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Messy Politics of Donor Support for HIV

Author: Laurie Garrett, Senior Fellow for Global Health
August 4, 2010

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Global donor support for the fight against HIV has flat-lined, while the total cost of treatment continues to rise. According to United Nations Joint Programme on HIV/AIDS (UNAIDS), in 2009 the combined G8 donors' disbursements for HIV were $7.6 billion, compared to the 2008 level of $7.7 billion.

The magnitude of the problem was indicated by a Futures Institute presentation at the 2010 International AIDS Conference in Vienna showing covering 85 percent of the existing HIV-positive population with antiretroviral combination therapy (ART) will cost an additional $11.5 billion between 2010 and 2015. About 2.5 percent of HIV patients in poor countries currently are on significantly more costly second-line therapy, due either to drug resistance or toxic side effects experienced with primary therapy: By 2020, that number will be 25 percent of the HIV treatment population, increasing average individual treatment costs.

Despite waning international donor support, criticism at the conference focused on the United States and the Obama administration, though it's unclear why. The United States is by far the biggest supporter of both bilateral and multilateral HIV efforts, alongside overall support for global health that dwarfs the scale of the rest of the wealthy world's commitments. By contrast, the conference's host country, Austria, has essentially zeroed out its commitment to any support for HIV programs and nearly all forms of health foreign assistance. Yet it faced no attacks and only one mild criticism. Similarly, none of the Eastern European or CIS governments--particularly Russia--even sent high-level delegations to the conference, though that region has the fastest-growing HIV epidemic.

The record on funding for the Global Fund, UNAIDS, and bilateral donations to HIV efforts in developing countries demonstrates that only the United States has been a significant donor, and just three countries (the United States, UK, and Netherlands) matched or exceeded HIV/AIDS support expressed as their nation's share of world GDP in 2009. Moreover, if contributions from private U.S. donors, especially the Gates Foundation, are added to the tally, the United States donates more than 85 percent of all support for HIV/AIDS efforts, though its share of world GDP is just 24.6 percent.

Indeed, only the United States, UK, and Netherlands increased support for HIV in 2009 by millions of dollars, pounds or euros; all other donor nations cut back or eliminated foreign assistance for HIV. Moreover, the new Cameron government in the UK has indicated its intention to shift overseas development assistance (ODA) from HIV to malaria programs in 2011, which could erase more than $350 million from the international AIDS effort.

Furthermore, the world's fastest-growing economies--China, Brazil, and India--are negligible donors, yet continue to receive billions of dollars in HIV/AIDS program support from the Global Fund and other external sources. The World Bank, struggling to maintain support for its International Development Association--the largest fund for poor countries--has called on these countries to dig deep.

This chart from the Kaiser Family Foundation illustrates the shrinkage in non-American support, as a percentage of overall ODA for HIV/AIDS programs, preceded the 2008 global financial crisis. This flies in the face of excuses for financial reductions proffered by Europe, Japan, and the UK.

Commitments by Donor

One rebuttal offered by those attacking U.S. support levels is that in contrast to Europe and Japan, the United States gives the lion's share of its money through bilateral and NGO channels instead of directly supporting initiatives such as the Global Fund.

This criticism is dubious. Compare France (which is rarely, if ever, subjected to political attack in international HIV/AIDS circles) and the United States: France gives 80 percent of its HIV foreign assistance funds to the Global Fund or other multilateral channels, versus the U.S. multilateral support level of 12 percent. But total French contribution reached only $338.4 million last year, which is $190 million less than the United States' 12 percent multilateral contribution. Which is preferable: a large (80 percent) chunk of a very small pie ($338 million), or a small (12 percent) piece of an enormous pie ($4.4 billion)?

AIDS Assistance

The shift from a G8 to a G20 world signals a likely further reduction in support for all aspects of global health, including HIV/AIDS. At the recent G8 and G20 summits in Canada, very little was committed to  public goods programs worldwide.  The G8 committed a mere $5 billion over five years to maternal and child health--its designated priority. And most of the pledge stemmed from previous donor commitments, with only Canada promising any new money to the campaign. Overall, government donations for health, development, humanitarian, and food support declined 11 percent between 2006 and 2009.

The brightest ray of donor hope in 2009 was private giving to humanitarian assistance, which was "up U.S. $3.2 billion in 2009 compared with 2006, despite an 11 percent drop in reported government aid in 2009; private contributions increased by 50 percent since 2006, reaching 4.1 billion," according to IRIN, the UN news agency. According to the Development Initiatives' 2010 Global Humanitarian Assistance report, private funding is the "rising star" in humanitarian aid. "NGO Médecins Sans Frontičres received U.S. $845 million of private funding in 2009, making it equivalent to the fourth largest donor country."

We cannot help but wonder how long politicians on Capitol Hill will listen to the metaphoric middle finger-pointing before deciding that an ungrateful world need not receive further support, particularly given the United States' dire economic situation. Last week the Senate Appropriations Committee approved $54.1 billion for FY2011 foreign assistance, otherwise known as Budget Account 150. Approved strictly on party lines, with the Republicans calling for dramatic reductions in Account 150 spending (on the order of $10 billion or more), the compromise budget is $2.6 billion below the White House request. The bill leaves just $8.2 billion for all global health spending--which is a $460 million increase over 2010 spending, but is a quarter billion dollars below the White House request.

The bill designates global health spending as follows:

  • $641 million for child and maternal health;
  • $645 million for family planning and reproductive health;
  • $55 million in direct support to the UN Population Fund;
  • $5.85 billion to HIV/AIDS (a $141 million increase over FY2010)

While the Obama administration has guaranteed its support for another five years, it's not at all clear that once- enthusiastic Republicans will stay the course amid the highly polarized politics of Washington. Obama finds himself in a seemingly no-win situation: If he promises more money for HIV, the deficit-conscious Republicans will attack him as an irresponsible Big Spender. But if he fails to push his own party toward greater generosity, he risks losing the support of his left flank.

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