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Dark Skies Ahead? 

A close family friend of mine is on the legislative staff of a member of the U.S. Congress. Having caught up recently on happenings in life (moves, job changes, etc.), I mentioned to her that for an HIV-related project I was in the process of trying to map the current funding landscape. Her response was indicative of the major issues surrounding U.S. Government global health spending today.

My friend called attention to what I’ve heard from many others around global health funding: that the economic recession and ensuing budget battles mean a major funding challenge for the world’s most pressing diseases, particularly for U.S.-based funders, who are the leading donors for many initiatives. According to the Kaiser Family Foundation, U.S. global health aid grew an average of 13 percent per year from 2004 to 2008, but projections show that this growth is set to decrease to around 6 percent for 2009 and 2010. UNAIDS’ 2010 Global Report revealed that between 2008 and 2009, total international assistance for HIV / AIDS effort did not grow, the first time that this has happened. While these changes in available funding present a daunting challenge, and one that only will get tougher in the near future as the battle over the 2012 federal budget emerges, there may be at least one silver lining: increased pressure on funding may force global heath efforts by low-and-middle-income countries (and supported by multilateral organizations) to find more effective and cost-efficient models for care.

Three important trends in the changing landscape of global health funding are integrating disease siloes, promoting country ownership of health efforts, and weighing the cost-effectiveness of programs. Approaches to U.S. health aid have already been changing. President Obama initiated the Global Health Initiative (GHI), which continues major contributions to HIV / AIDS, malaria, and tuberculosis, but places a greater focus on giving recipient country governments more ownership around directing funds. The extra pressure caused by reduced growth rates in funds available makes the stakes for the success of the Initiative higher. However, it may also help encourage focus on integrated care models that have exciting potential for making care more effective and sustainable, particularly by building in health service delivery into existing structures created to target other disease states.

Examples of this are taking shape in different contexts. South Africa is working to integrate tuberculosis care into its HIV / AIDS treatment delivery structures. There is growing interest and research on the potential for using infectious disease structures that have been built out in many low-income countries in response to the AIDS epidemic to tackle the rising wave of non-communicable diseases. Examples of greater focus on the cost effectiveness of health interventions are everywhere, from the development of lower-cost community-based treatment for drug-resistant tuberculosis to the questioning of expensive institutional care systems for orphans and vulnerable children.

It would be foolish to think that the coming reductions in global health funding will not have serious costs. As the world faces potential epidemics of drug-resistant diseases, the continued burden of HIV / AIDS, and the rapid growth of non-communicable diseases, reductions in global health funding are ill-timed and dangerous. Efforts to combat diseases with much lower prevalence but close to elimination, such as polio, will face even more pressure and controversy for using funds that could go to fight diseases with higher prevalence (recent posts on this blog on malaria-- --and polio-- --weighed questions of cost-effectiveness and elimination strategies). But, in the midst of this gloomy forecast, let’s not forget hope. These changing circumstances could lead to improvement of global health approaches. Reduced funding could force greater emphasis on innovative interventions that maximize effectiveness, reduce redundancy, and enhance coordination at the policy, civil society, and community levels. However, this will only happen if those funders, international organizations, policymakers, community-based organizations, and others working in global health understand the changing funding context and work together to support the most effective and efficient responses.

Readers, what do you see as the biggest challenges posed by cuts in global health spending? What are other examples of new intervention models and programs that could drastically impact current disease states?