Global health architecture: A new vision is needed
Global advocacy in an era of resource constraints and shifting global priorities
Von Eduard Grebe
The success of the global AIDS activist movement bringing about change in the global AIDS response is impressive. However, its time of greatest influence seems to be behind it, but the task ahead is still vast. It is critical that AIDS and global health activists revitalise their own movements and organisations.
While HIV/AIDS remains one of the greatest challenges facing humanity - 2.7 million new HIV infections and 1.8 million AIDS deaths in 2010 - huge progress has been made, not least in rolling out antiretroviral treatment in sub-Saharan Africa. The global AIDS activist movement deserves substantial credit for these advances; in fact, it may be the most impressive example of health activism the world has seen.
However, it is a movement that faces serious challenges: instead of the increases in resources for AIDS programmes in developing countries that would be required to sustain progress, resources are declining. The Global Fund is in crisis, HIV/AIDS is no longer perceived in international policy fora as the major priority it once was (with attention shifting to other important questions like climate change), HIV/AIDS and public health advocates are fighting among themselves about whether disease-specific programmes are appropriate and leading activist organisations like the Treatment Action Campaign (TAC) are in decline. If the progress that has been made is not to turn into reverses, the global public health activist movement must be revitalised and a new partnership forged around a vision of universal access to integrated and effective healthcare systems.
Local and global advocacy has contributed immensely to advances in AIDS treatment
The transformation of HIV/AIDS from an automatically-deadly diagnosis to a manageable chronic disease through the advent of highly active antiretroviral treatment (HAART) in the mid-1990s was initially of little use to people living with HIV in the developing world. In 1997 a year's treatment cost about US$16,000. But in the late 1990s an unprecedented global movement emerged, initially out of North American AIDS activism (itself drawing on the experiences of Stonewall-era gay rights activism). It comprised a network of activists spanning both the globe and social classes, bringing together people as diverse as gay activists from New York and Paris, women from poor villages in Africa and sex workers from South Asia. This movement forged a coalition that articulated access to healthcare and antiretroviral treatment as a human right and a moral imperative that could not be ignored. Together with a few visionary global leaders (Kofi Annan who drove the creation of the Global Fund to Fight AIDS, TB and Malaria, George W. Bush, who garnered support for the US President's Emergency Plan for AIDS Relief, Peter Piot, relentlessly working within the slow-moving UN system), sufficient momentum was attained to significantly expand access to antiretroviral drugs. The prices of ARVs were driven down to as little as US$143 per patient per year in 2010 (thanks largely to activist pressure for flexibility in intellectual property rights protection) and donor government disbursements increased from US$1.2 billion in 2002 to US$7.7 billion in 2008 (Kates et al 2011).
The Treatment Action Campaign in South Africa was one of many social movements to emerge in the developing world (if perhaps the most prominent) and played a critical role in both the establishment of global activist networks and domestic pressure for appropriate policy. TAC deserves a large part of the credit for the South African government's reversal of its AIDS denialism-inspired policy against the provision of antiretroviral treatment. It provides a model of poor and marginalised people effectively wielding social power against entrenched interests, including that of multinational pharmaceutical companies and a callous political class. It is particularly instructive for its use of both domestic civil society coalitions, meticulously built over time, and transnational activist networks in order to gain influence. Its influence even extended into the state and global institutions in what I have termed a "transnational network of influence". (Grebe 2011)
But it is also a movement whose success can probably not be readily emulated. First, the political conditions within which it operated do not exist in most other African countries. South Africa was a new democracy with very strong protections of civil and political freedoms as well as independent courts who were willing to apply a progressive constitution (which includes an explicit right to access to healthcare) in judgments against the executive. Civil society movements in most other African countries do not have the freedom to pursue campaigns like TAC's without risking being crushed by powerful governments impeded by few checks and balances. Second, the South African HIV epidemic approached its peak at a time when global AIDS activism also approached its zenith (in part as a result of TAC's work), in a period of highly visible and effective campaigning.
TAC's time of greatest influence is therefore probably (and sadly) behind it. It is in the midst of a slow and incomplete leadership transition, from its founding generation of leaders to a new generation that is competent and commited, but has less experience and inherits a movement of tired activists. It is faced with a new set of challenges: ensuring continued progress in antiretroviral treatment delivery, revitalising a crumbling public healthcare system and improving HIV prevention. The end of state-supported AIDS denialism has (paradoxically) weakened TAC by removing a source of public support and attention. Donors are turning to other projects. It is unlikely that TAC can rekindle the energy and the public support it had a decade ago.
The decline of the global AIDS treatment movement
This malaise extends to the global AIDS activist movement. Many passionate activists and advocates for AIDS treatment continue to work tirelessly. But the level of attention, both from the media and from policy makers, has declined substantially. Increasingly, attention is focused on other problems, especially the continuing global economic crisis (particularly acute in Europe) and the long-term risks of climate change (which is, even with increased attention, not being addressed adequately).
With high-income countries battling recession and stagnation at home, bilateral and multilateral assistance for HIV/AIDS dropped off substantially after 2008:from US$7.7 billion in 2008 to only US$6.9 billion in 2010 (Kates et al 2011). In contrast to the substantial increases that would be required to increase access to antiretrovirals beyond the mere 35% of the 15 million people who require treatment currently receiving it. The Global Fund has had to cancel its eleventh round owing to funding shortfalls. We have a long way to go, and now little chance of getting to the destination.
To make matters worse, the global health architecture created to give effect to the universal access vision is not functioning optimally. Allegations of corruption and suspension or delays in disbursements are routine for Global Fund-funded projects. Even TAC - where financial management is beyond reproach - narrowly avoided the shuttering of several large projects and the retrenchment of most of its staff earlier this year owing to severe delays in the disbursment of Global Fund funds that had been allocated to it. It has still only received a portion of these funds -- and this is in a relatively well-resourced country with greater capacity at its CCM than is the case in many others.
Furthermore, the oppositional discourse that has emerged in the debates on global health priorities has harmed the cause of increased resources, not only for AIDS, but for health in general. While AIDS activists, global health advocates and development experts have bickered about whether we should be investing in disease-specific programmes or strengthening health systems, whether we should be focusing on malaria or diarrhoeal diseases, donors have started to look elsewhere. (For a discussion of the backlash against AIDS-specific funding, see Nattrass and Gonsalves 2010). Instead of asking "what should we be spending on rather than AIDS?" we should have been asking "how can we best use the mechanisms and programmes we have built to ensure both increased delivery of AIDS treatment and stronger health systems?"
In this context, simply calling for increased funding for HIV/AIDS and/or for global health is unlikely to have much impact. This was brought home to me at the 2008 International AIDS Conference in Vienna, where the US Global AIDS Coordinator, Eric Goosby, was picketed by activists angry over the failure of the Obama administration to increase funding for PEPFAR. While I felt great sympathy with the cause of the protestors, it also appeared to me to be a campaign with no hope of success given the extent of the economic crisis in the United States and the hostility of the Republican-dominated Congress to increased international aid. It was clear that something more would be required than repeating the calls of earlier campaigns increasingly loudly in the face of a hostile political climate.
What is needed?
Reversing the declines in international AIDS assistance and building a new consensus on investment in global health requires that a new vision be articulated that can unite activists and policymakers in both donor and recipient countries. A good articulation of such a vision is provided by Mark Dybul (former US Global AIDS Coordinator and now with Georgetown University), Peter Piot (founding UNAIDS Executive Director and now Director of the London School of Hygiene & Tropical Medicine) and Julio Frenk (dean of the Harvard School of Public Health) in a recent article for the journal Policy Review (Dybul, Piot, Frenk 2012). They argue that while much of the progress achieved in the first ten years of this century has been thanks to newly-created disease-specific institutions and mechanisms (principally the Global Fund and PEPFAR and large philanthropic initiatives like the Bill and Melinda Gates Foundation), "the focus on specific diseases has exposed fault lines in delivering services in places where many suffer from multiple health issues at the same time or at varying points in their lives". They propose instead an integrated approach focused on the health of individuals and communities to be driven through a new international health strategy and architecture comparable to the Bretton Woods agreement of 1944 and the institutions (like the World Bank) that gave effect to it.
A new international agreement to build a rational global health architecture is a very ambitious proposal indeed. But it is a vision that global health advocates - including those focused on HIV/AIDS - can unite around and that can become the foundation for a moral consensus and policy agenda to drive a new round of activism. Unless we are able to overcome what I have referred to as the "oppositional discourse" around conflicting international health priorities (HIV/AIDS programmes vs. health system strengthening, bed nets vs. sanitation programmes) it will not be possible to focus our limited advocacy resources and stand a chance of building on the progress that we have already made in rolling out antiretroviral treatment in the poorest countries.
In pursuing this ambitious agenda, iterative and incremental advances can be achieved. While a new global health architecture is some way off (even in the best-case scenario), improvements can be made relatively quickly in the coordination and revitalisation of the architecture we already have.
It is also critical that building new partnerships on global health is not limited to mechanisms for transferring resources from high-income to low and middle-income countries. Significant assistance will undoubtedly remain necessary, but even the poorest countries can and must invest in the health of their populations. Not only is it unlikely - especially in the short to medium term - that sufficient resources will be mobilised from high-income countries to maintain the momentum towards universal access, but there are significant risks associated with dependency on external resources. Even now many treatment programmes are at risk because of reductions in funding to PEPFAR and the Global Fund. Countries like Uganda cannot continue to depend on donor funds for more than 90% of health expenditure. Activists, especially those who are based in low-income and African countries, must exert pressure on governments to increase health expenditure, at the very least to the 15% of national budgets that African Union members pledged to allocate to health in the Abuja Declaration of 2001. African countries have largely failed to implement this commitment, resulting in a lost decade of potential improvements in health systems, greater dependency on donors and a weaker moral voice when the leaders of the G8 and other rich countries are criticised for failing to implement commitments on international assistance.
It is also critical that AIDS and global health activists revitalise their own movements and organisations, in order to have a base from which to work. Organisations like TAC and the many similar movements across the developing world should be supported and assisted. They are our greatest asset and without them we cannot hope to succeed.
*Eduard Grebe is a Researcher and PhD Candidate at the AIDS and Society Research Unit, Centre for Social Science Research, University of Cape Town, http://cssr.uct.ac.za/. Contact: firstname.lastname@example.org
- Kates, J. et al. (2011) "Financing the Response to AIDS in Low- and Middle-Income Cpuntries: International Assistance from Donor Governments in 2010." Kaiser Family Foundation Report. Available at http://www.kff.org/hivaids/upload/7347-07.pdf
- Grebe, E. (2011) "The Treatment Action Campaign's Struggle for AIDS Treatment in South Africa: Coalition-building Through Networks." Journal of Southern African Studies, 37(4), 849-868. doi:10.1080/03057070.2011.608271
- Nattrass, N.,& Gonsalves, G. (2010) "AIDS funds: undervalued." Science, 330(6001), 174-5.doi:10.1126/science.330.6001.174-b
- Dybul, M., Piot, P. & Frenk, J. (2012) "Reshaping Global Health" Policy Review, no. 173. Available at http://www.hoover.org/publications/policy-review/article/118116