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Donor Government Funding for HIV in Low- and Middle-Income Countries in 2018

Introduction

This report provides the latest data on donor government resources available to address HIV in low- and middle-income countries, reporting on disbursements made in 2018. It is part of a collaborative tracking effort between UNAIDS and the Kaiser Family Foundation that began more than 15 years ago, just as new global initiatives were being launched to address the epidemic. The analysis includes data from all 30 members of the Organisation for Economic Co-operation and Development (OECD)’s Development Assistance Committee (DAC), as well as non-DAC members where data are available. Data are collected directly from donors, the Global Fund, and UNITAID, and supplemented with data from the DAC. Of the 30 DAC members, 14 provide 98% of total disbursements and individual-level data are provided for each. For the remaining 16 DAC members, data are provided in aggregate. Both bilateral assistance and multilateral contributions to the Global Fund and UNITAID are included (see methodology for more detail).

Findings

Total Funding

Donor government funding for HIV in low- and middle-income countries totaled US$8.0 billion in current USD in 2018, changing little from the 2017 level (US$8.1 billion) (See Figure 1 and Table 1).1 After accounting for inflation and exchange rate fluctuations, funding declined slightly between 2017 and 2018.2 Among the 14 donor governments profiled, seven increased funding between 2017 and 2018 (Australia, Canada, France, Japan, the Netherlands, Norway, and Sweden), five declined (Denmark, Ireland, Italy, the U.K., and the U.S.) and two were flat (the European Commission and Germany). In 2018, donor governments accounted for approximately 39% (30% was bilateral support and 9% was multilateral support) of the estimated $20.3 billion in resources available to address HIV, according to UNAIDS estimates; domestic resources accounted for 57%, and the remainder was from foundations, other multilateral organizations, and UN agencies. However, the estimated resource needed by the end of 2020 is US$26.2 billion, leaving a gap of several billion dollars, a gap that has grown in recent years.

Funding from donor governments rose rapidly from 2002 through 2008, marking the start of major new global HIV initiatives, and then began to level, and even decrease at the onset of the global financial crisis. Funding had a short rebound starting in 2012, and reached its peak in 2014, of $8.6 billion. Funding declined in 2015 and 2016. While these declines were largely due to a delay in disbursements by the U.S. as well as exchange rate fluctuations, and funding subsequently increased, in 2018, it was still more than $600 million below 2014 levels.

Figure 1: HIV Funding from Donor Governments, 2002-2018

The U.S. remains the largest donor to HIV efforts, providing US$5.8 billion in 2018. The second largest donor was the U.K. (US$605 million), followed by France (US$302 million), the Netherlands (US$232 million), and Germany (US$162 million).

Table 1: Donor Government Funding for HIV (bilateral & multilateral), 2010-2018 (current USD in millions)
Government 2010 2011 2012 2013 2014 2015 2016 2017 2018
Australia $104.5 $111.1 $124.7 $144.0 $100.4 $98.7 $78.0 $24.2 $45.7
Canada $136.1 $147.3 $154.5 $141.4 $124.6 $109.3 $95.5 $119.4 $122.5
Denmark $171.4 $205.6 $171.0 $191.7 $167.2 $138.8 $106.5 $90.4 $76.6
France $407.6 $412.7 $375.2 $409.8 $302.8 $263.1 $242.4 $267.7 $301.5
Germany $305.8 $303.7 $288.5 $285.3 $278.4 $200.9 $182.0 $161.9 $161.6
Ireland $81.9 $76.2 $60.5 $59.8 $51.4 $36.4 $31.1 $29.3 $25.2
Italy $11.4 $5.1 $13.9 $2.4 $25.6 $19.7 $26.0 $28.8 $26.8
Japan $157.1 $84.9 $209.1 $101.6 $175.9 $117.9 $113.2 $98.6 $156.2
Netherlands $350.5 $322.3 $193.5 $186.4 $218.7 $177.9 $214.2 $202.6 $231.5
Norway $119.4 $119.1 $111.4 $110.7 $103.8 $81.8 $70.5 $63.9 $70.1
Sweden $140.7 $164.0 $170.8 $172.5 $154.4 $109.2 $111.8 $91.1 $103.1
United Kingdom $890.9 $971.2 $800.1 $842.1 $1,114.0 $899.9 $645.6 $743.9 $604.5
United States $3,722.0 $4,506.6 $5,022.3 $5,620.8 $5,571.9 $5,004.6 $4,912.8 $5,947.0 $5,840.8
European Commission $101.7 $123.2 $100.7 $100.6 $91.2 $92.7 $36.9 $113.0 $114.4
Other DAC $169.1 $74.3 $61.2 $83.2 $89.4 $74.5 $67.7 $62.7 $61.7
Other Non-DAC $13.7 $19.8 $20.9 $27.6 $32.1 $12.4 $16.9 $27.2 $24.2
Total $6,883.8 $7,647.1 $7,878.1 $8,479.7 $8,601.8 $7,438.0 $6,951.1 $8,071.7 $7,966.4

Most funding is provided bilaterally (77%), including from the two largest donors – the U.S. and the U.K., though several others (Sweden, Australia, Norway, Germany, Canada, Italy, France, Japan and the European Commission) provide a larger share of their resources through multilateral channels (See Figure 2).

Figure 2: HIV Funding from Donor Governments by Funding Channel, 2018

Bilateral Disbursements

Bilateral disbursements for HIV from donor governments – that is, funding disbursed by a donor on behalf of a recipient country or for the specific purpose of addressing HIV – totaled US$6.2 billion in 2018, a slight decline (US$163 million) compared to 2017. The 2018 decrease was largely due to decreased bilateral disbursements by the U.K. (of US$158 million), without which bilateral funding from other donors as a whole would have remained flat. In addition to the U.K., four other donor governments decreased bilateral funding in 2018 (Denmark, Ireland, Italy, and the European Commission), four increased bilateral support (Australia, Canada, the Netherlands, and Sweden) and five remained flat (France, Germany, Japan, Norway, and the U.S.). While disbursements from the U.S., the world’s largest bilateral donor, were flat in 2018, without additional, new appropriations from Congress, disbursements will likely decline, as the funding pipeline has significantly diminished (see Box 1 and Figure 3).

Box 1: Understanding PEPFAR Funding Trends

PEPFAR, launched in 2003, led to a dramatic scale up of U.S. HIV efforts in low- and middle-income countries. In PEPFAR’s early years, disbursements trailed Congressional appropriations, which had increased steeply with the start of the program. The lag reflected the need to build infrastructure and significantly expand access to antiretroviral therapy in countries where few had access before; in addition, the program maintained a funding pipeline to ensure access to treatment if there were stock-outs or other delays. More recently, with the slowing and even decline in appropriations, PEPFAR shifted funding to later years for the startup of new programs, such as the DREAMS initiative, and to ensure that funds were spent as effectively and judiciously as possible in the context of flat or potentially decreased funding. As a result, funds from prior years were disbursed in 2017 and 2018. Because Congressional appropriations have been essentially flat for several years, this is not expected to continue and disbursements are likely to decline (see Figure 3).

Figure 3: U.S. Bilateral Funding for HIV: Appropriations & Disbursements, FY 2005-FY 2018

Multilateral Contributions

Multilateral contributions from donor governments to the Global Fund and UNITAID for HIV – funding disbursed by donor governments to these organizations which in turn use some of that funding for HIV – have fluctuated over time in part reflecting pledging periods to the Global Fund. In 2018, they totaled $1.8 billion (after adjusting for an HIV share to account for the fact that the Global Fund and UNITAID address other diseases), essentially flat compared to 2017. Funding for the Global Fund was $1.7 billion; funding for UNITAID was $103 million. Nine of 14 donors increased their multilateral contributions, while one, the U.S., decreased and four remained flat (Canada, Germany, Ireland, and the Netherlands). The U.S. decline was due to timing of payments and is expected to reach the same level as the prior year.3 Without this decline, multilateral contributions would have increased in 2018.

Recent Funding Trends

Donor government funding for HIV has slowed in the past decade. Moreover, without funding from the U.S., it would have declined significantly. Since 2010, HIV funding from donor governments, other than the U.S., declined by more than $1 billion, from US$3.3 billion in 2010 to US$2.1 billion in 2018, against a backdrop of budget constraints in the aftermath of the global financial crisis as well as rising refugee and other humanitarian emergency costs. Most of the decline since 2010 ($945 million) can be attributed to decreased bilateral support for HIV. However, while there were some increases in total funding provided to the Global Fund (for all three diseases) by these donors, they did not offset bilateral declines. In addition, UNITAID total contributions went down. Moreover, after adjusting for an HIV share, multilateral contributions also declined over the period. While Global Fund contributions from these donors have begun to accelerate in recent years, they still have not offset overall declines (See Figure 4).

Figure 4: HIV Funding from Donor Governments, Other than the United States, 2010-2018

Fair Share

We looked at several different measures for assessing the relative contributions of donor governments, or “fair share”, to HIV. These include: rank by share of total donor government disbursements for HIV; rank by share of total resources available for HIV compared to share of the global economy; and rank by funding for HIV per US$1 million GDP. As shown in Table 2, each measure yields varying results:

  • Rank by share of total donor government funding for HIV: By this measure, the U.S. ranked first in 2018, followed by the U.K., France, and the Netherlands. The U.S. has consistently ranked #1 in absolute funding amounts.
  • Rank by share of total resources available for HIV compared to share of the global economy (as measured by GDP): This measure compares donor government shares of total resources estimated to be available for HIV in 2018 ($20.3 billion) to their share of the global economy.4 By this measure, two countries, the U.S. and the Netherlands, provided greater shares of total HIV resources than their shares of total GDP (Figure 5). The U.S. provided the greatest share of total resources (29%).
  • Rank by funding for HIV per US$1 million GDP: After standardizing donor government disbursements by the size of donor economies (GDP per US$1 million), the U.S. ranked first, followed by the Netherlands, Denmark, and the U.K. (Figure 6).
Table 2: Assessing Fair Share Across Donors, 2018
Government Share of World GDP Share of Total Donor Government Funding for HIV1 Share of Global Resources Available for HIV2 Total HIV Funding Per $1 Million GDP
Australia 1.7% 0.6% 0.2% $32.2
Canada 2.0% 1.5% 0.6% $71.6
Denmark 0.4% 1.0% 0.4% $218.4
France 3.3% 3.8% 1.5% $108.7
Germany 4.7% 2.0% 0.8% $40.4
Ireland 0.4% 0.3% 0.1% $67.6
Italy 2.4% 0.3% 0.1% $12.9
Japan 5.9% 2.0% 0.8% $31.4
Netherlands 1.1% 2.9% 1.1% $253.6
Norway 0.5% 0.9% 0.3% $161.2
Sweden 0.7% 1.3% 0.5% $187.1
United Kingdom 3.3% 7.6% 3.0% $213.7
United States 24.2% 73.3% 28.8% $285.0
European Commission 1.4% 0.6%
Other DAC 0.8% 0.3%
Other Non-DAC3 0.3% 0.1%
1 – In 2018, donor governments provided an estimated $8.0 billion in international assistance (bilateral and multilateral) for HIV in low- and middle-income countries.
2 – UNAIDS estimates that US$19.0 billion was available for HIV from all sources (domestic, donor governments, multilaterals, and philanthropic) in 2018, expressed in 2016 USD. For purposes of this analysis, this estimate was converted to 2018 USD, or $20.3 billion.
3 – Represents Non-DAC member contributions to the Global Fund and UNITAID. Bilateral HIV funding from these donor governments is not currently available.

Looking Forward

As shown in this report, funding from donor governments for HIV in 2018 was well below its peak in 2014. Moreover, donor governments other than the U.S. have reduced their bilateral funding for HIV, declines not fully offset by their Global Fund contributions. If these trends continue, future funding from donor governments is likely to remain stable at best and will hinge largely on future U.S. support as well as the next replenishment period for the Global Fund. In the case of the U.S., Congressional appropriations have been flat, and the PEPFAR funding pipeline has diminished, which could lead to decreasing disbursements over time. There is also uncertainty about the U.S. pledge to the Global Fund although the Congress has indicated its intention to increase support. Most recently, the U.K. also pledged to increase its support as well. Still, UNAIDS estimates that there is a gap of several billion dollars between resources available, from donor governments and others, to address HIV and the amount needed and that this gap is growing.

Key Findings Methodology