Sobering Moments for Global Health: Kazatchkine Shake-up Spawns Fear
In previous blogs I have discussed the resignation of Dr. Michel Kazatchkine from leadership of the Global Fund to Fight AIDS, Tuberculosis and Malaria, and other aspects of funding fears across the board for global health. I have particularly underscored the danger inherent in acute dependency upon just two sources for the majority of global health support: The United States Government (which in 2011 gave 52 percent of all global health funding and 58 percent of support for HIV/AIDS programs) and the Bill and Melinda Gates Foundation (68 percent of all private support for global health). If either of the mammoth American sources of support dried up, the entire Global Health enterprise could crumble.
There is mounting evidence that difficulties in Geneva are leaving programs in the field in trouble. The Treatment Action Campaign (TAC) in South Africa faces shut-down, as its payments from the Fund, via the South African Ministry of Health, are now six months in arrears. TAC also reports outages in various clinics in South Africa of the vital anti-HIV drug Tenofovir and other medicines. Médecins Sans Frontiers (MSF)estimates 350,000 people in the Democratic Republic of Congo (DRC) are in need of antiretroviral medicines for HIV; only 44,000 currently receive them. In addition, according to MSF and UNICEF the DRC is experiencing a dramatic downturn in funding and supplies for malaria and tuberculosis.
The UNAIDS Programme warns that, “African dependency on external sources is destabilizing the AIDS response. Two-thirds of all AIDS expenditures in Africa come from external sources. International investments for AIDS dropped by 13 percent from 2009 to 2010.”
"With enough money spent in the right way, the world could soon reduce new HIV infections to zero, but global apathy and the financial crisis mean it might take another 50 years to stop the AIDS epidemic,” stated Paul De Lay, deputy executive director of UNAIDS. "There's a fatigue about AIDS. The attention span of the aid and global health community and the politicians is short-lived, and there are other priorities,'" he told AlertNet.
Africa needs $12 billion for HIV treatment, care and prevention; from all sources in 2011 it received $8 billion, according to UNAIDS. Underscoring the risk not only of dependency, but reliance on U.S. sources, UNAIDS notes, “All high-income countries should invest more in the AIDS response. There is a 139-fold difference in the share of international HIV assistance between the most and least generous.”
Dependency on the United States government is ominous, particularly during a highly contentious American election cycle. With the drumbeat for budget cuts and deficit reduction growing louder, the Obama White House released its proposed FY 2013 budget this week. The American fiscal year, for our foreign readers, commences on October 1. This year the budget must be completed one month before the Presidential election, or the nation is compelled to borrow money to pay civil servants and meet its purchases until the two political parties finally agree. Only a wild political optimist would at this stage predict that Congress and the White House will reach agreement before October 1. A more reasonable forecast would reckon no budget will be in place until the presidential elections are over, and the balance of each party’s seats in the House and Senate are determined. Barely had the ink dried on the White House budget proposal when the GOP released its “Debt on Arrival” denunciation.
The White House spending scheme released on February 13 must, therefore, be viewed as the first shot across one bow, at the start of a long marine volley of ship-to-ship cannon fire.
Obama’s budget would cut Global Health Initiative spending by 3.5 percent, including a 3.3 percent slice of PEPFAR – nearly 11 percent cut of HIV, specifically. While the bilateral programs would be reduced, Obama would increase support of the multilateral Global Fund by a whopping 26.9 percent. Nearly every U.S. Agency for International Development (USAID) program related to health would feel cuts in the Obama plan.
Total funding for the Global Health Initiative would go down by roughly $300 million (3.5 percent). The President’s Emergency Plan for AIDS Relief (PEPFAR) funding decreased from $7.1 billion to $5.4 billion in the Obama scheme. Total U.S. bilateral funding to HIV/AIDS programs decreased by roughly $540 million – which is a decrease of a little over 10 percent. (As noted above, Global Fund funding increased from $1.3 billion to $1.65 billion – which is an increase of nearly 26 percent).
In private briefings on Monday, White House officials said three goals dominated Obama’s budget planning: 1) Sustain job and economic growth in the short term; 2) Make investments in America’s future, specifically through education, innovation, and infrastructure for the long term; and 3) Bring down the deficit. Cuts in HIV and PEPFAR programs were defended by PEPFAR leader Eric Goosby, argued that programs have become more effective and efficient, therefore requiring less resources, while still meeting their goals for treatment access, prevention, and services.
Obama Administration officials made similar arguments for all projected global health cuts. Improvements in the organization and efficiency of the Global Health Initiative have made it possible to meet the same lofty goals for disease prevention and treatment across the board, with fewer financial resources. Moreover, an increase in attention to sustainability and local control of health programs has decreased dependency on outside sources. And shifting resources toward the Global Fund means the net U.S. support for poor and emerging market country health programs will be stable. When compared to budget plans for other agenciesthe global health cuts appear to be on par with those taking the largest cuts; Agriculture and Commerce. In absolute dollars, the Department of Defense will take the largest cut, though only 1 percent of its budget is reduced. This $5 billion cut represents the first decrease in Defense spending since the early 1990s, following the end of the Cold War.
MSF is not buying the “do more with less” argument. Sophie Delaunay, Executive Director, of MSF in the USA, said in a press release Monday night, just hours after the budget was released:
For those of us treating patients in some of the most affected areas, President Obama’s proposed budget cuts to many global health programs…is deeply disappointing and a far cry from what he has promised. It defies logic that the U.S. global AIDS program, PEPFAR, could treat 40 percent more people in 2012 with 10 percent less funding. And President Obama’s budget will actually cut the budget for treatment of neglected tropical diseases by nearly 25 percent.
The U.S. is only one of several major donor states that is spending 2012 simultaneously cutting its budget and undergoing national elections. Uncertainty is the norm.
Recently the Center for Global Development’s Denizhan Duran and Amanda Glassman produced An Index of the Quality of Official Development Assistance in Health, which quantifies aid effectiveness using a unique set of parameters and mathematic methods. They conclude, based on 2008-9 data:
There is mixed progress from 2008 to 2009: while progress has been made in some dimensions, such as untying aid, supporting global public good facilities, and establishing more significant aid relationships, donors fared worse in certain very important categories such as allocation according to disease burden and fragmentation across agencies. We also see mixed results as we compare overall aid effectiveness to health aid effectiveness: while the health aid sector seems more focused and concentrated, it does less well in allocating to poor or well-governed countries.
The CGD study assumes donor money aimed at health actually reached governments’ ministries of health. Not so, argues David Stuckler and colleagues. And they blame the International Monetary Fund’s program priorities. Surveying poor and middle income health spending between 1996-2006, the researchers discovered that, for each $1 of development assistance for health, about $0.37 is added to the health system. However, evaluating IMF-borrowing versus non-IMF-borrowing countries reveals that non-borrowers add about $0.45 whereas borrowers add less than $0.01 to the health system. On average, health system spending grew at about half the speed when countries were exposed to the IMF than when they were not. It is important to take account of the political economy of global health finance when interpreting data on financial flows.
It is worth remembering that one set of donors has disappeared because their economies have sunk to desperate lows. Portugal’s bonds are rated junk status, with Spain staggering behind. Italy is teetering between her northern European survivors, and her fellow Mediterranean grand recession sufferers. And in Greece, the pain of austerity and bankruptcy is so great that suicides have skyrocketed. In October The Lancet ran three papers demonstrating that the health of the Greek people is collapsing alongside her economic woes.
Budget cuts have gutted public health services in Greece, with 26,000 healthcare workers (including 9,100 physicians) losing their jobs, and another round of cuts now underway. Across the country public hospitals and clinics have downsized dramatically, eliminating an average 40 percent of personnel. Between the onset of the Greek financial crisis in 2009 to mid-2011, there was a 36 percent increase in suicide attempts, a 29 percent increase in actual suicides, and a 21 percent increase in the numbers of Greeks that have sought help to keep from killing themselves.
Individuals now must pay for more of their own healthcare, and are less likely to seek services due to financial stress, searching for jobs, and the general deterioration of government services. Large cohort studies in 2007 and 2009 show how severe this shift in care and treatment has been. With fewer people seeking routine care, there has been a 24 percent increase in emergency public hospital admissions; admissions to private facilities have fallen by 30 percent. During 2010 the numbers of IV drug users reportedly rose by 10percent; with that IV increase has come a sharp uptick in new HIV infections.
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