Kate Mukungu worked in Namibia in 2002-2006. She describes this time as life-changing. Working in HIV and AIDS and experiencing Namibian life as a family and community member brought home the real impact of HIV and AIDS. Here she talks about how reductions in international funding puts thousands of people at risk of losing out on their treatment.
Namibia is one of four countries most affected by AIDS globally and, at its peak in 2002, had a HIV prevalence rate of 22% among pregnant women attending antenatal care. In 2003 anti-retroviral treatment (ART) commenced through the state health system and progress since then has been impressive to say the least. Over 80% ART coverage and an amazing 60% reduction in AIDS related deaths had been achieved by 2012.
Namibians must have been alarmed by newspaper headlines in 2012 stating that their medicine was at risk of running out, due to reduced international funding. This research was undertaken in order to consider the facts regarding sustainability of ART in Namibia, which is crucial for the 90,000 plus Namibians depending on this lifelong treatment programme.
The two main sources of international funds for ART in Namibia are the United States President’s Emergency Fund for AIDS Relief (PEPFAR) and the international Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund). The Global Fund has contributed significantly to the costs of antiretroviral medication and laboratory costs, whilst PEPFAR has provided both the annual plans and funding for a wide variety of health posts.
The reduction of funding from PEPFAR has already commenced. Between 2012 and 2014 there will have been a reduction of US$10 million bringing funding for the programme to US $80 million. In 2010 a partnership agreement between the Namibian and US governments detailed how PEPFAR funds would reduce with the biggest hit being the salaries of the HIV workforce. The agreement expressed the Namibian Government’s commitment to picking up an increasing share of the HIV bill. The subsequent 2010 National Strategic Framework (NSF) represents the Namibian Government’s first analysis at how it would meet increased funding commitments up to 2015/16. NSF lays out twin aims of increasing government spending and improving the health system’s efficiency.
Increased government spending would be achieved through innovative approaches to raising public sector revenue, such as introducing a HIV levy. Namibia’s committment to narrowing the treatment funding gap received positive acknowledgement from UNAIDS in 2013 as it does here. However it has to be acknowledged that implementation is behind schedule to raise the required funds by 2015/16.
In relation to the NSF’s second aim of improving health efficiencies, the Namibian Government noted that between 2005 and 2007 the health system in Namibia was operating at approximately 53% efficiency. The Government therefore reasons that, had efficiency been 100%, then almost double the provision could be delivered at the same cost, or, the same provision could be delivered at half the cost. Whilst the target of improved efficiency has been set, details on the means to achieve this target appears not yet to have been articulated. Future financial projections have however been set around the premise of maximised efficiency.
My research expresses no objection to striving to improve the efficiency of Namibia’s health system, but expresses concern about the efficiency analysis used. It is one thing to state that maximised efficiency will save money but real factors that impact on the health system’s delivery, such as droughts/floods, do need to be considered. In short, relying on efficiency savings without being able to guarantee them runs the risk of a future resource shortage which would negatively impact on the sustainability of ART.
The next significant risk to acknowledge relates to the reliability of the Global Fund. Although the Global Fund is set to provide funding to Namibia until 2015/16 the situation beyond then is unclear. Significantly, the Global Fund has been affected by the global economic situation and in 2011 even had to cancel a whole funding round due to its own funding shortage. Whilst it is too early to project whether or not the Global Fund will be able to support Namibia post April 2016, there is a need to keep a close watch.
The will and commitment of the Namibian Government to meet the challenges of HIV and AIDS is unquestionable. Research findings do, however, narrate various risks to sustainability of ART in Namibia due to funding and capacity issues. This case study must be considered as part of a wider international context. ART sustainability is just as important for people living with HIV in other countries utilising international funding to develop treatment systems.
These countries will also feel the impact of the reduced international funding. It is imperative to keep a close watch on how countries like Namibia fare when left to fund increasing levels of treatment from domestic sources. Hopefully this will increase understanding of what happens when international funds reduce, and, more importantly, what can be done to reduce the harm to people living with HIV in developing countries.