Pepfarby Former Senator Tom Coburn
Posted on 2013-12-20
COBURN. Madam President, PEPFAR has been and remains one of the
most successful foreign policy achievements of the United States in the
21st century. This unprecedented humanitarian effort has touched
millions, either through providing lifesaving HIV/AIDS treatment,
keeping together families impacted by the disease, caring for orphans,
or improving the lives of others affected and infected by this horrible
disease as well as tuberculosis and malaria. In an era of war abroad
and deep political divisions at home, this program is one that has
bipartisan support here and has generated good will toward the United
States abroad. Every American should be proud of the success of this
initiative as it represents what is great about our Nation and has
restored hope for so many.
The Senate Foreign Relations Committee worked hard to get S. 1545, the PEPFAR Stewardship and Oversight Act, through this Chamber. I thank Chairman Menendez and Ranking Member Corker for their cooperation and attentiveness in the process. This bill, which became law on December 2, is a positive step toward increasing program transparency and accountability in PEPFAR's annual report. It also renews and strengthens several components of the last reauthorization, including Global Fund governance provisions and the requirement that more than 50 percent of PEPFAR's appropriations to be spent on treatment and essential medical care.
This latter component, the treatment spending requirement, is one of the key accountability provisions my colleagues and I fought for in the past. In short, PEPFAR is required to spend at least 50 percent of its appropriations on essential medical treatment and care. Members on both sides of the aisle voted for authorizations with this treatment floor. Congress sought to prevent the program from straying from its core mission of treating and caring for patients. If PEPFAR were to lose sight of this goal, the result would not just be a waste of money, it would be lives lost on account of mission creep. We cannot let PEPFAR become another well-intentioned but unfruitful and nebulous international development program.
This statutory treatment floor has changed somewhat over the last decade, but the purpose has remained the same throughout: to focus more than half of PEPFAR's total appropriations on essential treatment and medical care. Unfortunately, as I will discuss in a moment, the Office of the U.S. Global Coordinator, OGAC, at the Department of State has not been following this law. Rather, it has excluded a significant portion of its appropriations from the calculation and is now spending less than is statutorily required on treatment and care.
The original PEPFAR authorization in 2003, P.L. 108-25, first included a treatment spending floor that said, ``Not less than 55 percent of the amounts appropriated pursuant to the authorization of appropriations . . . shall be expended for therapeutic medical care of individuals infected with HIV, of which such amount at least 75 percent should be expended for the purchase and distribution of antiretroviral pharmaceuticals and at least 25 percent should be for related care.'' Similarly, the full reauthorization of PEPFAR in 2008, P.L. 110-293, included a treatment requirement that said, ``More than half of the amounts appropriated for bilateral global HIV/AIDS assistance . . . shall be expended for . . . (1) antiretroviral treatment for HIV/AIDS; (2) clinical monitoring of HIV-seropositive people not in need of antiretroviral treatment; (3) care for associated opportunistic infections; (4) nutrition and food support for people living with HIV/ AIDS; and (5) other essential HIV/AIDS-related medical care for people living with HIV/AIDS.'' This version expanded somewhat on the original category of ``therapeutic medical care,'' but Congress maintained a minimum percentage of appropriations intended for direct care and treatment services.
Lastly, the recent PEPFAR legislation, S.1545, now P.L. 113-56, reiterates and even clarifies the treatment requirement further. This new law says more than half of the funds appropriated for activities under section 104A of the Foreign Assistance Act--which contains all of PEPFAR's functions ranging from drug treatment to training health professionals and capacity building--need to be going to these five categories of essential medical treatment and care.
None of these definitions from laws in 2003, 2008, or 2013 has allowed for an exclusion of certain components of PEPFAR's funding from the treatment calculation. No appropriations bill has implemented an exception to the calculation. The charge and requirement has always been to examine total PEPFAR appropriations in a given year and ensure at least half goes to services in these five categories.
[[Page S9095]] As I said previously, PEPFAR management has not been abiding by the letter of the law. The Office of the U.S. Global AIDS Coordinator at the Department of State has been excluding several spending categories from the treatment and care calculation. A smaller denominator makes it easier for the program to meet the treatment calculation. In reality, hundreds of millions of dollars more should be going to treatment and care if the law were followed. Millions more patients could be receiving lifesaving antiretroviral treatment.
A Government Accountability Office report released in March 2013 highlighted how OGAC has been excluding a significant portion of PEPFAR appropriations, categorized as ``Other'' activities, from this calculation. In fiscal year 2008, this ``Other'' category accounted for about 15 percent of PEPFAR country budgets, or $574 million. By fiscal year 2012, the category increased to 21 percent of PEPFAR country budgets, or $710 million. Over the same timeframe, total spending on treatment and care decreased from $1.8 billion to $1.4 billion.
This ``Other'' category includes spending for health systems strengthening, strategic information, management and operations, and laboratory strengthening. OGAC told GAO it had excluded the ``Other'' category based on OGAC's interpretation of the intent of the treatment spending requirement. They have also not included any of OGAC's administrative costs.
As one directly involved with PEPFAR throughout my time in the Senate, I can say firmly the treatment spending requirement was intended for all of PEPFAR's appropriations, not just a portion.
PEPFAR's operational plan for fiscal year 2011 shows that PEPFAR received about $5.0 billion for all bilateral activities, including headquarters administrative costs. To be meeting the treatment spending requirement as written, PEPFAR should have planned to spend about $2.5 billion on treatment and care. Instead, it spent $1.6 billion. That figure about $900 million short of what should be going to direct treatment and care services that fit the categories already in law.
I understand the need for PEPFAR to invest in some capacity building and other ancillary development. A nation needs labs to check HIV test results, for example. Labs and clinics need health professionals, and a host government needs to be able to track the program results. However, we have seen time and again how development programs get off track, lose focus, and fail to meet their goals. They spend money on activities that are noble but ineffective. For example, in 2012, the U.S. Agency for International Development used millions of dollars to fund an economic development program in Morocco that included pottery classes, even though Moroccans have been making pottery for thousands of years. Not only so, but the classes were poorly designed. The instructor only used materials not available in Morocco, and the class's translator was not fluent in English. Ultimately, the development program failed.
To prevent mission creep and failure, Congress put a treatment and care requirement in law to ensure more than half of go to direct treatment and care services, which have a clear and measurable impact on the lives of those living with this HIV/AIDS.
I call on PEPFAR to follow the letter of the law when it comes to spending on treatment and care. All PEPFAR appropriations should be entered into the denominator of this equation. No funding will be lost from doing so. Rather, hundreds of millions of additional dollars will be going to essential treatment and care. Millions of new patients could start receiving new life.
I will continue to monitor whether PEPFAR is following this definition in the future. Given that 26 million people worldwide need antiretroviral treatment, we cannot afford to let PEPFAR get off track.