A controversial change of focus
The discovery of AIDS and HIV three decades ago has reshaped health spending in poor countries. The devastation that HIV/AIDS brought to the developing world commanded the attention of rich-country policymakers and led to the creation ofinternational institutions, most notably UNAIDS and the public-private Global Fund to Fight AIDS, Tuberculosis and Malaria.
But the rise of single-disease funding, which is most prevelant in US development aid, has prompted a polarised debate in the aid community, further fuelled by the realisation that the three Millennium Development Goals (MDG) that directly deal with health issues will not be met by their target date of 2015 unless there is a stronger focus on improving health systems overall.
Improving child and maternal health and eradicating HIV/AIDS, tuberculosis and malaria all require functioning health systems in individual countries, most notably an efficient distribution system for drugs and sufficient well-trained nurses.
The magnitude of the HIV/AIDS challenge is indisputable. Sub-Saharan Africa, the world’s poorest region, is home to just 12% of the world’s population – but almost 70% of people with HIV were living there last year. The region also accounted for 70% of new infections in 2010, despite a significant decline in infection rates.
South Africa alone is home to around 5.6 million people with HIV, more than any other country in the world. AIDS has returned to where HIV first emerged – the world’s most deprived region. It is today seen above all as a poverty disease, similar to tuberculosis and malaria, no longer a medical issue but a public-health challenge.
The success of single-disease spending has prompted two major reactions. The first, embraced by UNAIDS and the Global Fund to Fight Tuberculosis and Malaria, is to call for strategic investments to “eradicate” HIV/AIDS. The second, adopted by many donors, is to shift attention to other illnesses, especially non-communicable diseases such as heart conditions, diabetes, cancer or chronic respiratory diseases, and to strengthen entire health systems. (The impact on poor countries of non-infectious diseases – long seen as ‘lifestyle diseases’ that emerge with affluence – is now better understood.)
This shift is evident in the European Commission’s decision not to follow up on its current programme on HIV/AIDS, malaria and tuberculosis through “external action” (the programme was launched in 2007 and expires at the end of this year), and, instead, step up its support for improving the functioning of entire health systems.
Rather than issuing a follow-on paper on HIV/AIDS, the Commission’s development department is now preparing a draft paper on strengthening health systems.
The shift away from single-disease funding comes at a very difficult time, as donors tighten their purse-strings. Last week (23 November), the Global Fund to Fight AIDS, Tuberculosis and Malaria announced that it would not fund any new projects until 2014 because donors’ contributions had fallen short by $2.2 billion (€1.6bn).
Médécins Sans Frontières, a medical charity, said that funding problems were having “devastating effects” at a time when there is real hope that with new investment – the approach advocated by the Global Fund – the epidemic could be eradicated. The rate of access to retroviral treatment now stands at close to 50% globally; under the MDG, universal access was supposed to have been achieved last year.
“There’s a shocking incongruence between both the new HIV science and political promises on one hand, and the funding reality that is now hitting the ground on the other,” said Tido von Schoen-Angerer, who leads Médécins Sans Frontières’s campaign for universal access. “Donors are really pulling the rug out from under people living with HIV/AIDS, at precisely the time when we need to move full steam ahead and get life-saving treatment to more people.”
But an official in the Commission’s department for development aid said that the new approach, which he described as “transversal and comprehensive”, will not come at the cost of HIV-specific projects.
“We assume that better health systems will facilitate HIV-specific inputs,” he said. “The EU will continue giving to the Global Fund.”
He added that the EU intends to step up budget support to health sectors in poor countries, which allows these countries to fund their own programmes and priorities in a particular field. He expects around €330 million in Commission spending on HIV/AIDS in non-EU countries before the end of 2013.
The official also stressed that the failure to meet the goal of universal coverage in 2010 was not primarily related to funding. “We are late in our target because a decade ago the real drivers of the epidemic were not addressed. In eastern Europe, the main drivers are intravenous drugs and commercial sex; in eastern and south Africa it is multiple partners,” he said.
“A decade ago we didn’t really understand what was going on. Now we have a far better idea and are in a better position to address drivers. But now, unfortunately, we have these financial constraints, although we can be far more effective.”