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USA/Africa: Underfunding Global Health
May 10, 2009 (090510)
(Reposted from sources cited below)
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
(1) World Bank, "Averting a Human Crisis During the Global
Downturn" May 2009 http://tinyurl.com/o6vqct
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
(http://www.icssupport.org) 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
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
(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
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 firstname.lastname@example.org
May 5, 2009
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
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
"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
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
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
"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
... 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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