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.

During the Liberation Technology Seminar on March 1, Joshua Blumenstock, a Ph.D. candidate at U.C. Berkeley’s School of Information, demonstrated the use of “big data” to explore the economic impact of mobile phone technologies in sub-Saharan Africa. Blumenstock focused on a project in Rwanda, which leverages an enormous database of phone calls, text messages, and mobile money transfers. Using this data, he studies the patterns of remittances through mobile phones and explores if this new mechanism can serve as an effective social insurance during economic shocks. He hopes that this new data will provide insight into socioeconomic behavior, and improve policy and welfare in developing economies.

He argued that mobile money has quickly gained prominence in areas with very little formal banking, and it is used to send phone credit, make purchases and withdraw cash. On average, 200 million dollars are sent a day in Kenya alone through this mechanism, indicating the huge potential for such transfers in developing economies.

His data indicates that money is sent in response to shocks, supporting the hypothesis that phone-based technologies can enable risk-sharing. Blumenstock uses in situ evidence to explore the motives for this pro-social behavior. He used phone data from 1.4 million individuals over a period of 4 years to investigate how much money is sent, why it is sent and who benefits. He found that mobile money transfers have a highly reciprocal component and that most transfers go to the elite. In light of this evidence, Blumenstock concluded that while phones have had a positive impact on the lives of some people in times of crisis, the benefits of mobile technologies may not be reaching those with the greatest need.

The Program on Human Rights at the Center on Democracy, Development, and the Rule of Law, together with Stanford Summer Session are proud to offer a special session on human rights June 25 - July 25, 2012.  The new course entitled, New Global Human Rights presents the question of human rights from an interdisciplinary perspective, taking into account the 21st century context, which requires that both state and non-state actors are included in the movement for rights for all. The course will examine emerging trends in international human rights with an analysis of new categories of human rights victims, actors, and technologies. Other related courses will be offered to allow students to build a summer schedule that allows them to engage in the academic study of human rights in a truly transformative way.

Helen Stacy, director of the Program on Human Rights will teach the course which draws on the expertise of leading figures in the field of human rights. Keynote speakers include Fatou Bensouda, chief prosecutor of the International Criminal Court (ICC), and the former solicitor-general, attorney-general, and Minister of Justice of The Gambia. Last December, Bensouda was elected as the new ICC chief prosecutor and is the first African to hold a top position at the ICC. According to Stacy, “Her (Bensouda's) visit to Stanford is a unique opportunity for the Stanford community to learn about the continuity of the work of the ICC from someone who is genuinely concerned about human rights issues,” said Stacy.

Philip Gourevitch, an American author and journalist will also speak at the summer course. Gourevitch has written feature stories and books documenting global human rights abuses, including; the aftermath of genocide in Rwanda and Cambodia, the dictatorships of Mobutu Sese Seko in Congo and Robert Mugabe in Zimbabwe; the Tamil Tigers in Sri Lanka; and the abuses committed at Abu Ghraib prison in Iraq. “Gourevitch has reported on some of the major and current human rights issues across the globe, " said Stacy, "To hear him speak is the closest we can get the primary account on these situations.”

This course is cross-listed in POLISCI, IPS, and INTNLREL, and open to registered Summer Session students (including Stanford students who register for units in the summer) who wish to explore courses outside their major, or simply accelerate their degree program. They will be joined by students from around the world who are invited to experience campus life at Stanford. To find out more information or to apply, please visit summer.stanford.edu.