The uncalculated costs of global health insecurity

In the last decade, the United States has played a leading funder role in the preparedness and responses to global infectious outbreaks and the delivery of basic healthcare in developing countries. The proposed aid cuts in the U.S. 2018 budget arguably represent at the very least, a serious setback in achieving the Sustainable Development Goals (SDGs) and would diminish the capacity to prevent and coordinate interventions to address human health security issues, like Ebola. The reduction of funding to national disease surveillance systems, training and infrastructure in the developing world means lowering the guard to deliver rapid, coordinated and consistent assistance to tackle borderless infectious diseases.

In a recent interview commenting on Trump's proposed 2018 budget, the American economist Jeffrey Sachs said the cuts could lead to millions of deaths. Whatever the outcome of the US budget battle, the world must agree on new aid architecture, with strong leadership that pushes the international community to commit more financial resources.

Before Trump's Era

In 2015, the Organisation for Economic Co-operation and Development (OECD) statistics showed a U.S contribution to aid of over US$29b, through bilateral agreements (country to country), multilateral commitments (United Nations, World Bank, and others) and international and local non-governmental organisations. One-third of these financial resources (US$11b) have been used to fund basic healthcare services, and water and sanitation programs in developing countries, including diagnosis tests for malaria and HIV/AIDS, drugs, bednets, and new infrastructure as health centres, hospitals, and biomedical research centres. Altogether, U.S.leadership strengthen disease surveillance systems and global coordination on epidemic outbreaks by funding professional training, research centres, and working closely with developing countries. The U.S.'s commitment and leading role in pushing the agenda to combat HIV/AIDS, malaria and tuberculosis were noteworthy through the creation of President's Emergency Plan for AIDS Relief (PEPFAR) in 2002, and the President's Malaria Initiative (PMI) in 2005, and substantial contributions to The Global Fund (US$10b in 2015).

U.S's major financial contributions and the global commitment to the Millennium Development Goals resulted in significant achievements in the last 15 years (Millennium Development Goals(MDG): new HIV infections dropped by almost one-third from the epidemic peak; tuberculosis deaths declined by 3.7% between 2000 and 2013; child deaths from malaria in sub-Saharan Africa have dropped 31.5%, the under-five mortality rate has declined by more than half, and maternal mortality is down 45 percent worldwide in major diseases as HIV, malaria, and tuberculosis. If approved by the Congress, the budget proposed by Trump's administration would create uncertainty as to how to sustain MDG's results and achieve the SDG in 2030.

Blueprint?

The recently announced U.S. budget for 2018 "America First: A budget blueprint to make America great again" is sweet-and-sour on the international aid. Some important programs such as PEPFAR and PMI will be kept, but the aid flow channelled through distinct recipients (UN, Development banks, NGOs, etc.) will be reduced as a whole. This chain effect compromises the global effort to improve the health outcomes of people living in developing countries, especially their access to medical treatments and care.

Proposed 2018 US budget changes in international aid:

Cuts:

• The Fogarty International Centre
• Direct funding for international organizations such as the Department of State and USAID (-28%), multilateral development banks, including the World Bank, (US$650 million over three years), contribution to UN budget and UN peacekeeping costs (up to 25%)
• The Global Climate Change Initiative and the Emergency Refugee and Migration Assistance accounts

Maintains:

• President's Emergency Plan for AIDS Relief (PEPFAR) & President's Malaria Initiative (PMI)
• The Global Fund for AIDS, Tuberculosis, and Malaria contribution pledge for 2017.

Uncalculated costs

Jeffrey Sachs's warning about the consequences of cuts in US contributions to international aid programs are particularly pertinent vis-à-vis health security, as global epidemics are an unpredictable threat with unforeseen consequences requiring continuous financial resources and coordination. The latest Ebola outbreak (2014-2016) showed there was no robust and timely surveillance systems and local preparedness to tackle highly transmissible diseases. In Sierra Leone, Liberia, and Guinea, the human costs of the Ebola epidemics were enormous, killing over 11 000 people from Ebola, and around 21 000 additional deaths due to the reduction in access to healthcare services. The economic burden for these West African countries accounted for US$2.2b of the GDP. The international community response was estimated in US$3.6b, including US$2.3b from the U.S. government.

The fair share?

Trump has justified the US's aid budget cuts by stating that it's now time for "the world to pay their fair share." But the spending picture as a percentage of the gross national income (GNI) proves to be different. The signers of the Paris Declaration (2005) and the Accra Agenda for Action (2008) committed themselves to a contribution of 0.8% ratio of GNI to bilateral, multilateral and NGOs initiatives in developing countries.

In 2015, the top donors to promote the economic development and welfare of developing countries were Sweden, United Arabs Emirates, Norway, Luxembourg, and Denmark, all above 0.8% of GNI (1.4%, 1.1%, 1.0%, 0.95 and 0.8%, respectively).The U.S comes in 23rd position (0.16% of GNI) showing how marginal its relative contribution is compared with Malta, for example, which ranks 21st.

The interdependency of human health security concerns means the international community must achieve a robust coordination and financial commitment to disentangle historical inequalities and injustices that lead to 80% of the world's population living in the Global South with access to an unequal share (20%) of the world's resources and human welfare. This would represent a truly "fair share".

What's next?

Until 2017, U.S had a leading role in the areas of funding, research training and intervention. If approved by the Congress, Trump's first budget proposal is a game-changer by lowering the global response to finance basic healthcare in the developing world, and reducing the global disease surveillance systems. These new changes demand a new architecture and leadership in international aid, whether that calls for an action from a block of countries (leading EU countries and South-South Cooperation), to charities and foundations like Bill and Melinda Gates, or public and private partnership, or all together.

The world needs to take a coordinated action, and we are all responsible for its results.

This story is republished courtesy of PLOS Blogs: blogs.plos.org.