All about the money
Authors: Zoë Mullan
Journal: The Lancet Global Health (2015)

It's finally 2015: a year by the end of which extreme poverty and hunger are to be eradicated, maternal and child mortality are to be drastically reduced, and the trajectory of the global incidence of HIV, tuberculosis, and malaria are to be reversed. Much has been written about where the Millennium Development Goals succeeded and failed as global targets, and what has changed in the world since 2000. Much work has also been done to establish what happens next. In his synthesis report on the post-2015 agenda released last month, UN Secretary-General Ban Ki-Moon summarised and annotated this work, ultimately backing the 17 goals proposed by the Open Working Group on Sustainable Development Goals as the basis for a truly transformative agenda. He also devoted a hefty chunk of the report to the somewhat less exciting subject of how to pay for it. The International Conference on Financing for Development in July marks the first of three key meetings on the post-2015 agenda taking place this year (the others being the special UN summit in September and the 21st Conference of the Parties of the UN Framework Convention on Climate Change [COP21] in December). The conference will take as its starting point the report of the Intergovernmental Committee of Experts on Sustainable Development Financing, which lays out policy options for the four main sources of development finance—national public sources (eg, tax income), national private sources (eg, bank credit), international public sources (eg, official development assistance [ODA]), and international private sources (eg, trade and foreign investment). Some of the need for financing reform is explored in this month's issue. In a Comment, Bernadette O'Hare highlights the iniquitous tax exemptions granted to foreign mining and agribusiness companies in Sierra Leone—a country whose disastrously underfunded health system has been cast into the spotlight by the Ebola crisis. Designed to attract investment in the country, often in competition with neighbouring countries, such policies can result in “a race to the bottom”, O'Hare states, “with multinational companies being the beneficiaries and the population being the losers”. The importance of a joined-up and fair approach to national and international tax policy cannot be overstated. In a further Comment, Alexander Kentikelenis and colleagues point to problems with the lending policies of international financial institutions such as the International Monetary Fund (IMF). The IMF influences national financing policies by issuing conditional loans. Kentikelenis and colleagues contend that IMF conditions constrained domestic spending in the years leading up to the Ebola crisis in Sierra Leone, Guinea, and Liberia, including on health, and contributed to the health workforce crisis by capping the public-sector wage bill. The IMF's Sanjeev Gupta responds robustly against these claims, but the fact remains that financing strategies need to factor in conditional lending by the IMF and other bodies, and involve such bodies in ongoing policy discussion. ODA will continue to be an essential component of any future financing strategy, yet although it has steadily increased over the past decade, only five developed countries are currently achieving the target of 0·7% of gross national income, and in the country that most recently met the target—the UK—the political appetite for continued commitment to it is uncertain to say the least. A paper published in The Lancet Global Health last month explored the issue of “shared responsibility” as it pertains to the funding of HIV/AIDS programmes in 12 sub-Saharan African countries that collectively absorb 56% of total development assistance for AIDS. Robert Hecht and colleagues used a range of benchmarks such as AIDS's share of government health expenditure being 0·5 times AIDS's share of total disease burden, and showed that several countries could be spending more domestic funds on HIV than they do currently. In the case of upper-middle-income countries such as South Africa, Namibia, and Botswana, such increases could potentially cover all national spending needs on AIDS. Other countries, however, would not nearly cover their needs, even with the most ambitious spending, emphasising the crucial role of ODA and other international and national financing channels going forward. With the exception of research grants and fundraising in its most general sense, financial matters have not drawn much appeal from the global health community. But it is time to engage. We can't all be economists, thankfully, but this year we might resolve to be a bit more economically savvy in our advocacy and research. The International Monetary Fund and the Ebola outbreakIn recent months, the International Monetary Fund (IMF) has announced US$430 million of funding to fight Ebola in Sierra Leone, Guinea, and Liberia.1 By making these funds available, the IMF aims to become part of the solution to the crisis, even if this involves a departure from its usual approach. As IMF Director Christine Lagarde said at a meeting on the outbreak, “It is good to increase the fiscal deficit when it's a matter of curing the people, of taking the precautions to actually try to contain the disease. Full-Text PDF Open AccessWeak health systems and EbolaThe response to the Ebola crisis in west Africa is shining light on the weak health systems in these countries, which have been crippled by years of underinvestment.1 Full-Text PDF Open AccessResponse to “The International Monetary Fund and the Ebola outbreak”There are several factual inaccuracies in the Comment by Alexander Kentikelenis and colleagues.1 Full-Text PDF Open AccessFunding AIDS programmes in the era of shared responsibility: an analysis of domestic spending in 12 low-income and middle-income countriesThe proposed metrics could be useful to stimulate further analysis and discussion around domestic spending on AIDS and corresponding donor contributions, and to structure financial agreements between recipient country governments and donors. Coupled with improved resource tracking, such metrics could enhance transparency and accountability for efficient use of money and maximise the effect of available funding to prevent HIV infections and save lives. Full-Text PDF Open Access