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USA/Africa: Underfunding Global Health

AfricaFocus Bulletin
May 10, 2009 (090510)
(Reposted from sources cited below)

Editor's Note

President Obama's global health budget plan, pegged at $63 billion over six years and announced on May 5, one day in advance of the full budget statement, met with predictably mixed responses. The administration spin was that it was a major new commitment to a comprehensive approach; health activist groups charged that it actually marked a cut from prior commitments made in campaign promises and by Congressional pledges.

Both, of course, could find numbers to bolster the contradictory spins, although administration efforts echoed previous Bush administration budget public relations tactics. Lost in the back-and-forth, however, was the undeniable fact that, compared to the acknowledged needs, all sources of global health funding still fell far short. With both rich and poor countries facing the current world recession, the temptation is to pit funding for specific diseases against funding for comprehensive health systems, rather than to continue to ramp up commitments on all fronts. The World Bank warned that as many as 22 countries could face interruption of current AIDS treatment programs, and activists warned that international agencies were downplaying previous commitments to ensure universal access.

This AfricaFocus Bulletin contains a statement by African health activist groups directed to the annual meeting of African Health Ministers held in Addis Ababa earlier this month, two press releases from U.S. groups contrasting the Obama budget proposal with previous commitments, and excerpts from a background paper on health financing prepared for the African Health Ministers meeting.

Other recent reports with significant additional detail on related issues include:

(1) World Bank, "Averting a Human Crisis During the Global Downturn" May 2009
Includes sections on education, health services for the poor, AIDS treatment programs, and social safety nets.

(2) Dr. Brook Baker, "The Long and Tortured Road to Adequate, Sustained, and Spendable Domestic and Donor Financing for Health" for International Civil Society Support Group
( and Health GAP, April 2009
68-page paper provides detailed analysis and estimates of health needs and funding resources, including disease-specific, health systems, and human resources investment. Estimates 2009-2016 resource needs at $944 billion and projected funding at $272 billion, leaving a $672 billion resource gap.

(3) Kaiser Family Foundation, May 7, 2009
"Two-thirds of the public supports maintaining (39%) or increasing (26%) U.S. government funding to improve health in developing countries, while fewer than a quarter (23%) say the government is spending too much on global health, according to a Kaiser Family Foundation survey of the American people's attitudes towards U.S. global health and development assistance. ... [But only] twenty-six percent of Americans say that they have heard "a lot" about AIDS in Africa in the past year, about half the share who said so in 2004."

For previous AfricaFocus Bulletins on health issues, visit


AfricaFocus FYI
African Development Outlook 2009, launched in Dakar May 10

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

HIV is not in recession! TB is not in recession!

Press Statement 6 May 2009

Treatment Action Campaign

Contacts: Paula Akugizibwe, AIDS and Rights Alliance for Southern Africa, +27 83 627 1317; Inviolata Mmbwavi, Grassroots Empowerment Trust, Kenya +254 722 749 603; Dhiren Moher, RAVANE+ PVVIH Network for the Indian Ocean Region, Mauritius (Fran‡ais), +230 427 0151; Rebecca Hodes, Treatment Action Campaign, South Africa +27 79 426 8682

(Cape Town - Nairobi - Port Louis, 6 May) On the occasion of the Conference of African Ministers of Health in Addis Ababa, Ethiopia, a coalition of health advocates from Sub-Saharan Africa warn that the lives of millions of people in Sub-Saharan Africa are in jeopardy because of the lack of political will and investment to realise the right of access to life-saving treatment.

Only one third of HIV-positive people in need of antiretroviral therapy (ART) to survive have access to treatment in the African region. The coalition fears that national and donor governments are betraying their health commitments, particularly promises to support the universal roll-out of ART by 2010.

"The broken promises and skewed priorities of governments and donors have reduced the right to health and access to treatment to unattainable rhetoric. In the last few months, we have seen trillions of dollars spent on financial 'bailouts' to stimulate economic recovery", said Nonkosi Kumalo of the Treatment Action Campaign. "A tiny portion of this sum could have bought quality, sustainable healthcare for millions of people."

Dr Bactrin Killingo of the HIV Collaborative Fund warned that "if the current cost constraints faced by HIV treatment programs are not addressed, while the demand for expensive second-line treatment increases, we will find ourselves in a situation similar to the '90s, where millions of lives were lost unnecessarily because people could not afford the treatment they needed to stay alive".

The region of sub-Saharan Africa bears the greatest burden of disease, and has 68% of the world's HIV-positive people but only 1% of the global expenditure on health, and 2% of the global health workforce. A recent African Union report states that sub-Saharan Africa faces "a grim scenario with respect to the health of its people", estimating that only 7% of total government expenditure in the region goes to health despite the 2001 Abuja Declaration commitment to commit 15% of government expenditure to health.

These shortcomings will be highlighted at the CAMH in Addis Ababa this week, where the Africa Public Health Alliance is submitting a petition to African heads of state and ministers of health and finance to close the US$10.7 billion funding gap for regional implementation of the Global Plan to Stop TB.

Most governments in the region cover less than half of their national health budgets with national resources, while the rest comes from out-of-pocket spending or international funders - most notably, for HIV and TB, the Global Fund. The financial support of the Global Fund and other donor agencies has had a remarkable impact on scale-up of services in sub-Saharan Africa.

The Global Fund reports that it has saved an estimated 2.5 million lives worldwide and has disbursed 57% of international donor aid raised for TB, 50% of malaria, and 23% of funds for HIV/AIDS. However, the increasingly steep trajectory of demand for Global fund grants, coupled with dwindling donor input and the global economic crisis, have resulted in the Global Fund announcing that it is at least $4 billion short of the money that it will need to continue funding essential HIV, TB and malaria services in 2010.

In 2005, the leaders of G8 countries, the richest nations in the world, committed to the goal of universal access to ART by 2010 - a goal that governments across the world pledged to support. Many of these same countries are now becoming antagonistic towards disease-specific funding, calling instead for "horizontal" approaches to health financing such as the International Health Partnership, without committing to the massive increases in funding that would be necessary to finance health across the board.

The coalition rejects pitting HIV against other diseases. Contrary to what some influential health economists and 'development experts' are claiming, there is ample evidence that ARV roll-out has strengthened health systems, and the work done by AIDS service organisations has revolutionised healthcare in the developing world.

African heads of state in 2001 stated that "We are fully convinced that containing and reversing the HIV/AIDS epidemic, tuberculosis and other infectious diseases should constitute our top priority for the first quarter of the 21st century". This conviction is not reflected in the resources that African governments have commited to health, nor in the lethargic progress towards scaling up TB and HIV programs in the region. The global economic crisis threatens to worsen this situation, with a recent World Bank report estimating that the negative impact of this crisis on HIV programs will affect 70% of people on ART in Africa within the next 12 months.

Said Paula Akugizibwe of the AIDS and Rights Alliance for Southern Africa (ARASA): "We need to ensure that African lives do not become a silent casualty of the global financial downturn. Our lives are not cheap or expendable. We expect health to be prioritised over weapons, sports and lavish politics."

ARASA hosted a meeting on financing for Eastern and Southern African HIV/TB activists last week, out of which this coalition was formed to advocate around several key messages: "We believe that health is our right. We are committed to sustained, universal access to ART. We are committed to prevention and treatment for TB, malaria and other illnesses that devastate our communities. We demand that African governments and donors honour their commitments to funding for health, and close the resource gaps as needed to secure universal access to HIV and TB treatment. Through a sustained and coordinated regional campaign, we will fight for our non-negotiable right to health until it is realized."

Press Release: Obama proposes $6.6 bn cut to global AIDS programs

Global Aids Advocates Shocked by Drastic Funding Cuts in President Obama's First Budget; Expect HIV Treatment Interruption for Thousands if Congress Doesn't Restore $6.6 Billion Shortfall

Contact: Jennifer Flynn, +1-917-517-5202 or

May 5, 2009

Health GAP

Washington, DC: Today, President Obama released the details of his 2010 budget for Global Health, and outlined a new six-year global health initiative. However, the only aspect of the plan that appears "new" is a dramatic decrease in funding for programs to address HIV, malaria and tuberculosis.

Last year, with the help of then-Senators Biden and Obama, Congress reauthorized the US global AIDS, TB, and malaria programs (commonly called PEPFAR) at $48 billion over 5 years. A modest estimate to extend that level of funding over six years to match the new initiative would be $57.6 billion. The President's current proposal only calls for $51 billion for the same programs a $6.6 billion cut. This means there will be dramatic reductions to funding for AIDS, TB, malaria, and still very little left over for vital expenditures like maternal and child health and health system strengthening.

The President had previously committed to do significantly more on global AIDS, TB and malaria. In his statement, President Obama highlighted his commitment to the Lantos-Hyde US Global Leadership Against HIV/AIDS, TB and Malaria Act while he was a Senator. This legislation authorized $48 billion over five years for AIDS, TB and malaria. During his campaign, at several junctures, he promised to fully fund PEPFAR, including a written pledge to support $50 billion over five years for global AIDS alone. President Obama also committed to the training of one million new health workers globally.

"President Obama repeatedly committed to ensuring the US does its fair share to fight AIDS around the world. But this budget's drastic cuts to funding for AIDS, TB and malaria shows that his promises were just rhetoric," said Kaytee Riek, Director of Organizing for Health GAP. "Effective programs, and the people whose lives are saved by those programs, will suffer."

The Global Fund to Fight AIDS, TB, and Malaria is in particular danger. "The Global Fund board meeting is taking place right now and we are going to be making some difficult decisions about how to respond to the $5 billion funding shortfall. We had hoped that President Obama would fulfill his campaign promise with this budget and contribute the U.S. fair share to this lifesaving multilateral program. Sadly, with a mere $366 million increase in US funding for all AIDS, TB and malaria programs in 2010, there is not enough room to fully fund the Global Fund, and means the Global Fund may have to start cutting existing and future grants," said Asia Russell, Director of International Advocacy for Health GAP and a Board Member of the Global Fund.

The budget now goes to Congress for debate and approval. "This budget does not contain the funding for the Administration to meet targets Congress required when it reauthorized PEPFAR. In addition, this budget does not go nearly far enough on other global health priorities, including maternal and child health and health systems strengthening", said Siham Elhamoumi, a Health GAP core member and leader in the Vermont Global Health Coalition. "Fortunately, Senator Leahy, Representative Lowey, and others in Congress can ensure that the Administration has the resources they need to save millions of lives worldwide. We are hoping they will act."

RESULTS' Analysis of the Administration's Global Health Budget

Making sense of the Global Health Initiative Funding Levels

Media Contact: Blair Hinderliter, (202) 783-4800 x126


"We would like to believe this is a bold new global health initiative, but the numbers just don't add up. With this level of funding we can't achieve the bold targets we've set in the Lantos-Hyde legislation on AIDS, TB, and malaria while scaling up efforts to improve maternal and child health," said John Fawcett, global legislative director. "President Obama, Vice President Biden, and Secretary of State Clinton have all been champions of global health. We hope they will re-craft their proposed budget numbers to fully fund the important programs they made promises to expand, and we look to Congress to ensure that our global health goals are adequately funded."

Presidential Commitments Budget Realities

(1) Global Health

"My budget makes critical investments in a new, comprehensive global health strategy." "To reach these goals, the budget invests $63 billion cumulatively over six years (2009-2014) for global health programs."

The president's $63 billion six-year proposal does not represent an expansion of global health funding over currently planned levels. AIDS, TB, and malaria efforts are currently authorized at $48 billion over five years; extending that rate of funding to a sixth year would amount to $57 billion. If this planned expansion of AIDS, TB, and malaria funding was implemented and all other global health funding was flat-lined at current levels ($1.14 billion per year), it would still amount to $64 billion $1 billion over the the president's proposal.

(2) AIDS, TB, & Malaraia

"Last summer, Congress approved the Lantos-Hyde U.S. Global Leadership Against HIV/AIDS Act legislation that I was proud to co-sponsor as a U.S. senator and now carry out as president."

Congress authorized $48 billion over five years for AIDS, TB, and malaria, but the president's plan only calls for $51 billion over six years. If the Lantos-Hyde Act is fully funded at $48 billion, there would be only $3 billion available in the budget for 2014 which would mean drastic cuts to lifesaving programs.

(3) Child and Maternal Health and Family Planning

"The president's 2010 budget begins to focus attention on broader global health challenges, including child and maternal health, family planning, and neglected tropical diseases, with cost effective intervention."

Based on estimates on the total funding needed to achieve the Millennium Development Goals for maternal and child mortality, the U.S. needs to contribute a minimum of $4 billion annually or $24 billion over six years to seriously address maternal and child health and family planning. The Global Health Initiative announced by the administration includes only $12 billion for all nonAIDS /TB/malaria "global health priorities" half of what is needed for family health alone.

(4) Doubling Aid

The budget "puts the United States on a path to double foreign assistance. By increasing foreign assistance, the United States will reach out to the global community and renew its role as a leader in global development and diplomacy." At current levels, the U.S. would spend $49 billion over six years on global health. The pledge of $63 billion reflects a 28 percent increase far short of doubling funding for global health, one of the most important and effective pillars of U.S. foreign aid.

(5) the Global Fund to Fight AIDS, TB and Malaria

President Obama "pledged to provide . . . our fair share of the Global Fund, in order to at least double the number of HIV-positive people on treatment and continue to provide treatments to one-third of all those who desperately need them."

The Global Fund currently faces a major funding gap of at least $4-5 billion. The president's proposed global health budget does not provide sufficient space to adequately support both bilateral health programs and the Global Fund. The U.S. fair share for the Fund in 2010 will be $2.7 billion, which would far outstrip the president's proposed increase for AIDS, TB, and malaria programs of only $366 million. The Global Fund's multilateral, results-driven, transparent structure fits the new administration's foreign policy goals well, yet the Fund is not mentioned in the Global Health Initiative statement.

(6) Tuberculosis

"Already, American leadership, sparked in large part by President George W. Bush and a bipartisan majority in Congress, has helped to save millions of lives from HIV/AIDS, malaria, and tuberculosis."

The president's statement and accompanying budget chart inexplicably group HIV/AIDS with tuberculosis into a single funding category. The result is deeply misleading, as the U.S. currently spends almost 40 times as much on HIV/AIDS as TB. The budget proposal is not consistent with a plan to increase TB funding from the current level of $163 million to meet the five-year authorized level of $4 billion, as called for in the Lantos-Hyde Act.

Health Financing in Africa: Challenges and Opportunities for Expanding Access to Quality Health Care

Fourth Session of the African Union Conference of Ministers of Health Addis Ababa, Ethiopia 4-8 May 2009

[Excerpts from executive summary only. Full 48-page paper and other reports from the Conference are available on the African Union website:]

Executive Summary

... Africa South of the Sahara still faces a grim scenario with respect to the health of its people. The region which is home to 12 percent of the world's population accounts for 22 percent of the total global disease burden and more than 68 percent of the people living with HIV/AIDS. The region's poor health status is mirrored by crises in health financing and human resources for health. With only 2 percent of the global health workforce and only 1 percent of the world's health expenditures Sub-Saharan African countries are ill-equipped to adequately address their health problems. Low per capita income, limited capacity for domestic revenue mobilization, and pervasive health system bottlenecks complicate governments' ability to respond effectively to the health challenges in their countries. Even with substantial external assistance, large gaps remain between what resources are available and what are needed.

The African Union's Heads of State and Government met at Abuja in 2001 and recommended the allocation by member states of 15% of national budgets to health; and again in 2006 where they issued a Call for Universal Access to health services. The purpose of this paper is to review the context and progress towards achieving international health financing goals and targets subscribed to by African governments, discuss the constraints to achieving the goals and targets and examine emerging new and innovative financing mechanisms designed to expand health care access equitably and efficiently to populations, especially the most vulnerable members.

Progress toward financing targets is slow

Governments in Africa are constrained in their capacity to finance health, as evidenced by the low levels of public sector health spending in most African countries. On average, total health expenditures in sub-Saharan Africa (excluding South Africa) were $23 per capita in 2005. Governments spent $10.19 per capita on health in 2005, or 44% of this total. Private households spent $10.47 per capita or 45% of the total. The remaining 11% came from other private sources (primarily employers and private insurance arrangements). External resources for health, which flow through both the public and private sectors, accounted for approximately 17% of the total.

... Targets for health and poverty reduction established both by African leaders themselves as well as by the international community have re-focused attention on the commitment of country governments to financing health, as well as on the urgent need to provide a package of essential health services. However, progress to meet these goals is slow, and large resource gaps remain.

  • Not many countries have made progress towards achieving the African leaders' commitment to allocating 15 percent of total government spending to the health sector (the "Abuja target"). However, perhaps more importantly, a previous analysis for the AU cautioned that, ... the target itself might also be misleading if viewed as a true reflection of public commitment to finance a reasonable package of health services for the population. Per capita health spending was suggested as perhaps offering a better, though not flawless, approach to gauging this.
  • The World Health Organization's Commission on Macroeconomics and Health (CMH), estimated that a basic package of health services costs US$34 per capita (the so-called "CMH target"). However, current per capita spending on health is lower in sub-Saharan Africa than in any other region at $23, and would need to increase by 68 percent to provide the CMH package. Only four countries in the region are currently spending $34 per capita on health.
  • To reach the Millennium Development Goals (MDGs), it is estimated that the proportion of government spending on health would need to increase nearly six-fold and that more than 12 percent of GDP would have to be spent on health, which is unrealistic.

Furthermore, even if all countries were able to meet the Abuja target today (15 percent of government financing going to health), 23 countries still would not reach the $34 spending level. ...even under optimistic assumptions about economic growth, population growth, and tax revenue collection, and assuming that all countries meet the Abuja target, most countries in Sub-Saharan Africa will not meet the CMH target even by 2020.

Challenges of public sector financing cannot be ignored

In addition to providing an indication of commitment to a population's health and well-being, public sector financing for health can address equity issues through subsidizing health services for the poor and providing financial protection, and public financing is often the most efficient way to finance health services that qualify as public goods. However, there are significant challenges to public sector health financing in Africa, including limited fiscal space, low domestic resource mobilization capacity, and constrained economic growth. These challenges constrain African governments from significantly increasing the level of resources allocated to health.

New and innovative sources and approaches offer promise for improving efficiency & equity

While more money is needed, more money alone is not enough to overcome Sub-Saharan Africa's health challenges. How money is spent is just as important as how much. First, strengthening health systems in Sub-Saharan Africa through improving leadership and government effectiveness, increasing absorptive capacity, and fortifying the health workforce can help existing and additional resources go farther.

Second, as donors will continue to play a major role in health financing in Africa for the foreseeable future, greater emphasis is needed on ensuring external assistance helps to build the overall health system rather than funneling aid into 'silos' for specific diseases and interventions. Donor resources for the health sector have reached unprecedented levels and continue to rise. However, there are still problems with the efficiency, effectiveness, and quality of service delivery and health outcomes in many countries are poor. New, innovative international financing mechanisms, which are designed to address some of the problems with the global health aid architecture, have the potential to bring more flexible resources for health. All of these approaches need further implementation, monitoring, and evaluation.

AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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