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The Turning Point in Spending for Combating HIV/AIDS

Hillary Rodham Clinton, Aaron Motsoaledi

SOURCE: AP/Jacquelyn Martin

Secretary of State Hillary Rodham Clinton talks with South Africa's Health Minister Aaron Motsoaledi after attending a President's Emergency Plan for AIDS Relief, or PEPFAR, Transition Signing, Wednesday, August 8, 2012, at the Delft South Clinic in Delft South, a suburb of Cape Town, South Africa.

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Food for thought: Who spent more on preventing and treating HIV/AIDS last year—international donors or those developing countries trying to combat the disease within their own borders? In past years the quick and easy answer would have been “international donors.” But according to the new “World AIDS Day Report” issued by the United Nations, domestic spending in developing countries on HIV/AIDS outpaced international investments in 2011.

Notably, it isn’t just the more affluent developing countries such as Brazil and India that have upped their own health spending. According to the new report, more than 81 low- and middle-income countries increased their domestic investments in combating HIV/AIDS by 50 percent or more, as their combined HIV expenditures rose from $3.9 billion in 2005 to $8.6 billion in 2011. Global spending dedicated to HIV/AIDS came in at $8.2 billion in 2011. The fact that developing countries were able to assume real financial leadership in fighting the AIDS pandemic amid a global financial crisis is nothing short of remarkable.

This shift in spending also marks the way forward for the United States as it tries to maintain its leadership in fighting HIV/AIDS internationally while at the same time dealing with severe budget pressures at home. In our recent report, “Engagement Amid Austerity,” we offered some concrete recommendations about how the United States can best and most efficiently direct its scarce international aid dollars. One recommendation was for the flagship international anti-HIV/AIDS effort of the United States—the President’s Emergency Plan for AIDS Relief, or PEPFAR—to encourage greater burden-sharing with the seven upper-middle-income countries and regions where Washington has established “Partnership Frameworks” to help these countries and regions become more self-sufficient in managing their health challenges, including the challenge of HIV/AIDS.

In our report we argued that these more well-off developing countries should be able to take over 60 percent to 80 percent of the programs and activities currently funded by the President’s Emergency Plan for AIDS Relief within five years. While some thought this recommendation controversial at the time, the “World AIDS Day Report” suggests that, if anything, we aimed too low.

The U.S. government’s Partnership Frameworks outline the expected arc of U.S. government support over the next five years and how host-country investments and policy changes can position governments to assume primary responsibility for combating HIV/AIDS in the future. The five-year joint strategies outline cooperation between the U.S. government, the partner government, and other groups involved in service delivery, policy reform, and coordinated financial commitments. It’s expected that within this timeframe host countries will be better situated to control the management, strategic direction, performance monitoring, decision making, coordination, and, where possible, financial support and service delivery of their own HIV/AIDS programs. In many cases host governments should be able to deliver the same results, but more cheaply, because they rely more heavily on local institutions and local partners rather than comparably more expensive international expertise and organizations.

The frameworks are intended to be transparent, accountable, and open to participation from civil society, the private sector, and international organizations that will help strengthen the capacity of governments to plan, oversee, manage, and ultimately finance national HIV/AIDS strategies.

While the cost-sharing component in these agreements is good for the U.S. international affairs budget, the lasting benefit may well come from the Partnership Frameworks’ ability to provide a model for how to foster country ownership and transfer financial responsibility to recipient countries. The President’s Emergency Plan for AIDS Relief has become more effective as it has transitioned from acting like an emergency humanitarian assistance program to instead focusing on shaping a long-term, sustainable, and integrated approach to health and development.

Unfortunately, only about one-third of countries receiving funding from the plan (22 of 59 countries) currently have a Partnership Framework in place. But when operational, these frameworks have enjoyed a relative degree of success.

Case in point: South Africa, an upper-middle-income country that was an early leader in putting a Partnership Framework in place, signed the agreement in December 2010. In the last two years, it increased its scale-up of HIV treatment by 75 percent, and new HIV infections fell by 50,000, according to the “World AIDS Day Report.” South Africa’s Partnership Framework notes the country’s increase in domestic spending on HIV/AIDS to $1.3 billion this year, up from $576 million in 2008. During this same period, U.S. investments in HIV/AIDS in South Africa fell by $107 million to the current level of $484 million. These are considerable achievements for South Africa, but what can’t be quantified is the growth in country ownership as South Africa designed and implemented its own national AIDS response within its own health systems.

This opportunity for greater country ownership shouldn’t be confined to the more affluent developing countries. Yes, upper-middle-income standouts like South Africa and Botswana have dramatically increased domestic HIV spending, quintupling and doubling it, respectively, from 2006 to 2011. But the picture for many low-income developing countries is just as heartening. Kenya doubled its domestic HIV spending from 2008 to 2010, Togo doubled its domestic spending from 2007 to 2010, and Rwanda doubled its domestic spending from 2006 to 2009.

As low-income countries marshal increased resources for HIV/AIDS, funding and allocation decisions should also equitably increase. Every country that receives funds from the President’s Emergency Plan for AIDS Relief should be operating under a Partnership Framework that enumerates this devolution of decision-making duties and provides a clear guide for appropriate burden sharing.

If a country like Togo is willing to double its HIV/AIDS investment, the United States should be there, ready to assist its partner country buildup and manage its national health system through a sustainable approach to health that fits within a broader development model. This approach isn’t about the United States slashing foreign aid programs—it’s about using every dollar wisely to secure enduring change.

Casey Dunning is a Policy Analyst for the Sustainable Security and Peacebuilding Initiative at the Center for American Progress. John Norris is the Executive Director of the Initiative.

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