J. Stephen Morrison
Director, Global Health Policy Center
Last week, 40 countries gathered in New York at the United Nations to pledge $11.7 billion over the next three years to support the Global Fund to Fight AIDS, Tuberculosis and Malaria. Since the Global Fund was created in 2002, it has allocated $19 billion towards its three core diseases and associated health infrastructure.
Last week the United States committed $4 billion, a 38% increase over prior contributions (from the founding of the Fund in 2002, the United States has committed over $5 billion.) France, Canada and Norway raised their contributions by 20%, Japan by 28%. Given the parlous state of each of these countries’ national economies, these commitments are a testimony to the enduring belief among these donors that it is imperative to sustain momentum, despite exceptional adversity, and that the Global Fund remains a vital instrument. These commitments also reflect the power of constituencies in their respective societies and the extraordinary exertion by the Global Fund’s leadership to raise new resources. The two major component parts of the global response to AIDS, TB and malaria remain the Global Fund and the United States’ direct bilateral programs, organized initially as the President’s Emergency Plan for AIDS Relief (PEPFAR) and currently, in the Obama administration, organized as the Global Health Initiative (GHI)
Yet despite these substantial increases, the sum achieved -- $11.7 billion – did not even achieve the desired minimum amount, $13 billion, estimated to cover current programs. To give this even greater perspective, the original hope for last week’s replenishment had been to reach a middle option of $17 billion or a high option of $20 billion, amounts that could more fully address unmet demands concentrated in low income countries
If managed very carefully, the $11.7 billion may be able to increase the number of persons living with HIV and receiving life-sustaining anti-retroviral therapy from 3 million to 4 million. Currently, worldwide, an estimated 5 million total are on treatment, while true need is approximately 10 million out of the 33 million persons living with HIV.
The new stark reality however is that in this next three-year phase, an era of austerity, angst and uncertainty, robust growth by the Fund will not likely happen. What are we to make of this dramatic shift?
The most obvious reason for this shift is that 24 plus months of a global economic recession has taken its toll on traditional donors and put a brake, for now, on further dramatic expansion. Capacity is no longer the restraint on growth of programs. It is finances. As long as the recession persists, a more rational, better planned model of fundraising will be needed, one that preserves a vital sense of forward momentum and growth, but does not scale ambitions to heights that are no longer achievable. A more convincing logic to fundraising, better articulated to realities, will have higher credibility and likely generate less rancor and tension.
Second, the AIDS pandemic has less motivational power on the global stage – less exceptionalism -- than just a few years ago. The perceived threat has diminished. There is rising worry about the long-term costs of sustaining millions on treatment indefinitely. At the same time, the arc of the pandemic has not been broken: there were 2.3 million new infections in 2009, far more than number of persons added to treatment rolls. When those who passed away from AIDS are factored in, the global number living with HIV continues to rise by roughly 1 million per year. Over the long term, the grinding reality of these numbers has eroded donor will. A new more promising narrative is needed.
Third, there is simply no ready substitute for traditional donors, even while there is plenty of new motivation to push on new options that offer no short-term solutions but may over the long-term begin to close gaps. Foundations and the private sector cannot be expected to cover donor shortfalls. Innovative finance mechanisms deserve to be a higher priority but take time to evolve and are not likely to generate the sums needed. Low income countries are under pressure to shoulder a higher share of budgets and personnel, but most cannot afford to do so, at least in the near term. Emerging powers are showing very weak interest in climbing onto multilateral platforms like the Global Fund: Russia pledged a mere $60m and China $14 million, radically less than what was desired.
This era of acute scarcity will, one hopes, end in the near future. It may also extend for some time and worsen. In the meantime, it is important, in seeking both to preserve the Fund’s vitality and that of U.S. bilateral programs, to advance a new ethos of action: to improve efficiencies, better measure health impacts, return to basics, and shed the now unaffordable add-ons. To redouble attention to prevention, elevating it to a strategic priority; matched by redoubled attention to science and markets to bring about new affordable vaccines, diagnostics and therapies.
In the current context, it is critical to plan better for hard choices and ugly tradeoffs, anticipate and manage the inexorable conflicts over declining shares, and pay special attention to ensure fairness, orderliness, and stewardship of existing gains.
At the end of the day, what is most important is to preserve hope and some sense of momentum: stagnation or regression will be very damaging. In the face of current tough constraints, it will be very valuable to revisit the ethical obligations that the United States and other wealthy countries share in redressing gross health equities. And whether the issue is U.S. support to the Global Fund or U.S. bilateral programs, U.S. leadership must be grounded in national interests – advancing health security of communities, economic growth and U.S. foreign policy goals.