From exceptionalism to sustainability: AIDS financing revisited

In the past, lack of resources has not been a big issue for AIDS initiatives. ‘Exceptionalism’ – the view that the severity of the disease justifies donor funding regardless of the long-term financing implications – has been the financing paradigm. Now tougher economic conditions are challenging this paradigm and raising questions about how low and middle income countries will fund their AIDS responses.

Part of the problem is that levels of official development assistance have been rising more slowly than expected since the UN Conference on Financing for Development in Monterrey in 2002 and, in the wake of the 2008 global economic crisis, more and more donor countries are reassessing the amount of aid they can provide. At the same time, the success of antiretroviral therapy (ART) programmes in many countries means there is now an expectation among the HIV-positive population that care will be provided throughout their lives, presenting governments with an ethical as well as a financial dilemma.

To attempt to resolve this dilemma, the first step is to conduct a ‘baseline AIDS financing gap’. This can be done using data from National AIDS Spending Assessments and UNGASS reports, combined with macroeconomic forecasting, to set out the predicted resource availability against the expected resource needs.  The AIDS financing gap, in a scenario of 'business as usual', gives an idea of the extent to which countries are capable of scaling up the AIDS response to meet current and future demand.  Most often the AIDS financing gaps are substantial.

One way to fill any financing gap is to increase efficiency of service delivery. Data envelopment analysis and efficiency-gain projections will show whether a country is making effective use of its existing AIDS resources, as well as the savings that can be made in the short and medium term. In some countries, efficiency levels are very low. Lesotho, for example, could generate twice as much value from each dollar spent on HIV and AIDS programmes through efficiency programmes.

Alternative sources of funding are another strategy.  Special taxes – such as adding a fixed amount to flight costs for international passengers or incorporating AIDS into health insurance benefit packages – are an option. ‘Mainstreaming’ – promoting the idea that, since AIDS is a complex development challenge, everyone should play a part in working to combat it – is another. For example, governments could require public and private institutions to dedicate a certain proportion of their budget to AIDS work. Other possibilities include social health insurance, an increased allocation to AIDS from general taxation or setting up an AIDS Fund.

Once all the options to close the gap have been assessed, a ‘revisited AIDS financing gap’, can be calculated. Our analyses show that some countries, such as Botswana, Burkina Faso and Zambia, could significantly expand fiscal space for AIDS and close the AIDS financing gap in the medium term. Other countries, such as Lesotho, for example, are likely to remain heavily dependent on external assistance in the foreseeable future.