“It is a false dichotomy to have a tension between Universal Health Care or ‘ending the epidemic’,” said Global Fund Executive Director Peter Sands at the 22nd International AIDS conference, where scores of formal and thousands of informal discussions focused on the need to integrate HIV testing, care and treatment into the broader global health agenda.
“We will not succeed in ending HIV if we do not build the UHC platform,” Sands said, as a speaker on the panel of a session called ‘Eliminating the HIV epidemic on the road to Universal Health Care’. Describing the Global Fund’s mandate “around ending the epidemics of HIV, TB and malaria”, Sands said the Fund recognizes that “that can’t be done without building the component parts of a health system”.
In two major symposia as well as in a communities’ ‘networking zone’ townhall-style meeting, Sands repeatedly broadcast another message: That financing for the ongoing global fight against HIV – and by extension towards UHC – must be increased. It was widely acknowledged at this conference, including by the International AIDS Society-Lancet Commission on strengthening the HIV response in the context of a broader global health agenda, that funding for HIV globally has stagnated.
The IAS-Lancet Commission reports that from 2013 to 2016, international assistance for HIV was reduced by 20%, from almost $10 billion to $8.1 billion, though the number for 2016 was even lower, at $7 billion, a new report by the Kaiser Family Foundation (KFF) found. The $8.1 billion attributed to 2017 was partly a result of the timing of U.S. disbursements, including funds appropriated but not spent from previous years.
The world is not going to be able to work towards ending of the epidemics of AIDS, tuberculosis and malaria – and towards building UHC as “complementary and self-supporting” – on current resourcing levels, Sands said. “To pretend that we are is to be kidding ourselves,” he stated. “We need to be committing more.”
Where this ‘more’ might come from – and according to experts $6 billion is missing for the period between now and 2020 in order to reach ‘just’ the UNAIDS HIV targets for 2020 of 90-90-90 – comprises three sources, Sands said: public donors, the private sector (philanthropic individuals or corporations), and domestic governments (of implementing countries).
Three sources of financing for the HIV response
In a separate session titled ‘Where will the resources come from to end AIDS?’ Sands described the Fund’s perspective on this question in greater depth. First, a small number of governments in advanced economies have invested billions, he said, and continue to, in the fight against HIV, which “has been critical in getting us to where we are today”. Until 2010, development assistance grew strongly, but global health’s share of overall overseas development assistance (ODA) has remained stable, at just over a quarter, suggesting that there is room to increase the health share of ODA.
Sands added that the Fund needs to continue making the argument for how this money is channelled, citing the “distinct advantages” of multilateral mechanisms (such as the Global Fund) in order to reduce multiple interactions with governments. “The Global Fund is a proven vehicle for delivering impact across HIV, TB and malaria,” he said, saying that this was “an absolutely critical element in taking us to the SDG3 goal of ending the epidemics”, especially in the runup to the Fund’s 6th Replenishment in 2019.
The second ‘bucket’ of funding is the private sector, Sands said, and included the Bill & Melinda Gates Foundation and Product (RED) as examples of entities that have made a “huge contribution” to the work of the Fund. But there is an opportunity, he said, to step up the level of engagement and contribution from private individuals, foundations and – critically – the corporate sector.
“We don’t have enough engagement with the broader corporate sector around health,” Sands said, making the obvious but nonetheless often glossed-over point that most individuals affected by HIV (or TB, or hepatitis C, among scores of other diseases) have worked – or at some point will work – for private sector companies. “We need to engage that element of society more effectively in the fight against these epidemics,” he said, suggesting creative approaches apart from those already employed.
Sands’ third ‘bucket’ was domestic resources, an area of financing “where we absolutely need to change the game,” he said. Reiterating what he had mentioned in the session on UHC, Sands said that building resilient health systems is not going to be achieved by external resources. “Tax systems and governments are not mobilizing enough money. Even if they do, they’re not spending enough of it on health. And even if they are spending it on health, they’re not spending it on HIV and not on key populations – so we have a lack of political will even where there is the financial capability.”
Addressing the issue of innovative financing, which in recent years has become an eye-catching mechanism in the global health financing world, Sands declared that “innovative financing is not a source of money – it is a mechanism for getting money out of sources; it does not ‘magic’ money.”
Returning to the topic of the way forward, Sands outlined three courses of action for funding sources he described: First, that getting more money from ‘public donors’ required a compelling narrative backed up by evidence of impact. Second, stepping up – and getting more creative about – private sector engagement requires overcoming a cultural antipathy between the public health world and the private sector view of the world. Third, that increasing the domestic resources component in the global fight against HIV required sustained advocacy, strong domestic political leadership, and co-financing obligations to “push governments to make more commitments themselves”.
“The idea that this [fight against HIV] can be vanquished without committing serious resources is an illusion,” Sands said. “My belief is that the money is there, in the world. The question is, do we really want to make the Sustainable Development Goals a reality? If we do, it can be done,” Sands said.
“If we just want the warm feeling about declaring that we’ll get there, we simply won’t.”
For further reading on global financing for HIV as discussed at AIDS 2018, see:
- The Kaiser Family Foundation report (2018)
- UNAIDS’ ‘Miles to go’ Global AIDS Update (2018)
- The IAS-Lancet Commission report (2018)