An Unfinished Agenda – by Rifat Atun, Shaloo Puri and Gabriel Seidman
5 Mar 2015
An Unfinished Agenda – by Rifat Atun, Shaloo Puri and Gabriel Seidman

The HIV epidemic is still very much an unfinished agenda. Despite remarkable progress, a staggering 35 million individuals lived with HIV in 2013. With the advent of Antiretroviral Treatment (ART), HIV is no longer a death sentence but a chronic condition, with almost 13 million people in low and middle income countries now receiving ART.

While the trajectory of the HIV epidemic has begun to change with a declining number of new infections and mortality levels, the trajectory of costs has continued upwards, driven by lifetime treatment needs, longer living cohorts of persons receiving treatment, expanded treatment guidelines, and rising prevention costs in HIV-affected countries which have expanding populations. The global resource need that was US$3.8 billion in 2002 had reached US$19.1 billion in 2013, according to UNAIDS.

On 25 February 2015, RethinkHIV convened a roundtable event co-hosted by the Harvard T. H. Chan School of Public Health to explore the fiscal challenges of HIV. This workshop, titled “From a Death Sentence to a Debt Sentence: Meeting the Challenge of Long-term Liabilities of HIV funding,” brought together senior leaders and researchers from Harvard University, University of Oxford, the IMF, the World Bank, the African Development Bank, the Global Fund, Bill and Melinda Gates Foundation, Social Finance and the Innovative Finance Foundation, among others.

The discussions focused on the future financial obligation for HIV/AIDS, which in sub-Saharan Africa exceeds $250 billion and creates a huge hidden debt. There is a moral duty to continue funding for HIV, but in the face of declining donor funding and fiscal space constraints faced by countries, new sources of financing have to be found. In this spirit, the workshop explored the potential for innovative financing.

Several innovative financing instruments have been successfully used in global health, including solidarity levies on plane tickets or levies on extractive industries, social impact bonds, social development bonds and diaspora bonds, which could potentially be used to meet future obligations for HIV/AIDS in Africa.

Agreeing that one should not borrow to spend but rather to invest, the group set out to explore which specific financing instruments could used to finance HIV programming in different countries of sub-Saharan Africa..

In particular, the questions raised fit into three key themes:

  • Is the financing mechanism politically supportable?
    –  What moral justification will best mobilize policymakers to deploy innovative finance for HIV interventions? Who should pick up this duty of rescue?
    –  What conditions and incentives are necessary for various stakeholders, such as governments, private sector, community and donors, to finance specific mechanisms?
    –  What is the right balance between government and donor funding?
    –  How do we prioritize which countries and populations receive additional funding?
  • Is the financing mechanism technically correct?
    –  Is front-loaded financing (such as bonds) appropriate for HIV interventions?
    –  Does the fiscal space in countries really permit new taxes/ levies? Who bears the burden ultimately?
    –  Are there assets or revenue streams associated with HIV interventions that can mobilize private sector investment in effective interventions?
  • Is the financing mechanism fit-for-purpose?
    –  How do we strike a balance between allowing countries to set their own priorities (e.g. eliminating earmarks) and ensuring that commitment technologies are in place to ensure that governments spend resources where they originally intended to?
    –  Should debt mechanisms be used only for “investment” programs, such as prevention, and not for ongoing liabilities such as treatment costs?

RethinkHIV is planning more work to explore how innovative financing can provide solutions to the challenge of long-term financing liabilities for HIV. More research and continuing dialogue with countries are needed to address this problem that can no longer be ignored.

Professor Rifat Atun is Professor of Global Health Systems at Harvard University, and the Director of Global Health Systems Cluster at Harvard T. H. Chan School of Public Health.

Dr. Shaloo Puri is a Research Fellow at Harvard Kennedy School of Government and a Visiting Scientist at Harvard T. H. Chan School of Public Health

Gabriel Seidman is a Doctoral Candidate and Centennial Fellow at Harvard T. H. Chan School of Public Health.