Preview document (🔗 origineel)

---

Global Financial Architecture of the Aids Responses

Plenary session – Session Room 1

Tuesday, August 5

12.45 – 16.00

Honourable Ministers, ladies and gentlemen,

I am pleased to have an opportunity to give my perspectives on the topic
of this afternoon’s discussion, the Global Financial Architecture of
the AIDS response.

In 2006 global leaders made a commitment to achieve universal access to
HIV prevention, treatment, care and support by 2010. This commitment
represents an exciting level of ambition and hope, but also poses
formidable challenges to all of us. Each one of us represented in this
panel - implementing country governments, donors, financing institutions
and global normative agencies – is grappling with difficult questions
that will be the topics of this afternoon’s discussion. How can we
make sure that scaling up HIV services contributes to health systems
strengthening, rather than detracting from it? How can we ensure that
resources, domestic and international, are spent effectively? How do we
sustain funding for life-long treatment when we know that resource needs
will increase dramatically over the coming years? And how can we
collectively better support national efforts to fight HIV/AIDS and limit
transaction costs to developing country governments?

I want to focus my intervention on two critical areas. Firstly I want to
speak about the level of funding and the way funds are used. Secondly I
will reflect on linkages between HIV/AIDS and the broader health and
development issues.

Funding for HIV/AIDS has increased twenty-fold over the last decade to
an estimated USD 10 billion in 2007. This is unprecedented in
international development and we owe that to the unwavering efforts of
many advocates around the world. Is it enough? Not nearly so. UNAIDS
estimates that funding levels must quadruple between 2007 and 2010 to
achieve universal access. 

We welcome the political resolve in the United States to renew its
global AIDS program and to significantly increase the resources that
will be made available. We would like to see similar resolve in other
major economies of this world. A recent study by UNAIDS and the Kaiser
Foundation listed my country, the Netherlands, as the number one
per-capita donor on HIV/AIDS, and the third international donor in
absolute terms, after the United States and the United Kingdom. Whilst I
am proud to be the number one per-capita donor, I have mixed feelings
about being the third largest donor internationally. Should I consider
this an achievement of a relatively small economy? Or is it rather a
sign of underachievement of all those other countries with economies
that are far larger than ours? I tend to the latter interpretation.

Are we spending our money effectively? The latest UNAIDS report that was
released last week contains some encouraging news. Three million people
in low and middle income countries are now on treatment and the numbers
of deaths due to AIDS are slowly declining. More HIV-positive pregnant
women receive antiretrovirals to prevent the transmission to their
children. HIV prevention efforts are beginning to show success in some
countries and we see encouraging signs of sexual behaviour change among
young people. These are welcome indications that funding has produced
results and impact. We can, and must, however do much more to increase
our effectiveness. We must look harder to reach the people who do not
have access to treatment. These are disproportionally the disadvantaged
and marginalised groups in our societies. We must massively scale up
prevention efforts and address the real drivers of the epidemic. “Know
your epidemic” should the basis for evidence based planning with no
room for ostrich tactics and denial. Power dynamics and the poor
position of women and girls increase their vulnerability for infection.
We must do much more to empower women and respect their sexual and
reproductive health and rights. We must do much more to protect the
rights of marginalised groups such as injecting drugs users, sex workers
and sexual minorities and increase their access to effective
interventions. Last week’s edition of Science contained a rather
disturbing figure on prevention expenditures on men having sex with men
in Latin American countries with highly concentrated epidemics in this
group.

With some positive exceptions – Mexico and Peru in particular – the
overall picture was grim and illustrates the overt bias against sexual
minorities in many countries in this region.

Are we spending our money equitably? Last week’s Science clearly
demonstrated we are not. Whilst a number of well-organised countries
have been successful in securing significant commitments from donors,
others have not. Rwanda has received over USD 2000 per infected person
while this amount is lower than USD 150 for countries such as the
Democratic Republic of Congo, Central African Republic, Sudan and
Myanmar. Corrupt governments, civil wars and the absence of
infrastructure scare away donors. There are no simple solutions to this
and yet we know that any global response to AIDS must address the impact
of the epidemic in fragile states. This is a collective responsibility
and one where each and every one of us must be prepared to take risk.

Secondly I want to share some reflections on the need to improve
linkages between the AIDS response and the broader health and
development agenda. It is evident that better integration is needed to
achieve and to sustain universal access. We must combine the incredible
energy and activism of the AIDS community with the long-term approaches
to sustainable and equitable development. For too long this debate has
been polarised in a very unhelpful way. I also believe that the onus for
integration has too often been put with the AIDS community whereas the
health and development community has a responsibility too. Integration
requires all of us to move to a middle ground and I am convinced that
there is so much that we can learn from each other.

Over the last few years there has been a particularly heated ideological
debate on health systems versus HIV/AIDS. Speeches during the opening
session and during yesterday’s meetings indicated that there is a
great openness in the AIDS community to have these discussions. We know
that there are real issues in some countries. A recent public
expenditure review in Tanzania pointed to the distortive effects of
targeted HIV funding on health systems. But there is also a growing body
of evidence of countries that have managed to use targeted funding to
achieve disease specific outcomes and broader systems benefits at the
same time by investing in key areas such as human resources and
infrastructure. Rwanda and Ethiopia are countries that come to mind. We
should learn from these experiences and work towards pragmatic
solutions. We simply can not afford competing over scarce resources. The
sad reality is that health systems have been underfunded for decades and
HIV is certainly a long way off being considered overfunded. We must
demystify what we mean by health systems and clarify what needs to be
done to meet people’s needs and legitimate expectations when it comes
to health care. Primary health care might be a good binding framework to
integrate these different elements. In any case, solutions will need to
be country specific. As international agencies – donors, multilateral
agencies and financing institutions – we have a moral obligation to
support countries in these efforts. I would be interested to hear from
panellists how they see their role in this regard.

Apart from funding, the AIDS response has introduced important paradigm
shifts that are of great relevance to the health sector, and development
more broadly. One important shift is the notion that access to care and
treatment is a right, not a charity. Another one is the recognition of
the crucial role of civil society organisations as advocates, as watch
dogs and as service providers. If we manage to integrate this thinking
into our approaches to health systems strengthening we can make a giant
leap towards the development of responsive health systems that deliver
results that matter to people.

Sustaining universal access over the long term requires better
integration of HIV/AIDS in the broader development agenda. Unfortunately
these obvious linkages are often poorly developed. In many cases the
AIDS response happens quite in parallel from broader development
efforts. In too many countries HIV/AIDS is still not well integrated
into poverty reduction strategies and Medium Term Expenditure
Frameworks. Moreover these instruments are rather exclusively focused on
the public sector. One could say that many of the traditional aid
instruments are not sufficiently AIDS proof. This can have huge
implications, even more so as many bilateral donors are moving towards
upstream funding modalities such as direct budget support. At the same
time most of the AIDS funding is delivered through different channels
such as PEPFAR, the Global Fund or the World Bank MAP. I see a serious
risk for an increasing and persistent disconnect between the two
efforts. So whilst there is a compelling case for linkage there is as
yet little evidence on how that should be done. Again this requires all
of us to rethink the way we are doing business.

It requires the main AIDS funding agencies to improve their behaviour as
far as harmonisation and alignment is concerned. But is also requires a
much more thorough discussion on how HIV/AIDS, and other cross-cutting
issues such as gender for that matter, are really part of our
traditional aid instruments. And on the potential negative spill-over of
the implementation of the Paris declaration, if important development
issues are not adequately addressed in the tools that we use. Again I am
very much looking forward to hear the panellists view on this.

We have a panel of highly distinguished speakers that represent
different elements of the global architecture for HIV/AIDS. We have an
audience that is brimming over with energy, creativity and passion.  I
am very much looking forward to a lively debate between all those
participants.

Thank you for your attention.

 PAGE   5 

 PAGE   4