The government’s far-reaching health care foreign aid program has contributed to a significant decline in adult death rates in Africa, according to a new study by Stanford researchers. 

Between 2004 and 2008, the U.S. President’s Emergency Plan for AIDS Relief was associated with a reduction in the odds of death of nearly 20 percent in the countries where it operated. The researchers found that more than 740,000 lives were saved during this period in nine countries targeted by the program, known by its acronym, PEPFAR.

“We were surprised and impressed to find these mortality reductions,” said Eran Bendavid, an affiliate at Stanford Health Policy, part of the university’s Freeman Spogli Institute for International Studies.

“While many assume that foreign aid works, most evaluations of aid suggest it does not work or even causes harm,” said Bendavid, an assistant professor of medicine at Stanford’s School of Medicine. “Despite all the challenges to making aid work and to implementing HIV treatment in Africa, the benefits of PEPFAR were large and measurable across many African countries.”



The study is the first to show a decline in all causes of death related to the program. It appears in the May 16 issue of the Journal of the American Medical Association.

Bendavid is the lead author of the study. It was co-authored by Grant Miller and Jay Bhattacharya, who are both core faculty members of Stanford Health Policy and associate professors of medicine. The study was funded by the National Institutes of Health and the Dr. George Rosenkranz Prize for Health Care Research in Developing Countries.

PEPFAR began in 2003 under the Bush administration with a five-year, $15 billion investment in fighting AIDS around the world and a focus on treatment and prevention in 15 countries. It was reauthorized by Congress in 2008 and has expanded its reach to 31 countries.

To measure the impact of the program, Bendavid and his colleagues analyzed health and survival information for more than 1.5 million adults in 27 African countries, including nine countries where PEPFAR has focused its efforts. The researchers examined data available in the Demographic and Health Surveys, a USAID-funded project that involves a representative sampling of in-person interviews among women in which they discuss their health and the health of their family members. These surveys form the foundation of many health measurements in developing countries.

They found the odds of death from any cause among adults were 16 to 20 percent lower in the PEPFAR-targeted countries.

To bolster the results, the scientists did a separate analysis using specific data on PEPFAR programs in Rwanda and Tanzania. They compared regions of the two countries where PEPFAR’s investments led to widespread increases in the number and size of sites providing antiretroviral therapy, with areas where PEPFAR had fewer services available.



“We observed a similar reduction in mortality when exploring PEPFAR’s effects using a different lens,” Bendavid said.

In Tanzania, the odds of death were found to be 17 percent lower and in Rwanda 25 percent lower in the districts with greater support from PEPFAR.

Bendavid speculates that the program’s commitment to building an infrastructure that includes drug distribution systems, clinics, pharmacies, laboratories and testing facilities has been an important factor for its success.

“The scale of PEPFAR’s investment was unprecedented,” Bendavid said. “People working in PEPFAR’s focus countries describe working supply chains, stocked pharmacies and staffed clinics.”



Although the program was targeted to address HIV, these services could have benefitted patients with a variety of other health concerns. For example, one study found that some uninfected, pregnant women in Ethiopia, Rwanda and Tanzania chose to deliver their babies in facilities supported by PEPFAR, Bendavid said.

Some have argued that focusing resources on a specific disease, such as AIDS, may detract efforts from other diseases and activities, undermining some of the benefits of such programs. But the latest study does not support this argument. Rather, it suggests that PEPFAR helped prevent additional deaths from causes other than HIV/AIDS.

“Whether disease-specific programs like PEPFAR have synergies with other health improvement efforts – or instead undermine them, as some have worried – is really an open question,” Miller said. “There are reasons to think either scenario is possible, and more research is needed. We don’t find much evidence of PEPFAR undercutting other initiatives. If anything, we see hints of synergies.”



Bendavid said the program managed to accomplish the reduction in mortality in the face of enormous challenges – from persuading people to go for HIV testing and treatment to dealing with problems of drug shortages and drug resistance.

Historically, few other large-scale health initiatives have succeeded to such an extent. Smallpox, which was eradicated by 1979, is among the rare and more notable examples.

“PEPFAR’s success with HIV … may be considered the clearest demonstration of aid’s effectiveness in recent years,” the researchers concluded.

In 2009, PEPFAR was folded into a new Global Health Initiative that calls for a broader agenda, with some resources redistributed to other programs, such as maternal and child health.

Its budget, which rose dramatically in the early years, has remained relatively flat or declined slightly since then. It peaked at $6.8 billion in fiscal year 2010, then declined to $6.7 billion and $6.6 billion in fiscal years 2011 and 2012, respectively, according to figures from the Kaiser Family Foundation. The Obama administration’s budget request for the 2013 fiscal year is $6.4 billion.

While the program appears to have had an impact within a few years of its implementation, Bendavid noted that reduced investments in fighting AIDS, both through PEPFAR and other international aid programs, could have implications for the future of the epidemic.

“We are transforming the face of the epidemic but funding shortfalls will change the road ahead,” he said.



Ruthann Richter is Director of Media Relations for the Stanford School of Medicine.

Adrian Bonifacio, a second generation Filipino-American from Chicago, is one of the recipients of the Program on Human Rights and the McCoy Family Center for Ethics in Society's 2012 Human Rights Fellowship.  The Program on Human Rights at the Center on Democracy, Development, and the Rule of Law together with the McCoy Family Center for Ethics in Society offer four annual summer fellowships in human rights open to Stanford undergraduates interested in working for organizations, government agencies, NGOs or international organizations that promote or defend human rights.

This summer, Bonifacio will work with the Asian Pacific Mission for Migrants, a non-governmental organization based in Hong Kong that promotes and defends the rights of migrant workers, a majority of whom are Filipino. Filipino immigrants in Hong Kong work predominately as domestic workers. The situation of Filipino diasporas is very complex with more than 10% of the Filipino population abroad, and over 4,000 Filipinos leaving the country every day.

Passionate about Filipino and Filipino-American issues relating to human rights such as migration, exploitation, and servitude, Stanford undergraduate Bonifacio has joined Filipino groups such as Stanford’s Pilipino American Student Union (PASU) and Anakbayan Silicon Valley, a youth organization based in Santa Clara County. He is currently pursuing a major in international relations with a minor in economics as well as co-term masters degree in sociology.

In the 1970s, Filipino dictator Ferdinand Marcos began the Labor Export Policy (LEP), a deliberate policy to send Filipino workers abroad. “This became a vicious cycle, the Philippines tried to achieve economic development based on remittances but because it sends both high skill and low skill workers abroad, and because the remittances they send are not usually put towards investment and long term development, there is not much progress happening in the country," explained Bonifacio. "Every president since Marcos has continued to promote the LEP in the name of national development.”

Last summer, Bonifacio worked for HURIGHTS OSAKA, a human rights non-profit organization, where he conducted research related to Filipino migrants in Japan to understand the link between human rights and remittances. “Although it was difficult integrating with the community in such a limited timeframe, a lot of different opportunities presented themselves—celebrating Philippine Independence Day, cooking Filipino food for events, even performing traditional dances," said Bonifacio. "My supervisor at work and all the migrants I have come to know made my transition into life in Japan, as well as my research, much easier.”

Japan and agencies in the Philippines that facilitate labor migration are notorious for abusing “entertainment visas” which allowed young women to be trafficked into Japan. Many Filipino women were promised jobs in high-end hotels as singers or dancers, but upon arrival in Japan, were trafficked into bars, with some entering prostitution rings and red light districts... Starting in the mid-1980s, many Japanese men in rural areas began to “import” Filipino women as mail-order brides, to solve the demographic problem of low birth rates caused largely by women moving out to cities to pursue professional careers.

Although the mail-order bride phenomenon has died down and Japan has since abolished the entertainment visa in 2006, there are still cases of abuse and human trafficking. Moreover, Filipino men have a history of working in construction, often as day laborers with insecure sources of income and housing. According to Bonifacio, “It is hard to determine the proportion of remittances that come from exploitation, but if you look at general trends and the types of employment Filipinos have all over the world—for example as “entertainers” in Japan or domestic workers in Hong Kong, Saudi Arabia, and even the United States—one could say that remittances and exploitation are closely connected.”

In preparation for his fellowship in Hong Kong Bonifacio says, “I was humbled by what I saw in Japan. I think that one of the best things one can do to educate oneself - and something that does not always happen in a classroom - is to understand the community we want to serve. We need to learn about the issues these communities face before considering fighting for change.”

Students interested in applying to the human rights fellowship for the summer of 2013 should contact Nadejda Marques to learn about the selection process and deadline for submission.