Where previously, the discourse was around mobilising domestic funds as additional resources for advancing progress on HIV and health, now the objective is to replace dwindling international funds.  Challenged by the HIV community, donors were asked if now  ‘flat-lining is the new increase’ and ‘reducing is the new flat-lining’. Yet, after years of assuming more can be done with less, the limits have been reached. UNAIDS, normally optimistic, says it is concerned. The GFAN more explicitly, says ‘we’re off track’. A surge in HIV transmission and the plateauing of mortality has already been reported.

The health economists’ pre-conference ‘Sustainable AIDS Response Results in the Era of Shrinking Donor Funding’, reflected this concern. Excellent presentations on political economy, including from the Netherlands and PEPFAR as bilateral donors, previous and current leaders of the Global Fund, UNAIDS and others, highlighted how transition away from international resources is now inevitable. Others focused on cost-effectiveness analyses and economic modelling, as possible instruments for optimising decision-making with a restricted resource envelope. However, the difficult choices that would be in real life the consequence of such theoretic modelling and investment comparisons were rarely touched upon, and nobody questioned the shrinking international and overall funding as a given. Some people were perhaps happy that sustainability was finally taking centre stage again, after 20 years of ignoring the reality of poor countries and weak health systems.

So what does planning for shrinking the AIDS response to a sustainable level really imply?

We know that restricted resources can result in competition between health issues, unhelpfully pitting diseases against each other, and leading to ‘Peter being robbed to pay Paul’. Within the HIV response , similar tensions are arising. More people surviving, means that ARV expenditure is increasing, creating fears about insufficient funds for other important expenses such as prevention or improved adherence measures. Stopping treatment initiation, in order to protect those who are already on treatment, is also under consideration, although it is known that doing so increases morbidity, pre-ART mortality and eventually costs. Are we willing to reverse recently adopted test and treat policies which show undeniable evidence of improved survival and viral suppression?

Take West & Central Africa, which lags behind on coverage and is facing a one third reduction of Global Fund (GF) allocations compared to the previous funding period. In Guinea, insufficient room for planned ARV scaleup within the current GF envelope and no other donors, means initiation will be restricted. The government is expected to take over the funding and procurement of ARVs for 14,000 PLHIV by 2020, yet uncertainty around the disbursement for ARV purchase and repeated experiences with ARV shortages, raise concerns around the country’s capacity to ensure the availability of ARVs at optimal prices and quality outside the pooled and prequalified circuit. In Mali and Sierra Leone too, ARV purchase is expected to shift from GF to government. If you think premature transition is only happening in Upper Middle Income countries, think again!

HIV/AIDS is rarely portrayed as the deadly epidemic and global health threat that it still is, and the Holy Grail of Sustainability has replaced Survival. In planning for the “end of AIDS” and modelling its economic feasibility, an insidious shift in political and practical commitment has occurred. Overconfident claims and international fatigue has led to early disengagement and a return to business as usual, breaking the momentum towards goals which were supposedly within reach. Yet, how ‘normal’ is an epidemic that causes nearly a million deaths per year?

In many countries the global response revolution has not begun, and in places like West and Central Africa, PLHIV face the continued burden of systemic barriers that delay, deter and discourage patients from accessing early and continued treatment. In Eastern Europe and Central Asia incidence is growing unchecked. Pre-treatment mortality is compounded by death among long-term users of ARV who experience treatment failure. AIDS still claims many lives, with recurring disease being detected late or not acted upon.

The conversation is shifting from the smart use of every dollar for effective scale-up, to the question of how to reduce harm for every dollar that is taken away, and little attention is given to the clinicians and health providers who must ration ARV, in a situation that is reminiscent of the early days when treatment availability in Africa was limited. Of course, death can be cost-effective, and the lives of vulnerable people can be sacrificed to broader political and economic considerations, however, this is a dangerous way of thinking.

This is no time to become complacent and we should not accept the idea that economic sustainability is more important than life!

The music band reference is triggered by UNICEF starting off with a song on U–H–C. We did not end up dancing (it takes two to tango) but it was overall a very stylish whirling show, with its fair share of slogans and advertising pages for ‘disruptive innovation’ demonstrations and a ‘Business unusual’ fair (‘phones and drones’ someone called it).

Now you might suspect I’m not the singing kind (anymore) and maybe I didn’t feel in a festive mood -especially after reading the UHC Monitoring report which said we are seriously off track: half of people worldwide doesn’t have access to basic care and every year 100 million are pushed into extreme poverty by health expenses, just for starters. I cannot deny the major efforts to ensure this UHC Forum would be profiled as a new start, one of the grand, historic moments launching the UHC-movement.

Maybe that was exactly the problem: my head was spinning with all the smart slogans, the savvy VIPS and the utopian visions that were eloquently exposed. It left little space to discuss practical, real life problems and to come up with some concrete action points. People kept repeating that UHC was not about health only; it was about governments’ political leadership, multisector transformative initiatives and incentivising health investments by linking it to macro-economic ratings. But in fact it was all about health systems strengthening; rarely other contributions to UHC were mentioned- such as lowering costs for drugs, diagnostics and vaccines; the key role of community systems; policies of exclusion for non-citizens or marginalised or criminalised people; special needs for HIV, TB, malaria, severe patients needing hospital care… to name just a few.

Not a shade of doubt was allowed on the mantra that countries’ economic growth would now mobilise the necessary domestic resources for health. As such, risks of stalling expansion of service delivery or leaving anybody behind were left out of the equation. Any remaining gap would be tackled by ‘Innovative funding’ involving loans and banks, entrepreneurs and the private sector. I can’t help having second thoughts about this imposed optimism. To see health care as an economic investment implies exclusion of those patients without favourable return on investments. Pandemic preparedness and Global Health Security Agenda choose the threats (to who?) worthy of response, while devastating ‘local’ epidemics, such as cholera and measles in DRC or diphtheria among the Rohingya are likely to continue to be neglected.

We all need visions and aspirations, but an ideal cannot do without good, concrete, smaller yet essential actions. The human dimension risks to be lost, both making the individual feel insignificant (the bankers will solve it) and blurring the focus: people burdened with ill health and patients excluded from adequate care.

Moreover, civil society remains largely left out of the UHC dynamic. Several people expressed the feeling that the UHC forum and the UHC2030 initiative were too heavily government dominated. ‘Governments change, the people stay!’, a participant said, ’Without civil society we will not succeed’.

Some see similarities between the ‘UHC movement’ and Alma Ata, but yesterday someone reminded us that 40 years later we are still waiting for Health for All. Undoubtedly, the UHC ambitions can give renewed hope and drive, but songs and slogans alone will not change real life suffering. The invisible patients, the most vulnerable people, they will be the ultimate and only valid accountability test for UHC.

Anyhow, failure or success, opportunity grasped or missed, I was there, I have the WHO umbrella to prove it!

I’m surprised and puzzled about many of the FfD conversations. The jargon is hard to follow: many strange terms and acronyms. I know MDG, SDG, ODA, DAH, PPP and now FFD. Maybe you also use MIC, LDC or FCAS. But can you explain DRM? Or TOSSD or CBDR? These obtuse letter combinations might make quite a difference for us health workers in the coming years, so better get going- even if you don’t intend to tweet about it…

FfD3 talks a lot about DRM, domestic resource mobilization, including for health goals. Donors keep telling us that’s where the solution lies, as overseas development assistance (ODA) is expected not to increase anymore after 2015. Rich countries blame the financial crisis for their failure to keep previous aid commitments. The EU pushes back spending 0,7% of their GNI on ODA to 2030!  Also the focus of the FTT (Financial Transaction Tax) has shifted away from developing countries. Budget gaps to fill at home, you know…

In contrast everybody is very optimistic about the ability of developing countries to find rapidly the necessary resources in their own country. Aid can help countries to expand taxation capacity, i.e. a catalyst for more DRM, but aid no longer buys direct results for people. There is no acronym yet for “Tax Inspectors without borders”, but it seems to appeal to rich countries.

Other ‘new’ sources of money would come from emerging economies (BRICS etc –even if the China crisis casts a shadow), from remittances and from the private sector. The rich countries want to use public ODA money to ‘leverage’ private money into development. They assure us that entrepreneurs are keen to join, happy with ‘reasonable’ returns on investment. You’ll hear even more about PPP (public–private partnerships). You also better brush up on your banking and insurance-terms, expected to dominate this brave new world.

You might even need stop speaking about ODA (grants & concessional loans), as now incorporated into TOSSD: Total Official Support for Sustainable Development. A difficult acronym for a convenient mechanism to include all flows going into a country, including commercial bank loans, private investments, credit institutions, NGOs, charity, etc.  ODA budgets were already expanded to diverse activities such as peacekeeping, trade for aid and support to migrant policies, but now TOSSD aspires to be the new measure to show how rich countries value solidarity.

Development financing will have to be blended, integrated, bridging, leveraging, catalytic, complementary… Will smokescreen terminology contaminate also the mindset of humanitarian community? Soon humanitarians might be forced to speak about economic models and business opportunities, blurring the reality of the people that need our aid most and most urgently. Health for the most vulnerable is rarely an economically interesting investment and economics hardly helpful in realizing the FfD slogan ‘leaving no one behind’.

Newspeak is not on the AAAA (Addis Ababa Action Agenda), but quite some people say the FfD3 is unlikely to bring any concrete outcomes. Some propose to recycle the FfD acronym in the spirit of sustainability and read the logo now as ‘Financing for Dependency’. Let’s see which one will stick.