Editorial by Gorik Ooms (ITM)
During the first decade of its existence, the Global Fund (to fight AIDS, TB and Malaria) has been at a crossroads too often. This time, I fear the situation is worse than it has ever been before. In an interview with Spanish newspaper El Mundo, the new general manager Gabriel Jaramillo argues that “the creation of the Fund was done on the basis of three feelings: emergency, fear and generosity”, and that now only “the best of them” remains: generosity. It reminds me of something we wrote for Global Health Governance about a year ago: “With the ‘AIDS is a security threat’ argument eroding, the right to health argument might be the only one that can preserve AIDS exceptionality – i.e. open-ended reliance on international solidarity.” I’m not writing this to suggest Jaramillo borrowed an argument from us; I’m writing this to express my sincere belief that the importance of Jaramillo’s analysis should not be underestimated.
The motivation behind the international assistance wealthy states provide through the Global Fund is, and always has been, far more complex than generosity or charity. It contains the seeds of advancing mutual interests (as in wealthier countries helping poorer countries control epidemics), but also, thanks largely to creative, impassioned civil society activism, the seeds of realizing the universal right to health (as in AIDS treatment as an international entitlement). However, now that the fear of an uncontrolled global AIDS epidemic has receded, the strength of the right to health argument will be tested. If we consider the feelings of emergency and fear as one leg of the Global Fund, and the right to health as its other leg, the Global Fund will now have to advance on one leg. The main problem with this approach is that the right to health does not countenance exceptional treatment of a particular disease (and neither do an increasing number of civil society organizations): if we want the Global Fund to become a tool for the realization of the right to health, it will have to broaden its mandate.
Realizing the right to health on a global scale is not an easy task. It requires, first and foremost, an unequivocal break with development assistance as we know it. Development assistance as we know it is based on the assumption that after an externally financed development kick-start, global market dynamics will decrease inequality between nations and between households worldwide. Even within the World Bank, inequality experts don’t believe this anymore, and argue that “we need to develop some rules for global redistribution”, as Branko Milanovic does here in his essay for the UN. But global redistribution of income – or global financing of essential social services – could undermine national efforts and even hinder the assumption of national responsibility. How do we make sure that national and global responsibilities amplify each other? The Joint Action and Learning Initiative on National and Global Responsibilities for Health tries to clarify and – with your help – answer some of the questions.
All in all, another “make or break” situation for the Global Fund is but a minor symptom of a much larger problem. Are we going to continue with development assistance as we know it? Or are we aiming for global social policy and global redistribution of income, with the Global Fund cast as a somewhat reluctant pioneer, as Bob Deacon, Eeva Ollila, Meri Koivusalo and Paul Stubbs suggest here? If the Global Fund wants to be seen as an important tool for the realization of the right to health and a pioneer in global social policy, it will have to move away from infectious disease control to comprehensive primary health care. Right now, it seems to be moving in the opposite direction. As a temporary survival strategy, perhaps such a move can be justified, but it must declare explicitly that what it is becoming now is not what it wants to become.