US Global AIDS Funding Restored: The Highs and the Lows

How often do you get more money than you ask for? Not that often and probably less so when it has to do with helping poor countries to improve their citizens' health. In a surprising but welcome move on January 29th, the House Appropriations Committee filed their joint continuing resolution for FY 2007 to complete the unfinished federal funding bills for the current fiscal year 07. While most programs were funded at FY06 levels a few "High Priority Needs" were selected for increased investments. For Global Health, one such high priority need, most of the increase is directed at HIV/AIDS and malaria, while funding for other accounts such as child survival, maternal health and family planning will stay at their FY 2006 levels and some areas such as Avian Flu remain entirely unfunded. Highlights from the bill (.pdf) can be found on the Appropriations Committee website and include a description of the additional investment in Global Health over FY 06 levels:

• Global HIV/AIDS funding: $4.5 billion, an increase of $1.3 billion to expand efforts to combat HIV/AIDS, and TB programs including in the 15 focus countries and the multilateral efforts through the Global Fund to Fight HIV/AIDS, TB and Malaria. This includes: $3.2 billion from the State Department's Global HIV/AIDS Initiative account; $712 million from the Child Survival and Health Programs Fund account at USAID; and $494 million for CDC and NIH Global HIV/AIDS activities. Of these amounts, $724 million is for the US contribution to the Global Fund, $625 million from State/USAID and $99 million from HHS.
• United States Agency for International Development Malaria Programs: $248 million, an increase of $149 million to allow the Agency to expand its bilateral global malaria initiative activities from the current 3 countries to 7. Country programs expand access to long-lasting insecticide treated bed nets, promote and support effective malaria treatment through the use of proven combination therapies; and increase prevention efforts targeted to pregnant women.

This is more than good news for Global Health, but with a few caveats:Kudos to the all that made it happen, but your work is not done: This is probably one of the best rewards to all the tireless HIV/AIDS advocates and they should be proud of it. Despite this well deserved victory, what is of concern in the most immediate term is whether this action necessarily indicates an upward trend for US funding for HIV/AIDS next year? The House Appropriations Chairman, David Obey, needed some heavy persuading before agreeing to AIDS funding increases and who knows whether AIDS advocates have spent all their political capital with him. Obey's own comments suggest that this year's budget decisions are not indicative of any larger trends:

I don't expect people to love this proposal, I don't love this proposal, and we probably have made some wrong choices...At least we have made them in order to bring last year's issues to a conclusion so we can turn the page and deal with next year's priorities.

So, much more needs to be done to make this a priority for next year as well (and perhaps differently), especially since the US has made commitments and should be banking on fulfilling these in its much needed effort to re-build diplomacy and trust as a global leader, as my colleague Michael Bernstein discusses in a related post on the issue of cutting budgets and losing trust.Delays in Congress will still lead to delayed implementation: Even if money was appropriated by Congress today (don't forget the House decision is still pending Senate approval), those funds will not reach AIDS programs in affected countries for many months. In fact, a forthcoming paper from the HIV/AIDS Monitor documents that a majority of the funds appropriated for HIV/AIDS at the beginning of a fiscal year does not reach program implementers for 6 months or more. Money first makes a number of stops at different departments and agencies in Washington, before it is released for use by initial recipients, many of whom will then have to sub-grant money to other recipients. When Congress finishes its business on the 2007 budget, it should consider looking into ways to make the money move more quickly from here to the recipient countries.Global Health priorities - it's time for a better balancing act: Prioritizing is by definition a difficult process because something or someone gets more attention than the other(s), but prioritizing is more acceptable and perhaps even justifiable when there is a transparent process and real evidence to justify the choices. Once again in this victory for Global Health, Global HIV/AIDS (and Malaria) funding has been singled out over other health accounts like child survival and family planning, not to mention that potential global health disasters such as Avian Flu didn't even make it on the radar screen. The reasons for these choices are not clear, as my colleague Jeremy Shiffman points out in a recent editorial on HIV/AIDS and the Rest of the Global Agenda (.pdf):

While HIV/AIDS imposes a high burden, as of 2001 it was far from the dominant cause of illness and mortality in low and middle-income countries, representing 5.3% of deaths and 5.1% of disabiliity-adjusted life-years, 2 figures that are unlikely to have changed significantly since then.

So, what is it that drives HIV/AIDS funding at the expense of other health priorities? If this is a result of phenomenally heroic and unprecedented health advocacy efforts, and active participation of civil society in driving priorities, isn't it time for health advocates to reconsider their advocacy strategies? The relative disease burdens faced by low and middle income countries are from more than just HIV/AIDS. As fabulous as it will be, if we get to the point that AIDS, TB and Malaria don't kill, there's a lot more that will...Update: The FY2008 PEPFAR budget request fact sheet (.pdf) is now available.