Since its recognition in 1981, the HIV and AIDS epidemic has been a defining factor in the financing of health across Africa. The reasons are simple: AIDS is exceptional. It primarily infects adults; it is incurable; if untreated, death results; and while treatment is available, it is complex and expensive.

There has been massive and effective mobilisation of funds and support for people living with HIV. This movement was initially among affected groups in the rich world, but became global, and led to international action. The global development agenda from 2000 set eight Millennium Development Goals (MDGs): three directly related to health, and one specifically on AIDS, TB and Malaria.

In 2000 the UN Security Council passed Resolution 1308, stating: “the HIV/AIDS pandemic, if unchecked, may pose a risk to stability and security.”(1) In 2001 the UN Secretary General Kofi Annan, called for spending on AIDS to be increased tenfold in developing countries, and the Global Fund for AIDS, TB and Malaria was established. In 2003 US President George W. Bush pledged $15 billion toward the Presidential Emergency Program for AIDS Relief (PEPFAR), and the WHO launched the “3 × 5” campaign to get three million people on treatment by 2005.

Global Progress and the Health Agenda

The attention to AIDS led to ‘collateral’ gains across the health sector. TB, which is intimately linked to failing immune systems, and malaria, a vector borne disease, were funded and health systems have benefited. Life expectancy, which had plunged in high HIV prevalence countries such as Swaziland, Zimbabwe and South Africa, has begun to climb, and the numbers of deaths from TB, malaria and HIV have all declined. According to the latest UNAIDS figures new HIV infections in adults and children have fallen to 2.1 million in 2013 – the lowest since 1990.(2)

Currently, the question is how health objectives will be funded. This is important for two reasons. First international development aid is significant as it has reached the highest level ever recorded in 2013.(3) This growth was driven by Development Assistance for Health (DAH) which increased at over ten per cent per year from 1990 to 2010, reaching $US 31.3 billion in 2013. Ironically, DAH for HIV and AIDS peaked in 2011. According to the Kaiser Foundation, commitments were $8.8 billion in 2011, falling to $8.3 billion in 2012 and $8.1 billion in 2013. Disbursements however peaked at $8.5 billion in 2013.(4)

The second reason is that DAH is essential to fund the AIDS response, especially since treatment is relatively expensive. The July 2014 Medicins Sans Frontieres report on prices put the average cost of drugs alone, for first line treatment, at $136 per person per year. The UNAIDS estimate of the annual per patient cost for established patients was $177 in 2011.(5)

The cost of HIV and AIDS needs to be seen in context (see Table 1). The actual per person government health expenditure in some settings is lower than AIDS treatment cost. UNAIDS has warned of the “AIDS dependency crisis”, in which African countries depend on external funds. Increasing Domestic Funding

This is then the backdrop against which calls for increased domestic funding should be seen. The pressure is growing, indeed a Results for Development review of 12 PEPFAR noted, “deeply ingrained perceptions by finance and other senior government officials that ‘donors will take care of the AIDS program,’ as indeed donors have done over the past decade” (page 5).(7) The British government announced an end to DFID funding in South Africa and India in 2013(8) and PEPFAR is planning its own ‘transitions’.(9)

Domestic funding for health is typically allocated from the government budget raised through taxes. There is room for increased taxation and the possibility of greater spending on health, but it will be in competition with other fiscal demands. There is room for using economic tools, cost effectiveness and cost benefit analysis to improve resource allocation. Improving efficiencies by focusing on cost-effective, evidence basedinterventions frees up existing resources.(10)

Beyond existing funding streams numerous studies have examined innovative financing mechanisms. More than 100 schemes were evaluated by the High Level Taskforce on Innovative International Financing for Health Systems. On the surface there appear to be a diverse array of approaches, however, there are really only three different general models.(11) The first is borrowing, akin to a taking out a mortgage because the funds have to be paid off over time. The second is the advanced market commitment (AMC) model, similar to investing in futures markets that may pay off. The final model of innovative financing is new taxation on a range of activities. Diet-associated public health sins, greed and overconsumption are logical targets for taxes benefiting health. Whatever the new source of domestic funds, it must be supported by political will and commitment to health.

Ways forward

Countries have to take responsibility for their own health systems and funds. International development assistance was not designed to last forever yet the emergence of the AIDS epidemic changed the discourse and landscape of health financing. A shift towards increased domestic responsibility for national health and sources of finance in Africa is critical for achieving and sustaining equitable universal access to healthcare. Innovations must include efforts to increase the efficiency of existing health services, based on cost-effectiveness and evidence. However, even with increased domestic commitment, international assistance will still be necessary to achieve global health objectives.

The key to improved domestic financing is increased and sustained political will to allocate these funds towards health. Health ministries need to emphasize that investing in health makes economic, political and moral sense. Continuing to invest in AIDS, TB and malaria not only addresses a major disease burden but also strengthens health systems. External funding should in turn be linked to domestic mobilization. Moreover, concepts such as ‘fair share’, ‘global compacts’, and ‘duty of rescue’ need to be considered and operationalized.