An evaluation of the president's emergency plan for AIDS relief effect on health systems strengthening in sub-Saharan Africa

Background: President's Emergency Plan for AIDS Relief (PEPFAR) has been criticized for its vertical or "stove-piping" structure, with resources targeting a specific disease rather than working to strengthen the underlying health system. This study aimed to evaluate whether PEPFAR activities were associated with system-wide improvements in both proximal and distal indicators of health systems strengthening. Methods: The World Bank database provided 12 indicators of health systems strengthening that were analyzed for their relationship to PEPFAR. Poisson and linear regression models were used to estimate the time trend. We evaluated the PEPFAR impact on health outcomes by comparing the time trend in each of the above indicators between 2 time periods: from 1995 to 2002 (pre-PEPFAR) and from 2004 to 2010 (during PEPFAR). Results: PEPFAR activities showed strong and statistically significant associations with improvements in proximal indicators of health systems strengthening, those related directly to HIV, specifically life expectancy (P = 0.003) and tuberculosis incidence, prevalence, and mortality (P , 0.0001). There were nonsignificant associations between PEPFAR and improvements in distal indicators of health systems strengthening, namely infant mortality and under 5 child mortality. Conclusions: The progressive scale-up of PEPFAR-supported activities was associated with consistent improvements in proximal indicators of health systems strengthening. It was also associated with improvements in broader measures of health system strength, most clearly life expectancy. Given the limited number of health measures available for this type of analysis, more data must be collected for other indicators to evaluate the effectiveness of the many multibillion dollar global health initiatives.