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A “Strategic Revolution” in HIV and Global Health?
GFO Issue 151

A “Strategic Revolution” in HIV and Global Health?

Author:

Dr. David McCoy

Article Type:
Commentary

Article Number: 3

ABSTRACT Responding to an article in The Lancet on a "strategic revolution in HIV and global health," David McCoy writes that the article "somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.... Perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health - one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries."

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

either of these two reported developments; but neith

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

er is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to b

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

e worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AID

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

S suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they u

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

nderlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support he

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

alth systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate th

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

e U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well a

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

s for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry wit

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

either of these two reported developments; but neith

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

er is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to b

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

e worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AID

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

S suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they u

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

nderlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support he

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

alth systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate th

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

e U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well a

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

s for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in

Last week, The Lancet invited the international health community to welcome a “strategic revolution in HIV and global health” following the U.N. high-level meeting on AIDS at which The Lancet said two “turning points” occurred.

Turning point 1 consisted of the adoption of new global targets, to be achieved by 2015: halving the sexual and intravenous drug-related transmission of HIV; ensuring that no child will be born with HIV; and aiming to place 15 million HIV-positive people onto treatment (jumping from a figure of six million people today). Turning point 2 was “invisible” and consisted of “the realisation that simply strengthening the vertical programme that is AIDS has to end.”

There is nothing wrong with either of these two reported developments; but neither is there much to be excited about. The world’s track record at achieving U.N.-brokered targets is poor and, in this case, the setting of new global targets for HIV/AIDS needs to be more critically assessed in the light of previous un-met targets – such as those set through the millennium development goals (MDG) process – and within the context of broader social and developmental goals.

As for the realisation that AIDS programmes should be better integrated, this has actually been growing over the past ten years or so. The various fragmented and ‘verticalised’ global health programmes (often disease-based) that emerged since the late 1990s have had direct and real benefits for many, many people, but they are often unsustainable and inefficient, and, at times, harmful to the broader needs and responsibilities of health systems.

But there is no need to reopen the debates between the so-called verticalists and horizontalists; nor to revisit the tension between selective and comprehensive primary health care. There is more consensus today about the need for a balance between top-down and bottom-up; between focusing on a narrow selection of cost-effective medical technologies and providing a more holistic and social approach to health improvement; and between diseases and health systems. And there is perhaps better understanding that the “correct” balance cannot be determined at the global level in Geneva or Washington, but rather needs to be worked out at the country level, taking into account a host of local and contextual factors.

This shift in understanding over the past decade has been gradual, although punctuated by a number of milestones. These include the “three ones” principles (attempting to improve harmonisation of only HIV/AIDS responses); the launch of the International Health Partnership; the Maximizing Positive Synergies report and meeting in Venice; and the joint health systems funding platform of the World Bank, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Fund. In the case of the Global Fund specifically, there have also been various steps taken to move from stand-alone disease-based grants towards a more rational grant-making architecture with greater emphasis on systems development and coherent national strategy development.

One doesn’t want to overstate the importance of a quickly written Lancet editorial, and one can understand the need for old wine to be periodically re-bottled to give new impetus and freshness to old challenges. What is more important is whether “a strategic revolution in HIV and global health” is really taking place. On this matter, the Lancet article raises two important issues.

The first concerns financing. The Lancet article made reference to a study that calculated the funds required to respond to HIV/AIDS. According to Schwartländer and colleagues, $16.6 billion is required this year, rising to $22 billion in 2015. The frequent computation of global price tags for health has become something of an industry within the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

hin the international health community over the last ten years (ever since the Commission on Macroeconomics and Health). But it does help focus attention on the critical issue of financing.

In fact, the real “turning point” we should be concerned with is the financial crisis of two years ago. Not only did this precipitate a squeeze on aid budgets, it also revealed the fundamental flaws in the global financial architecture and systems, and highlighted how they underlie the impoverishment of many countries (and health systems) worldwide. The mal-distribution of global wealth, unfair economic governance arrangements and the ongoing perverse subsidy of the rich by the poor, continue to be unspoken elements in the present discourse around global health financing which remains mostly focused on aid, private charity and corporate philanthropy, and which is now increasingly characterised by a view that a reduction or stagnation in overall aid and health budgets in poor countries is inevitable.

While new U.N.-brokered global targets on HIV/AIDS suggests a commitment to health and development in poor countries, a better litmus test would be the adequacy and fairness of the financial and economic governance reforms that followed the financial crisis. It is in the realms of global financial regulation and transparency, trade agreements, fair taxation, and the governance of institutions such as the IMF that we in the health community should be looking and calling for “turning points.”

Two years ago, a High Level Taskforce on Innovative International Financing for Health Systems was established to identify financing mechanisms that would complement traditional aid and bridge the financing gaps that compromise attainment of the health-related MDGs. The Taskforce was deficient in a number of respects (see here for a critique), but it laid much valuable groundwork for resolving the problems of inadequate, unsustainable and inequitable health financing in low and middle income countries.

As we face up to major financial challenges, we might want to re-assess the work, outputs and impact of the Taskforce. In such an exercise could lie the seeds for a real strategic revolution in HIV and global health – one that would result in adequate, sustainable and predictable financing for health within the context of fairer and more democratic economic and financial arrangements.

The second important issue raised by The Lancet concerns stewardship of the world’s response to HIV/AIDS. This is important because the financial squeeze on HIV/AIDS requires better and more efficient management of resources, plans and initiatives at the global level. In addition, the imperative for HIV/AIDS programmes to support health systems strengthening efforts and to act as a catalyst for general improvements in health requires more effective and coordinated leadership across the array of global health institutions.

According to The Lancet, UNAIDS “is perhaps in the best position to be a catalyst for integration.” The reasons given by The Lancet for this include: “the politically astute and charismatic” leadership of Michel Sidibé; the fact that “unlike WHO [World Health Organization], UNAIDS is not a member-state governed organization”; the fact that “UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other U.N. and non-U.N. bodies”; and the fact that “its mandate is to be bold, to say and do what others cannot say and do.”

While improving “AIDS governance” at the global level is legitimate and would be useful, The Lancet‘s cheerleading for UNAIDS is somewhat surprising and unconvincing. UNAIDS is in fact a member-state governed organisation, albeit one that is governed by representatives from 22 rotating and geographically distributed member states. Also, it does not have a mandate to be bold, or to say and do what others cannot say and do – its primary function and mandate is to coordinate the U.N. system’s response to HIV/AIDS. (See here for a summary of UNAIDS’ mandate and governance arrangements.)

Inevitably, as the positive growth trend of global funding for health starts to slow down and possibly reverse, there will be competition between different actors for the remaining resources, as well as for influence and kudos. Is The Lancet‘s pitch for a new and bigger role for UNAIDS to be understood in this context? Or are there real strengths associated with UNAIDS which can be capitalised upon?

But if so, what would this mean for the WHO or the Global Fund? And where does the joint platform of the Global Fund, World Bank and GAVI fit in? Similarly, should we not also be talking about the future of the International Health Partnership and the central role of ministries of health in global health governance from the bottom-up? UNAIDS has many clear comparative advantages for providing a leadership role in addressing the social determinants of HIV/AIDS; but when it comes to leading the integration of HIV/AIDS programmes within health care systems, there are other candidates or solutions that need to be considered.

When discussing this aspect of global health governance, perhaps we need to be more ambitious and imaginative in proposing a real revolution in HIV and global health – one that would result in global health institutions that are less competitive with each other and more responsive to the particular needs and contexts of lower income countries.

The Lancet has done us a favour in drawing attention to the need for a revolution in AIDS and global health. But it has somewhat missed the mark in describing what that revolution should consist of and how it could be brought about.

Dr David McCoy (david.mccoy@aidspan.org) is a public health physician who is supporting the development of Aidspan’s policy and research programme.

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