The World Bank has just recently issued a “new” report: The fiscal dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda. The Report doesn’t really feel “new” because it represents a recurrent theme in the World Bank approach from the earliest days of the global AIDS pandemic – it’s not fiscally sustainable to treat people living with HIV in high impact, low-resource countries – instead the world must focus on “prevention.” The World Bank is seriously out-of-date, or conversely, perversely pig-headed, for four main reasons:
First, its report now issued in March of 2012 is already seriously out of date since it relies almost exclusively on pre-2009 data. Despite opportunities to do so in the editing process and in its media work, the World Bank has chosen to totally ignore the exciting new science concerning treatment-as-prevention – research that shows that suppressive anti-retroviral therapy reduces the risk of onward transmission of HIV by at least 96%! This gold-standard research is now being confirmed by ecological data showing actual declines of new infections in places where anti-retroviral scale-up has reached a “tipping point.” Some of the most exciting findings come from KwaZulu Natal province in South Africa, the
epicentre of the pandemic, where community infections are dropping precipitously now that a deadly delay in treatment rollout has been reversed.
The Report is also seriously out of date because it fails to take into account recent evidence of greatly enhanced efficiencies in AIDS programming. The US PEPFAR program has evidence that its treatment costs have decreased by over 2/3 in just the past few years. Doctors without Borders is achieving stunning efficiencies by
task-shifting treatment initiation and monitoring to nurses and community health workers respectively, by moving services to the community level, and by involving patients in groups support and adherence activities. Both of these dramatic developments call most of the World Bank’s calculations into question.
Second, there is growing evidence, again ignored by the World Bank, that even a moderate expansion of investments now in treatment scale-up and in diffusion of scaleable prevention methods like male circumcision, condoms, and needle-exchange can have significant impacts on new infections and thus future treatment costs. One would think that a premiere economic think-tank like the World Bank could more strongly champion the idea that spend-a-dime-today
instead of a dollar-tomorrow makes good economic sense. The Bank has certainly strengthened its understanding of the fiscal impacts of HIV/AIDS by taking into account the predictable future costs of continuing and new infections, but it has failed to appreciate the Big Bang benefits of early investments.
Third, the World Bank uses magical thinking rather than evidence to rally support for unspecified “prevention” activities. The Bank was one of the main proponents of prevention-only throughout the 1990s. Treatment was too expensive, it wasn’t cost effective to treat poor people living with HIV, expenditures couldn’t exceed revenues, donors are fickle so don’t count on them, etc. Although the Bank’s language has become less coarse and callous, many of the same “truisms” are repeated in the current report. Using the neutral language of quasi-liability (instead of what other pundits call a treatment mortgage), the Bank argues that the costs of treating people infected now and of those newly infected (discounted to present value) show that treatment expansion is “unsustainable.” The Bank treats each and every country in its study solely within the context of its own economic resources showing severe domestic fiscal constraints, when it could in fact call for innovative global financing – like a financial transaction tax – and more predictable and long-lasting pooled global resources – like at the Global Fund. It emphasizes – indeed almost excuses – donor defunding because of a global financial crisis that is too precipitous to permit a ramp-up in global health spending, but apparently a crisis that is not so serious so as to preclude a multi-trillion dollar bailout for banks and to continue numerous military follies. The truth of the matter is that principles of global solidarity for global health should be promoted by the Bank as the real solution to short- and mid-term fiscal pessimism.
Fourth, the World Bank appears to neglect the economic and social benefits of a healthier population and to ignore some of the costs of premature deaths. Focusing on fiscal costs of treatment, while ignoring the huge social and economic benefits of the survival of the vital age 25-45 cohort is just plain strange. Young and middle age adults are economically productive, they raise and help education children, and they care for elders. In a pure economic sense, they build economies, promote economic development, pay taxes, provide care labour, and
innovate. Earlier deaths decrease the value of investments in education and impede social reproduction. Likewise, the Report makes some reference to macroeconomic impacts of HIV on macroeconomic growth, but it seems to discount
the long-wave impacts of successive losses of the middle-generation. Focusing primarily on fiscal costs while forgetting economic benefits is an unbalanced way to inform policy choices.
Countries need advice on future costs, but they need it based on current facts. They need advice not just about how selfishly the world economy and governance is currently constructed, but how they might be revised to make the right to
health and Universal Access real. The failure of the Report is not a failure of the collective researchers or the individual authors, but rather of the rigid and dogmatic ideology of the World Bank that consider “fiscal space” a law of nature, while ignoring newly discovered evidence that treatment is now one of the most promising tools for prevention. Let’s hope the Bank issues a new, more hopeful report, responsive to recent development and cognizant of the power of new investments to end AIDS.
