This is a writeup of a shallow investigation, a brief look at an area that we use to decide how to prioritize further research.
In a nutshell
- What is the problem? HIV control and treatment receives substantial funding, but much of it may be spent suboptimally.
- Who else is working on this? The Gates Foundation has provided some funding to projects aiming to improve the allocation of HIV funding overall, and a number of smaller organizations have worked on specific aspects of the issue, but we do not know the extent of funding in the area.
- What could a new philanthropist do? Pressuring major funders to improve the impact of their spending and supporting those funders and other organizations to collect data on the burden of the disease and the effectiveness of different interventions may help to increase the impact of HIV funding.
1. What is the problem?
Global HIV treatment and control is supported by roughly $15 billion in annual funding, but much of the spending in the area may be allocated suboptimally.1 Because of the amount of money involved, improving the allocation of spending in this area may have a significant humanitarian impact.
Examples of potentially suboptimal spending include:
- Substantial funding goes to interventions with limited evidence, such as abstinence promotion. On the other hand, male circumcision – which has stronger evidence – remains under-funded.2 The WHO has a target of providing voluntary male circumcision to 80% of uncircumcised adult men in fourteen priority countries in Africa, at a cost of approximately $1.5 billion (~20 million circumcisions).3 As of December 2012, 3.2 million African men had been circumcised through specific services for voluntary circumcision.4
- Despite the fact that first-line drug regimens are more cost-effective than second- and third-line treatments, funders are paying for existing patients to move to second-and third-line treatments while substantial demand for first-line treatment still remains.5
- The optimal variety of medication is not always used. For example, the drug formulation most commonly used for first-line treatment in South Africa is more costly and less efficacious than other drugs which serve the same purpose.6
- Interventions often aren’t effectively targeted, either to the locations which could be helped most cost-effectively or to the demographics within a given area that have the highest needs.7
- Funders frequently use US contractors to deliver services when working with country-based organizations might be less costly.8
A hurdle to improving HIV spending is that there is a shortage of data available on how money is being spent and on which interventions are working. This appears to be because the large funders collect limited data on the effectiveness of their programs and do not share much data on their interventions or on their budgets. According to Amanda Glassman, Director of Global Health Policy at the Center for Global Development, “It is not possible to track spending on HIV treatment and prevention by intervention, since large organizations working on HIV don’t collect or share sufficient information and the field has poor reporting standards.”9
2. Who else is working on this?
According to Dr. Glassman and Anil Soni, former CEO of the Clinton Health Access Initiative (CHAI), PEPFAR and the Global Fund want to improve the impact of their own spending – including by restricting funding to effective interventions, more closely tracking their costs, and switching to country-based technical assistance rather than high-cost US contractors – but it is unclear to what extent changes will happen in practice.10
The Gates Foundation has provided some funding to address this issue, including supporting a group of economic experts at the United Nations Programme on HIV/AIDS to focus on efficiency and sustainability.11
A number of other organizations have done some work on specific aspects of HIV spending, including:12
The American Foundation for AIDS Research
The International Budget Partnership project at the Center for Budget and Policy Priorities
The Institute for Health Metrics and Evaluation
The World Bank, which does public expenditure tracking and measures and maps service delivery, although not specifically focused on HIV spending.
Some civic groups within African countries, which monitor HIV treatment programs
There are also a number of academics who have researched and worked on efficiency issues in HIV spending.13
We do not have an estimate of the amount of funding working on this issue.
3. What could a new philanthropist do?
Possible philanthropic approaches include:14
- Supporting groups that monitor intervention coverage and quality within target countries.
- Funding the collection of better epidemiological data so that interventions can be targeted more accurately to the demographics or the locations with the highest need.
- Pushing for specific interventions that are cost-effective and supported by evidence, such as male circumcision.
- Running large scale trials to determine and demonstrate which interventions are most effective.
- Working with countries to help them better allocate the funding they receive from the major funders.
- Pressuring the HIV community to improve data sharing and to spend money more efficiently. This might involve funding a group like the Center for Global Development to research and write about this issue or donating enough money to a large organization such as the Global Fund to secure a seat on its board.
- Aiding countries in reallocating HIV-focused vertical funds to approaches that promote health more broadly.15
We do not have a strong sense of the likely effectiveness or cost-effectiveness of these different approaches.
4. Questions for further investigation
Our research in this area has been limited, and many important questions remain unanswered by our investigation.
Amongst other topics, further research on this cause might address:
- Which strategies to improve funding allocation for HIV/AIDS programs are most cost-effective?
- How large are the possible gains from reallocating HIV-related spending? How does the expected cost-effectiveness of improving funding allocation for HIV/AIDS programs compare to the expected cost-effectiveness of advocating for increased funding for HIV/AIDS programs?
- To what extent might the Global Fund and PEPFAR improve their transparency and spending on their own over the next few years?
5. Our process
For this investigation, we had conversations with 3 individuals with knowledge of the field, including:
- Anil Soni, former CEO, Clinton Health Access Initiative
- Amanda Glassman, Director of Global Health Policy and Senior Fellow, Center for Global Development
We also reviewed documents that those individuals pointed us to and conducted a limited amount of desk research.
|Center for Global Development Financial Flows of PEPFAR report||Source (archive)|
|Center for Global Development More Health for the Money Report||Source (archive)|
|Conversation with Amanda Glassman on December 13, 2013||Source|
|Conversation with Anil Soni on October 18, 2012||Source|
|UNAIDS report on the global AIDS epidemic 2013||Source (archive)|
|WHO voluntary medical male circumcision for HIV prevention fact sheet||Source (archive)|