearly one-third of all health aid. Since then, the U.S. remains one of the largest contributors to the U.N. Joint Program on HIV/AIDS (UNAIDS) and is the largest donor to the Global Fund, which focuses on HIV/AIDS, tuberculosis, and other global health issues.

The conviction demonstrated by U.S. leadership matters. Global challenges like HIV/AIDS, climate change, and human rights require a decisive call to action. The U.S. administration chose the issue of AIDS in 2003 and, in doing so, began to scaffold both a platform and a coalition.

Cultivating a multi-stakeholder coalition. Those crafting PEPFAR tapped people from public and private sectors, faith communities, science and academia, and more, then transferred ownership of key programmatic planning and execution to local communities.

Two separate coalitions have been key to PEPFAR’s success: the coalition required to pass the legislation, and the coalition required to sustain it.

PEPFAR became law because both Democrats and Republicans believed deeply in the cause and were willing to make compromises to cobble together the votes for the plan to pass. The zeal to do this extraordinary thing was contagious: faith organizations were the first and most outspoken to join the effort, celebrities like Bono were actively advocating for the issue, and nongovernmental organizations representing a wide array of positions and expertise came to the fore. There was a sense that this was a unique moment that couldn’t be allowed to pass.

And then there’s the work to actually do PEPFAR. One of its unique components is the role host countries have played in the design and implementation of its initiatives. In fact, 90% of the partner organizations that work with PEPFAR in the field are local. Because there is no a single approach to implementation, governments have had to take ownership for the programs that are executed in their countries, adapting interventions to the needs and cultural norms of their own populations.

Delivering immediate and long-term wins. PEPFAR delivered both immediate health wins and long-term development of civil society. The plan has been effective in separating health aid from economic development, and in doing so, uses the former to address the latter, and thereby welcomes more partners in the fold and amplifies their impact. Because it resulted in declines in HIV-specific and all-cause mortality, life expectancy subsequently increased in PEPFAR-engaged regions. This led to increased employment (particularly among men), bolstering economic development, food and housing security, education, child immunization rates, and GDP growth. This powerful interplay between the health and social sectors, including the labor market, also necessitated welcoming more local PEPFAR partner agencies into the work with expertise in programs designed to train and hire young men.

Creating an infrastructure for accountability. A laser focus on results has kept countries accountable to PEPFAR’s goals and ensured that lessons learned from it could be translated to other projects and organizations working in global health. The emphasis on outcomes has also generated new monitoring and evaluation capabilities across a range of countries and diseases, with transparent data and resource sharing. This isn’t just good for HIV/AIDS mitigation and prevention, but has transformed how a variety of health metrics are being tracked today.

Reminding global powers of their responsibility to act. In Bush’s closing remarks at the 2022 Global Leadership Summit, he discussed the war in Ukraine. “Americans are hurting at home, but not nearly as much as Ukrainians are hurting in their home. This is the fundamental question … of PEPFAR. It’s the question that confronts every administration in every Congress on a regular basis: Do we care about the human condition elsewhere? The human condition elsewhere can jeopardize the security of the United States, and therefore isolationist tendencies have huge national security implications at home.”

PEPFAR’s future

PEPFAR was made possible because lawmakers invested — collectively — in its passage. And to be sure, there were plenty of moments that it could have all fallen apart. And it has succeeded because the global community has been invested — collectively — in its success.

Twenty years later, all indications point to continued investment as PEPFAR heads to the 118th Congress for reauthorization this session. The challenge the U.S. now faces is how to leverage the lessons of PEPFAR to aid in supporting other humanitarian crises that can be addressed only with tenacious bipartisanship and multilateralism. Indeed, as the world continues to demand swift action to address multiple co-occurring crises, we’d be wise to heed the lessons of PEPFAR for global good: champion local agency, demand accountability, and build meaningful, sustainable partnerships that nurture population health and prosperity.

Peter Yeo is the senior vice president of the United Nations Foundation and president of the Better World Campaign.