Stephanie M. Topp
Research Associate and Health Systems Advisor, Centre for Infectious Disease Research in Zambia (CIDRZ) and School of Medicine, University of Alabama at Birmingham (UAB).
As part of the current cohort of Emerging Voices (in residence in Cape Town preparing for the upcoming ICASA conference) those of us in the Health Systems track have been engaging in a lively debate around post-2015 HIV financing and policy options. As we approach the MDG target date and move towards the post-MDG era, many questions are being posed about the threats to, and opportunities for, disease-specific programs. Front and centre in this debate is the future of financing and technical support to maintain and continue scaling up HIV prevention, care and treatment services in high-burden countries, and how these HIV-specific needs will be influenced by the gathering momentum to invest in Universal Health Coverage (UHC).
In 2012, following the AIDS conference in Washington, human rights lawyer and global health researcher Gorik Ooms described what he saw as a conscious distancing of AIDS practitioners and activists from the UHC agenda. He noted that this trend appeared to be linked to AIDS activists’ concern over the weak articulation of the need for continued global financing by the UHC movement. As many of us would be aware, the global HIV community continues to argue strongly for increased (versus static or reduced) commitments from bilateral and multilateral funders to close the estimated US$4-5 billion gap between current HIV/AIDS expenditure and the global target of US$22-24 billion. As demonstrated at the Washington event, part of their fear seems related to a perception that a shift of momentum towards UHC, and particularly a focus on potentially more cost-effective interventions would crowd out or require ‘rationing’ of funds for HIV prevention and treatment.
But let us step back for a minute. In high-prevalence settings such as sub-Saharan Africa, HIV prevention and treatment services will likely remain highly cost-effective interventions in both short- and longer-term. These interventions have, moreover, evolved from what was initially a semi-targeted service (testing for all, but initiation of treatment only for those meeting eligibility criteria) into an increasingly population-level approach. In the last two years for example, PMTCT B+ has emerged and seems set to become (albeit controversially) the policy norm in many low- and middle-income countries with full or partial adoption by Malawi, Zambia, Zimbabwe, Mozambique, Uganda, Cameroon and many others. Similarly, there is ground-swell of support for earlier initiation of HAART for all HIV-positive individuals that suggests a move towards policies enabling a test-and-treat approach within many HIV treatment programs.
PMTCT Option B+ and test-and-treat policies are most frequently promoted for their population-level benefits including reduced HIV incidence and the possibility of ‘ending the epidemic‘. Less often articulated, is that for these policies to have the full impact attributed to them, UHC will be a necessity. Without universal coverage (financial and service-related) Option B+ and test-and-treat will likely become another sub-optimally implemented and potentially damaging health intervention; damaging both in clinical terms due to the potential for drug resistance, and in health engagement terms, due to the inequity of service availability and further marginalization of geographically or socio-economically vulnerable populations.
Thus it seems that for those countries most effected by the HIV epidemic, the future of HIV financing and service scale-up on the one hand, and UHC on the other hand, are not a ‘zero sum game’. Rather, in these high-prevalence settings, HIV scale-up and UHC are intricately linked and even co-dependent elements of a broader strategic push to ensure health for all.
Various commentators have made observations relating to the potential for a symbiotic relationship between disease-specific, and more broad-ranging health initiatives. In this article, for example, Kent Buse articulately points out how HIV scale-up has created the space and opportunities in areas ranging from strengthening local capacity for pharmaceutical manufacturing to the contribution HIV treatment services have made in terms of establishing or re-establishing a model of chronic care at the primary level. Nor is it so difficult to imagine the ways in which UHC – if developed with appropriate nuance – could facilitate people’s access to, and retention in, HIV treatment programs in countries most affected by the disease. Perhaps the more pertinent question, then, is not whether there is common ground between the two agendas, but rather, for countries experiencing generalised HIV epidemics, how this common ground can be used to underpin policy and programmatic reform leading to more equitable and responsive health systems?
Reflecting on some aspects of these questions, the Global Health 2035: A World Converging within a Generation report has just been launched. The report includes a review of trends and context of global health investment over the last two decades and advocates for a new investment framework that the authors claim will help achieve dramatic health gains (for all) by 2035. However, it remains to be seen whether stakeholders positioned on either side of this debate will be willing to challenge and overcome the path-dependency of current financing and governance arrangements to make HIV and UHC true partners, not adversaries, in health.