Growth in South African AIDS spending – crowding out other health investments?

I recently posted about the possible North-South conflict over AIDS spending that might emerge when donors discover that South African taxpayers (i.e. relatively wealthy South Africans) are getting a reprieve while the global fund releases scarce millions of dollars for AIDS treatment in that country — rather than to a country with less domestic fiscal capacity.

But, as Albert Van Zyl’s recent post on the Open Budgets Blog indicates, and I probably should have emphasized, AIDS expenditures have been growing quite substantially in absolute terms and as a share of the overall national budget. He shares responses from a range of South African civil society organizations including a nice analysis from the Centre for Economic Governance and AIDS in Africa. They highlight the growing pressure of AIDS expenditures on the overall AIDS budget:

The HIV and AIDS programme continues to receive the largest resources in the 2012/13 health budget: 33.5 per cent of the total national health budget in 2012/13, increasing to 35.9 per cent in 2013/14, and to 37.6 per cent in 2014/15. This is the second-highest allocation in the health sector. The Hospitals, Tertiary Health Services and Human Resource Development Programme receives 61.4 per cent of the total health budget in 2012/13, but interestingly, the budget proportion for this programme decreases in the medium term (59 per cent in 2013/14 and 57 per cent in 2014/15) as the proportion for HIV and AIDS escalates. We should assess more closely whether HIV and AIDS is crowding out other health expenditures, as this affects the overall mobilisation and utilisation of funding for health in general.

The political scientist in me wonders when this too will become an overt political conflict. Recent scientific studies have shown that Anti-retroviral therapy, which accounts for much of the AIDS bill, is good for prevention as it reduces the likelihood of transmission. But that reality could get lost on people who begin to observe different levels of health care and expenditure allocation based on their sero-status, especially as the AIDS bill takes on a larger and larger share of the overall budget.

The Global Fund and South African taxation

The UN news service just reported that the Global Fund FINALLY released funds for South African AIDS treatment, and several leading actors are quoted expressing profound relief, citing a long delay from promise to payment. Of course, the context is a country with the world’s largest number of people infected with HIV and in need of treatment.

Meanwhile, the SA finance minister just proclaimed the good health of the country’s economy and announced a series of tax breaks.

Hmm, do I smell a recipe for donor resentment? Maybe SA should be footing a bit more of the bill for AIDS treatment and let extremely scarce global fund monies go to countries where there is little economic base or potential for tax collection? Good governance should not be punished, but in a moment of increasingly scarce resources for a critical problem, maybe some budget adjustments would be in order?

The Silent Crisis that is Swaziland

So here are the facts on Swaziland: it’s a land-locked Southern African country with the highest HIV prevalence on Earth. About 1.1 million people live in this Kingdom country, the only fully autocratic, hereditary monarchy left on the planet. Earlier this year, profound budget shortfalls led to service cuts and requests for new loans from international agencies and South Africa.

Life expectancy is 32 years old.

from AVERT

Meanwhile, King Mswati III, in power since the age of 18, maintains a fortune inherited in trust for the Swazi nation of at least $100 million, which he has used to build multiple palaces and to maintain his private jet.

This year, as I’ve written about a few times, Swazi citizens have begun to protest, but each time, the state has deployed massive repression to keep people at home.

Yesterday, the UN news service wrote about a bleak outlook for food security in the face of archaic agriculture (no irrigation systems, planting that relies wholly on rain, very little secure land tenure) and increasingly erratic rains.

So why isn’t the international community doing more (almost anything) to come to support some type of regime change in the face of gross human rights violations and as people continue to die in waves (the population is actually declining)? Here are a few hypotheses:

1. Domestic protests aren’t loud enough – this looks nothing like the Arab protests. To be certain, there have not been massive uprisings, which might suggest that citizens are not nearly as unhappy as the Egyptians or the Syrians. Well, there is the issue that Mswati is still a hereditary monarch in an almost completely homogeneous Swazi country, so indeed, citizens do view him as a legitimate leader. Also, there is the fact that a huge proportion of the adult population is very poor and hungry, HIV-positive, or both, and may simply be too weak or too pre-occupied to protest.

2. Swaziland is in South Africa’s orbit, and South Africa is too nervous to intervene. If Swaziland were outside the sphere of a major African power – let’s say it were out in Central Africa – the U.N., U.S. or the E.U. might feel that they could and should parachute in and help out. But these Western countries most likely feel that this is South Africa’s and Southern Africa’s business, the same way the Zimbabwean quagmire has largely been delegated to the region. In this case, South Africa is not defending Mswati based on the brotherhood of liberation leaders (as is the case with Mugabe), but I imagine that there remains general sensitivity about violations of the norm of state sovereignty, particularly given South Africa’s large Swazi population. One sad irony is that if Swaziland had been incorporated into South Africa rather than becoming the sovereign nation that it is, I think the plight of Swazi citizens would be far better today (though they would have lived under the boot of apartheid for a few decades which would not have been a very good price to pay).

3. Swaziland is a homogeneous country. I am betting that if Swaziland were an ethnically diverse country, the outrageous pattern of rule would likely be described as some type of ethnic oppression and the situation would have caught the imagination of more outside powers and news media.

4. Swaziland is small and contains few valuable resources.

Admittedly, outside powers are between a bit of a rock and a hard place. The most promising initiative for political change appeared when the South African labor confederation, COSATU, began to get involved. But the resources committed appear to have been small, and there has not been much progress. Shortages of ARV drugs may lead some HIV activists to protest,  but I fear that the general enthusiasm around and empathy for AIDS activism is simply not what it once was.

Health and Human Rights blog

I recently wrote a piece for the Health and Human Rights blog on the governance of infectious disease.

So who should be responsible for governing the threat of infectious diseases such as HIV/AIDS, tuberculosis, and malaria? As the “old” paradigm of strong centralized state public health programs was found to be outmoded, a new set of governance models emerged in its wake, all involving greater devolution of authority and more horizontally organized reporting structures. In particular, a few appealing terms have buzzed about during the past three decades of the global AIDS crisis, including “multisectoral,” “synergistic,” “partnership,” “mutual accountability,” and “coordination.” Who could argue with any of these?

You can read the full post here: Health and Human Rights

Amazing: Scientific knowledge translated into South Africa HIV policy

Various scientific studies have recently demonstrated that putting people who are HIV-positive on ARV drugs much earlier will help to extend their lives and to reduce the rates of transmission. All-too-often, that type of discovery fails to be implemented for the people would benefit most. But this week, the UN News Service, IRIN, reports that South Africa is changing its treatment policy to begin treatment when CD4 counts fall below 350, rather than 200.

I have spent a lot of time writing about the political barriers between good science and implemented practice… and this has been quite a longstanding pattern in South Africa. It is certainly encouraging to see progress without such blocks, especially in the country that continues to host the largest number of HIV-positive individuals in the world.


PlusNews Global | SOUTH AFRICA: Govt moves to earlier HIV treatment | South Africa | Care/Treatment – PlusNews | HIV/AIDS (PlusNews).

AIDS Study Marks Prevention Breakthrough With Antiretroviral Drugs –

AIDS Study Marks Prevention Breakthrough With Antiretroviral Drugs – This is very exciting news — for a long time, AIDS activists made the claim that offering treatment to people who are HIV-positive was a good strategy for prevention, because without access to treatment, why would anyone get tested? And if you didn’t know your HIV status, you were much less likely to practice safe sex, etc. While this was and is plausible, I’ve never seen this hypothesis tested.

However, the recent medical study demonstrates conclusively, what medical professionals have been thinking/hoping for some time now — that ARVs reduce infectiousness. In the study cited, it reduced transmission among heterosexual couples by 96 percent! It’s not a vaccine, but it certainly implies that treatment will be critical for prevention. When world leaders get together for the high level UN meeting on AIDS in early June, no one will be able to credibly propose switching AIDS-related budgets away from treatment in favor of prevention. Perhaps this link helps to explain why we are beginning to see infection rates fall in several African countries — as treatment access has greatly expanded in recent years.

Can HIV prevention benefit from social media in Africa?

Today, UNAIDS convened a meeting in South Africa to discuss possibilities for leveraging social media/facebook, etc. for renewing the fight against AIDS. In the wake of the Arab spring, and the rising penetration of mobile technology and the internet in Africa, certainly, it’s worth a try. (Indeed, one of the great hopes of the Uwezo project in East Africa I am currently studying is that social media will help spark positive citizen action.) But I think we need to be cautious before jumping to the conclusion that the power of facebook can translate easily to every development challenge. In the case of HIV prevention, it’s still not clear which messages actually work for behavior change, or if young people, or any people, will be moved by such posts in a manner that’s different from the signs they see everywhere, the commercials on tv, the radio, etc. People couldn’t plan a political revolution out in the open and in schools, and protests required tight coordination of individual actions, so social media had much to offer. Perhaps in the area of HIV prevention there could be substantial benefits if people join groups where others pledge to practice safe sex and/or where members of a social network provide clear and accurate information, respond to questions about prevention methods, etc. But, unfortunately, those same networks are routinely used for the spread of false information, and help to facilitate sexual contacts that may increase the risk of greater spread.

Too many HIV prevention campaigns have been launched based on instinct without much in the way of solid research, and I hope that part of the UNAIDS approach to this new terrain will be to promote such investigations. The Gates foundation has only recently begun to invest in social science research for global health and this would be a great area for new studies.

Global governance of hiv, health

The UNAIDS/IAS workshop concluded yesterday. The most interesting aspect of the day’s session was the consideration of the “global governance” of HIV, which is the configuration of international institutions and actors that try to shape policies, services, behaviors, etc. relevant to the control of the epidemic. The speakers were right to point out some concerns about the problem of large institutions not being able to react with the speed necessary for some types of problems, and for what may seem an unbalanced distribution of authority (still dominated by Northern rich countries, as population and target problems are weighted toward the global South.) To be certain, in an increasingly integrated world, we need to think more about what are the right institutions for addressing truly global problems, rather than thinking about them as problems facing an amalgamation of states.

But I still think it’s worth reflecting more on the enormous successes of global governance organizations in responding to and coordinating responses to this pandemic. Activists can, of course, claim that more should have been done. To think that the rich countries were going to support millions of people on life-saving pharmaceutical treatment in Africa and elsewhere while in many cases (well, really just the U.S.), our own domestic politics does not provide much health care to our own citizens… well, that’s a remarkable story.

Am here at the Tokyo airport, and for the most part, all seems pretty normal here — except for the closure of moving walkways, owing to power cuts associated with the fallout of last month’s natural disasters.

Off to UNAIDS workshop in Bangkok

Tomorrow morning I head off to Bangkok for a two-day workshop on “Thinking Politically About HIV.” Kent Buse from UNAIDS and Dennis Altman from Latrobe university in Australia are bringing together a bunch of political scientists,  policy scholars who write about politics, and several political actors, especially regional directors of UNAIDS, to discuss how various political forces have shaped responses to the epidemic.

I am looking forward to the meeting. Lately, I’ve found myself writing about a lot of dismal stories on African development, and while the AIDS pandemic is still a monumental challenge, there’s actually a great deal of good news, including increases in risk-conscious behavior, greater treatment access, and lowered HIV incidence in many countries. The theme of the workshop is how to harness politics for good, and indeed, political activism has played a very positive role in the global response to AIDS. In the next couple of days, I will try to write about some of the key themes or findings, assuming the discussions are not embargoed. In any case, I’ll post some of my comments… which I need to finish on the plane-ride over… which will attempt to define the ambiguous terms “political will” and “political commitment,” and to share some of my research on municipal councilors in South Africa.

I am not looking forward to the TRIP, however. There are no longer direct flights from New York, so I’ll fly to Tokyo and then connect to Bangkok — I leave at 3pm, arrive close to midnight the next day, wake up and do two days of workshopping, then depart for the airport at around 330am to catch a 6am flight back to Narita, and then back home. I am hoping this trip will be so quick I won’t have time to feel the jetlag…

World TB Day — not today’s top story

Amidst the disaster in Japan, what looks a lot like war in Libya, other developments in the Middle East, and so on, “World TB day,” didn’t get much attention today. Even the WHO’s home page top story concerns the efforts to address the damage from the March 11 natural disasters. And of course, that makes a lot of sense given the crisis and desperation of the situation. But it also reminds me of the longstanding challenge of addressing global health threats like TB: it is rare that any single news event will capture the public imagination and elicit a wide response. Rather, as was the case with HIV/AIDS, attention must be created through steady activism and pressure. However, particularly with relatively slow moving epidemics, that momentum often doesn’t build until the human tolls are staggering, and we find ourselves looking back and saying, “if only…” At the moment, I can’t help but find myself concerned about the stream of reports about drug resistant tuberculosis. Intrinsically bad, MDR and XDR (extremely drug resistant) strains exacerbate the severity of HIV epidemics, especially in high-burden countries, where there is substantial co-infection such as in South Africa.

Reuters reports that the WHO estimates that 2 million people will contact some form of MDR TB by 2015 (Reuters), and not surprisingly, the spread continues in places where there is a lack of diagnostic and treatment infrastructure… which in turn is likely to lead to the development of increased drug resistance.

TB is an “old” disease, and has never garnered the activist energy that helped propel HIV/AIDS onto the global agenda. It nicely rode the coattails of such activism – regard the Global Fund for HIV, TB and Malaria… But given my sense of some global fatigue with spending on the AIDS pandemic, TB advocates may need to really launch their own heroic campaign to support the goal of universal detection and treatment of MDR-TB.