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In the global war against Aids, activists have devoted much of their energy into getting the world to pay attention and commit hard cash. But getting the money may turn out to be the easy part. Spending it to save lives is much harder.
The world has belatedly come to appreciate the scale of this modern plague. Thirty million people are infected with HIV and 3m are dying annually from the disease. In sub-Saharan Africa, Aids has pushed life expectancy down from 62 to 47.
Western governments have finally mobilised to raise serious resources. In the past five years, about $7bn has been raised to fight HIV and Aids through The Global Fund, the World Bank and individual donor countries. Even private organisations such as the Gates and Clinton foundations are becoming big players. In January 2002, George W. Bush pledged $15bn over five years to fight the pandemic in Africa and the Caribbean, dwarfing previous US commitments.
There is no doubt that this new money is sorely needed. Only 3 per cent of African adults living with HIV are receiving anti-retroviral treatment, which costs about $200 per person per year. If treatment ends, patients die.
These funds have come from various sources almost simultaneously, typically with a "use it or lose it" clause. The pace of new funding is staggering. Over a two-year period Lesotho and Swaziland received a 1,000 per cent increase in donor support, Zambia experienced more than a 650 per cent rise. This wave of cash pouring into countries previously starved for funds is far larger than all other public health spending and donors still want to do more.
It would be a challenge for even the most sophisticated economies to absorb these dramatic increases in resources. For poor countries, it is even more daunting. Even though the need for funding is great, developing countries grappling with the Aids epidemic are less able to adapt than rich countries, because of logistical constraints on the systems to provide drugs and supplies, shortages of key staff and a limited local pool of managerial and medical expertise.
Quick fixes will not work. If patients are to survive with Aids, they require lifelong treatment. This means funding must be provided for the long term.
What needs to be done? First, recipient countries must be allowed to bank incoming funds rather than be forced to spend the money all at once.
If each country were allowed to establish a dedicated HIV/Aids fund for its donations, that could be achieved. Allowing countries to spread spending over several years would not only prevent overloading but would help to smooth out expenditure, even when donations were volatile.
Some countries have ample experience with similar national funds for revenues from oil and other natural resources and these can be used as blueprints.
Second, funds to fight Aids need to be focused not only where there is immediate need but where they can be used most effectively. That means a heavy emphasis on prevention and on areas where personnel and infrastructure are already in place.
Finally, and most important, the fight against HIV/Aids cannot be separated from initiatives to strengthen national healthcare institutions. Large vertical programmes, such as those for HIV/Aids, undermine the building of effective health institutions by distorting existing mechanisms for dealing with other health challenges and bleeding the rest of the system of much-needed human resources.
A combined effort is needed to build healthcare institutions and address the HIV/Aids crisis. The growing demands placed on fragile healthcare systems mean that the ambitious Aids treatment and prevention agenda will be held back, unless resources, talent and time are injected to ensure that the funds are used properly and effectively. Merely focusing on the supply of drugs and on building up staff numbers is to neglect critical ingredients such as management, logistics and motivation of personnel that make health systems work and ensure improved performance and accountability.
If the billions raised by the international community are not well-spent, the credibility of public and private programmes that encourage donations will be put at risk and future money for Aids prevention and treatment will evaporate.
To cope with the challenge, donors need to change the way they operate. The HIV virus is constantly adapting; the international community needs to do likewise.
The writer is senior fellow at the Center for Global Development