H.I.V./AIDS: Looming Funding Crisis

One of many child-headed households in Mtubatua, South Africa

One of many child-headed households in Mtubatua, South Africa, used by the local community to accommodate the growing number of orphans left unable to care for themselves. (Photo: Rafs Mayet / AFP-Getty Images)

Three major recent events signal that financial support for international remedial efforts against H.I.V./AIDS may be facing an uncertain future.

First, the UNAIDS in a report released in June projected a looming funding gap of $18 billion for H.I.V./AIDS in developing nations between 2005 and 2007. The funding gap, according to UNAIDS, can scuttle ongoing strategies for access to comprehensive prevention programs against H.I.V. transmission. It would also jeopardize the aim of providing antiretroviral treatment (ART) to 75 percent of individuals clinically qualified to receive these medicines in 2008 (about 6.6 million individuals). A funding shortfall between now and 2007 would also slow down the progress made in providing social and healthcare support for AIDS orphans and other vulnerable children affected by the pandemic. Critical programming costs and urgent training needs for health personnel would also suffer, according to UNAIDS, if projected funding shortfall becomes a reality. Currently, none of the major donor countries, including the United States have stepped forward on how to end the looming funding gap identified by UNAIDS.

Second, the Global Fund to fight AIDS, tuberculosis and malaria has already identified a funding gap of $700 million for 2005 alone. In addition, the Global Fund estimates that it needs additional funding pledges from donor countries of about $2.9 billion in 2006 and $3.3 billion in 2007 to continue its cycle of replenishing successful country-based programs and supporting new grantees. In 2004, the Global Fund accounted for 20 percent of all H.I.V./AIDS funding worldwide. These funding gaps has the potential to undermine an invaluable by-product of the Global Fund mechanism: the belief by poor countries that they can plan ahead knowing that accepted proposals will get financial support and approved projects will get funded throughout the project cycle. It is instructive to note that the 2005 Group of 8 communiqué on the Global Fund only pledges to “meet the financing needs for H.I.V./AIDS, including through the replenishment this year of the Global Fund to fight AIDS, TB and Malaria.”

Third, the apparent unlikelihood that the World Health Organization and its collaborating partners will succeed in the goal to provide 3 million people dying of AIDS with antiretroviral treatment by 2005 in resource-poor countries (“3 by 5”). As of June 2005, the W.H.O. estimates that about 1 million qualified individuals are now on ART as a result of the “3 by 5” program. It is important to note that the W.H.O. estimates that 6.5 million individuals worldwide need urgent anti-retroviral therapy, immediately. In Africa, despite the tripling of individuals on antiretroviral therapy since W.H.O. launched the “3 by 5” program 18 months ago, nearly 90 percent of those in need do not have access to ART.

In view of the major funding gaps in international H.I.V./AIDS remedial efforts, what are the prospects for additional funds in the next two years?

Prospects for Additional H.I.V./AIDS Funds

The prospects appear mixed. The declaration by G-8 leaders at their 2005 summit in Scotland to provide funds for “universal access” to antiretroviral therapy by 2010 for those in need is a very significant positive development. The political leaders of the richest nations on earth are now on record as making a definite political commitment to end the current dichotomy of access to ART in developed and developing nations. The implication of the declaration is that G-8 leaders will increase financial and technical resources to meet the 2010 timeline.

The commitment of G-8 nations to fully meet the financial obligations of the Global Fund for 2005 is also encouraging. However, these commitments should be counterbalanced with somber news: every day, every week, every month and every year, fathers, mothers, sons and daughters who are clinically qualified for ART will die without immediate assistance to readily available medicines. The cost of avoidable delays in mobilizing and utilizing resources in the fight against H.I.V./AIDS is very finite for millions of individuals in need of ART: they will die.

The situation is especially bleak for Africans dying of AIDS. For the 4.2 million Africans currently in need of ART, the G-8 pledge of universal access to treatment by 2010 will be academic since most of them would have lost the fight against AIDS. Delays in providing a comprehensive H.I.V. preventive program can only mean additional cohorts of newly infected individuals and affected families.

Another important development is that a looming war appears in the horizon between donor and recipient countries on governance reforms. The 2005 G-8 communiqué is the most specific documentation of rich nations resolve to hold recipient countries accountable for verifiable progress in governance and anticorruption measures. It is likely that G-8 nations will not redeem their pledges of additional financial assistance to recipient countries deemed lacking in governance.

On the other hand, recipient countries are likely to chafe against overt and subtle pressures from donor countries on yardsticks for governance, especially stamping out corrupt practices. Recipient countries will cite the need to let the judicial system take its course once public officials are indicted for corrupt practices rather than being stampeded to politically solve corruption cases. The next few years may witness heightened tensions as G-8 and other rich nations aggressively pursue governance reforms in recipient countries as a condition for increased development assistance.

Thus, a situation may arise within the next few years whereby disagreements on governance between donor and recipient countries may hold up the disbursement of urgently needed financial and technical resources for H.I.V./AIDS remedial efforts. The irony is that H.I.V./AIDS target populations in recipient countries will bear the brunt of the disagreements over governance reforms. Future attempts by donor countries to “reward” good economic or political “performers” in recipient countries will also consign H.I.V./AIDS positive citizens of non-favored nations to second class status and avoidable suffering and death.

What can be done to end the looming funding crisis for H.I.V./AIDS remedial efforts in resource-challenged environments?

Ending a Potential H.I.V./AIDS Funding Crisis

First, the G-8 and other rich nations should pledge to meet all verified H.I.V./AIDS funding shortfalls between now and 2010 in order to satisfy two important remedial goals:

A) Providing comprehensive preventive services to individuals at risk of contracting H.I.V.; and,

B) Providing universal access to treatment for all individuals clinically qualified to receive antiretroviral therapy.

A pledge sooner rather than later by G-8 nations will have the benefit of allowing bilateral and multilateral agencies and recipient governments to plan ahead knowing that all legitimate H.I.V./AIDS program needs will be met. An immediate pledge by G-8 and other rich nations to meet all legitimate shortfalls in H.I.V./AIDS funding between now and 2010 would also set in motion a comprehensive process for verifying H.I.V./AIDS funding needs so that politicians and policy makers can make a more convincing case to their tax payers. A funding pledge by G-8 and other rich nations would also force recipient countries to set up verifiable indicators of governance since donor countries have already pledged to support legitimate funding needs. G-8 nations should honor their pledges as and when due.

Second, all poor countries with more than 5 percent H.I.V. prevalence should have 100 percent debt cancellation and savings invested in verifiable programs. The G-8 nations deserve commendation for the cancellation of the debt of 18 poor countries. However, in the fight against H.I.V./AIDS, AIDS-hit poor countries should not service foreign debts when their citizens are dying because of lack of access to available medicines. The cancellation of the debt burden of AIDS-hit poor countries will also force recipient country governments to accelerate their governance reforms and take concrete steps to combat corruption. In addition, the civil society of these countries will become active watchdogs of their government and policy makers.

Third, it is now critical to resolve donor concerns about governance in recipient countries. It is no secret that donor countries are growing increasingly frustrated with lack of progress on governance issues in recipient countries. Misappropriation of funds, difficulties with organizing legitimate elections, inability to secure lives and property, lack of independent judiciary, marginalization of minorities, limited capacities to enforce contracts and monopolization of political power are major concerns of donor countries. The relatively weak standing of national civil society organizations and human rights watchdogs is also complicating governance reforms in many recipient countries.

It is now time for donor and recipient countries to establish PRINCIPLES OF GOVERNANCE with verifiable indicators that are public knowledge to tax payers in donor and recipient countries. These principles should apply to all governments and should have no sacred cows in recipient countries. Donors should also not play favorites and should not provide sanctuary for ill-gotten gains from recipient countries. For recipient countries, it is critical for opposition parties, professional associations and the civil society to play a verifiable watchdog role on H.I.V./AIDS remedial programs.

Finally, it is critical to reform H.I.V./AIDS remedial efforts with a principal focus on how to meet the needs of individuals and families infected and affected by H.I.V./AIDS. In the last five years, steady progress has been made on mainstreaming H.I.V./AIDS in the political, economic and social arena. The rich nations have set a timeline (2010) for universal access to ART. Recipient countries are moving more into population-based democracy and making gains in governance. Debt cancellation as a weapon in the fight against H.I.V./AIDS is now widely accepted.

However, what has failed so far is how to make a difference in the lives of individuals and families battling with H.I.V./AIDS. Very few domestic or international H.I.V./AIDS remedial programs can provide a verifiable answer to a basic question: How many individuals living with H.I.V./AIDS received direct benefits as a result of the remedial effort? How many families affected by the sufferings of a loved one living with H.I.V./AIDS received direct benefits from the remedial effort?

Today, while AIDS remedial efforts continue to mature and become more sophisticated, the target population in resource-poor countries remains outside its sphere of influence. There is a danger that the AIDS bureaucracy, public and private, worldwide, may become more important than the needs of the target population. A lack of impact on the target population may lead to an increasing emphasis on process indicators as barometers of H.I.V./AIDS remedial efforts. The lack of a significant, sustained impact on the target population may lead to the celebration of modest program successes for a pandemic that kills more than 2 million people every year. For example, in Africa, is it correct to celebrate the fact that only 500,000 people out 4.7 million qualified individuals (about 11 percent) are on ART?

For a pandemic that had been around for more than 2 decades, the lack of impact of remedial efforts at the individual and family level is remarkable. The needs of the target population should now assume primacy.

Every AIDS agency should focus on how its actions or inactions affect the individual or family dealing with H.I.V./AIDS. Every measurable indicator should include evidence of how specific action will impact individuals and families dealing with the pandemic. Future funding estimates and projections should show verifiable evidence of how past remedial efforts impacted individuals living with H.I.V./AIDS and their families.


A funding crisis looms in H.I.V./AIDS remedial efforts in resource-poor countries. The UNAIDS estimates a funding shortfall of $18 billion between now and 2007. A funding shortfall would have devastating consequences on steady gains made in H.I.V. preventive programs and access to lifesaving, antiretroviral therapy. G-8 and other rich nations should step forward and ensure that H.I.V./AIDS remedial efforts remain fully funded. Recipient nations should ensure that concerns about governance and corruption become a thing of the past. H.I.V./AIDS remains a deadly pandemic, killing more than 2 million people every year. Individuals and families infected and affected by H.I.V./AIDS should become the cornerstone of future H.I.V./AIDS remedial efforts.

Chinua Akukwe teaches graduate courses in global health at the George Washington University School of Public Health, Washington, D.C.

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