have worked to integrate health system strengthening (hss) measures into programmatic implementation. however, the existing global debate questions the efficacy of hss programs aimed at targeting technical solutions with clear measurable outcomes versus those more broadly focused on supporting holistic health systems. in 2008, an evaluation of gavi's vaccine and immunization support – "evaluation of the gavi phase 1 performance" – reported increased coverage of hepb3, hib3 and dtp3 and increased coverage in rural areas but also a lack of cost data disaggregated by vaccine that prevented gavi from accurately evaluating the cost effectiveness of its programs and vaccines, and an "unrealistic" reliance by gavi on the market to reduce the cost of vaccines. the same year, a study of the financial sustainability of gavi vaccine support – "introducing new vaccines in the poorest countries: what did we learn from the gavi experience with" – found that although gavi funding equated to $5 per infant in developing countries per year for the period 2005–10, resource need was accelerating faster than growth in financing. findings from two evaluations of gavi's support for health systems strengthening (hss) were published in 2009. an external evaluation by hlsp found insufficient technical support provided to countries applying for gavi grants, an under-performing independent review committee (irc), and weaknesses in gavi's monitoring of grant activities. the study also found that countries were using gavi grants for 'downstream' short-term hss fixes rather than 'upstream' and long-term structural reform. a study by john snow, inc praised the multi-year, flexible and country-driven characteristics of gavi hss grant funding and encouraged gavi to continue this support. but also found weak m&e of grant activity, low civil society involvement in the hss proposal development process, unclear proposal writing guidelines, and over-reliance by countries on established development partners for assistance in implementing health system reform. pepfar a quantitative study by stanford university in 2009 – "the president's emergency plan for aids relief in africa: an evaluation of outcomes" – calculated a 10.5% reduction in the death rate in pepfar's 12 focus countries, equating to 1.2 million lives saved at a cost of $2450 per death averted. in 2007, an evaluation of pepfar by the institute of medicine found that pepfar had made significant progress in reaching its targets for prevention, treatment and care but also reported that budget allocations "limit the country teams ability to harmonize pepfars activities with those of the partner government and other donors", and pepfars abc (abstinence, be faithful, and correct and consistent condom use) priorities "fragment the natural continuum of needs and services, often in ways that do not correspond with global standards". the pepfar program has brought about substantial impact in its recipient countries. the level of urgency and scale of initiatives led through the pepfar program were commensurate with that of the hiv/aids epidemic at the time of implementation. existing debates suggest that the next phase of the program consider placing emphasis on the development of knowledge surrounding hiv/aids programming. examples united states global health initiative the united states global health initiative was created in 2009 by president obama in an attempt to have a more holistic, comprehensive approach to improving global health as opposed to previous, disease-specific interventions. the global health initiative is a six-year plan, "to develop a comprehensive u.s. government strategy for global health, building on the president's emergency plan for aids relief (pepfar) to combat hiv as well as u.s. efforts to address tuberculosis (tb) and malaria, and augmenting the focus on other global health priorities, including neglected tropical diseases (ntds), maternal, newborn and child health (mnch), family planning and reproductive health (fp/rh), nutrition, and health systems strengthening (hss)". the ghi programs are being implemented in more than 80 countries around the world and works closely with the united states agency for international development, the centers for disease control and prevention, the united states deputy secretary of state. the aid effectiveness agenda is a useful tool for measuring the impact of these large scale programs such as the global fund to fight aids, tuberculosis and malaria and the global alliance for vaccines and immunization (gavi) which have been successful in achieving rapid and visible results. the global fund claims that its efforts have provided antiretroviral treatment for over three million people worldwide. gavi claims that its vaccination programs have prevented over 5 million deaths since it began in 2000.