Between 1986 and 1997, the World Bank committed nearly $500 million in loans and credits to national programmes worldwide. However, the resource distribution did not adequately match the disease burden, while the funding was disproportionately low considering the growing epidemic. HIV was not a priority for the World Bank; its focus was instead on health sector reform. Together with the low demand from national governments for HIV-focused programmes, this led to a decline in funding during this period. In 2000, due to high institutional mobilization and prioritization of HIV, the World Bank launched the Multi-Country AIDS Program in Africa to mitigate the effects of HIV, with a commitment of more than $1.2 billion. However, that amount was far lower than the estimated $7–10 billion required for addressing the HIV epidemic in low- and middle-income countries.
In 1987, WHO established the Special Programme on AIDS – subsequently known as the Global Programme on AIDS (GPA) – to coordinate research and country responses to HIV. The programme’s Global AIDS Strategy adopted a rights-based approach. However, the GPA was widely judged to be inadequate, lacking in the necessary capacity and funding.
The UN faced organizational challenges that affected its capacity to lead the design and implementation of international development policies. WHO was also under scrutiny by the donor community, and was being urged to reform its internal management and coordination processes. In response to such criticism, the UN Economic and Social Council created UNAIDS. This initiative aimed to strengthen inter-agency collaboration in the UN for a robust multilateral effort towards tackling the HIV epidemic, and to build a global consensus on policy responses to HIV. UNAIDS was one of the earliest initiatives within the UN system to include formal representation of civil society in its governing board – an achievement credited to the leadership of the agency’s director, Peter Piot. The agency also had responsibility for coordinating funding for HIV, but not for distributing funds. UNAIDS launched a year after the closure of WHO’s GPA, with only $130 million in funding from voluntary contributions. Funding challenges subsequently reduced the opportunity for a scaled-up response to the epidemic.
Building the narrative for funding
Before the HIV epidemic, global health initiatives often made their appeals for international funding on humanitarian grounds. However, the World Bank’s 1993 World Development Report (WDR) argued the economic case for investing in global health. Similar arguments were advanced again in 2000 by academics who provided additional evidence for investing in health to achieve economic growth. The idea gradually succeeded in turning around the perspective from ‘you have to deal with poverty to address health’ to ‘you have to deal with health to address poverty’ by expounding the evidence case for investment. The introduction in the 1993 WDR of disability-adjusted life years as the metric for measuring the cost of health interventions also enabled political leaders in donor countries to better understand the value of the funding and future outcomes.
In the late 1990s and early 2000s, G8 leaders placed development and fighting poverty at the top of their agenda and acknowledged the role of public health in tackling these issues. The possibility of measuring the economic burden of disease and the benefits of health interventions was useful for leaders, as it allowed them to defend political decisions on foreign aid spending to their electorates. Leaders were now able to demonstrate how the decisions were responsible for effective interventions.
In 1998, the UK hosted the G8 summit in Birmingham, formally placing global health on the G8’s agenda, with the discussions focused on malaria. As part of that, the UK argued that health interventions to reduce the impact of malaria could enable poverty reduction and economic development in low- and middle-income countries. Malaria interventions were relatively low-cost and achievable, and their impact was measurable. There was a realization that a significant increase in funds from international donors was also needed for HIV and tuberculosis (TB) – both of which were recognized alongside malaria as diseases of poverty. Funding treatment, which was the basis of most HIV programmes, was beyond the financial resources of many low- and middle-income countries.
Meanwhile, at WHO, after assuming her position as director-general in 1998, Gro Harlem Brundtland conducted a review of the health expenditure in low- and middle-income countries and identified a striking imbalance. Low- and middle-income countries bore 90 per cent of the disease burden but had access only to 10 per cent of the resources used for health. She entered WHO with the fundamental belief that to achieve reductions in poverty, it was necessary to promote good health. Brundtland was instrumental in bringing health onto the development agenda and in weaving economics and politics into the WHO strategy. Brundtland’s mission and ideas within WHO were advanced by the efforts of Jeffrey Sachs, a noted economist and Harvard academician, who chaired the WHO’s commission on macroeconomics and health between 2000 and 2002. This commission influenced the way global leaders thought about health, introducing new methods for funding and emphasizing the role of health in poverty reduction and economic development.
Low- and middle-income countries bore 90 per cent of the disease burden but had access only to 10 per cent of the resources used for health.
At this point, there was a growing realization of the need for new financing initiatives and partnerships to bring the required resources to the problem. Individual ‘champions’ from academia, civil society and politics advocated for a separate funding stream for diseases of poverty – namely HIV, TB and malaria – and key donors were keen that the new fund be established outside of WHO and the UN architecture. Malaria was still the focus of global health investment in 2000, as plans for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) were being developed. Malaria and other tropical diseases were reported as causing more deaths than HIV among children. However, this was later acknowledged as being inaccurate, again making HIV the greater priority. The high cost of HIV treatment meant that attempts to include funding for HIV medicines were met with resistance from some donors. To justify a focus on prevention rather than treatment, opponents of financing access to treatment argued that antiretroviral programmes would not be viable in African countries, due to a limited number of health workers, limited infrastructure and expectations of poor adherence to treatment regimens. Furthermore, there was tension over the funding agenda – i.e. whether the Global Fund would be dedicated solely to HIV or become a broader communicable disease health fund.
In 1999–2000, the economic impact of HIV in African countries was affecting food security and agricultural productivity. UN secretary-general Kofi Annan was approached by several African political leaders with concerns over HIV and its effect on their countries’ economies. Having witnessed the realities of the disease, Annan worked tirelessly with Brundtland and Piot in lobbying global leaders for the creation of a global fund.
In January 2000, the UN Security Council (UNSC) debate on the ‘Impact of AIDS on peace and security in Africa’ was one of the earliest efforts to address a health concern as a security threat. The debate, largely driven by US permanent representative at the UN Richard Holbrooke, ushered in the discussion around HIV – specifically the HIV epidemic in Africa – as an issue of national and international security. HIV was regarded as a threat to the military capabilities of countries and international peacekeeping forces. The number of military personnel in sub-Saharan Africa living with HIV was estimated to be significantly higher than that among the civilian population. However, not all members of the UNSC agreed with the security narrative – China, France and Russia opposed the idea of declaring the HIV epidemic as a threat to international peace and security; but, under US influence, those countries conceded the council’s final resolution. Following the debate, the UNSC passed resolution 1308, designating HIV as a security threat to the nations of the world. In 2001, the UN General Assembly special session focused exclusively on HIV, raising the epidemic to a global political priority and resulting in political leaders from 189 countries – including both affected countries and donors – adopting the Declaration of Commitment to achieve time-bound targets to reduce the burden.
Though not a dominant approach, the security narrative was one of the ways UNAIDS sought to build a sense of urgency for a global response to HIV. While UN resolution 1308 discusses the claims linking the HIV epidemic to international security, most of the actionable sections were focused on peacekeeping personnel. In 2005, UNAIDS commissioned an expert team to produce a report providing the evidence base to support the HIV/security narrative. While the report highlighted the potential impact of HIV infection among peacekeepers and military personnel, it criticized the previous high estimates as being the result of recycled secondary literature and of soft opinions. The tone of evidence in this report was instrumental in persuading the UNSC to drop HIV from its security agenda in 2005. However, in 2006, it became apparent that many of the goals in the 2001 declaration had not been met. The UN developed a five-year follow-up plan, the 2006 UN Political Declaration on HIV, to reaffirm HIV as a critical foreign policy issue and to achieve universal access to HIV prevention, care and treatment support by 2010. This declaration was an initial effort to treat health as a foreign policy issue.
While the security narrative was taking hold, global movements such as Jubilee 2000 – so named as it called for the cancellation of developing country debt by the year 2000 – emerged to pressure industrialized countries to fight poverty and push for debt relief of heavily indebted poor countries (HIPCs). These calls to action described HIV as a disease of poverty that could not be addressed while debt inhibited additional spending on health by HIPCs. In September 2000, the UN established the Millennium Development Goals (MDGs): eight international development goals that committed nations to a global partnership to reduce extreme poverty and set time-bound targets for 2015.
By setting specific goals aimed at reducing poverty and halting the spread of HIV, these priorities were effectively placed at the forefront of the international agenda, thereby influencing foreign policy and fostering the development of new international commitments. The MDGs were integrated into development fund policies such as the European Commission’s programme, the UK Department for International Development and the Norwegian Agency for Development Cooperation, all of which highlighted their moral duty to address poverty and set HIV as a priority area. The development and human rights dimensions of the HIV narrative thus began to take precedence over the security approach, and were the predominant arguments used to encourage donors to increase their support.
In the late 1990s and early 2000s, the cost of providing HIV combination therapy to people living with HIV still exceeded national health expenditure per head in many countries in sub-Saharan Africa. In 1997, in an effort to address the issue of cost, South Africa had approved the Medicines and Related Substances Control Act. The legislation sought to enable the Ministry of Health to provide affordable medication to people living with HIV. The South African government believed that the act would legally allow it to take advantage of flexibilities in the World Trade Organization’s agreement on trade-related aspects of intellectual property rights (TRIPS) to engage in compulsory licensing or import generic drugs at a lower cost if faced with a health crisis. Pharmaceutical companies resisted this view, seeking to protect their patents; the US initially supported that resistance and threatened South Africa with sanctions if it invoked compulsory licences.
Grassroots activism played an essential role in highlighting the drug access inequities in Africa. The proximity of a US presidential election meant a unique opportunity for activists to bring the issues to a larger audience. A coalition of Médecins Sans Frontières (MSF), Act Up, Transatlantic Consumer Dialogue, Health Action International, Consumers International and Consumer Project on Technology achieved a unified campaign in South Africa and the US, protesting against the pressure exerted by the US on the South African government. Strategic measures – such as garnering significant media attention, staging public protests during presidential campaign rallies and linking the US policies to race and poverty – effectively intensified the pressure on the US government to change its aggressive approach and suspend legal action. In September 1999, US president Bill Clinton announced that the US would enforce flexibility in drug patents when countries faced a public health crisis. Furthermore, the US approved local production and import of cheap drugs into Africa, as long as imported drugs had intellectual property rights protection.
Activist groups and public pressure played a key role in emphasizing the moral duty of richer countries to provide further funding to respond to HIV and increase access to treatment in poorer nations.
Activist groups and public pressure played a key role in emphasizing the moral duty of richer countries to provide further funding to respond to HIV and increase access to treatment in poorer nations. UN secretary-general Annan used this argument in his address to the 2001 African Summit on HIV/AIDS, Tuberculosis and Other Infectious Diseases, by stating that the public no longer tolerated a situation whereby individuals were at higher risk of acquiring and dying from HIV-related illness because they were poor. The effectiveness of antiretroviral treatment (ART) and its availability in high-income countries led to a shift in HIV activism towards addressing the lack of access to medication in low- and middle-income countries, as well as raising debates on equity and justice. The 2000 International AIDS Conference held in Durban, South Africa, was a significant event that pressured governments by putting HIV treatment on the front page of newspapers, raising public awareness, and issuing a global call for ‘treatment for all, now’. The Abuja Declaration in 2001 saw African Union member states committing to allocate 15 per cent of their government budgets to healthcare. Later in 2001, at the WTO ministerial conference in Doha, Qatar, the Doha Declaration was adopted. The declaration gave each country the right to define a national emergency and affirmed that compulsory licensing policies were acceptable under the TRIPS agreement. This outcome represented success for developing countries seeking access to affordable HIV treatment. However, the declaration was limited to compulsory licensing and did not include parallel importation.
Global leaders saw the value of reduced drug pricing if they wanted to fit the economic models of health achievements and sustain funding for the cause. The human rights argument and the need to increase access and reduce the cost of treatment were highly influential in triggering an increase in funding. Costing $10,000 per patient year, HIV treatment was unaffordable in low- and middle-income countries. It took numerous deliberations to achieve a compromise and reduce drug prices; these deliberations included private discussions between Brundtland, Piot and drug manufacturers. Pharmaceutical companies understood the threat of HIV to high-income markets and, following additional pressure from Annan in 2001–02, finally agreed to reduce the prices of antiretroviral therapy (ARVs) – making the economic case for HIV investment more attractive. The industry’s issuing of voluntary licences to manufacturers in low- and middle-income countries to produce generic versions of HIV drugs was a major factor in reducing prices. The industry was later engaged in supporting the Medicines Patent Pool (MPP), a mechanism that MSF – an influential civil society actor in the campaign for access to HIV medicines – proposed to the French foreign ministry and UNITAID. (UNITAID was launched in 2006, with leadership from Brazil, Chile, France, Norway and the UK, to promote the health-related MDGs.) UNITAID established the MPP in 2010 as a new international organization to expand affordable and timely access to HIV medicines through public health-oriented licensing deals with manufacturers of generic medicines. In addition to voluntary licensing, the MPP has substantially increased generic drug supplies for the global HIV response.
Political leadership
In 2000, when the surge in financing for HIV began, there was no strong superpower rivalry, creating a conducive environment for global cooperation. International leaders focused on steady global economic growth and sharing global prosperity by eliminating poverty. Providing funding for global health initiatives such as the HIV response, and working to eliminate diseases of poverty, were key parts of those efforts. The support of several individual political leaders was critical in advancing international funding for HIV during this period.
HIV and other infectious diseases had been high on the agenda of G7/G8 summits prior to the funding surge. For instance, HIV was prioritized at the 1987 G7 summit due to the collective vulnerability that all countries present felt, and their realization of the physical and psychological impact of the disease. In the 1990s, Canada, France, Italy and the US were severely impacted by HIV, as were Japan and Russia later on in the decade. (Russia joined the G7 – thereby expanding it to the G8 – in 1997, before being expelled in 2014.)
In 1997, at an international conference on AIDS held in Abidjan, Côte d’Ivoire, French president Jacques Chirac gave an impassioned speech outlining the need for an international solidarity fund to pay for HIV treatment. The International Therapeutic Solidarity Fund was subsequently launched in 1998 with Luxembourg and South Korea to mobilize additional funding beyond the public sector, to incorporate private companies, donations, foundations and the pharmaceutical industry. In 2006, Chirac implemented the world’s first solidarity tax on kerosene and airline tickets to fund the fight against HIV – this was the original main funding source for UNITAID. Germany, Cameroon, Chile, the Republic of the Congo, Madagascar, Mali, Mauritius, Niger and South Korea later followed suit.
Meanwhile, US national intelligence reports on the growing epidemic of HIV in low- and middle-income countries were pivotal to the enhanced response from the US. In May 2000, President Clinton declared HIV a major threat to national security, further focusing global attention on HIV. The US Department of Defense feared that the spread of the disease could result in military collapse and power vacuums. Economic and political instability was feared in southern Africa and Latin America if the pace of the epidemic continued.
By 2001, other significant events had begun to shape US policy interests, increasing the focus on health security. Most significantly, the 9/11 terrorist attacks in New York and Washington, DC brought the security argument back to the fore, and with it the potential threat of the HIV epidemic and other communicable diseases to international security. The US believed that nations struggling with poverty, corruption and fragile institutions were more likely to harbour terrorist networks, thus presenting imminent threats to US interests. Moreover, the HIV epidemic exacerbated the economic challenges faced by such nations, further compounding their predicament. The events of 9/11 were shortly followed by the anthrax attacks and later by the SARS epidemic of 2003, which also played a role in global health being placed on the US foreign policy agenda and its inclusion in the US bioterrorism and security strategies.
In the UK, the international political leadership of Prime Minister Tony Blair and Chancellor of the Exchequer Gordon Brown at that time was characterized by a commitment to invest in poverty alleviation and development in Africa. They belonged to a generation that had witnessed a wave of domestic activism to get HIV onto the health agenda; this experience seemed to add impetus to their support. It was under their leadership that the UK’s foreign aid budget reached the UN target of 0.7 per cent of gross national income, a level of commitment that was incorporated into UK law. Africa had been a priority focus for the UK government since 2003 and in 2004 the UK created the Africa Commission to inform recommendations to the G8. During the 2005 G8 summit at Gleneagles, there was a push for debt relief and increased official development assistance to help achieve the MDGs, with a particular emphasis on African countries. G8 countries shared a ‘moral conviction’ to support progress in Africa. As part of these commitments, there was a focus on achieving universal access to HIV treatment, investing in vaccine research and increasing funding to the Global Fund.
The Global Fund – the multilateral mechanism
The Global Fund has been the major multilateral financing mechanism for raising and disbursing funds for programmes to reduce the impact of HIV, TB and malaria in low- and middle-income countries.
The idea of a G8 collective effort against infectious diseases was proposed at the Okinawa summit in 2000, with support from Japan as the host country and from the US. Japan led with a national commitment to spend $3 billion over a five-year period under the Okinawa Infectious Disease Initiative to fight infectious and parasitic diseases in developing countries. Clinton and his vice-president, Al Gore, galvanized the discussion around infectious disease threats – and HIV specifically – seeking a unique funding partnership (a global fund), additional resources and leadership from other member countries. The European Commission pledged to spend €120m for the prevention and control of HIV, and additional funding pledges were made by from Canada, Italy and the UK. However, some members resisted the attempt to set up a dedicated global fund, and the summit ended without the Global Fund being endorsed. The proposal eventually succeeded at the 2001 G8 summit hosted by Italy in Genoa. During that summit, as a part of fundraising efforts, Italy proposed a model that would include voluntary contributions of $1 million from each of 1,000 major multinational corporations, but this concept did not receive approval from other summit members. A multi-stakeholder model was instead adopted, with national governments playing a prominent role in providing the funds.
The Global Fund was launched in 2002, initially as a unit within WHO, later becoming a stand-alone organization based in Geneva, Switzerland. It was created as an innovative financing mechanism to provide governments with funding based on proposals and implementation plans designed by the affected countries themselves. WHO and UNAIDS continued to provide the much-needed technical and on-the-ground experience.
Around 94 per cent of the total funding for the Global Fund comes from donor governments, while the rest comes from the private sector, philanthropic foundations and innovative financing mechanisms.
The Global Fund used multiple strategies to ensure a sustained funding stream. Governments, international organizations and non-state actors relatively new to the global health architecture were brought together, and tactical collaborations were built to identify solutions. Around 94 per cent of the total funding for the Global Fund comes from donor governments, while the rest comes from the private sector, philanthropic foundations and innovative financing mechanisms such as the Product (RED) branding and marketing project. The latter was developed and launched by rock star Bono and Bobby Shriver in 2006 as a mechanism for raising capital for HIV prevention and treatment activities.
The Bill & Melinda Gates Foundation, one of the major philanthropic donors to the Global Fund since its creation, ensured its commitment to the Global Fund initiative by strategizing with government heads to invest in the international HIV response movement as it matured. Through its global advocacy, the Gates Foundation also helped to promote private sector health financing mechanisms.
Chirac made a personal commitment to increasing funding for HIV treatment and was instrumental in the establishment of the Global Fund. In the initial period, when the Global Fund was inclining towards prevention programmes, the French government argued forcefully for the inclusion of a treatment component in the fund’s remit. After Chirac left office in 2007, some feared that the Global Fund would lose momentum and funding. However, Carla Bruni-Sarkozy – the wife of Chirac’s successor as French president, Nicolas Sarkozy – played a significant role in championing the HIV cause in France and beyond. The HIV-related death of her brother prompted her commitment to the cause, which was further demonstrated by her appointment in 2008 as the Global Fund’s ambassador for the protection of women and children against HIV/AIDS. Bruni-Sarkozy is credited with ensuring significant French contributions to the Global Fund, which are ongoing (France is currently the second largest donor to the Global Fund).
Despite the goodwill and impetus behind the Global Fund from its launch, it was subject to some criticism. Its initial ‘first come, first served’ approach often led it to fund ambitious proposals that did not consider cost-effectiveness, and some donors felt that such proposals were draining the fund and that the money was not reaching priority countries as a result. The Global Fund was built on the aspiration of giving high priority to the ‘most affected countries and communities’ and focusing on countries with the least ability to finance efforts to tackle the three target diseases. However, evaluations of the funding allocations yielded mixed results, with some pointing to a limited relationship between Global Fund disbursements and country income and disease burden. Later, in 2013, a new funding model was implemented that allocated shares of each replenishment based on a country’s disease burden and ability to pay for disease programmes, as well as other factors such as the availability of other external financing. Donors to the Global Fund played a key role in the decision-making process around funding allocations. Civil society involvement in the Global Fund is credited with securing the finances required for funding cycles and ensuring that the resources reached and benefitted affected communities. Civil society actors have three seats on the Global Fund board with voting rights, securing their influence over policy decisions. Civil society participants have helped ensure that recipient country interests were included in the decision-making process.
The Global Fund was set up to report on measurable, tangible outcomes such as the number of people treated or tested. It attempted to produce an exact calculation of the measures based on assumptions about the consequences of interventions that were financed; such reporting has been useful in demonstrating to donors the return on their investment. Later, the setbacks in programme delivery and desired targets following the COVID-19 pandemic led to the greater recognition of the importance of health-system strengthening as one of the strategic pillars in reducing the burden of HIV, TB and malaria. The Global Fund is investing $1.5 billion a year during the 2021–23 funding cycle for the strengthening of health systems.
The Global Fund achieved pledges totalling a record high of $15.7 billion in its seventh replenishment round in September 2022, which included notably both implementing governments stepping up as donors and increased private sector contributions. Pledges fell short of the initial ask of $18 billion. But, in the context of the economic crisis following the COVID-19 pandemic, funding pressure as a result of the war in Ukraine and the general downturn in global economic conditions, this figure can still be seen as a significant achievement and, to some extent, a demonstration of political support for long-term investment in global health priorities.
PEPFAR – bilateral over multilateral funding
In 2003, one year after the launch of the Global Fund, US president George W. Bush announced his administration’s commitment of $15 billion over the next five years to the global HIV response under a new bilateral mechanism, the President’s Emergency Plan for AIDS Relief (PEPFAR). The US was, and still is, the world’s largest single contributor to the HIV response, and has long favoured bilateral assistance over multilateral funding, which has given it greater control over how money is spent.
The creation of PEPFAR was influenced by several factors. One was the initial refusal of the G8 to agree on collective action at the Okinawa summit, which gave justification for the US to proceed with a large assistance programme of its own. The security concerns related to the HIV epidemic also affected the policy commitment. In addition, Bush used moral and religious rhetoric to appeal to both conservative and Evangelical supporters and liberal humanitarian groups. The resulting, unique alignment of both liberals and conservatives over the PEPFAR proposal was key to its realization and successive reauthorizations of the programme by the US Congress.
PEPFAR invested a significant amount of money in the HIV response on the ground and, with $18.8 billion committed in the first five years, became one of the largest global health initiatives for a single disease. The programme’s success, however, has largely been due to its focus on results and pre-established goals, rather than just the amount of funding. In particular, the programme pushed for the engagement of all stakeholders in the country and for community-based ownership. For example, the rollout of ARVs by PEPFAR in South Africa in 2004 depended on sustained efforts from civil society groups like the Treatment Action Group and other non-governmental organizations. While the inclusion of a policy against generic drug purchases for HIV treatment attracted criticism initially, that policy was amended in 2005. The results-driven success of PEPFAR led Bush’s successor as US president, Barack Obama, to increase the financial commitment to the plan in 2011 and to call for PEPFAR to go further in helping to realize ‘an AIDS-free generation’. While PEPFAR has often been characterized as taking a ‘top-down’ approach, its collaboration with implementing countries has helped strengthen those countries’ health systems and provided essential health services beyond HIV.
HIV, unlike other infectious diseases, is a long-term challenge, with no revolutionary vaccine and the requirement for consistent life-long treatment. Significant progress has been achieved to reduce the burden of HIV and mortality linked to the disease, but the problem still requires sustained international funding. Economic recession, global conflicts and the cost of catastrophes such as the COVID-19 pandemic affect donor priorities and the provision of international aid, leading to reversals in HIV programme successes and progress. The US has maintained PEPFAR funding for the last 20 years, recognizing it as one of its most successful initiatives in global health development. By January 2023, the programme had invested over $100 billion in more than 50 countries, saving 25 million lives. However, the annual funding for PEPFAR has been relatively flat since 2015, at around $4.8 billion, despite it receiving additional emergency funds in 2020–21 towards the COVID-19 response.
