Themed “Own, Scale-up and Sustain” the 16th International Conference on AIDS and STIs in Africa (ICASA), held in Addis Ababa last week, appeared to have been conceived in a different funding climate. The recent cancellation of Global Fund Round 11 was on everyone’s minds and lips and overshadowed what was a very well-organised, stimulating event. However all was not doom and gloom and many delegates looked on the bright side of things with one going as far as to claim that the cancellation of round 11 was the “best thing that could have happened to Africa.” His logic was simple: if African leaders were to assume ownership of their health systems they needed the push of donor cuts. An extreme position to be sure.
The vocal activists chanting “Where is the money for HIV and AIDS” prior to the final day plenary address by the Global Fund’s Deputy Executive Director, Debrework Zewdie, were calling on African leaders to increase their ownership and increase funding for HIV treatment for their people. As a European I think Europeans need to call their leaders to revisit their part in the decision to delay/cancel funding Round 11. Even if the leaders of the Global Fund refuse to admit there is a crisis we need to tell European leaders that more than the Global Fund is in crisis. To take such a decision, especially in light of promising evidence on treatment as prevention, undermines our common humanity, a real crisis.
Yes, European leaders should focus on our financial system but they should also show solidarity with our fellow world citizens whose lives are being wasted by their inaction. Stephen Lewis called on President Obama to ask the US Congress for the full $6 billion for the Global Fund, not the $4 billion he is asking for now. For me such numbers are unfathomable but he helped put it in simple terms. Jeffrey Sachs and colleagues estimate that the US military spends $1.9 billion PER DAY. So, when you think this additional $2 billion is to be spread over three years (2011-2013) it is not such a large chunk of change. The scientific evidence shows what a difference access to PMCTC makes to a pregnant woman and her family; is now the time to freeze funding and deny this intervention? Stephen Lewis was vocal about the need for American support. As Europeans we need to call on our leaders to review their funding decisions.
Which brings me to an important question: where were European political representatives at ICASA? The Americans were there in full force with George Bush receiving a standing ovation for his role as the father of PEPFAR. However one may feel about Bush, the overall positive impact of PEPFAR was recognised by delegates and has increased good-will towards the US on the continent. Other high level US representatives were there too, but again where were the Europeans? European support has been vital to the global AIDS response and their absence was very disappointing.
Most people would agree it is long past time that African leaders fulfil their Abuja pledge of at least 15% of their annual budget to improving the health sector. According to the WHO only two African countries have met this pledge, South Africa and Rwanda. At ICASA speaker after speaker, including Dr. Peter Piot, showed delegates the extent of different African countries’ dependence on international assistance to fund their HIV/AIDs programmes. The Democratic Republic of Congo is 100% dependent on international financing for HIV treatment and according to MSF only 12% of those eligible for treatment are receiving it. Will national ownership solve the country’s funding and priority setting problem? In the short term of course not. However it is clear that in the absence of country ownership no long-term, lasting progress will be made on social justice issues like access to the social determinants of health, including access to life-saving HIV treatment. Yet international assistance remains key to helping scale-up and sustain efforts for the foreseeable future. Moreover, many would argue it is also an international legal obligation for European Union countries and other wealthy States Parties to the International Covenant on Economic and Social Rights.
At the Conference I attended many sessions on financing with complex modelling around the financial cost of scale-up. None of the financing sessions I attended tackled the tricky question of reforming global health governance to ensure that country ownership was the basis of funding decisions. If the donor community is serious about country ownership, as it claimed in the Paris Declaration and Accra Agenda, it needs to change its thinking. We need a global funding mechanism which does not allow donor priorities to shape the agenda. Using a human rights framework can help define agendas, obligations and responsibilities. It can also be used as a basis for accountability. National efforts to stigmatise and criminalise vulnerable key populations, including men who have sex with men, injecting drug users, migrants and sex-workers, not only undermine the fight against AIDS, they also violate international (not European) human rights norms and International Labour Organization Recommendation No. 200 on HIV and AIDS and the World of Work.
African countries need real partners to negotiate with. Partners who respect and fund national plans with national funding goals. Partnership is a complicated issue but it requires that both sides inspire confidence. If African leaders invest in their people’s futures through health and education those countries in a position to assist should help them scale up and sustain these programs. International financing should assist countries in fulfilling their national health plans – not encourage them to apply for funding for programmes they don’t need because none is available in areas in which they need assistance.
If the world wants to build on the progress made in stemming the HIV/AIDS epidemic now is not the time to stop. African leaders need to invest in the health of all their people and those countries fortunate enough to be in a position to support national efforts need to provide long term predictable funding to scale-up and sustain these efforts. We need to work as true partners to make this a world where the birth lottery has better odds. Hopefully world leaders will listen to the voices and evidence we heard in Addis and ensure that Africa can own, scale-up and sustain HIV funding.