Poor start for Bush's Aids programme By Linda Bilmes
President George W. Bush visits Africa this week having seized the moral high ground in the fight against HIV/Aids. His January State of the Union pledge to spend an unprecedented $15bn to combat the disease represents a tenfold increase in previous US spending. Congress swiftly authorised the programme. At the Group of Eight summit in Evian, the president touted his success with Congress and used the commitment to put European leaders on the back foot. Even France's President Jacques Chirac conceded that Mr Bush's pledge was "historic" and that Europe "must do more" on HIV.
The figure of $15bn continues to be repeated. Last week, for example, Mr Bush reiterated it in a White House briefing with African journalists. "There is tremendous suffering on the continent of Africa," he said. "And we will put a strategy in place that effectively spends $15bn over five years to help ease the suffering from HIV/Aids."
In reality, nothing like $15bn will ever be spent. In the Byzantine world of the US budget process, Congressional "authorisation" by itself means little. What really counts is the annual appropriation that approves the federal budget and without which nothing can be spent. Using this yardstick, the programme is already falling woefully short of the $15bn rhetoric.
The culprit for this shortfall is not Congressional budget-cutting but the president's failure even to ask for the amounts needed to fulfil his pledge. His 2003 budget requested only $1.9bn - an increase of just $450m on what was spent in 2002 and a third less than the $3bn a year implied by the State of the Union promise.
In January, Mr Bush promised to make a contribution of $1bn over five years to the Global Fund to Fight Aids, Tuberculosis and Malaria. But the budget earmarks only the minimum $200m - far less than the $350m the US contributed to the fund last year. Nor is that all: even that $200m is made conditional on European nations matching every $1 that the US chips in with at least $2 of their own.
The president's budget also imposes new restrictions on how existing US funds can be used. For example, there is a provision that directs a third of bilateral HIV/Aids money - about $130m - to be spent on "abstinence- until-marriage" programmes. Such programmes may well have a role to play. But leading HIV/Aids medical groups, such as Physicians for Human Rights, have expressed concern that restrictions such as these will impede the overall prevention programme.
The only significant item of new spending - at a cost of $450m - is a new programme at the State Department to co-ordinate all US assistance on HIV/Aids. This programme will hire personnel to consolidate initiatives that are currently scattered among government departments, including Health and Human Services, Defence, State and the Agency for International Development. In other words, the only genuinely new money is being spent not on drugs or health clinics but on bureaucratic reshuffling back in Washington.
That is bad news for field organisations, which urgently need more resources and are fully capable of absorbing them. According to the International HIV Treatment and Access Coalition - a well respected group of pressure groups, foundations, research institutes and medical centres - more than 4m Aids sufferers in Africa need retroviral drug treatment immediately. Only 1 per cent have access to such drugs now. Field organisations are well set up to provide this service. Mr Bush's own Aids plan calls for treating 2m HIV-infected people, as well as preventing 7m new HIV infections, and caring for 10m HIV-infected individuals and orphans. The United Nations Aids organisation estimates that treating and preventing Aids in Africa will cost $10bn in the next two years. The need is enormous - and immediate.
Of course, Congress has yet to approve the budget and priorities may well get reordered. But the widening federal budget deficit, and Congress's usual parsimony with foreign aid, mean it will be difficult for Congress to produce an HIV/Aids budget higher than the president requested.
The president's Office of Management and Budget no doubt has plans "on paper" for funding the full $15bn in the next four years. But having failed to deliver the promised $3bn this year, it is hard to imagine Mr Bush doing much better in future - especially as US voters (few of whom understand the intricacies of the budget process) already give him credit for providing a significant boost to Aids funding. Distracted by the 2004 election and faced with the need to rein in spending to pay for tax cuts, the administration's will to follow through on its commitment is certain to wane.
Mr Bush's initiative has certainly helped to put the fight against HIV/Aids back on the international policy agenda - and he deserves credit for that. But in terms of providing a big increase in resources on the ground, the US still has to put its money where its mouth is.
The writer teaches budgeting and financial management at Harvard University's Kennedy School of Government. She served as assistant secretary of commerce under President Bill Clinton