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AIDS funding debate heats up

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The billions of donor dollars spent on combating HIV/AIDS in the last decade, often at the expense of other fatal diseases, have done little to strengthen weak national health systems, some global health experts argue.

On the contrary, say others, the HIV/AIDS epidemic has sparked massive increases in international aid for health that have benefited a range of health issues and systems. The debate over prioritizing HIV/AIDS in global health spending received fresh impetus after recent data from the World Health Organization (WHO) and the UN Children's Fund (UNICEF) highlighted the millions of children's lives lost to easy-to-treat diseases like diarrhoea.

Worldwide, diarrhoea kills an estimated 1.5 million children under the age of five every year, but receives less than 5 percent of all funding available for disease research and treatment. A WHO diarrhoea specialist noted that huge progress made in the 1980s had stagnated as attention was diverted to AIDS, tuberculosis and malaria.

Meanwhile, funding for HIV/AIDS rose from 5.5 percent of health aid in 1998 to nearly half of it in 2007, according to an analysis published in a special supplement of the journal, AIDS, focusing on the impact of the HIV scale-up on health systems in developing countries. Total funding for health nearly tripled between 1998 and 2007.

An article by Jeremy Shiffman and others at Syracuse University in New York challenges the argument that the focus on HIV/AIDS has generated greater attention and resources for all health issues.

A comparison of donor funding for four major public health issues - HIV/AIDS, health systems strengthening, population and reproductive health, and infectious disease control - found that the amount spent on HIV/AIDS and, to a lesser extent, infectious disease control, grew rapidly from 1998 to 2007, while funding for strengthening health systems, and population and reproductive health, declined steeply.

In another article, Samuel Lieberman and others from the World Bank's Global HIV/AIDS Programme take the view that the "unprecedented challenge of AIDS" helped generate the overall increase in health funding and mobilized an international push for more equitable health care access.

Martha Embrey and others from Columbia University maintain that global AIDS initiatives have significantly improved the procurement and distribution of drugs, not only for AIDS but for many other diseases.

Organizations like the Clinton HIV/AIDS Initiative and UNITAID have secured substantial price reductions for drugs, while other donor initiatives have helped countries improve their systems for drug procurement and supply chain management, they point out.

HIV-support programmes have contributed to building the skills of pharmacists to provide adherence counselling while pharmacy assistants and nurses in primary health care clinics have been trained to dispense antiretrovirals and drugs for other chronic diseases.

Ruth Levine and Nandini Oomman, of the Centre for Global Development in Washington, in the US, focus not on whether HIV/AIDS has received a disproportionate share of donor funding but on how best that money can be spent both to improve access to HIV treatment, prevention and care and to strengthen health systems.

Several AIDS donor organizations have begun shifting their efforts to strengthening health systems, based on the realization that weak health systems are frustrating their AIDS-related goals. President Barack Obama's administration has announced that the US President's Emergency Plan for AIDS Relief (PEPFAR) intends to widen its focus to include maternal and child health and tropical diseases.

Read more:
 Thinking outside the AIDS funding box
 AIDS funding is justified, say activists
 Donor AIDS money weakening health systems
 Donors single out AIDS

The authors suggest that donors will need to "align their actions with the priorities and approaches of partner governments and other national stakeholders" to achieve a broader focus on health-related issues.

In an introduction to the supplement, Wafaa El-Sadr, of Columbia University, and Kevin De Cock, director of HIV/AIDS at WHO, caution against encouraging competition between health issues.

"There is strength in diversity and debate, yet there is also danger of fragmentation," they note. "Global health needs global financing, and there is enough money in the world to assure it."

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