Global Policy Forum

By John Gershman

Of all the policy proposals in his State of the Union address, perhaps the most surprising--and the one for which President Bush has received the most kudos--was his announcement that the administration will propose $15 billion over five years to combat HIV/AIDS abroad. The proposal marks a significant departure for a Republican administration, and is widely recognized as a positive step. The initiative appears driven by a combination of pressure from activists outside the administration, support by administration officials like Secretary of State Colin Powell, National Security Adviser Condoleezza Rice, and Senate Majority Leader Bill Frist, and the administration's need be seen as promoting something that is of concern to African-American advocacy organizations in the aftermath of the Trent Lott fiasco.

While generally viewing the proposal positively, many AIDS activists and experts are still waiting to see whether the administration will actually be able to wrestle the money away from a less enthusiastic Republican-controlled House of Representatives. Furthermore, they have expressed concern that even in this forward-looking proposal the Bush administration has slighted multilateral efforts to combat HIV/AIDS--particularly the Global Fund to Fight AIDS, Tuberculosis, and Malaria--in favor of a renewed emphasis on bilateral initiatives. Only $1 billion of the $15 billion total is scheduled to be channeled to the Global Fund. The concern about the administration's prioritization of bilateral over multilateral initiatives is linked to other concerns: insufficient funds, timing, consistency, and process.

First, some numbers. The HIV/AIDS pandemic has killed at least 20 million of the more than 60 million people it has infected thus far. In Africa, nearly 30 million people have the AIDS virus--including three million children under the age of 15. There are whole countries in Africa where more than one-third of the adult population carries the infection. More than four million people in Africa require immediate drug treatment, yet only 50,000 AIDS victims are receiving the medicine they need.

Experts from UNAIDS and the World Health Organization (WHO) have previously estimated that at least $10.5 billion annually is needed from donor countries in order to mount a credible response to HIV/AIDS worldwide, including massive prevention programs, reduction of mother to child transmission, and care for the 40 million people living with AIDS. Of the $15 billion in the Bush proposal, $10 billion represents new money that had not already been promised or planned for AIDS programs.

The Global Fund is facing a cash crunch because some donors are failing to fulfill their pledges, which may make the Fund unable to supply the funds for grants already approved. To date, $2.1 billion has been pledged to the Global Fund over five years. On January 29, 2003, at the Global Fund's recent board meeting, executive director Richard Feachem noted that the Global Fund needs $ 6.3 billion in 2003 and 2004 alone and that so far $1.2 billion has been pledged for that time period. Washington has so far committed $500 million over two years, while Feachem has urged the United States to contribute $2.5 billion to $3 billion over the next two years. The administration likes to assert that the U.S. is the greatest single donor to the Global Fund, with more than $500 million committed to date. This is a misleading claim given the size of the U.S. economy. For example, the countries of the European Union, which combined have an economy roughly the size of the U.S., have given close to twice as much, over $1.1 billion.

Second, timing. AIDS activists and experts note that the Bush plan back loads a significant chunk of the $15 billion into the end of the five year period. (For example, only $2 billion is allocated for fiscal year 2004). This delay is costly in terms of lives lost and greater expenditures later to treat people who might be prevented from contracting HIV today. "The current situation requires a substantial front-loaded capital investment to scale up existing efforts," said Prof. Richard Feachem, executive director of the Global Fund. "The programs are ready. Any delay now will be measured by millions of lives lost and billions of dollars of additional cost to later respond to the expanded epidemics."

Third, many activists and experts, such as the U.S.-based group HealthGAP, contrast the administration's proposal with its attempts to derail the negotiation of an agreement under the World Trade Organization (WTO) that would strengthen developing countries' abilities to gain access to essential medicines. Although all WTO members, including the U.S., signed a WTO declaration at Doha in 2001 permitting countries to prioritize public health and access to medicines for all over the intellectual property rights of pharmaceutical companies, the Bush administration has worked to reverse this agreement and undermine its implementation. A full year of negotiations revolved around one aspect of the Doha Declaration: how to revise restrictions in WTO rules to permit countries without the ability to make generic drugs to obtain needed medicines from exporting countries. The U.S.--along with the European Union, Japan, and the pharmaceutical industry--lobbied stubbornly for strict limitations and conditions, leading to an impasse as negotiations ended in December 2002 without an agreement.

Finally, the process of decisionmaking in the Global Fund is markedly different from that of bilateral initiatives--most notably, the participation of affected communities and the balance of power between donors and recipients. The Global Fund represents a major innovation in multilateral aid programs. It includes communities affected by AIDS, Tuberculosis (TB), and Malaria at every level of the decisionmaking process and is governed by a board composed of an equal number of donor and recipient countries. In its short lifetime (the fund is just over a year old) the Global Fund has created an innovative, demand-driven model where country-level grant applications are created and submitted by consortia of public and private sector NGOs, government officials, and organizations representing people with AIDS, TB, and Malaria.

All of this is not to say that there isn't room for bilateral initiatives, but the Global Fund has already demonstrated capacity, is scaling up existing effective programs, and has brought together governments, civil society organizations, and the private sector. Unfortunately even when it wants to do a good thing, the Bush administration appears unwilling to surrender its unilateralist impulses.

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