Working to Advance Health Equity in Africa



HEARD hosts high level discussion on ‘The future of AIDS financing in Africa.’

HEARD recently hosted a unique meeting of African ministers of Health at the Ditchley Foundation, Oxford, in the UK. Also in attendance were selected Directors of National AIDS Commissions, UNAIDS officials, the World Bank, United Nations Development Programme, Swedish International Development Cooperation and other concerned organisations to consider the future of AIDS financing.  The meeting was organised by Professor Nana K. Poku, Health Economics Research Chair at the UKZN. The discussions turned on the call by UNAIDS for greatly increased funding in order to meet its accelerated ‘Fast Track’ for the five years to 2020 – and beyond that, to the 2030 Sustainable Development Goals (SDGs).

Discussions focused on two fundamental tensions.

The first, being that HIV and AIDS are now sited within the very large and encompassing SDG, which cover nearly every important aspect of human security and environmental stability. The cost implications of any combination of the larger of these issues (climate change; ending poverty in all its form) will sharpen the unavoidable political differences over prioritisation. The second of these tensions being the imperative of establishing or greatly extending and improving Universal Health Coverage (UHC) in southern African countries, while consolidating and furthering the advances made against AIDS to date.

There is very considerable inertia behind the massive and costly roll-out of anti-retroviral treatment (ART) to 18 million individuals, which include the burdens entailed in keeping these regimes in place into succeeding decades. In addition, as many as twenty-six million HIV-positive people await treatment availability; and a ‘test and treat’ approach has been advocated by UNAIDS. Yet, despite the changed and changing fiscal landscape, a ‘more of the same, but better’ ethos persists – and with it, not a grounded reconsideration of ends and means, but a hope that African states will be able to ‘create fiscal space’ and find efficiencies on a scale that will not only cover donor shortfalls but will also secure a near-doubling on resources.

Historically, we know that the steepest declines in new HIV infections have arisen from behavioral change, but identifying what is most effective has proved difficult to identify and is very likely to be highly context-dependent. This makes more research into effective and enduring behavioral change for the purpose of reducing infections a first-order priority.  Also evident in the discussions was a divergence over the how the struggle against AIDS should relate to the progression of UHC.  Although arguments which turn on ‘vertical versus horizontal’ approaches are over-simplifications, so too are the ideas that (where it exists), complementarity between AIDS and primary health services can obviate the need for hard choices, or that the negative and disruptive legacies of AIDS provision in matters ranging from sustainability to staff shortages can quickly be surmounted. Nor can the AIDS funding crunch be abstracted from the political and legal responsibilities of Health Ministries, the worsening problem of non-communicable diseases, or normative expectation (both local and international) for something which at least approaches the ideal of universal health.

The era of AIDS primacy and abundant resources is already over, but we have not yet adjusted our strategic thinking—and now, more than one year into the five-year ‘Fast Track ‘ period, we have no time to lose. Instead of insisting on and hoping for the ideal, we must calculate how much we can accomplish with considerably less. Hard choices await, but failure to recognise that ‘business as usual’ is not an option will make those choices harder still.


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