We could end AIDS, but will we? There are two things standing in the way: political will and the money to do it. These two barriers came into painfully clear view last week when the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria announced that it was cancelling its latest call for applications for funding and adopted a set of drastic measures so that it could maintain funding for the essential services that it is currently supporting. At precisely the moment we've realized how to curb HIV, donors have left the Global Fund treading water, struggling to keep funding flowing to preserve the lives of those who are already on treatment.

The Global Fund was supposed to be a “war chest;” a well-resourced fund that could rapidly push large amounts of money out to well-performing, evidence-based and country-owned programs in order to enable a massive scale-up of the fight against AIDS, TB and malaria. In 10 years it has disbursed more than $18 billion dollars and has saved close to 8 million lives. It has put more than 3.3 million people on HIV treatment and has provided services to 1.3 million women to prevent mother-to-child transmission of HIV. It has built stronger health systems and increased civil society engagement. Its deep commitment to human rights and marginalized groups has resulted in policy change and scale-up of services for those who would otherwise not receive them. As a myriad of external evaluations have demonstrated, the Global Fund has consistently proven that is good value for the money.

We knew this crisis was coming, but many of us, myself included, were in denial that donor governments would let something falter that has so fundamentally changed the dynamic of the HIV response for the better. The Global Fund’s last replenishment conference in October 2010 resulted in pledges and projected resources of approximately $11.7 billion for the period 2011-2013. At that time, the Global Fund Secretariat had said it needed $13 billion just to continue programs it was already supporting.

Since the replenishment conference, it has become clear that a number of donors will not fulfill their pledges. At the moment, the Fund has just over $6.5 billion in confirmed pledges for 2011-2013 and close to $4.4 billion in tentative pledges for future years (some of which may be provided in 2012 and 2013). This falls far short of the projected $11.7 billion and even further short of the need. The U.S., for example, pledged $4 billion, but given increasing hostility toward foreign aid in Washington and the fraught deficit negotiations, the Fund will be lucky to receive $3 billion over the period. Japan, in the aftermath of the earthquake and tsunami, reduced its announced contribution to the Global Fund by two-thirds. The Netherlands cut its contribution by more than $40 million per year. Other governments such as Germany and Denmark have flat-lined their contributions. The Global Fund’s financial crisis has nothing to do with mismanagement of funds, but everything to do with donor governments withdrawing or flat-lining their support for the Fund at a time when we need more investment, not less.

Earlier this week Jeffrey Sachs and Stephen Lewis rightly pointed out that this is an issue of misplaced priorities on the part of donors that verges on the criminal. When it comes to waging war or bailing out banks, money can always be found. Just $2 billion dollars is needed to ensure that developing countries are able to continue to scale up effective HIV, TB and malaria services over the next two years. Just $2 billion is needed to make progress in treating the more than 9 million people who are still waiting for HIV treatment and prevent millions more new infections. In the scheme of things, this is not a lot of money; it’s less than 0.05% of the budget of the U.S. Government. But it is the very thing that is needed to make sure that the Global Fund can support countries to begin to bring about an end to AIDS.

So this World AIDS Day, instead of reflecting on our successes, we need to recognize that we haven’t done enough. We need to demand that donor governments do more. At the minimum, we need an emergency replenishment of at least $2 billion so that the Global Fund can reopen the door to new, ambitious applications and countries can get to the business of saving millions more lives. I for one don’t want to look back on 2011 as the year that we could have turned the tide against HIV, but didn’t.

One of the Global Fund’s hallmarks has been its willingness to take risks and to invest in the most marginalized communities. Through its bold statements on gender inequalities and the health and rights of sexual minorities, I have witnessed the Global Fund prompt countries like Uganda to move away from demonizing sex workers and men who have sex with men to establishing strategies that address the HIV needs of these vulnerable communities.

In countries like Ukraine and Zambia, I have seen the Global Fund empower civil society and people living with and affected by the diseases to hold governments accountable when they fail to appropriately manage Global Fund grants.

Through its use of an independent, non-political technical review panel to judge whether the programs it supports are the ones likely to have the greatest impact, I have also seen the Global Fund prompt countries like Thailand and Swaziland to take a hard look at their HIV programs and refocus on addressing the most critical gaps in their responses.

For these reasons, the Global Fund is one of the most innovative, transparent, and effective aid organizations currently in operation. It has contributed to stronger civil society organizations, stronger community-based responses, and stronger health systems. But now, the Global Fund is at a crossroads. The decisions the Board and Secretariat make over the next few months will determine whether it continues to be a high-impact aid organization that is responsive to the needs of communities, or whether it becomes irrelevant.

The past few years have not been easy for the Global Fund. Its October 2010 replenishment failed to bring in the money necessary to continue to scale up programs, leading to delays in the launch of new funding opportunities and increased pressure to prove that its investments are achieving value for money. The ongoing global financial crisis continues to put downward pressure on aid dollars, while donor fatigue with the AIDS response and a shift by donors to prioritize funding for broader health systems have made fundraising even more difficult. To make matters worse, the misuse of funds by recipients in a limited number of countries has put pressure on the Global Fund to prove that its risk mitigation systems are adequate to the task of moving billions of dollars to scale up health programs and save lives, while safeguarding against fraud and corruption. Over the past few months, increasing risk aversion from the Secretariat and local partners has resulted in a level of micromanagement that has paralyzed programs and the ability to adapt to changing circumstances on the ground.

Fortunately, the Global Fund has several opportunities to change course and refocus. The Board and Secretariat will meet on September 26 to review recommendations made by the “High Level Independent Review Panel on Fiduciary Controls and Oversight Mechanisms.” If adopted, the panel’s broad and far-reaching recommendations could fundamentally change the way the Global Fund does business. The recommendations range from changing the job description and authority of Fund Portfolio Managers, to reorganizing the board, to creating a more iterative process for proposal development and review. In addition, the Board and Secretariat are developing a new five-year strategic plan that has the potential to refocus the Fund on achieving its mission: preventing new infections and saving lives.

The Global Fund’s Board and Secretariat have a real opportunity at this point to take this organization to the next level, increase its effectiveness, and ensure that its funding is really being used to save lives.  As it does this, the Global Fund should strive to:

• Fight fraud while continuing to support risk-taking and innovation (which are often the things that make aid programs effective);
• Build in more consistent feedback loops with countries and allow greater flexibility to adjust programs according to changing needs;
• Ensure greater predictability and more transparency of funding in order to increase accountability;
• Strengthen “country ownership” by supporting the real and meaningful participation of all stakeholders in decision-making about the use of Global Fund resources, particularly most-affected and marginalized communities;
• Give more attention to improving program quality and building real capacity in countries;
• Empower civil society to monitor transparency in the procurement, supply, and quality of medicines, and ensure technical assistance for the effective use of flexibilities within intellectual property agreements; and
• Put human rights front and center to make sure that it is funding appropriate interventions and addressing real barriers to care.

It would be unfortunate if the Global Fund emerges from this process with a focus only on strengthening its financial safeguards without also committing to address some of the other factors that can just as easily undermine the effectiveness of its programs, such as a weak civil society or inadequate protections for human rights. Strengthening civil society, increasing transparency, and challenging the unjust legal and policy environments that allow HIV, tuberculosis, and malaria to flourish should be just as much a priority.

Globally, more than four million people are currently receiving treatment, with support of PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, UNITAID, national governments, and other donors. But there are at least six million people who need treatment now, who are still unable to get it.

Instead of scaling up, now the Obama Administration is saying enough is enough. It is telling the health providers that it funds that they can only put new people on AIDS treatment if some of the people they are already treating die.

The Boston Globe article quotes Eric Goosby, the U.S. Global AIDS Coordinator, as saying “People are struggling to find resources to honor the commitments we have made… We’re not at a cap point yet. If it gets worse, we’ll have another discussion.”

Well, we just got our hands on a letter the U.S. government sent to treatment providers in Uganda in October, 2009. It says:

“In FY 2010 and 2011, each Partner should expect to have a set flat-lined budget for ARV procurement that should not be exceeded without discussion and written approval from their funding agencies. PEPFAR Implementing partners who directly provide antiretroviral treatment should only enroll new ART patients if they are sure that these new patients can continue to be supported without a future increase in funding...

“In filling treatment slots that are made empty through attrition – i.e. deaths and loss to follow-up estimated at 12-30% annually – priority should be given to the sickest patients, eligible pregnant women, children, TB/HIV patients, and family members of persons on ART. Partners should provide support as needed to ensure that patient information records are up to date and an equitable system of triage for total ART slots is worked out within their sites before enrolling any new patients.”

If that’s not a cap, then what is it?

Peter Mugyenyi, an AIDS specialist in Uganda, talked in that article about the anguish of turning people away: “Virtually every day, we have to turn away patients who need treatment, including breast-feeding women… We have to tell them ‘There is a freeze.’”

And at an event in DC on Monday as reported in the Science Speaks blog, Dr. Lydia Mungherera, a Ugandan medical doctor, activist, and woman living with HIV, said, “The hopelessness we had in the 1980s, when we had no treatment, is what we are going back to now… The basic issue of right to life is being disrupted.”

Sources on the ground tell us that as many as 800 people are being turned away from clinics in Uganda a month, with no other option but to go home and hope that somebody else who is already on treatment dies before they do.

Treatment is one of the single most important HIV prevention tools that we have. Much, much more needs to be invested in better and more effective prevention programs. But at the same time we know that treatment reduces infectivity and the availability of treatment encourages the uptake of voluntary HIV counseling and testing. According to the briefing report Will We End the HIV Epidemic? (download the PDF from the International AIDS Society website), simply treating all of the people who need treatment now would decrease new infections by as much as a third. When people know their HIV status, regardless of whether they are positive or negative, they are also more likely to take measures to protect themselves and others from HIV infection, whether that be by using condoms, reducing multiple partners, or not sharing needles.

Yet, the U.S. government’s decision to cap treatment is undermining the overall HIV/AIDS response in Uganda. As Mungherera put it: “Seventy percent of Ugandans don’t know their status. But what are we going to tell those people who come for testing? I’m sorry, there’s no treatment?”

The Boston Globe article made clear that it’s not just Uganda. The U.S. government has ordered a stop to building clinics in rural Mozambique and is starting to put limits on treatment in Zambia as well.

At the same time that the Obama Administration is flatlining PEPFAR funding, it is not doing anything more to make sure that it can leverage funding from other donors to help fill the gap. For every $1 that the United States gives to the Global Fund to Fight AIDS, Tuberculosis and Malaria, other donors give $2. Yet in its FY2011 budget, the Administration proposed to not just flatline, but cut, funding to the Global Fund as well.

And, as I’ve written before, other donor governments appear willing and ready to follow the U.S. government’s lead.

Don’t let it happen. Go to the International AIDS Society website where you can send a personalized email to President Obama and other G20 leaders, asking them to fully fund the Global Fund and keep their promise to universal access to AIDS treatment and prevention now.

In 2001, the heads of state of African governments got together in Abuja, Nigeria, and pledged to contribute 15 percent of their national budgets to health.  Like donor governments’ pledges to commit 0.07 percent of their gross national income (GNI) in official development assistance, progress in meeting this target has been slow.

According to a report by the Global Fund, in 2007 only three of 52 sub-Saharan African countries met the Abuja target: Botswana, Djibouti, and Rwanda. Another seven had consistently allocated more than 12 percent of their budgets to health: Benin, Burkina Faso, Gabon, Malawi, Mali, Namibia and Tanzania. Overall, 25 of the 52 countries had increased the percentage of government spending on health between 2001 and 2007, but the remaining 27 countries decreased spending. Swaziland— the country with the biggest HIV burden in the world — decreased spending from 11.8 percent of the national budget in 1999 to just 9.5 percent in 2007.  Uganda decreased spending from 11.3 percent to just 8.9 percent, and Zimbabwe’s declined from 10 percent to 8.9 percent. (The report, Trends in Development Assistance and Domestic Financing for Health in Implementing Countries, is available as a PDF from the Global Fund.)

While many developing country governments use poverty as a reason for their limited investments in health, it may just be that their priorities are misplaced.  The AIDS and Rights Alliance of Southern Africa (ARASA), an Open Society Institute grantee, is currently running a brilliant campaign called Eye Spy, which draws attention to the choices governments are making on how they spend their money.  Too often it seems, governments are spending exorbitantly on luxury transportation or whittling away the money that is available through corrupt deals and private off-shore bank accounts, instead of investing in health.  According to ARASA, the annual cost of corruption to the African continent is about US$148,000,000,000. That amount of money could buy one year of HIV treatment for 704 million people. Check out their eye-opening Lords of the Bling video:

While thousands of people who need anti-retroviral therapy are being turned away in Uganda, Yoweri Museveni bought a private jet for US$48,000,000. That’s the cost of providing a year of HIV treatment for 229,524 people.

The $500,000 spent by Swaziland’s King Mswati III to buy a state-of-the-art luxury car could have been used to provide TB treatment for 21,001 people. And the $250,000 used for Zimbabwe President Robert Mugabe’s 85^th birthday party could have treated 10,500.

At the Global Fund’s first replenishment meeting in The Hague in March, donors rightly showed indignation about the lack of investment in health by developing country governments and said they needed to see greater commitment. Developing countries do need to get their priorities in line and they do need to be held accountable for spending more on health.

But then again, so do the donors.  According to the Organization for Economic Cooperation and Development, in 2010 the 22 richest countries will give on average only 0.33 percent of their GNI in official development assistance. Only six will meet or exceed the 0.07 percent target. The U.S. and Japan tie for last place at 0.02 percent.

And, as ARASA helpfully reminds us, the US$700 billion spent on the bank bailout in 2008 was more than 100 times the budget of the U.S. President’s Emergency Plan for AIDS Relief.

What do you spy with your little eye?

Community Health Meeting in Tigray Region, Ethiopia. Shannon Kowalski/Open Society Institute

Jeff Sachs recently published a blog post in the Guardian calling for changing the mandate of the Global Fund from AIDS, TB and malaria to health generally.  It’s a great idea. But in truth, the Global Fund is already doing a lot to fund health systems.

At least 30 percent of the Global Fund’s funding in rounds one through seven were focused on health systems inputs. In rounds 8 and 9 the Global Fund made its commitment to providing funding for strengthening health systems much more explicit and encouraged countries to submit cross-cutting health systems strengthening proposals.  The Global Fund is already funding: training and paying health care workers, strengthening laboratory capacity, upgrading infrastructure, strengthening procurement and supply chain management systems, improving monitoring and evaluation, and even strengthening health insurance systems, to name just a few key areas.  While this funding must be related to improved outcomes for the three diseases, spending on health systems has never been restricted to just fighting the three diseases (although some countries may have planned and implemented programming in that way).

In November, I visited some of the projects the Global Fund is funding in Ethiopia and saw for myself how Global Fund resources are being used to strengthen health systems. Ethiopia’s Health Extension Programme trains workers in rural areas to provide health education and basic services to their communities. These services include family planning, encouraging pregnant women to get antenatal care and give birth in health facilities, HIV prevention, testing and treatment, the distribution of bednets to prevent malaria, and education about nutrition and sanitation, among other things.  The community members I spoke with told me how these small interventions made a big difference in improving lives and health in their village.  It’s a great example of what the Global Fund is doing and already can be doing more of, if only countries would ask for it.

Of course, much more needs to be done to improve health systems, beyond what the Global Fund is able to do and should do. But the Global Fund is not the only player in this field.  The GAVI Alliance and World Bank give significantly in this area, and the three partners are currently discussing launching a joint health systems funding platform that could cut down transaction costs of applying for and managing health systems funding considerably.  Bilateral donors and, of course, national governments, are also investing in this area.  The question the Global Fund’s board and donors will need to answer is: Can the Global Fund do more in this area, without compromising on its commitment to effectively fight AIDS, TB and malaria?

The elephant in the room of course is money.  Sachs acknowledges that this is an issue and states that to effectively address health more broadly the Global Fund needs $12 billion a year.

This is a year of replenishment for the Global Fund and donors will make their pledges in October for the period from 2011-2013.  And while many are calling for the Fund to expand its mandate even further, public sector donors are indicating that pledging even $13 billion over three years might not be possible (nevermind the $36 billion Sachs proposes).  As I have written previously, a $13 billion replenishment ($4.3 billion a year) will not let the Global Fund scale up its response to the three diseases, let alone effectively address any other health issue. That means very few additional people receiving anti-retroviral treatment, few additional women and children sleeping under bednets, and only modest expansions in the number of people receiving basic TB care (while letting multidrug-resistant TB run rife). We would be giving up the fight, just as we could achieve major public health breakthroughs.

So let’s talk about the Global Fund for Health.  But, until we see the outcomes of the pledging conference in October, the Global Fund’s board and secretariat should tread carefully. The test is the amount of money that donors put on the table. If they do pledge $12 billion a year as Sachs proposes, I will be the first to champion it.

We could do it. But will we?

As donors to the Global Fund to Fight AIDS, Tuberculosis and Malaria meet in The Hague this week to discuss replenishing the Fund for 2011-2013, this is the choice they will make.

The Global Fund has just released three scenarios outlining what they will be able to achieve over the next three years depending on the amount of resources pledged:

• $13 billion ($4.3 billion/year) would allow the Global Fund to continue funding programs and services that it is already funding. While the Global Fund notes that there will be room for very limited scale-up of services to fight the three diseases, we would essentially be left with the status quo. About 2.7 million people will continue to be infected with HIV annually. At least 10 million people who need HIV treatment will not receive it. Malaria will continue to be a very real threat to the health and lives of millions in malaria-endemic countries.  And any progress would be limited.
• $17 billion ($5.6 billion/year) would allow the Fund to continue funding existing programs and services and scale them up, but at a rate lower than they have been supporting scale-up over the past two years. This would be better, but not enough to begin to reverse the trajectory of the three diseases.
• $20 billion ($6.6 billion/year) would allow the Fund and countries to accelerate the scale-up of programs. It would allow an additional 5 million people to access HIV treatment, 5.4 million to access TB treatment, and 156 million more long-lasting insecticide-treated bed nets could be distributed to prevent new malaria infections. But even at this level the world would not come close to meeting the Millennium Development Goals adopted by 189 nations in 2000.

To do what we now know is possible, to turn back the tide of these three diseases, it is going to cost significantly more.

In the scheme of things, these amounts are not a lot of money. In 2007, $2.6 trillion was spent on health care in the United States alone; in 2010 the UK will spend about $179 billion. In 2008, the U.S. government spent $711 billion on the military and fighting the wars in Iraq and Afghanistan and another $700 billion bailing out Wall St. bankers. The difference that more money for the Global Fund could make in improving health systems and saving lives is huge.

But instead of doing the right thing, behind closed doors public sector donors are currently sending all of the wrong messages: that any increases in funding over existing levels will be small and $13 billion may not even be feasible. In other words, maybe the Global Fund will be able to continue funding what it is already funding, but no more and definitely not at the level that is going to reverse the spread of AIDS, tuberculosis, or malaria.

Or more starkly, saving lives is just not worth the money.

Donors will make their pledges to the Global Fund at a pledging conference in New York in October. The question is: Will they make the right choice? We need to make sure that they do.