panel participants agreed that international financing is necessary, but also
pointed to the need for increased domestic funding, both to help fill the gap,
and to take over if and when international funds dried up.
Katz of Health Systems 20/20 said that while countries were increasingly
looking to identify key priorities and potential efficiencies, worryingly few were
considering how to "mobilise resources beyond donor funding." This
was despite Katz's analysis that international funding levels are "well beyond
the levels that can be sustained by [countries]."
addition to simply allocating more to their budget, countries could consider
taxation; taking out loans; debt conversion; and risk-pooling schemes to raise
more money for HIV. For example, Kenya, by enacting an insurance premium among
government employees and a tax on airline tickets, as well as simply increasing
the government budget for HIV, decreased donor dependency. While donors were
responsible for 84% of the total HIV budget in 2008/2009, this figure dropped
to 73% in 2012/2013 once the new funding mechanisms were imposed.
that countries must "have sustainability plans before investment
begins….each time there is a new investment there will be a gradual and
well-planned transition from the donor to the country."
Shakarishvili, UNAIDS country coordinator for Ukraine, noted that while only
50% of the country's HIV/AIDS budget came from external sources - a relatively
low proportion when compared with many high burden countries, especially those
in Africa - nearly all of the funding for vulnerable populations, such as men
who have sex with men, intravenous drug users, and female sex workers, is from
international aid, specifically the Global Fund.
country's HIV prevalence rate is 0.8% - the highest in Europe - these rates jump
significantly among marginalised populations: 22% of intravenous drug users, 9%
of female sex workers, and 6% of men who have sex with men are infected with
country's refusal to pay for most at-risk populations comes from social
marginalisation and stigmatisation of the most vulnerable, and slow political
change. In part because of a high dependence on external funders, a $138
million gap is expected by 2015. The country's ARV program, while nearly
entirely financed by the government, currently only treats 23% of those in
need; only 0.7% of Ukraine's health budget goes to HIV. Shakarishvili is
convinced that "sustainable financing," her euphemism for increased
domestic financing, was possible, but that external support would still be
needed as government increased the allocation of domestic resources.
countries have already increased their domestic financing for HIV. Thobile
Mbengashe from the Department of Health, Republic of South Africa, noted that
the country currently paid for 80% of the country's AIDS response, mostly from
a conditional grant set aside by the government specifically for HIV, and the
remaining from provincial budgets. 70% of the country's total HIV budget goes
to treatment. Currently South Africa pays approximately $600 per person per
year, as compared with $200 per person per year in other African countries. He
explained that this is because South Africa is a "middle income country
and most of the costs for human resources are higher compared to other
countries, despite the fact that we have [reduced] costs using [nurse-initiated
management of ART]. In our last [ARV] tender, we were able to reduce the cost
of drugs by 50%…But there are a lot of opportunities to reduce cost
further." Mbengashe also noted that more money should be put into
recognition that long-term, effective HIV programs require significant
financial resources, and noting the instability of international funding,
donors, international agencies, and domestic governments alike are looking for
alternative resources to ensure sustained and robust funding. Innovative
approaches for HIV financing are being modeled and implemented so that coffers
can be increased.
of a "home-grown solution" to innovative HIV financing is the
Zimbabwean AIDS Levy. First enacted in 1999 through an act of Parliament, the
levy requires 3% of income tax for every person formally employed within the
country, which is collected at the end of each month. The monies are then used
to fund the HIV response and the National AIDS Council of Zimbabwe (NACZ),
whose multi-sectoral members are responsible for deciding how the funds should
50% of the funding is used for HIV treatment, with the rest going to monitoring
and evaluation, prevention, and creating an enabling environment. Myriad groups
can apply to receive some of the funding, and the fund is subject to an internal
and external audit annually.
to Albert Manenji of the National AIDS Council of Zimbabwe (NACZ), the fund not only generates much-needed revenues,
but also shows "significant political commitment" and allows for
Zimbabweans to set their own domestic priorities with a predictable flow of
funding, as "donors will say where they want the money to be used,
irrespective of whether its a priority in the country or not".
is not without its problems, including significant depreciation of the fund
during a period of hyperinflation, and it draws revenue from approximately 30%
of the Zimbabwean population, as the rest are either unemployed or informally
employed. Nevertheless, it raised US$7.9 million in the fourth quarter of 2011.
Manenji hopes the Zimbabwe example can act as a model for other countries to
implement their own taxes. "If this can happen in an economy that is
performing at 40% of its capacity, [it] shows that the opportunity to grow is
Hill of Liverpool University said that other taxes could potentially raise
millions for the global HIV response, as well as for other public health
what he dubbed a "Global Health Charge," Hill suggested that a one-US-cent tax per ten millilitres of alcohol and a 10-US-cent tax on a pack
of 20 cigarettes could generate enough money in 10 of the 20 countries facing
the highest burden of HIV to not only fund universal access, but also spur
efforts to fight TB and malaria.