The Kaiser Family Foundation recently published a survey that stated "the public's sense of urgency about the HIV/AIDS epidemic around the world has declined." This sentiment appears to be reflected in President Barack Obama's 2010 proposed budget, which fails to fully fund the President's Emergency Plan for AIDS Relief (PEPFAR) at the level authorized by Congress. The Global AIDS Alliance estimates that diminished AIDS funding will result in one million people around the world who will not receive lifesaving HIV treatment, and 2.9 million women who will not receive treatment to prevent transmitting HIV to their infants during childbirth.
Over the past few years, many large global health donors have become interested in funding and promoting broader initiatives such as health system strengthening, insisting the HIV problem is well supported and now in need of less attention. Whether or not this trend will continue is yet to be seen. Yet, the scale-up of AIDS treatment and prevention around the world has itself resulted in broad-based benefits for health systems in the form of improved supply chains for all medications -- not just HIV drugs; human resources task-shifting that allows key clinical jobs to be performed by nurses, clinical officers, and community health workers; and increased laboratory and clinical infrastructure, to name a few. Despite these gains, many critics argue that too much money has been spent on a single disease, and that HIV treatment scale-up has consumed the resources of national health systems in low-resource settings at the expense of treating other preventable and curable diseases that kill far more people every year.
I spoke to TAG's policy director Sue Perez and international AIDS activist Gregg Gonsalves about these challenges.
Scott Morgan: AIDS is slipping as a top priority among global health funders. This is a huge concern, but equally distressing is the desire among some key voices in this field to return to certain strategies such as sector-wide approaches [SWAPS] that focused on building up health systems as a whole. Despite the well-intentioned purpose of SWAPS, these strategies were not entirely successful in the past and in some ways they were disastrous. Do you think that global health initiatives are headed in the right direction?
Gregg Gonsalves: When the AIDS epidemic arrived, health systems in developing countries were already weakened and hobbled by macroeconomic policies of the International Monetary Fund and the World Bank that pushed countries to drastically cut back on their public sector investments in favor of pursuing economic growth. These policies had a huge negative impact on poor countries' health systems by setting up years and years of chronic underinvestment and institutional decay. AIDS activists are often pigeonholed as single-issue advocates, but we understand the need for strong health systems more than most people -- AIDS is a disease of primary care where it is treatable. What AIDS activists found when they started pushing for treatment was that health systems were a wreck -- so health systems strengthening and AIDS treatment scale-up needed to go hand in hand. But the old style of health sector reforms -- SWAPS -- hasn't had a great track record. What we've learned in AIDS is that programs require a strong component of accountability and transparency to ensure proper governance. Advocates in AIDS have provided such oversight, and attempts to strengthen overall health systems need to learn from and build on our experiences in AIDS and not revert to ways of working that simply did not work!
Donors look at the major health indicators and they see less progress in reducing maternal and child mortality than with other health issues, and they try to understand why that is. The fact that health systems remain weak after years of investment is a very serious problem, and one that needs to be carefully analyzed, but some have jumped to the conclusion that the resources devoted to AIDS are to blame for these shortfalls in other areas. In my view, this is a tactic to divert attention away from addressing far more intractable root causes -- lack of accountability, lack of capacity, inefficiency, and harmful donor policies.
Despite all the talk and good intentions to address these root causes, not many action steps have been taken. There seems to be this strong resistance to dig deep and learn from the past, correct bad behavior and bad policies, learn the important lessons that AIDS has taught us about health systems, and move forward.
SM: Sue, you are a civil-society representative for the International Health Partnership and related initiatives [IHP+]. Do you see the IHP+ backing away from disease-specific initiatives?
SP: The IHP+ is supposed to focus on the critical issues of accountability, country ownership and capacity, and inefficiency for health, but in many ways, it has become a political vehicle for moving forward a divisive agenda that pits the United Nations Development Program's Millennium Development Goals for child and maternal health [MDGs 4 and 5] against those focused on fighting HIV, malaria, and other diseases [MDG6]. Civil society has been strongly pressing the fact that people are at the center of all of these health goals and that people face multiple health issues that cut across all the MDGs. You can immunize a child against a preventable disease, but if you don't also support the efforts in that child's country to control malaria, that child may die.
SM: What do you think is the essence of this "AIDS backlash?"
GG: Well, there are a couple of things going on. It is reminiscent of the backlash against AIDS research funding at the NIH [National Institutes of Health] in the 1990s, when advocates for Parkinson's disease and heart disease were saying that AIDS was getting too much money. Back then we were able to cobble together a coalition that rejected these false notions and that recognized that the real problem was an overall underinvestment in research. That is, the pie needed to be bigger -- we didn't need to continue to squabble for crumbs from the table. The current AIDS backlash is promoting the same zero-sum game. Some people are surrendering to the notion that the relatively paltry amounts devoted to global health simply need reallocation rather than asking for further substantial investment across the board. Yes, maternal and child health, respiratory diseases, diarrheal disease, chronic diseases are vastly underresourced, but so is AIDS when compared to the need for AIDS treatment and prevention services. Pitting diseases against diseases, conditions against conditions, is not helpful. AIDS advocates didn't steal resources from other priorities to support our programs; we made a better argument than others had before us for new investments in global health. The true villains here are not AIDS activists but national governments that have never spent enough on health. The current backlash is very convenient for these governments -- instead of arguing for a vast investment in global health to lift all boats they can watch advocates fight among themselves over a too-small pie. We can't let this happen.
SM: Where do you see the political and economic AIDS backlash manifesting domestically?
SP: The United States is still regarded by countries worldwide as a champion for AIDS. PEPFAR is the largest bilateral program directed toward a single disease in history. President Obama's launching of a "new, comprehensive global health strategy" focuses on a more integrated approach with emphasis on health systems strengthening and making more rapid progress in reducing maternal and child mortality. This unfortunately signals the beginnings of a shift in focus and attention away from AIDS, which is reinforced in President Obama's fiscal year 2010 budget proposal. Many AIDS activists, including TAG, were disappointed by his budget, which did not live up to the fully authorized level for PEPFAR.
GG: Sadly, the AIDS backlash is being perpetuated by the Obama administration. Look at the new NIH budget. The institutes' budgets are largely flat funded, except for a modest increase in the budget of the National Cancer Institute. With flat funding for biomedical research, we are undermining the search for new and better treatments for HIV/AIDS, tuberculosis, and all health conditions. We had expected President Obama to be a champion for biomedical research; I guess we were wrong.
And there are worrying signs from the White House that the president's advisors are buying into the idea that international AIDS funding should no longer be a priority either. Zeke Emmanuel, the special advisor to the director of the White House Office of Management and Budget for health policy, seems to be the brains behind a move to take a bit of money out of PEPFAR and give it to maternal and child health efforts. The White House is calling this a new Global Health Initiative. I'm sorry, but taking a slice out of AIDS funding and giving a small bit to maternal and child health is called robbing Peter to pay Paul. Moving money around isn't helpful to AIDS or to maternal and child health -- we need significant new investments for both. At this point, despite all the bad things about President Bush's AIDS policies, they were more serious about global health than the current administration's. I can't believe I would ever have to say that, but the numbers don't lie.
: On the plus side, domestically, after years of the United States requiring and promoting the development of national AIDS strategies in developing countries, we are finally moving toward developing our own National AIDS Strategy to be led by the Office of National AIDS Policy within the White House. We are seeing a genuine reflection at the highest levels of U.S. government on how to deal with the epidemic at home.
SM: What evidence is there to support the notion that AIDS funding and initiatives have improved the ability for countries to deliver better health care across the board?
SP: There is definitely growing evidence. The Global Fund and PEPFAR have been compiling data. The International Treatment Preparedness Coalition's Missing the Target report number 6 also provides data. There is a new effort by the World Health Organizaation to demonstrate the positive synergies between efforts to strengthen health systems and global health initiatives such as the Global Fund and PEPFAR.
GG: AIDS can help or hurt health systems. In a recent paper I wrote with Nicoli Nattrass, from the University of Cape Town, we show evidence that distortions in the health sector due to AIDS scale-up did occur in places like Malawi. But there is other evidence that shows that AIDS programs can strengthen health systems. No one sets out to hurt health systems, nor do I think people set out to hurt AIDS or TB programs. The best approaches try to find a balance between breadth and focus in health systems; between horizontal approaches that strengthen the sector across the board and disease-specific priorities; and then try to keep an eye on what is happening, and adapt, looking for signs of problems along the way.
SM: What do you think of the notion of an expanded international aid and public health fund similar to the Global Fund?
GG: There is clearly momentum right now to invest in health systems strengthening and other areas of international health other than AIDS. If we can build on the success on AIDS as we move toward broader goals, I think there is a better chance of success. While this means securing a sizable new investment in global health overall, it's not all about ensuring that we have a much bigger pie. While the money is important, we also need to learn from the ways in which AIDS programs have been successful. Simply giving the Global Fund an expanded mandate without new money would be a disaster, but so would ignoring the lessons from AIDS as maternal and child health and other programs are scaled up. I guess the bottom line is that if there is real commitment from donors to support a broader vision for global health financially, and if we can keep from backsliding into old-style health sector reform, it will be a good thing. But achieving this is going to take a tremendous advocacy effort, dwarfing all we've done thus far as the AIDS movement.
SM: Where do you think we go from here?
SP: There are several battles -- a battle against backsliding on donor commitments; a battle against political agendas and donor policies that hurt and don't help ensure the right to health for all; a battle to unite and not allow donors to divide civil society working on global health. We have a lot of work to do.