New perspectives: Funding of an epidemic in an epidemic

By Langton Mutoya

In the year 2014, the world embarked on a fast-track strategy to end the Aids epidemic by 2030.

To reach this goal after over three decades of the epidemic in living memory, countries used the powerful tools available, held each other accountable for results and committed that no one was left behind along the journey.

In 2016, the United Nations General Assembly’s Political Declaration on Ending AIDS mobilised countries to the 90–90–90 targets, which aimed to bring HIV testing and treatment to the  majority of people living with HIV by the end of 2020 and to reduce the amount of HIV in their bodies to undetectable levels so that they live healthy lives and to prevent the further spread of the virus.

According to the UNAids target tracking report, globally, there have been generally remarkable gains across the HIV testing and treatment cascade.

The report asserts that, almost 59% of people living with HIV globally had suppressed viral loads in 2019.

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However, achieving the 90–90–90 (this means 90% of people living with HIV knowing their HIV status; 90% of people who know their status on treatment; and 90% of people on treatment with suppressed viral loads) targets reflects that 73% of people living with HIV have suppressed viral loads.

Based on the statistical evidence, there is reasonable assumption that the global target for the end of 2020 was missed.

The next five-year target begun 2021 up to 2025. The revised target is now 95-95-95 translating to: 95% of people living with HIV knowing their HIV status; 95% of people who know their status on treatment; and 95% of people on treatment with suppressed viral loads to end Aids by 2030.

Another milestone was completed.

The journey was travelled from 1 December 2020 to 30 November 2021. Ironically, 2021 marks the beginning of the 95-95-95 target and the journey began in the second year of the striking of another epidemic.

The coronavirus disease 2019 (widely known as Covid-19) brought another epidemic in the middle of another epidemic era.

The global epidemics response has typically followed cycles of panic driven by the emergence of epidemics in an already epidemic environment.

The world once again is highly vulnerable to massive loss of life and economic shocks from natural or human-made epidemics.

Quantifying the size of the losses caused by large-scale epidemic outbreaks is challenging because the epidemiological and economic research in this field is still diverse and inconclusive.

Main limitation in assessing the economic costs of epidemic outbreaks is that they only capture the impact on income.

Previous studies in health financing attempted to address this limitation by estimating the inclusive cost of epidemics as the sum of the cost in lost income and a dollar valuation of the cost of early death.

They found that, for example, Ebola and severe acute respiratory syndrome (SARS), the true inclusive costs were two to three times the income loss.

For extremely serious pandemics such as that of influenza in 1918, the inclusive costs were over five times income loss.

The inclusive costs of the current Covid-19 are estimated to be around US$570 billion annually or 0·7% of global income (range 0.4–1·0%).

Given the magnitude of the threat, there is great need for scaled-up health financing of both international and home grown collective action for epidemic preparedness and investment in human life.

This paper presents the lens to introspect and brainstorm roles of government agents and other development partners in funding epidemics in an epidemic and test the health systems preparedness and response mechanism to future similar outbreaks as we commemorate the World Aids Day on December 1.

The influx of Covid-19 reviews that the global funding architecture is proving insufficient — and the risk is great in developing countries.

Impact of Covid-19

Currently the Covid-19 epidemic has proven to be a threat to public health care, to the general livelihoods of millions of people and to the national economies across the globe.

This has challenged the development finance actors for health to reconfigure their support towards more focused investments in transnational interventions.

Ideally, it requires a shift from targeted support to specific communicable diseases, to more systemic resources to prevent chronic diseases and meeting the challenge of universal health coverage.

For over three decades, Africa has been heavily strained in resources to fight against HIV and Aids and now the continent is battling yet another epidemic in the Covid-19.

Covid-19 has shattered the continent’s economies and human life investment strategies.

While various measures have been taken to reduce the spread of the pandemic, coronavirus has increased the financial burden across the globe.

According to the UNAids report of 2020, the Covid-19 pandemic also could contribute towards a negative impact on viral load.

There were notable severe disruption in HIV treatment which could result in increased Aids-related deaths in sub-Saharan Africa.

To date, some countries have reported reductions in medicine collections of up to 20% in some areas and there have been multiple reports of people living with HIV not having access to antiretroviral medicine during the Covid-19 induced lockdowns over the past close to two years.

Some reports further claim that some people abandoned their HIV treatment due to a lack of food during the lock downs as well.

However, monthly data from January to June 2020 reported by countries to UNAids accessed by the writer have not shown substantial declines in the numbers of people currently on treatment over the six-month period reported.

Health sector financing

Financing the health sector is a long-standing development challenge. The World Health Organization (WHO) estimates that an additional US$ 370 billion per year are needed for primary health care to achieve the SDG targets on Universal Health Care (UHC) in low- and middle-income countries (WHO, 2019[2]).

Development co-operation continues to play an important role in this sector, with official development assistance (ODA) to health reaching US$26 billion in 2018.

Development assistance to health represented 12% of total health spending in lower middle-income countries, and 29% for low-income countries.

Zimbabwe context

Zimbabwe fall under the low-income countries bracket.

The Covid-19 epidemic came at a time when the country was in the pathway of economic recovery.

The epidemic has overturned the public healthcare system up-side-down, eroded the livelihoods of millions of people, and further contributed to the economic crisis of the country. It is common understanding that Zimbabwe has been in a crisis mode due to various reasons since the beginning of the 21st Century.

Amid these challenges, there still exist the urgent need for funding to maintain the combat of the epidemic spread as well as cushion the poor and vulnerable communities from the already visible effects of the new epidemic under an already troubling HIV and Aids epidemic.

Additional resources are needed to support the critical sectors of the economy that have been withered by economic inactivity due to the coronavirus prevention strategies put in place.

In order to fight emerging epidemic such as the current Covid-19, Zimbabwe need both financial and non-financial resources.

Specifically, the country requires massive liquidity and financing support to deal with the immediate fall-out from the epidemic and economic impacts.

The government of Zimbabwe is applauded for scaling up domestic financing of the HIV and AIDS through the National Aids Trust fund.

In terms of the Covid-19 epidemic the government also did a wonderful job. Funding gaps are however inherent given the demand in prevention interventions.

According to the estimates provided by the government, the country requires US$2.2 billion in order to effectively contain the Covid-19 (Zimbabwe Coalition on Debt and Developments -Zimcodd, 2020). As the experiences of countries such as China, the United Kingdom, United States, and the European Union have all shown, even the well-resourced countries are struggling to manage the outbreak of the Covid-19 pandemic.

Clearly, without the same capacities and capabilities Zimbabwe faces an enormous task.

This includes providing more hospitals, more hospital beds, more medical staff, more medical supplies, and personal protective equipment among others.

The closure of international border has seen the country’s foreign currency earnings drop as a result of the fall in mineral exports, travel, tourism revenues, and diaspora remittances.

Consequently, government has witnessed massive reductions in revenues which are desperately required for containing the Covid-19 epidemic whereas the demands of the HIV and Aids set investments still exist.

It is, therefore, the object of the next section to unpack  some of the challenges that the country is facing in its bid to funding known epidemic against emerging epidemics such as the current Covid-19.

Challenges

The global financial recession coupled by the Covid-19 epidemic has sent glaring fears to developing countries’ continuity and sustainable financing.

According to WHO, there has already been an increase in demand of financial resources from other emerging non- communicable diseases (NCDs) such as cancer and diabetes in Africa and refugees in Europe.

In Zimbabwe the HIV and Aids financing has greatly been dependent on external sources.

Global Fund and PEPFAR are the major funding mechanisms for HIV, investing in millions of lives.

Inversely, there is a trend of a decline in financing the HIV response globally, which translates that, Zimbabwe must increase domestic resource allocation to sustain the HIV and Aids response or else the gains of the past decades may be reversed or eroded.

Sadly, Zimbabwe economic crisis was worsened by industries’ Covid-19 influenced lockdowns.

The industrial shutdown   has a negative impact in Aids  Levy collections meant to mitigate the devastating effects of HIV and Aids extended demands in the emerging epidemic.

The other problem is that, the current global response to the menaces of the coronavirus is in the form of loans instead of grants.

This simply means that the support offered by the developed world to deal with the impact of the Covid-19 is more of a paracetamol prescription which does not address the real ailment; instead, it just postpones the pain without a cure.

Some Covid-19 epidemic prevention measures such as lockdown and movement of people’s restrictions posed a challenge to the HIV and Aids response.

These prevention measures negatively affected the achievements gained thus far as a result of service disruption, constrained supply chain systems and diversion in financing of the response.

For instance, major donor communities are now prioritizing their own domestic economic challenges that have been brought about by Covid-19 epidemic.

The health system is getting overwhelmed due to the epidemic, thereby affecting service continuity for HIV and Aids and other related essential services.

In summary, it is not “either or”, rather we must put all efforts to manage both the existing and the emerging epidemic.

It has been proven that, when HIV is not managed through the intake of ARVs, it can eventually turn to Aids which is lethal hence leading to loss of human life.

The aggressive national Covid-19 prevention measures have seen HIV and other related chronic disease clients less likely to attend facilities (defaulting treatment) due to fear of contracting Covid-19.

This was coupled by the lack of movement of public transportation, fear of encounters with law enforcement officers, and curfews.

These barriers to health care may result in increased HIV and TB-related morbidity and mortality in the short-term.

Health workers have been reassigned to meet the Covid-19 testing demand, leading to very few people conducting HIV testing.

Medical staff anxiety and burnout is also playing a role in testing, as staff are overwhelmed with Covid-19 testing.

The other challenge being currently faced is limited funds for HIV programmes due to minimum funding through the government.

As alluded to earlier, In Zimbabwe, around two thirds of HIV investments comes from international donor sources.

There are current discussions and debates that HIV and Aids is no longer an epidemic and these assumptions require thinking outside the box on the current funding matrix to the HIV and Aids continued investments.

Opportunities

Despite the obstacles outlined above, there still exists some opportunities for Zimbabwe to mobilise funding to contain the coronavirus.

It is pleasing to note that contributions are already flowing towards the emergency fund set up by government.

Below is a snapshot of some of the donations that Zimbabwe has received since the advent of the coronavirus:

The EU: US $45.5 million to Health Development Fund which is jointly managed by the Uniced and the UNEFPA.

US $25 million from the Global Fund.

US $5 million from African Medallion Group.

100,000.00 Pounds donation of protective equipment to Wilkins Hospital from the Department for International Development (DFID, UK).

US $470,000.00 from the United States Agency for International Development (USAID).

US $7 million grant from the World Bank Group.

US $3 million donation from China International Development Cooperation Agency to Unicef Zimbabwe (all figures were collected from the press reports by the author).

Given the narrative of the donor support discussed above, chances are the diversion of funding from the HIV and Aids interventions and burden at country level.

The question that comes is, are the available domestic funding options adequate and sustainable to maintain the Zimbabwe HIV and Aids human life investments? Zimbabwe at country level adopted the Abuja Declaration on Health Sector Financing, where it was resolved that 15% of the National Budget should go towards health.

Of late Zimbabwe allocated 22% of its fiscal budget toward health which is far more than recommended Abuja Declaration alluded to earlier.

The Abuja Declaration was formed in 2001 following a pledge made by African Union countries to allocate “at least 15% of [the] annual budget to improve the health sector.”

The declaration also “urged donor countries to scale up support.

Recommendations:

Based on the discussion above, the following are the recommendations according to the researcher’s assumptions:

Increase in domestic resource mobilisation

While the epidemics affect most of the poor and economically vulnerable countries across the globe, Zimbabwe has been hard hit because of years of international isolation.

The emerging of the coronavirus crisis provides Zimbabwe with the best opportunity to rethink its domestic resource mobilisation strategies.

This is because, even before the outbreak of the Covid-19 pandemic, the on-going global developments including, international migration, global financial crisis, and the rise of economic nationalism in the US and some parts of Europe, external sources of financing have been slowly drying up.

Therefore, the need to increasingly raise domestic resources rather than rely on more volatile external finance such as official development assistance should be privileged in Zimbabwe.

Presently, there are a number of calls for domestic measures which the various stakeholders are lobbying the government to consider.

The following to extracts has a potential huge bearing to the funding of the National Aids Trust Fund [ 3% Aids Levy] should the government buy in the suggestion.

• Government should consider a temporary reduction in individual income and tax which will leave the population and companies with some additional disposable income to counter the negative effects of the Covid-19 pandemic.

Faced with the need to self-isolate and limit movement, individuals and households are faced with the need to continuously stock groceries, medicines and other essentials, hence the need to lower income taxes.

• Government should consider deferring payment of corporate tax because the lockdown has resulted in a lot of companies having cash flow gridlocks and at times failing to honour their tax obligations.

As such millions of jobs in both the formal and informal sectors of the economy are threatened.

Apart from the emergency measures outlined above, it is the argument of this engagement that government and policy makers should equally give premium attention to the long term impact of the coronavirus on the increased demand of the HIV and Aids investment.

In this respect, it is imperative for government to craft policies that will lead to greater domestic resource mobilisation.

It is known that Zimbabwe is richly endowed with natural resources including huge tracts of arable land, timber, wild life, and fisheries.

Besides, the country has the world’s third largest platinum reserves and is the fifth largest producer of lithium, which is essential for rechargeable batteries (African Development Bank, 2018).

The country is also rich in precious stones and other mineral resources such as gold, coal, iron ore, chromium ore, diamonds, vanadium, asbestos, nickel, and copper among others. All these should be captured to contribute to the HIV and Aids investment in Zimbabwe.

Understandably, at the moment the depressed global demand for commodity exports may hinder the country from benefiting from its resources, however, as the world slowly reopens to business, Zimbabwe should stand ready to take advantage of the opportunities that will avail themselves in the post-Covid-19 crisis.

It is recommended that Zimbabwe Revenue Authority (Zimra) the mechanism used by the Ministry of Finance to collect tax broaden their net to capture the informal sector to comply with the tax laws, mining sector, telecommunication and the tollgate fees collected through Zimbabwe National Road Authority (Zinara) to foster a wide financial basket.

It is hoped, that way, Zimbabwe can increase the purse for funding HIV and Aids epidemic in another epidemic environment such as this current Covid-19 epidemic.

There is dire need to protect essential HIV and Aids health prevention and treatment services patronised by a large segment of Zimbabweans and to resist the ongoing virtualization of Covid-19 services at some of the better-resourced key national health institutions, which hitherto provide services for many clients with other ailments.

There is also a need to rapidly procure more molecular diagnostic instruments so as to ease pressure on the reduced number of platforms currently available for , HIV  testing.

UNAids launched a call centre to increase testing for Covid-19 and HIV (UNAids, 2020).

This innovative call centre has the potential to mitigate the challenges of public transportation by providing home testing or sample collection and to boost HIV and testing.

Additionally, innovative differentiated service delivery models for HIV clients have a role in streamlining the delivery of health services and reducing the time clients spend at health facilities.

This paper further recommends that the government in collaboration with its local and international partners work together to maintain the HIV testing and services during the Covid-19 epidemic, with particular emphasis on diagnosis and treatment services for the more than one million individuals in need.

There is need to fund the use of tele-health and innovative technology solutions to limit congestion in health care systems and the adverse effects of potential disruptions to health care facilities.

Finally, the diversion of funding to the Covid-19 response at the expense of HIV responses should be avoided although the HIV prevention programmes should find creative ways to restore the scale-up trajectory that existed in the pre-Covid-19 era.

Conclusion

Zimbabwe is struggling with the outbreak of the coronavirus impact on public health care, livelihoods, and the national economy.

It was also observed that the country has been in the crisis mode since the beginning of the 21st century hence the Covid-19 crisis found the country without resources and unprepared for the pandemic.

The article decoupled some of the obstacles and opportunities for financing not just the health dimensions of the crisis but also the livelihoods of millions of people that have been destroyed by the measures meant to curb the spread of the virus as well as the negative impact of the pandemic on the critical sectors of the economy

Future research needs to focus on how government can enhance its domestic resource mobilisation efforts especially through innovative financing mechanisms in order to have financial independence as it battles against the immediate, medium and long-term effects of the coronavirus.

Be that as it may, this study is important to policy makers, health professionals, donors, civil society, and the media all of which are directly involved in the fight against the coronavirus.

It identifies the challenges they need to overcome and the opportunities they need to take in order to limit the scourge of the pandemic in Zimbabwe.

What is ironic in the advent of the Covid-19 epidemic is regardless the fact that the funding for HIV and Aids was dwindling but suddenly resources were poured from all corners towards the Covid-19.

Happy World Aids Day commemorations!

• Langton Mutoya is writing here in his personal capacity as an academic. May the views be taken for academic debate in which the article is premised. Mobile +263772702361 email mutoya2007@yahoo.com