26 Nov 2013

There are just two years remaining on the clock for developing nations to achieve the Millennium Development Goals, including Goal Six, targeting the global fight against AIDS, TB and malaria. While some progress in some parts of the world has been made, it looks increasingly clear that the goal – of halting and reversing the spread of HIV; of achieving universal access to treatment by 2010; and of halting and reversing the incidence of malaria and other major non-communicable diseases – will not be met.

But even as the clock winds down, global health advocates are equally preoccupied with what comes next. There seems to be little political will to maintain health as a priority; indeed, the key words in the UN Secretary General’s global development framework beyond 2015, known as the High Level Panel Report, are poverty, growth, partnership and access.

While WHO members have since 2005 made a commitment to achieve universal health coverage, there remain critical obstacles for those leading the fight against the three diseases.

Equally, the global health environment is stacked with new and emerging challenges, particularly with respect to non-communicable disease. A recent Global Burden of Disease study carried out by the Institute of Health Metrics and  Evaluation in Seattlefinds the major killers in low-income countries are lower respiratory infections: 98 per 100 000;  followed by AIDS, at 70 per 100 000. Malaria comes in at  7th on the list at 38 deaths, followed by TB at 32. The ratios change as income increases: in lower middle income countries, heart disease and stroke top the list, with AIDS coming in 7th at 24 deaths per 100 000 and TB 8th at 22. Malaria does not even rank. And in upper middle and high income countries these diseases barely appear.

Yet AIDS, TB and malaria remain dangerous inhibitors of growth and development and central to the burden of disease across the developing world. In South Africa, a Human Sciences Research Council survey in 2012 estimated 12.3 percent of the population is living with HIV: over 6 million people.The 2011 Swaziland HIV Incidence Measurement Survey (SHIMS) found HIV prevalence among adults aged 18-49 has remained unchanged between 2006-2011 at 31-32%, and among women aged 30 to 34 the prevalence was 53.8 percent. In Uganda there is evidence of rising incidence.

 The message that the AIDS and TB interest groups need to learn is one well-understood by those working in malaria. It is rare that diseases can be eliminated; at best we should expect to prevent, contain and control them. This requires vigilance, monitoring and resources.

In the first week of December, the Global Fund to Fight AIDS, TB and malaria will look to donors to provide $15 billion over the next three years to finance the best possible arsenal of prevention, harm reduction and treatment options in the countries that need them most. All signs suggest that the fundraising targets will be achieved, but it is quite possible that this is the last time that multilateral financing mechanisms are prepared to shoulder the bulk of the burden. This must compel the countries afflicted with these diseases to develop their own domestic sources of funding, a theme that is emerging in boardrooms and conference halls the world over including most recently at a ministerial meeting in the Ethiopian capital, Addis Ababa.

Convened by the Global Fund and the African Development Bank, the conference on Domestic Financing for Health hosted by the African Union sought to help countries begin to conceive of strategic budget planning to include a greater share of health financing. The topic will again be taken up in December at the International Conference on AIDS and STIs in Africa, although it is important to remember that AIDS has been treated differently than most other diseases in poor countries.

With the ominous warning from the National Security Council in 2000 that AIDS was a  "a threat to US national security that could topple foreign governments, touch off ethnic wars and undo decades of work in building free-market democracies abroad,"  the government of former US president George W. Bush moved  three years later to launch the President's Emergency Plan for AIDS Relief (PEPFAR), with funding of $15 billion.  The US was also a major driver of the establishment of the Global Fund.

International support for the AIDS response grew dramatically, with developed-country advocates spearheading initiatives and foreign bodies pouring money into fighting the scourge. But this may have had an enduring negative legacy for developing-country governments, which ceded responsibility and management to their deep-pocketed and well-meaning supporters in the north.The somewhat selective battles being fought by passionate and committed AIDS activists means that deep-rooted prejudice, which in many countries including Russia as well as in Africa has been transformed into ruinous legislation, has not received nearly enough attention.

Also preoccupying is the question of resources. Laurie Garrett of the Council on Foreign Relations has written a thoughtful paper on ‘Existential Challenges to Global Health’ in which she notes that “The spectacular growth of global health was propelled by urgency and activism, chiefly directed to the AIDS pandemic. This meant the WHO’s importance and funding was diminished, and numerous new entrants into the field, “spawn[ed]confusion, complexity, even anarchy”.

In a corollary paper by the think tank Results for Development, a review of 12 PEPFAR countries found “deeply ingrained perceptions by finance and other senior government officials that “donors will take care of the AIDS program,” as they have for the past decade.

There is no question that the global community must ‘fund the Fund’. Because AIDS and TB have yet to be brought under control, costs will continue to rise. More people will require treatment in what remains a life or death issue. There is, however, room for more domestic investment. Whether through taxes or levies, or more efficient spending of existing resources, there are a number of bold and innovative things that can be done by individual countries to reduce their national burdens of disease.

People working on AIDS, TB and malaria are aware that the period of limitless  resources is over. There has to be a partnership between governments and donors. What is not perhaps yet fully appreciated by national AIDS control programmes and ministries of health is that this is an opportunity. If they can make a case to external funders then the same case can be made to the ministries of finance at home. What should follow the Millennium Development Goals is the era of Domestic Resource Mobilization.

Professor Alan Whiteside, director of the Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban. Dr Whiteside is a member of the Aidspan board of directors.

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