There is bad aid and there is good aid. The bad aid is that one which creates dependencies, but good aid is that which is targeted to create capacities in people so that they are able to live on their own activities – Paul Kagame
It has been a short three months. GHC-wise, I have had to adjust to my new environment, conceive a practical work plan, experience my first of many check-ins and – already in my next 90 – stare admiringly at my untouched copy of ‘The First 90 Days’. In terms of ‘building the movement for health equity’, it has been an action-packed period. With Ebola effectively dominating global headlines, a lot has been ongoing that should have the health equity advocate glowing with optimism yet burdened with skepticism at the same time. But to this, I shall return in a later blog. Another longstanding matter warrants attention: AIDS.
There is little doubt that HIV has attracted the largest, most enduring, and most expensive global health intervention in human history. Equally indisputable is the fact that there is every justification as to why it should. Aside from its effects on health and well-being, the pandemic has and continues to impact all spheres of human existence; the social, the economic, and the political.
In its initial stages, little was known about the disease. Initial monetary efforts to combat it were therefore mainly driven by donors’ anxiety over the unknown. Lawrence Gostin, in his book, “Global Health Law“ takes a stricter stand. He contends that donors’ initial reaction to AIDS was worse than mere anxiety. Citing then US President Reagan’s aversion to uttering the word ‘AIDS’ in public, he argues that at best, the socio-political response was “denial, ignorance and silence.” But the World has since transcended this history.
HIV is now hardly the mystery that it was; the financing of its global response is also undergoing considerable metamorphosis. As I write, it is no longer sufficient that funds are being mobilized for the AIDS response; the effectiveness of said funds has become a necessary concern of an increasingly stretched donor community. Innovative strategies are being sought on how to best utilize available resources for maximum impact. Moreover, with an increasing number of global actors working in the AIDS field, the ever-present challenge of coordinating and synergizing AIDS-related efforts remains. My placement organization, UNAIDS, has and continues to address this challenge with commendable success.
Although UNAIDS has done a tremendous job of guiding, especially the donor community, the response to AIDS, signs of donor fatigue are again beginning to manifest. Fresh questions are now arising as to how long and what stake/role the most affected countries have to play in their own response. With vision 2030 being the northern star of the global AIDS response, donors are demanding an indication of what it will cost the world to end AIDS by 2030. The next logical question is who picks up the tab. I was fortunate to arrive at the UNAIDS US Liaison Office at just the time these questions were taking on significant meaning and urgency and thus able to make a contribution to the wider discussion.
It is indisputable that the donor community still has an important role to play in the global AIDS fight. However, it is also true that a country cannot expect to sustainably combat AIDS on another’s benevolence. In donor countries, politicians change, economic priorities shift and, as Ebola has demonstrated, even global health priorities are not static. Country ownership and locally mobilized funding for AIDS is therefore both an urgent and prudent undertaking. Indeed, many low and middle income countries have already shown initiative. South Africa now funds 88% of its AIDS budget nationally and PEPFAR – the single biggest donor for AIDS – is steadily working out an exit strategy. Kenya too is on course to shed off donor dependency for its HIV programming.
Because the above success stories remain in the minority, there is a need to share knowledge and learning about which strategies have proved effective. South Africa has levied excise taxes on alcohol and tobacco (given the role their consumption plays in HIV and TB transmission) to fund its National Strategic Plan. Zimbabwe introduced such a levy on personal income tax, while Zambia introduced a levy of 1% on all gross interest earned in any savings or deposit accounts, with revenue generated earmarked for supporting these governments’ efforts to increase access to HIV treatment. Others have suggested an earmarked employer’s levy on the payroll, which could function similarly to the skills development levy, in the absence of employers providing workplace programs that include treatment or medical insurance coverage. For all these strategies to have even minimal impact, one cannot escape both the efficiency conversation and the political leadership discussion. Every dollar must count and every dollar must be targeted. There must be political will to ensure that generated funds are spent in the hardest hit geographical areas and on key populations to fund strategies that work. Only then shall the world truly be on track to make AIDS history.