June 11, 2008, Panel 5: Resources and Universal Access -- Opportunities
and Limitations
UN High Level Meeting on HIV/AIDS
My name is Asia Russell, I am a member of Health GAP, an AIDS advocacy
and policy organization in the US that fights for global access to HIV
treatment, care, and prevention; I also serve on the board of the
directors of the Global Fund to Fight AIDS, Tuberculosis and Malaria,
representing NGOs from the developed world. Before I begin I want to
make sure that I note that I am standing in for Mr. Vladimir Zhovtyak
of the Eastern European and Central Asian Union of People Living with
HIV/AIDS in the Ukraine. He was unable to present at this meeting
because he is part of his country’s delegation.
I am here today to address the issue of funding universal access to
AIDS treatment care and prevention by 2010, from the perspective of
civil society.
7 years ago, when the UN deliberated over the global AIDS crisis at a
special session of the general assembly, the cost of ensuring access
to life saving treatment and prevention was too often used by
countries to excuse their own decisions not to increase AIDS spending—
just seven years ago, it was considered by many country governments
unwise to agree to invest billions in the response to AIDS in the
developing world.
Since that time, a powerful global civil society movement of people
with HIV and their allies has forced governments to retreat from that
position, and as a result to significantly scale up AIDS spending.
Although we have made moderate progress, for example in the area of
HIV treatment, which just 7 years ago was considered by many developed
and developing countries--as well as many UN agencies--
‘inappropriate’ or ‘unsustainable’ for millions in low income and
middle income countries. Now there are 3 million people on ARV
treatment, in defiance of that failed position, and the world has
committed to reaching the estimated 10 million people in urgent need
of treatment by 2010—which is only two years away.
What now are the major financing roadblocks preventing us from
achieving universal access? Current UNAIDS estimates project that
globally, the cost of reaching universal access by 2010 to prevention,
treatment and care is approximately $40 billion per year; today
developing and developed countries together spend approximately $10
billion per year—this is a figure that includes the out of pocket
expenditures for services by HIV-positive people in low- and middle-
income countries who in any reasonable costing model cannot actually
afford to pay. The funding gaps are huge, and they are caused by
developed and developing countries’ refusal to allocate predictable
financing consistent with their fair share of the global AIDS funding
burden.
We are extremely concerned that several G8 donor countries are
breaking their commitments to fund efforts to reach universal access,
and are not yet shouldering their share of the burden of the AIDS
response, for example countries such as Japan, the world’s second
biggest economy, but only the 6th largest contributor to the Global
Fund.
Likewise the UK has just announced a long term funding commitment of
about $12 billion, but currently with no clear spending target for
AIDS and no clear way for civil society to monitor and trace those
investments, and to ensure real results for people in developing
countries. In four weeks at the G8 Summit in Toya-ko Japan, the
announcements of the G8 could indicate the major donors of the world
are falling behind in their own AIDS funding commitments.
However the G8 hardly has the monopoly on breaking funding promises;
in the developing world, governments are also largely refusing to
prioritize recurrent AIDS funding at appropriate levels. In 2001
African heads of state gathered in Abuja committed to spending at
least 15% of domestic spending on health budgets, but perhaps only two
countries have since reached that target.
In other regions, for example Eastern Europe and Central Asia, there
are a range of critical concerns, including: insufficient funding
levels by national governments; lack of transparency regarding
expenditures of money, for example in procurement of medicines that
are more expensive than WHO pre-qualified generic equivalents; or in
insufficient involvement of people living with HIV in planning and
implementing the national response.
In some countries, despite concentrated epidemics among men who have
sex with men and other sexual minorities, sex workers and injecting
drug users, country plans do not prioritize interventions in those
populations, nor do they include those populations in the national
planning process. In some countries, policies that restrict the
response to vulnerable groups such as sex workers, for example the
prostitution loyalty oath that the U.S. government requires funding
recipients to sign, are clearly blunting the impact of the global AIDS
response, and resulting in AIDS funding that is already committed,
being poorly spent at country level.
Or their are decisions by some governments, for example Cambodia, to
arrest and detain sex workers rather than ensure programming that
protects and promotes their human rights--there are too many examples,
each indicating that we have much more work to do together when we
consider the urgent need for increased funding for programs that work,
not programs the undermine the rights and fundamental entitlements of
HIV positive people and those at greatest risk of infection. Civil
society has proven itself to be a critically important partner in
program implementation, but we are still excluded from program
implementation efforts. To reach universal access, this must change.
We face another tremendous roadblock: in order to scale up rapidly to
reach universal access, the severe shortage of health workers, doctors
and nurses and community health workers who provide care and treatment
and prevention services, primarily in sub Saharan Africa, must be
integrated into the response to HIV.
It is unacceptable that a nurse in a rural clinic in Kenya is paid the
same in one month as it costs to eat dinner for two here in Manhattan—
although she is doing the work of a nurse, doctor, counselor, outreach
worker, emergency surgeon, and palliative care provider. Donors must
end their refusals to invest in recurrent costs such as increased
salaries and other incentives for health workers; donors must invest
in professional training to increase the supply of health workers, and
donors must end their own recruitment and other practices which
contribute to the hemorrhaging of health workers from the developing
to the developed world.
While the price tags associated with AIDS spending might seem
staggering compared with other recent health investments, the cost of
not making these investments far outweighs the cost of countries
paying their fair share, now.
Likewise, we must challenge the macroeconomic policies of the IMF, too
often supported and upheld by Ministries of Finance, which dictate
that countries hold back from scaling up crucial investments in health
and education, despite an urgent need for increased investment in
these areas to reach universal access and the MDGs. Recently reports
from the IMF’s own evaluations have shown that 70% of the increases in
donor aid to sub Saharan Africa between 1999-2005 were not spent as
aid but instead were spent on paying down domestic debt or was
redirected into increasing international currency reserves in central
banks. These overly restrictive macroeconomic policies mean countries
cannot implement emergency health worker retention and production
plans; as a result HIV positive people in those countries facing the
most acute health workers shortages are suffering and dying
unnecessarily. The G8 summit presents a tremendous opportunity to
address the shortage of health workers, and should map out concrete
efforts to reach the target of at least 4.1 doctors, nurses, midwives
and community health workers per 1,000 people, as well as a doubling
of health workers in Africa to 1.5 million, by 2015.
AIDS is still an exceptional crisis, I wish that were not the case,
but it is as true today as when the first cases were reported 25 years
ago. The global movement for AIDS treatment and prevention access for
all recognizes that there is a simultaneous need to guarantee secure
financing for AIDS as well as increased financing for comprehensive
primary health care. It is not a question of either AIDS spending, or
investments in other health priorities. We are not spending too much
on AIDS. We are spending too little, and we are spending shockingly
too little on primary health care programs as well.
The AIDS crisis and the global response have exposed health systems
that have been weakened to point of collapse by decades of
underinvestment, neglect, and structural adjustment policies of the
IMF and World Bank.
We are actively building bridges to health advocates in other
movements, without denying the reality: AIDS requires adequate,
predictable, and long-term funding rather than the current
unacceptable reality of escalating funding gaps. We reject the false
choices that are being posed by some, pitting funding for AIDS against
horizontal funding for health systems, funding that all too often
comes without clear and traceable funding targets and benchmarks, and
with no meaningful involvement of civil society either as watchdogs or
as implementing partners.
We are fighting for universal access, but we are also working for
global health justice. These essential health needs are interrelated
and collective, not competitive—we call on governments and policy
makers to stop once and for all pitting so called ‘vertical’ disease
specific AIDS programs against general health spending—at the mid
point of the MDGs, and with only two years until the goal of universal
access.
In order to reach this target, these steps are required:
• Governments must develop and implement transparent and
accountable AIDS plans and take full responsibly to meet the
presentation, treatment, care and support needs of their citizens;
• Civil society must be involved fully as equal partners at
every step of the planning and implementation processes in all
national and global health initiatives;
• Governments in rich countries must close the funding gap by funding
the massive shortfall, to ensure that promises we hae already made to
reach universal access to treatment, prevention and care, are kept.
Thank you.
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