Politics and Policy of HIV/AIDS

In thinking about President Bush’s request to extend PEPFAR’s life for another 5 years and an additional $30 billion, I’ve come across some data that suggests the U.S. is having disbursement problems. While I don’t think this will pose a problem for PEPFAR reauthorization in the short run, I wonder if these problems are unique to the U.S. and what is their origin. I blogged about it before and Kim Yi Dionne of UCLA suggested bureaucratic delays might be partially responsible.

According to data from Jennifer Kates of the Kaiser Family Foundation:

• In 2006, the U.S. committed $2,631.7mn for bilateral and multilateral HIV/AIDS programs in the developing world and disbursed $1,589.8mn (a disbursement level of 60.4%).
• In 2005, the U.S. committed $1918.7mn and disbursed $1095.0mn (a level of 57%) .

In conversations with some other folks who work on this issue, colleagues suggested this was not unique to the United States. Other bilateral donors may be experiencing this problem. The Global Fund was identified as also potentially suffering from a disbursement gap.

I first looked into Canadian and UK patterns of disbursement, and it doesn’t appear that they have those problems. Of course, the Canadians aren’t giving nearly as much, though I suppose it could be a lot for them. The British come closer in terms of volume and given the size of their economy, it is pretty substantial.

When I look at Jennifer Kates’ data on 2005 and 2006, DFID and Canada disbursed all that they pledged for bilateral giving. Canada’s bilateral pledges/disbursements were $107.1mn and $63.1mn in 2005 and 2006 respectively. The UK bilateral pledges/contributions were $637.1mn and $779.6mn in 2005 and 2006 respectively. The only other major bilateral donor that faced a disbursement gap was the Dutch. In 2006 they pledged more than $900mn and only disbursed $345mn.

As for the Global Fund, it has made agreements of grants of nearly $7.6bn since inception and disbursed about $4.6bn (a disbursement level of 61%). There is considerable variation by region with southern, western, and Central Africa’s 57.6% disbursement level and large proportion of overall grants (about 30%) driving the average down. See here for data.

What accounts for this disbursement gap? The Global Fund website suggests this is normal:

Disbursements will always lag behind commitments. The Global Fund follows a performance-based approach to grant-making. This means that additional funds are not disbursed until evidence of progress has been seen. Disbursements are typically made on a quarterly basis.

Cynics might suggest the $15bn and the $30bn figures are designed for maximum political effect with few able to gauge and monitor the actual disbursement levels. I wouldn’t doubt that the President is hoping to achieve some positive press for a now politically popular cause, but the more tricky issue which could bedevil attempts to ramp up spending in the future is absorptive capacity.

Michael Bernstein of the Center for Global Development suggests this may be a huge barrier to getting more money dedicated to this problem:

A major barrier to moving money more quickly is the limited capacity in recipient countries. Many countries with large AIDS epidemics historically spent little on health, so a sudden inflow of large sums cannot be easily absorbed. Donors disbursement policies can exacerbate the problem, making it harder for recipients to manage AIDS funds.

He provides this graphic which shows the rapid increase in donor financing for HIV/AIDS efforts from PEPFAR, the Global Fund, and, to a lesser extent, the World Bank. He notes that:

The new resources provided by the “big three” funders represent a huge increase in funds at the country level. In Uganda and Ethiopia, once AIDS money began flowing from all three funders in 2004, the amount of money provided quickly approached (and by 2005 had exceeded) the governments’ 2003 budgets for the entire health sector.

He emphasizes the difficulty of complicated reporting requirements that vary by donor, and the amount of time it takes to get proposals through. He also details the vagaries of the way in which PEPFAR agreements of various forms take shape with recipient countries. Bernstein recommends more flexibility in how donors allow funds to be spent.

In any case, this is an interesting area. Some of my colleagues suggest rescinding U.S. restrictions on prevention spending would enable the U.S. to spend more (rules requiring 2/3 of prevention funds be spent on faithfulness and abstinence, restrictions on talking with sex workers). Since prevention is only a piece and a smallish piece of U.S. HIV/AIDS spending (20%), I wonder if flexibility post-reauthorization would provide all that much cushion in the U.S. ability to disburse more.

I think the real challenge is what happens if donors (even partially) make good on their commitments at Gleneagles to provide universal access to treatment by or near 2010. The UNAIDS study on the costs of scaling up, not only for treatment but prevention and care, are quite large, requiring a doubling to quadrupling of current flows, as I blogged about here.

The absorptive capacity issues will likely loom even larger in the months and years to come, which could be problematic for donor’s willingness to foot a larger assistance program.

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Filed under: Politics and Policy

The Economist has a great story on the replenishment process for the Global Fund that is happening in Berlin. I am a big supporter of treatment, but here is the nub of the issue, which gets back to the notion of an open-ended lifetime entitlement that Western donors are providing for those infected with HIV.

The problem with AIDS is that the more successful you are at treating it, the more you end up paying. That is because, unlike malaria and tuberculosis, it is incurable. Once someone is infected with HIV, the virus that causes it, they will end up requiring treatment for life.

UNAIDS has a new report that examines three possibilities for expanded coverage for treatment, looking at modest expansion of current rates (8 million people by 2015, universal access by 2010 for 14 million, or universal access by 2015). The price tag is pretty high.

Scaling-up at current rates. This approach would require between US$ 14 to US$ 18 billion and would provide treatment for 8 million people by 2015.

Universal Access by 2010. This approach envisages significant increases in available resources and an urgent and dramatic scale-up of coverage in all countries. The approach would provide treatment for 14 million people by 2010 and would require between US$ 32 to US$51 billion. In 2015 the approach would require between US$ 45 and US$63 billion.

Phased scale-up to 2015. This approach assumes different rates of scale-up for each country based on current service coverage and capacity, with the achievement of different programmatic targets at different times and the achievement of universal access by all countries by 2015. The approach would require between US$ 41 and US$ 58 billion in 2015.

Cheap by Iraq War standards, but expensive when you think about what donors provide for global public health. The additional $32bn-$51bn a year is more than twice than busines as usual for the extra 6mn people. This year, $10bn will be spent so gearing up to $32bn or more is going to be some tough sledding.Fortunately, some money will come from middle income countries like Brazil who will finance much of their country’s own efforts to deal with the problem, so it’s not all donor dependent.

That said, the level of external resources is pretty amazing. I’m surprised by the continued commitment, but the political support in the U.S. and the UK is pretty deep and broad. With both the G8 meeting and the replenishment conference being held in Berlin, Germany’s new Merkel government has started to change its tune. In the UK, Gordon Brown, has already announced a £360mn (about $720mn) over 2008-2010, which is about half of what activists wanted. On the other hand, it’s still about $300mn more than what the UK pledged in the period 2005-2007 when it pledged $437mn.

I’ll post some new stuff soon about the other pledges from other donors. We need to come to grips with prevention strategies that work, lest this unmet need for ARV therapy for people continues to climb inexorably.

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Filed under: Politics and Policy

Senator Frist is back in the news this past week for his laudable involvement in Save the Children.  Save the Children has joined a new One initiative calling for an increase in US foreign aid for mothers and children of low-income countries.  Laudable certainly but a bit disappointing too when I read this in the NYTimes [Sept 7, "Ex-Senator to Lead Global Drive on Children's Health"]…

Save the Children hopes Mr. Frist will open doors, and it is still in the process of recruiting senior Democratic leaders, to make its appeal bipartisan.

“The children and mothers who die are in huts beyond the end of pathways with no direct access to political or
media leaders,” Mr. MacCormack said. “We need people who can walk into prime ministers’ and presidents’ offices.”

The children and mothers live in countries whose leaders are clearly failing them.  Their leadership, not ours alone, should be plying the wide halls of prime ministers and the fine offices of presidents.  I work in East Africa and still remember clearly the local constituent outrage over Uganda’s very public problems with the Global Fund.  Taxpaying Ugandans, as citizens anywhere, demand performance and accountability from government.  More of that grassroots, old fashioned constituent involvement is needed if external efforts are to have any lasting impact.

*Matobo was the fictional African country in The Interpreter.

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Picking up the theme Ben mentioned earlier, economist Emily Oster suggests (see our prior blog post here) that exports helped determine the rate of diffusion of AIDS in Uganda. As prices of Ugandan coffee exports declined, men had less pocket money which made it harder for them to have more sexual partners. This view actually could make it possible for Helen Epstein’s arguments on concurrency to co-exist with Oster’s work, as the Center for Global Development argues. They suggest that there could be a problem of people having multiple sexual partners and also true that export price fluctuations might alter how many partners they do have. Here’s a video link to Oster’s presentation at TED (Technology, Entertainment, Design).

It’s interesting to think about Oster’s thesis, and I’m not sure it sits that well with Epstein’s recent book. If Oster is right, then it may be harder to replicate Be Faithful programs around the continent through conscious efforts. It may be harder for people to be faithful if commodity prices increase and give people more income to be able to afford to support more sexual partners.

However, I’m not sure if Oster’s thesis is internally consistent. If people have more money, then, according to Oster, a cost-benefit ratio over the long-term would suggest they have more to live for, so they shouldn’t wreck it by being risky. On the other hand, she also finds that a large proportion of the variance in AIDS rates is explained by variations in export revenue. With higher export revenue, AIDS prevalance goes up. What gives? Am I wrong or are these two conjectures at odds? I believe there may be a correlation there with declining export revenue and prevalance in Uganda, but is the causal connection between walk around money and how many girlfriends men could support right?

Postscript: Oster’s old paper is the one that made the claim that richer people should be more risk averse because they have more to live for. Her newer paper makes the claim that higher export earnings are correlated with higher prevalence levels. It seems to be driven by volume and the time truckers are away from home rather than individual earnings power. More exports means more time demanded of truckers to be away from their families. However, that must also mean more money in their pockets which should mean that, as any forward thinking rational animal, truckers should put a sock on it. Sounds like they don’t which sits uneasily with Oster’s previous work, as far as I can tell.

Postscript 2: I had a good interchange with Oster about this issue, and she sought to reconcile it by talking about long-term vs. short-term behavior change. She wrote that the subject of her first paper was how making people richer over their whole lives could motivate behavior change. It wouldn’t happen overnight, as it relied on shifts in people’s expectations about the future, and she noted that the effects were small.

Whereas the first paper relied on long-term behavior change, she suggests the export story in her new paper is really short-term, as trend data has been explicitly removed. With more exports she says, there are more truck drivers. They have more sex partners, driving epidemic rates up. Over the long-term, high exports could make the country richer, leading people to protect themselves, but in the short-run, the issue is one of more exports–>more truckers–>more risky sex–>more HIV.

The more I read her paper, and from her e-mail, it’s really not about income, but it’s about export volume and the presence of more truckers on the road. She disputed the notion that export volumes in the short run would necessarily mean more income. But, unless truckers have more pocket money, how are they able to enter into these sexual relationships?

I think the mechanism influencing the number of sexual partners needs more elaboration. Do truckers’ change their number of sexual partners in response to education/information, income, or time away from home. It seems like Oster’s thesis comes down to the third explanation. Guys are away from home, and no matter how much money they have in their pocket, they will engage in risky sex. The fact that Uganda experienced a a decline in prevalence wasn’t because the truckers got information or even that they had less money, but there were simply fewer of them on the road. This may be a hasty read of her argument, but I still think it needs some tweaking/refinement.

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Filed under: Epidemiology, Politics and Policy

Jennifer Kates of the Kaiser Family Foundation and her collaborators found that in 2006, the U.S. promised much more for global AIDS funding than it disbursed for the second year in a row. In fact, the U.S. only disbursed 56% of bilateral funds that were promised. In 2006, the U.S. committed $2,362.8mn but only disbursed $1,320.9mn. In 2005, the U.S. committed $1,918mn but disbursed only $1,095mn.

The U.S. was still the largest donor, contributing more than 44% of bilateral donations in that year, but it does raise questions. Is the gap a problem with U.S. overpromising or insufficient absorptive capacity in recipient countries? Would disbursement be higher if the U.S. delivered more funds through the Global Fund than through bilateral channels? (In 2006, the U.S. committed about $464mn to the Global Fund, only 58% (abou $269mn) of which went to AIDS.)

Anybody know?

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Filed under: Politics and Policy