By Sharon Atieno

A decline in international funding and the rapid shifting of the financial burden to affected countries threatens to reverse efforts in the fight against the twin epidemics of HIV and tuberculosis (TB), warns a new report released by Médecins Sans Frontières/ Doctors Without Borders (MSF).

While in 2018, globally, the funding for HIV decreased by USD 1 billion, the funding for TB decreased by USD 3.5 billion, in comparison to 2017.

The MSF report shows a significant drop in funding from international organizations contributing to HIV and TB financing in the nine countries (Central African Republic, Democratic Republic of Congo, Eswatini, Guinea, Kenya, Malawi, Mozambique, Myanmar, Zimbabwe) it examined.

For instance, Global Fund’s grant amounts for HIV and TB signed with DRC dropped by approximately 20% for the 2018-2020 period in comparison to the previous period. In Guinea, the 2018-2020 signed grants for HIV and TB were reduced by approximately 17% relative to the prior three-year period.

While PEPFAR’s funding in Eswatini decreased from USD 61 million in 2018 to 58 million in 2019, in Kenya PEPFAR’s Country Operation Plan (COP) declined from  USD 505 million to USD 375 million in the same time period. Also in Mozambique, PEPFAR’s COP dropped by 16% between 2018 and 2019, and translated into a shift in priorities.

The Bill and Melinda Gates Foundation, United Populations Fund (for key populations) and others have also begun to cut back as evidenced by the reductions in funding noted in Zimbabwe and Kenya, the MSF report titled: Burden sharing, not burden shifting reads.

“This recent downward trajectory in funding comes at a critical juncture for the HIV and TB response,” says Dr. Mit Philips, one of the contributing authors of the report. “While gains made in countries such as Mozambique are at significant risk of backtracking, there is an even higher risk that countries in regions such as West and Central Africa, which are already lagging behind in the HIV and TB response, may see the situation deteriorate even further.”

In Central African Republic (CAR), for instance, where at least 110,000 people are living with HIV, the Global Fund’s current allocation treatment covers only 39% of these people. However, various health stakeholders are pushing the government to take on a bigger share of healthcare expenses. In July 2019, funding limitations and delays in procurement led to a massive stockout of antiretroviral (ARV) drugs in the country, threatening treatment interruption for thousands of patients.

Also, in Guinea, where the Global Fund is the primary source of funding for HIV and TB responses, various factors such as a lack of sufficient buffer stock and delays in orders, have contributed to gaps and shortfalls. In 2018, these factors culminated into an interruption in the supply of ARV drugs.

“Every day, MSF teams in these countries witness how patients are suffering and dying from these treatable diseases,” says Dr. Maria Guevara, another of the report’s contributing authors.

“The number of people on lifetime HIV treatment keeps on expanding, but the money available to support them keeps on shrinking. With not enough drugs or support services available, many people are not starting treatment on time or are forced to abandon treatment altogether. Others must dig deep into their pockets to pay for drugs so as not to interrupt their treatment. All of this contributes to increased transmission, higher mortality, more treatment failures and an even higher prevalence of drug resistance – further increasing the cost of care for HIV and TB.”

The report further predicts more funding shortfalls with the withdrawal or flatlining of donor support noting that while commitment and the political will to increase domestic funding for health may exist, the translation of intention to practice remains far from reality.

“Some of the countries reviewed in this report – such as Democratic Republic of Congo, Guinea and Mozambique – are struggling with conflict or political and economic problems,” says Dr. Philips. “Yet they are being put under pressure to swiftly mobilise additional resources for HIV and TB within restricted budgets and with insufficient donor funding. This needs a serious reality check.”

In view of the existing economic and fiscal challenges, the authors of the report call for a comprehensive assessment of countries’ real ability to increase domestic health resources in the short term, given the impact of funding shortfalls on the lives of people living with HIV and TB and the ability of health workers to care for them.

“Sharing the burden of HIV and TB funding can be positive, as it shows that everyone should contribute to an increased resource envelope,” says Dr. Philips. “But this approach should be adapted to the reality in each country. Burden sharing should not lead to burden shifting. When projections of a country’s capacity to raise domestic resources turn out to be over-optimistic, this puts both health programmes and people’s lives at risk.”

“Donor countries must urgently reverse the recent decline in HIV and TB funding and adapt their approach to the challenges facing their partner countries, now and in the coming years,” says Dr Guevara. “Failing to fix this will undermine past achievements and may lead to an epidemic rebound that will cost many lives. The Global Fund replenishment conference should mark a crucial moment in mobilising the necessary resources to prevent the response from veering further off track.”

 

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