*Preventive Medicine Program, Walter Reed Army Institute of Research, Silver Spring, MD †Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD.
J Acquir Immune Defic Syndr. 2013 Apr 1;62(4):471-9. doi: 10.1097/QAI.0b013e3182816a86.
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.
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).
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.
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.
总统艾滋病救援计划（PEPFAR）因其垂直或“烟囱”结构而受到批评，因为资源针对特定疾病，而不是努力加强基础卫生系统。本研究旨在评估 PEPFAR 活动是否与整个卫生系统加强的近端和远端指标的系统改进相关。
世界银行数据库提供了 12 个卫生系统加强指标，用于分析它们与 PEPFAR 的关系。使用泊松和线性回归模型来估计时间趋势。我们通过比较上述每个指标在两个时间段（1995 年至 2002 年（PEPFAR 之前）和 2004 年至 2010 年（PEPFAR 期间））之间的时间趋势，评估了 PEPFAR 对健康结果的影响。
PEPFAR 活动与近端卫生系统加强指标的改善呈强相关且具有统计学意义，这些指标与 HIV 直接相关，特别是预期寿命（P = 0.003）和结核病发病率、患病率和死亡率（P < 0.0001）。PEPFAR 与卫生系统加强的远端指标的改善之间存在无统计学意义的关联，即婴儿死亡率和 5 岁以下儿童死亡率。
PEPFAR 支持活动的逐步扩大与近端卫生系统加强指标的持续改善相关。它还与更广泛的卫生系统实力措施的改善相关，最明显的是预期寿命。鉴于这种分析类型可用的健康措施数量有限，必须收集更多数据来评估其他指标以评估许多数十亿美元的全球卫生倡议的有效性。
