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Africa: Paying for Health

AfricaFocus Bulletin
Feb 3, 2012 (120203)
(Reposted from sources cited below)

Editor's Note

"Simply put, if we allow the fund to fail, many people will die, and we will forfeit the chance at the "AIDS-free generation" that U.S. Secretary of State Hillary Clinton called for in November. This is no time to step back." - Paul Farmer

The Global Fund to Fight AIDS, Tuberculosis, and Malaria has suspended new grants, and, overall, the growth rate of development assistance in health has slowed due to the global recession, according to a December report from the Institute for Health Metrics and Evaluation. Even though domestic health funding in developing countries contains to grow, and is in total far greater than the total of development assistance in health, the gap between the needs and the funding provided remains high. This is true both for key diseases such as AIDS, malaria, and tuberculosis, and for the overall financing of health systems.

Filling this gap in Africa, it is clear, requires sustained and increased funding both from global institutions and from African governments.

This AfricaFocus Bulletin contains Paul Farmer's op-ed on the Global Fund, from the International Herald Tribune; a speech by UNAIDS Executive Director Michel Sidibé calling for greater responsibility by African governments for AIDS funding and action, and a report from the UN's IRIN news service on successful increases in domestic funding for AIDS from the national AIDS levy in Zimbabwe.

For a comprehensive quantitative report on financing of health in developing countries, including data both on development assistance for health and domestic health financing, see the report released in December by the Institute for Health Metrics and Evaluation ( To download the full report, as well as tables and charts, visit

For additional background on developments at the Global Fund, see recent issues of the independent Global Fund Observer (, particularly the issue of January 24.

For previous AfricaFocus Bulletins on health issues, visit

++++++++++++++++++++++end editor's note+++++++++++++++++

Why the Global Fund Matters

By Paul Farmer

Paul Farmer is chairman of the department of global health and social medicine at Harvard Medical School and a cofounder of Partners in Health, which has received support from the Global Fund in Haiti, Lesotho and Russia.

February 1, 2012 and

Ten years ago, the heads of the G-8 countries met in Genoa, Italy, to back the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria — a new funding mechanism that dramatically increased resources available to fight preventable, treatable diseases stalking the poor and depleting developing economies around the globe.

In 2001, very few people — almost none, really — living with H.I.V. in Africa had access to antiretroviral medicines. Today, more than 3.3 million people — more than half of those on treatment worldwide — are on treatment supported by the Global Fund: A true victory for the global community. The fund and the U.S. international AIDS program, Pepfar (the President's Emergency Plan for AIDS Relief program), are the most ambitious global health endeavors in generations.

Now, 10 years since its founding, the Global Fund is facing a serious financial shortfall, and the fund's board voted recently not to accept new grant requests until at least 2014. Bill Gates' announcement of a $750 million contribution to the fund in Davos last week was welcome news — the Bill & Melinda Gates Foundation has been among the greatest supporters of the Global Fund since its inception — but will not change the board's decision. They knew of Gates' donation before they canceled the current round of grant-making.

This funding deficit hit right when the end of AIDS became plausible: Last year, scientific breakthroughs provided conclusive evidence that putting more people on treatment earlier can significantly reduce incidence of H.I.V. Treatment is prevention.

Beyond AIDS, the Global Fund is currently the largest donor in the world for tuberculosis and malaria programs. Operating in 150 countries, it has treated more than 8 million cases of tuberculosis and distributed 230 million insecticide-treated nets. Deaths from malaria are down nearly 40 percent in most of Africa. The question is not whether the Global Fund works, but how to ensure it keeps working for years to come.

In my mind, there are four reasons this is imperative:

First, the world needs to expand, not contract, access to health care because of the sheer burden of disease. It is unconscionable that, in 2012, we are still living in a world where millions of poor people die of preventable and treatable diseases.

Second, the Fund doesn't simply give handouts; it takes the longer road of investing in and working with health ministries. In doing so, it seeks to build (or rebuild) local health systems, develop platforms for transparency and accountability, boost local procurement and improve supply chains, and help train civil servants and health professionals.

This approach has had profound spillover effects on other health and development priorities. In central Haiti, for example, establishing effective treatment programs for AIDS, tuberculosis, and malaria has raised the standard of care for chronic conditions like major mental illness, heart failure and several forms of cancer.

Third, the Global Fund proves how much multilateral organizations can accomplish. While the usual players — the G-8, say — bear the greatest financial burden, I would urge some of the recipient countries to consider themselves partners of and contributors to the fund. In today's global economy, countries like India, Russia and China play meaningful roles as donors and as recipients of grants. Gabriel Jaramillo, a Brazilian banker who last week was named the fund's general manager, will surely strengthen these links and reinvigorate its leadership. The Global Fund is a truly multilateral organization, and stronger for it.

Fourth, a recession is a lousy excuse to starve one of the best (and only) instruments we have for helping people who live on a few dollars a day. Most marginalized populations around the globe have always faced economic contraction; "financial crisis" has been ongoing for them since the day they were born. It would be a great mistake to allow one of the world's most effective global health institutions to fail because we need to get our own fiscal house in order.

Along with Pepfar, the Global Fund has, without question, helped turn the corner on AIDS. It has also helped realize substantial gains against TB and malaria that must be maintained. We need to summon the funding and political will, now, to protect the hard-fought progress of the past decade.

Simply put, if we allow the fund to fail, many people will die, and we will forfeit the chance at the "AIDS-free generation" that U.S. Secretary of State Hillary Clinton called for in November. This is no time to step back.

AIDS Dependency Crisis: Sourcing African Solutions

Michel Sidibé, Executive Director of UNAIDS

28 January 2012

Place: Addis Ababa, Ethiopia

Occasion: 26th Summit of the NEPAD Heads of State and Government Orientation Committee


Ten years ago, AIDS was transformed from an epidemic of fear and denial to a political issue that African leaders brought to the UN General Assembly. Leadership on AIDS in Africa has been sustained and strengthened thanks to many of you: Presidents Kagame, Goodluck Jonathan, Toure, Wade, and Zuma; Prime Minister Meles; and others in this room. Last year, President Bongo even brought AIDS back to the UN Security Council.

This is the only continent where national leaders have made progress on AIDS a defining legacy of your commitment to your own people.

Ten years ago, Senegal and Uganda were the only two success stories we had in Africa. Now 22 African countries have lowered the rate of new HIV infections by 25% or more. Today, more than 5 million people living with HIV in Africa are alive because they have access to treatment. The end of this tragic epidemic is finally within our reach.

Ten years ago, AIDS was the crisis in Africa that moved international donors to make the paradigm shift from millions to billions. It led to the creation of the Global Fund and the biggest scale-up of any health or development programme in the history of Africa. Today, over $US 8 billion is spent every year on the AIDS response in Africa.

These are massive resources but they are still not enough to sustain the fragile gains we have made.

Why? The dilemma of dependency. Africa is too dependent on external resources, especially for the AIDS response.

In over half of African nations, more than 50% of the resources for treatment come from external sources. Over 4 million Africans depend on external donors for the medication they take every day to stay alive.

What if these funds run out? Where will millions of Africans turn to for hope and for life? This is a source of great risk and potential instability. The status quo cannot be sustained.
The global financial crisis has shown in cruel terms that external aid is the first thing some donors will cut when they need to protect themselves. Countries cannot plan and prioritize their AIDS response without pattern, without predictability, without sustainability.

Especially now, when donors are scaling back, we are clinging to a massively inefficient and unsustainable paradigm. It is time for a new development paradigm that is developed and owned by the leaders of Africa.

For the first time in history, global investments for HIV are declining. The Global Fund faces an unprecedented crisis, and has announced no new funding until at least 2014.

We must continue to fight for the Global Fund. It is an irreplaceable partner, and is essential to meeting the targets and commitments of the Political Declaration and the MDGs. But the health of millions of African cannot depend on decisions made in Geneva.

The treatment gap is growing wider and costs are rising quickly. Five million Africans are still waiting for ARVs. Every day, more people must move to costlier second-line treatments because they are developing resistance.

Meanwhile, we now know that putting people on treatment early can reduce the risk of transmission to a partner by 96%. This is a major opportunity to reduce new infections, and we cannot afford to miss it.

This highlights Africa's other dangerous dependency: medicines. The vast majority of HIV treatment drugs consumed in Africa are imported from generic manufacturers. Over 80% come from one country: India. This arrangement is unpredictable and unsustainable. Changes in markets and trade rules could move drugs out of the reach of people who depend on them.

Africa should produce its own high-quality, low-cost HIV medicines that can get from the lab to the marketplace quickly and are protected from counterfeiters. Only African leadership can make this happen.

In crisis lies opportunity for Africa.

I am confident Africa will be the source of new solutions to the outdated development cooperation paradigm. In doing so, the AIDS response will help Africa will reduce its overall external dependency on aid.

First, we must get quality-assured drugs sooner to the people who need them. Africa needs its own African Medicines Regulatory Agency. The AIDS response—with its successful history of patent and licensing advocacy—can be a catalyst.

Second, we need to establish centres of excellence for the local production of medicines in Africa.

Most importantly, we must decrease dependency by growing African investments. We are ready to work with you to mobilize innovative sources of domestic funding that can be owned and sustained by Africa.

There are many examples of this: Make more use of "soft loans" from African sources, like the African Development Bank. Tap into remittance flows from the African diaspora. Create public-private partnerships to bring African business into the funding picture. Create new, innovative taxes and levies, like a few cents from a mobile telephone call or a currency transaction. We can learn a lot from Zimbabwe and Kenya, who are already putting these mechanisms in place.

The poor and marginalized often face catastrophic health expenses. Countries should introduce more innovative social insurance schemes as a way to channel health and social spending more efficiently and fairly.

External aid is not going to disappear, and it should not. Instead, governments should negotiate more predictable, sustainable investments from international partners.

Your Excellencies, It is time for Africa to demonstrate that you are leading your response to AIDS to ultimately transform your response to development. It is tragic that 24 million people in Africa have lost their lives to this epidemic. But it is unacceptable that when we have the science, the medication and the resources available in Africa. It is unacceptable that we have people on this continent still getting infected with HIV and dying from AIDS.

It is time to demonstrate that countries can come together with a single purpose: Defining a new paradigm based on social realities and economic progress. A paradigm that centres on shared values, shared responsibility, and mutual accountability. A paradigm that will deliver a new, socially sustainable agenda that is written and owned by Africa.


Zimbabwe: Improved AIDS levy collections fill part of funding gap


Harare, 3 February 2012 (PlusNews) - With global funding for HIV/AIDS on the decline, Zimbabwe's innovative AIDS levy - a 3 percent tax on income - has become a promising source of funding for the country, with a dramatic increase in revenue collected in the past two years.

The levy was introduced in 1999 to compensate for declining donor support, but low salaries and the poor performance of industry meant not enough money had been collected - until recently. In its 2010 report on Zimbabwe's progress in implementing the Declaration of Commitment on HIV/AIDS, adopted by the General Assembly in 2001, the government admitted the levy was "essentially non-existent in 2007-2008 due to economic challenges the country was facing".

According to the organization's recently published audited financial statements for the year ending 31 December 2010, a total of US$20.5 million was collected in 2010 against $5.7 million the previous year.

Murombedzi Kuchera, chairman of the National AIDS Council Board, attributed the increase to improved revenue flows owing to improved political and economic stability in the country, which has created more jobs in the formal sector and improved tax remittances. Zimbabwe's economy has witnessed steady growth following the formation of the coalition government of Prime Minister Morgan Tsvangirai and President Robert Mugabe in 2009.

"The 259 percent increase in the collections was mainly through the increased capacity utilization by industry and commerce," Kuchera said in his statement.

Although the revenue figures for 2011 have not yet been audited, the National AIDS Council estimates it collected about $25 million. However, the exact figure will be confirmed after the audit by the Comptroller and AuditorGeneral, which audits all the finances of parastatals, at the end of 2012.

"The AIDS Levy is certainly proving to be a good source of funding for the country's HIV and AIDS response," National AIDS Council information and communication officer Orirando Manwere told IRIN/PlusNews.

"Our projections are that for 2012, with the growing economic stability in the country, we will collect more than $30 million through the funds and even more in 2013. However, this is all largely dependent on economic growth," he added.

Although 347,000 people are on antiretroviral (ARV) treatment in the country, another 600,000 need the medication. The treatment gap widened after Zimbabwe adopted the new World Health Organization guidelines that recommend starting treatment earlier.

The AIDS levy contributed almost a quarter of the money to purchase ARVs, while 76 percent of the treatment programme was financed by international donors such as the Global Fund to fight AIDS, Tuberculosis and Malaria and the UK Department for International Development.

But the country - one of the hardest hit by HIV/AIDS - still needs a lot more funding to cover the "worrying" treatment gap, cautioned HIV/AIDS activist Stanley Takaona.

"Many people are dying because they cannot access treatment. Zimbabweans are playing their part to take care of their own by contributing to the AIDS Levy but this is not enough. Government must allocate funds from the fiscus to fund the HIV/AIDS response; it's their responsibility," he said.

Kumbirai Mafunda, spokesperson for the Zimbabwe Lawyers for Human Rights, warned against complacency. "Yes, the increase in the AIDS Levy is remarkable but we all know it's not enough... now government has to increase budget allocations to the health sector."

AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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