As the global public health community gathered in the South African city of Durban this week to talk about the end of AIDS, they were greeted with news that annual international support for combatting the epidemic had fallen by more than US$1 billion.
The news added weight to existing calls for middle-income countries to take more responsibility for funding their own responses. As part of a global strategy to end the epidemic by 2030, representatives from many of the world’s middle-income countries say they are willing to take on that challenge, and with it the opportunity to assume more control in guiding their national programmes.
However, there are deep concerns, both among officials and activists.
Governments fret that there is not enough time to plan and guide the rapid pace of the transition, which could cause critical services to be interrupted. And civil society groups are concerned that the move to greater dependence on domestic funding will allow administrations that already criminalise specific groups – including gay men and sex workers – to drop HIV services for them entirely.
Less in the pot, less support?
International donor support for HIV responses in low- and middle-income countries fell from $8.6 billion in 2014 to $7.5 billion last year, according to new figures released by the Kaiser Family Foundation. The announcement was timed to coincide with the start of the International AIDS Conference, which returned to sub-Saharan Africa this week for the first time in 16 years.
There had long been concerns that the funding situation was worsening, but there was widespread surprise that the drop in donor support had been so dramatic.
“We came into this conference talking about the risks…from flat funding,” said Dr. Chris Beyrer, president of the International AIDS Society, which organises the annual event. “Then we realized we’re not talking about flat funding, we’re talking about declining funding.”
The news was of particular significance for sub-Saharan Africa where more than 70 percent of people with HIV live. Hundreds of thousands of them are dependent on international funding to pay for life-saving treatment. Donor dollars are also being used to avert new infections. The Kaiser analysis underscored a new reality that people living in this region may no longer be able to count on the same level of international support.
Filling the gap and taking back control
In a recent publication detailing the funding necessary to end the AIDS epidemic by 2030, UNAIDS underscored the need for increased financial commitments from middle-income countries. The specific funding targets it lays out include a 91 percent increase in commitments from lower-middle-income countries, from $4.3 billion in 2014 to $8.2 billion by 2020. Upper-middle-income countries are expected to jump from $9.4 billion in 2014 to $11.3 billion by 2017 – a 20 percent increase.
Olive Shisana, a public health researcher in Cape Town, and co-chair of the Durban conference, told IRIN the demand was appropriate.
Governments “can reprioritise some of the money that’s going into the military to actually go and save lives,” she said. “I think it’s a realistic call to say, ‘all of us must search deeper in our pockets to get more money to be able to provide HIV services’.”
The shift to more domestic funding is already happening. Such funding made up $10.9 billion – or 57 percent of total HIV resources in 2015, according to the Kaiser report. Shisana’s country is at the forefront of that trend. South Africa’s anti-retroviral therapy (ART) programme, the largest in the world, is largely financed by the government. The South African health ministry recently announced that it would further scale up the programme to make treatment available to all South Africans who tested HIV positive – in line with the latest World Health Organisation recommendations.
This followed an extensive modelling process to determine what interventions would save the most lives while also being the most cost effective. Mark Blecher, chief director for health and social development at South Africa’s finance ministry, said the decision was also rooted in a perspective of seeing “access to [anti-retroviral medication] almost as a right. We feel so strongly about it that even in a time of economic slowdown, when we have a budget cap, even then, we reprioritise money from other areas”.
South Africa’s investment in its treatment programme has given the government control – in collaboration with partners – over how it will achieve its end goal of universal access to ART. And that’s something health officials in other middle-income countries, tired of donors setting priorities, point to as one of the key advantages of increasing domestic financing.
Groups at risk
It also has some experts and activists worried – especially about countries that criminalise some of the groups most in need of HIV services, such as men who have sex with men and sex workers.
“In a lot of countries, including South Africa, donors bear a disproportionate financial responsibility for delivering services to key populations, as well as [for] prevention in general,” explained Michael Chaitkin, a programme officer with Results for Development, a non-profit focused on development challenges in low- and middle-income countries.
As funding in many of those nations shifts from international to domestic, so will the responsibility for providing services to those populations. If countries choose to deny services, it would raise issues about their basic human rights obligations, while also undermining the broader global effort to end the epidemic.
Adding to this concern is that civil society organisations charged with monitoring government responses are also largely dependent on shrinking international donations. It’s unlikely that governments will step in to supplement funding to such groups.
“Who wants to pay for the dogs who bite and bark?” pointed out Javier Hourcade Bellocq, an advocate with the International HIV/AIDS Alliance from Argentina.
What to cut, and when?
The funding transition has country officials worried for different reasons. Nduku Kilonzo is the director of Kenya’s National AIDS Control Council. Last year the World Bank re-categorised her country from low income to lower-middle income and she is worried about what that means for the HIV response.
Kilonzo told IRIN there has been increasing pressure for the government to up its HIV financing – something she said Nairobi have expressed a willingness to do, but that they need more time.
“What would be useful is if we had a plan around how that investment happened, instead of simply: ‘Invest more, invest more,’” she said.
Donors’ lack of timelines for withdrawing funding made it difficult for her to approach the finance ministry with a plan for when new funding would be needed. It also increases the risk that, as international donors retreat, programmes could fall through the cracks resulting in treatment disruptions for patients as well as stalled prevention efforts.
Despite the concerns about interrupted services, there is a recognition that more domestic financing may not be the only answer. That is the lesson of Botswana – one of the countries to most aggressively pump national resources into its HIV response. It was the first sub-Saharan African country to introduce a national ART programme in 2002.
But health ministry official Lesego Mokganya told IRIN the government had committed funds at the expense of other aspects of the health system. “We lost the women we had saved from HIV to abortion when they had unplanned pregnancies because family planning was neglected,” she said. “Or we lost them to cervical cancer because that aspect was neglected.”
Now Botswana is turning to foreign donors to help shore up those missing components of the health system, even as the government continues to focus on HIV.
Mokganya warned it was a lesson international donors should keep in mind as they push middle-income countries to take financial control of their epidemics.
(TOP PHOTO: A community care-giver passes a long line of patients at a rural clinic in South Africa's KwaZulu-Natal Province to pick up anti-retrovrial medication for members of her community treatment group, Greg Lomas/MSF)
Andrew Green reported from Durban on a fellowship with the International Reporting Fellowship (IRP).