Donor disbursements in 2012 totalled US$ 7.86 billion

GENEVA/Washington D.C., 23 September 2013––As world leaders prepare to meet to review progress towards the Millennium Development Goals, a report from the Kaiser Family Foundation and the Joint United Nations Programme on HIV/AIDS (UNAIDS) evaluates international efforts to finance the response to the AIDS epidemic. The annual funding analysis finds donor governments disbursed US$ 7.86 billion toward the AIDS response in low-and middle-income countries in 2012, essentially unchanged from the US$ 7.63 billion level in 2011 after adjusting for inflation.

Overall, donor government funding for HIV has stayed at about the same level since 2008 - a plateau that followed a period of dramatic growth that saw donor nation support increase more than six-fold between 2002 and 2008. This flattening mirrors a similar trend in development assistance more generally, reflecting the economic and fiscal constraints of the post-financial-crisis period.

The United States government remains the largest donor to HIV efforts, contributing US$5 billion in 2012 towards the AIDS response in low-and middle-income countries and to the Global Fund, up slightly from the US$ 4.5 billion in 2011. The U.S. increase results from a quickened disbursement rate of previously approved funding.

"After years of sharp increases in donor government support which led to significant progress in the fight against the HIV epidemic, funding flattened after the worldwide recession and is likely to remain flat for the immediate future," said Kaiser Family Foundation President and CEO Drew Altman.

"We are at a critical moment in the AIDS response," said Luiz Loures, Deputy Executive Director, Programme, UNAIDS, "Scientific advances and new guidelines are providing opportunities to accelerate action and expand access to lifesaving HIV services. To take full advantage of these opportunities all efforts must be made to ensure the response to HIV is fully funded."

Five donor governments - Australia, Canada, Japan, Sweden, and the U.S. - reported increased total assistance for HIV in 2012, with U.S. assistance increasing by just more than US$ 500 million. Six decreased funding in 2012: Denmark, France, Ireland, the Netherlands, the U.K., and the European Commission. Three donor governments - Germany, Italy, and Norway - stayed constant in their support in 2012. The report found that the great majority, US$ 6 billion, of international HIV assistance is provided bilaterally.

The United States accounted for nearly two-thirds (63.9%) of disbursements from donor governments bilaterally and multilaterally. The United Kingdom was the second largest donor (10.2%), followed by France (4.8%), Germany (3.7%), and Japan (2.7%). When viewed as a share of national economies, Denmark provided the highest amount of resources for HIV in 2012, followed by the U.K, Sweden, the U.S., and Ireland.

The new report, produced as a partnership between the Kaiser Family Foundation and UNAIDS, provides the latest data available on donor funding based on data provided by governments.

This report is based on analysis of data of 24 donor government members of the Organization for Economic Co-operation and Development's Assistance Committee. It includes their combined bilateral assistance to low- and middle-income countries, and contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as to UNITAID. 

Credit: UNAIDS

Big questions were raised about getting the best results in health and development at the World Bank’s Africa Development Forum 2013. The event brought together Ministers of Finance and Health from some 30 African countries to explore effective and creative ways to ensure the future health of the continent. 

With the umbrella theme finance and capacity for results, the aim of the forum was to identify concrete strategies to ensure that investments in health produce sustainable results on a large scale. Also sought, were new ways to finance and build institutional capacity so that African countries can design, implement and evaluate health investments.

“We need more money for health and more health for money in Africa,” said the host Makhtar Diop, Vice President of the World Bank Group, Africa Region in his opening remarks. “This landmark conference aims to jointly decide on concrete actions for countries and show partners how to further invest in health and sustainable growth in Africa,” he added.

Urgent change needed 

Several key characteristics of the continent’s health systems need to be urgently addressed, according to the participants. For instance, the average per capita health spending in Africa was seen as low. However, it is higher than in many South Asian countries where health outcomes are considered generally better. Therefore, Africa would not only need more health financing but also, it would need to spend what it has more effectively.  

In addition, out-of-pocket expenses for accessing health services were also defined as extremely high, constituting about one third of all health expenditure in sub-Saharan Africa and more than 60% in several countries like Cameroon and Sierra Leone. Such personal spending may contribute to increase poverty and decrease the use of medical services.

Many African countries are still heavily dependent on external resources to finance their health sector. For some, as much as 40% comes from this stream and in 26 of 33 countries in sub-Saharan Africa, donor support accounts for more than half of HIV investments. Participants defined this dependency as a serious sustainability issue requiring more self-sufficiency and building of domestic capacity with self-financing as the ultimate goal. 

Speaking about sustainable financing, the Minister of Finance of Nigeria Hon. Ngozi Okonjo-Iweala stated that, “It is not only the volume of financing that matters but how that really responds to the need of the poor,” said Minister Okonjo-Iweala. “In a country deciding on how to best respond to those needs, political will and leadership are key.

 In Africa, a shift from investments that focus on inputs and processes to those that focus on results and systemic changes is already underway. Health sector reforms and efficiency improvement initiatives, results-based financing (RBF), and public-private partnerships in many countries have resulted in rapid scaling up of service coverage and improved efficiency in how resources are used for health.

President of The World Bank Group Dr Jim Yong Kim (left) and UNAIDS Executive Director Michel Sidibé.

The RBF approach at the facility level, pioneered in Rwanda, has resulted in a substantial increase in coverage of high-impact activities such as immunization, family planning, the distribution of mosquito nets, and skilled attendance at delivery. Today, more than 20 sub-Saharan African countries are piloting some form of RBF. Development partners are also trying out this mechanism at the country level. For example, the new World Bank financing instrument known as Program-For-Results (PforR) will now be used in Ethiopia to link disbursement directly with achieving national programme results. Many sub-Saharan African countries have also established social safety nets. Through these initiatives, people with limited or no resources may have improved access to basic health services, among other services, so that they do not have to skip necessary care or endure financial hardship related to it.

The AIDS response: a new paradigm  

In charting the way forward Michel Sidibé highlighted the role of the AIDS response in pioneering a new paradigm of sustainable development, shared responsibility and global health solidarity. He stressed that, despite the progress made in reducing new HIV infections in Africa, more funding, both donor and domestic, and more strategic use of that funding for greatest impact were necessary.

“Our world is shifting and we have to think about long-term financing for results,” said UNAIDS Executive Director Mr Sidibé. “Our objectives are to help countries revisit their programmes and find new mechanisms for investments in health and social development. In the AIDS response, we are seeing a major shift with the domestic investments surpassing those of the donors. We also need to maximize external aid and value for money,” he added.

Participants at the forum committed to building on African countries’ successful initiatives and experiences showing promise such as national health financing strategies, efficiency improvement programmes, results-based financing and introducing safety nets for the poor.

Closing the conference, the President of The World Bank Group Dr Jim Yong Kim said, “We need to help countries to get innovative systems for health to lift the burden. We have a unique opportunity to recommit ourselves to universal access to health that is critical for short, medium and long term growth, ending poverty and building shared prosperity.”

UNAIDS Executive Director Michel Sidibé (left) met with Vice-President of Myanmar Dr Sai Mauk Kham on 26 October in Nay Pyi Taw. Credit: UNAIDS

The Vice-President of Myanmar, Dr Sai Mauk Kham, reconfirmed his government’s commitment to effective HIV programming during a meeting with UNAIDS Executive Director Michel Sidibé. The two leaders met in Nay Pyi Taw, the country’s capital, where they discussed the progress made by Myanmar in its AIDS response despite the enormous challenges faced by the country.

Vice-President Sai Mauk Kham highlighted that Myanmar is struggling with twin challenges—human resources capacity and funding. “Myanmar’s main obstacle is funding. We need US$ 340 million dollars for our response to HIV. Right now we have reached 50% of our target. We have to continue our efforts,” said Dr Sai Mauk Kham.

Unlike other low- and middle-income countries in Asia, Myanmar has received little international support during the past two decades. However, the country has still managed to make some progress in its national AIDS response. Around 216 000 people were living with HIV in Myanmar in 2011 with an HIV prevalence among the adult population estimated at 0.53%. Health authorities estimated that 8 500 new HIV infections occurred in 2011—a drop from 11 000 in 2008 and an estimated 32% of people living with HIV in need of treatment were accessing it, compared to just 12% in 2008.

“This is a transformative moment in Myanmar. Despite difficult times, Myanmar is managing to deliver results,” said Mr Sidibé. “UNAIDS will support Myanmar’s efforts to seize this window of opportunity and expand HIV programmes to make significant returns on investments.”

Since reform and political change have occurred in Myanmar, international donors are investing more in the country’s AIDS response. At the same time, the country is increasing its domestic budget for HIV. This month, the government announced that for the first time ever, Myanmar will dedicate funds to acquire antiretroviral drugs. The Ministry of Health is planning to spend its own resources on HIV treatment which will be distributed through the state health system.

Reforming laws

Mr Sidibé also met with Myanmar’s Attorney General Dr Tun Shin and called on his support to reform existing punitive laws which often date back to colonial times. Existing laws criminalizing same-sex sexual activities between consenting adults, sex work and drug use are hampering the AIDS response in the country.

UNAIDS Executive Director Michel Sidibé; and Myanmar’s Attorney General Dr Tun Shin. Credit: UNAIDS

“Our goal is universal access to HIV services but we face universal obstacles,” said Mr Sidibé. “Anything we can do to remove obstacles will be very supportive of the AIDS response. We will not reach zero discrimination without reforming laws,” he added.

Dr Shin explained that amending or drafting laws is a two-step process in Myanmar, with ministries in charge of initiating the legal reform in their area. Once the ministries have drafted the laws they come to his office for vetting and processing. Dr Shin said that it is important for the people of Myanmar and the international community to see that the government is serious about change through the reform of its laws. He assured Mr Sidibé that the Office of the Attorney General would support the efforts of UNAIDS in this area.

L to R: Dr Sonia Boni, Executice Secretary, National AIDS Committee; Professor Kindé Gazard, Minister of Health; H.E. President Boni Yayi, President of the Republic of Benin; Dr Mamadou Diallo, UNAIDS Director, Regional Support Team for West and Central Africa; Ms Nardos Bekele-Thomas, United Nations Resident Coordinator.

At an extraordinary session of Benin’s National AIDS Committee on 23 October, President Boni Yayi called for a series of measures to accelerate progress in the country’s AIDS response. Held at the Palais des Congrès in Cotonou, the session was attended by more than 350 participants, including ministers, ambassadors and representatives from the private sector, civil society, networks of people living with HIV, and United Nations agencies.

According to government estimates, about 60 000 adults and children are living with HIV in Benin. Over the past decade, Benin has succeeded in reducing national HIV prevalence—from 4.1% in 2001 to 1.2% in 2012. Eight out of ten people living with HIV now have access to antiretroviral treatment and one in two HIV-positive pregnant women have access to services that prevent new HIV infections in children.

To build on these gains, Benin’s President called for improved governance in the AIDS response. He announced that he would rapidly undertake a national audit of the country’s AIDS structures—including the National AIDS Committee (NAC), the Global Fund Country Coordinating Mechanism (CCM) and the national AIDS Control Programme (NACP)—and said that the NAC’s Executive Secretariat, previously under the authority of the Minister of Health, would be placed under his direct leadership.

President Yayi pledged to address the recurrent issue of HIV drug stock-outs by simplifying procurement procedures and adopting special custom regulations for antiretroviral medicines. He said he would focus national efforts on achieving the twin goals of universal coverage to HIV treatment and the elimination of mother-to-child transmission of HIV by 2015.

Though Benin has increased its AIDS budget in recent years, more than 75% of national AIDS investments are funded through external sources. In the spirit of shared responsibility, President Yayi pledged to increase the national HIV budget from US$ 1.2 million to US$ 3.2 million. A new airfare tax earmarked for the national AIDS response was also highlighted.

Donors attending the meeting congratulated Benin’s Head of State on these measures. “This is a true example of shared responsibility in action, which is advocated by the UNAIDS Executive Director,” said the Ambassador of France, Jean-Paul Monchau.

The meeting in Cotonou offered a platform for dialogue between all AIDS stakeholders around the implementation of the African Union’s Roadmap on Shared Responsibility and Global Solidarity for AIDS, Tuberculosis and Malaria.

Launched in July 2012, the Roadmap offers a set of long-term sustainable strategies to finance and provide access to HIV treatment, prevention and other health services in Africa. In his capacity as Chair of the African Union, President Yayi presented the Roadmap to African leaders at a September 2012 high level side event of the UN General Assembly.