Addressing reductions in US global health funding: An opportunity for a rethink, or more of the same?

By guest contributors Garrett Wallace Brown, University of Leeds, United Kingdom; and David Bell, Independent Global Health Consultant, Lake Jackson, USA.

Introduction

A recent Opinion in PLOS Global Public Health by Ooms et al. calls ‘upon the international community to protect the global responses to HIV, TB and malaria’ in the face of recent funding cuts by the United States (US). The authors argue that other countries must make up the shortfall, particularly for the 2027- 2029 replenishment cycle of the Global Fund to Fight AIDS, Malaria and Tuberculosis (GFATM), since the GFATM is highly dependent on US funding. To support this rallying call, the authors argue that HIV/AIDS, malaria and tuberculosis are ‘global health security threats’ that require continued collective action. ‘Undermining such collective action’, they argue, ‘makes the world less safe for everyone’.

We recognise that HIV/AIDS, malaria and tuberculosis remain the three biggest communicable diseases, killing millions of people annually with significant socioeconomic impacts. Moreover, we agree that policy priorities should be fastened to the greatest disease burdens, promoting locally owned, contextualised, effective, efficient and equitable responses. However, we disagree that the response should consist simply of seeking to direct the same money into more of the same, since after more than two decades of increasing support for institutions like GFATM, equitable global health security remains stagnate.

Health Security from What?

Ooms et al. argue that inaction on HIV/AIDS, malaria and tuberculosis ‘makes the world less safe for everyone’. This statement mirrors another popular phrase within the global pandemic prevention, preparedness and response (PPPR) lexicon; namely that ‘no one is safe until everyone is safe’. Statements such as these are purposefully highly securitised and emotive, cultivating collective interest via a direct appeal for one’s self-preservation.

Yet, such claims are often inaccurate and overblown.

First, in the case of the GFATM, 71% of its funding portfolio is directed to Sub-Saharan Africa, which accounts for 95% of all deaths from malaria, 70% of all deaths from HIV/AIDS, and 33% of all deaths from tuberculosis. Although the effects of the three diseases represent security risks as determinants of political instability, economic underperformance and societal cohesion, they remain relatively geographically confined. Moreover, despite impacts of climate on vector range, temperate countries and wealthier tropical countries continue progress in reducing malaria burden while other regions continue to fail. This is because the three diseases are primarily associated with poverty and health system dysfunction. Thus, they represent geopolitical security interests and moral imperatives for donor countries rather than major direct threats to their health security.

Second, Ooms et al. echo the idea that more donor money means better outcomes. Whilst this may be a short-term truth, twenty-five years of putting large resources into global health institutions has not generated corresponding health outcomes, with some outcomes worsening over recent years. Rather than funding more of the same, this should be a wake-up call to reconsider the entire, vertical disease- and commodity- based health model on which GFATM is based. Should we just look for more funds, including as Ooms et al. suggest, draining funds from low-income countries to be cycled through centralized Western-based institutions like GFATM, or consider new models that prioritize health systems and underlying economic and health resilience?

Third, the argument for an increased investment in GFATM under conditions of increasing scarcity overlooks the numerically larger threat to global health financing; the diversion of unprecedented funds to PPPR. According to WHO and the World Bank, the financial request for PPPR is $31.1 billion annually, with annual investments of $26.4 billion required of low- and middle-income countries (LMICs) and an estimated $10.5 in additional overseas development assistance (ODA). The World Bank suggests a further $10.5 to $11.5 billion a year for One Health. As argued elsewhere, mobilizing even a fraction of these resources to PPPR is not commensurate with known risk, representing significant opportunity costs through diversion of funds away from AIDS, malaria and tuberculosis. In context, this constitutes a disproportionate distribution where the estimated annual $10.5 billion ODA costs for PPPR represents over 25% of 2022 ODA total spend on all global health programmes, while tuberculosis, which kills 1.3 million people per year, would receive just over 3% of ODA.

Health Security for Whom?

A common argument against the securitisation of health is that it is underpinned by an ontology that understands threats as being exclusively from the ‘Global South’, from which developed countries need to remain vigilant. However, an argument could be made that the health security of the Global South is actually undermined by the northernly led GFATM. The argument is threefold. First, despite twenty-five years of increasing GFATM investment global health equity within its portfolio remains underwhelming. Second, GFATM investment has poorly facilitated national ownership, self-reliance, and capacity building, arguably perpetuating aid dependency. Third, and relatedly, though the GFATM was originally designed to make itself redundant, with a mandate to improve country level capacities as a ‘bridge fund’ there are few signs of such redundancy. It has continued to expand its staffing and portfolio.

Conclusion

We agree that the international community should continue to prioritize the highest burden infectious diseases.  However, we disagree that every country should make assessed payments equivalent to 0.01% of GDP to centralized agencies such as GFATM, GAVI, and the Pandemic Fund. There are wider questions that must be asked on how global health policy is designed and implemented, particularly PPPR, and what constitutes success. Currently, global health is poised to spend billions on pandemic threats of unknown severity based on underdeveloped evidence, and questionable political processes. It has delivered poorly on its ‘golden era’ promises of national ownership, aid effectiveness and health system strengthening. Ultimately, health security is weakened by continued aid dependency and its modular approach. In this regard more is not better, but simply more of the same. The US withdrawal should prompt a re-think before refunding.

About the authors:

Garrett Wallace Brown is Chair of Global Health Policy at the University of Leeds. His research focuses on global health governance, health financing, health system strengthening, health equity and estimating the costs and funding feasibility of pandemic preparedness and response. He has over 100 research publications in global health and has conducted policy work for over 25 years with NGOs, governments in Africa, the UK government, WHO, G7 and G20.

David Bell is a clinical and public health physician with a PhD in population health and background in internal medicine, modelling and epidemiology of infectious disease. Previously, he was Director of the Global Health Technologies at Intellectual Ventures Global Good Fund in the USA, Programme Head for Malaria and Acute Febrile Disease at FIND in Geneva and worked in infectious diseases and coordinated malaria diagnostics strategy at the World Health Organization. He has worked for 20 years in biotech and international public health, with over 120 research publications in this field.

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