'Spectacular progress', 'huge opportunities' and 'jeopardy and vulnerability' - with these stark headlines the former Global Fund chief, Sir Richard Feachem, framed Africa's past, present and future in the battle against Aids, tuberculosis and malaria.
Speaking at the Economist conference, "Healthcare in Africa - future approaches to funding, partnerships and access", in Cape Town on Wednesday, Feachem's words were perhaps as relevant to the ambitious conference theme as they were to the three diseases that have galvanised the global community in the past decade.
Feachem, the founding director of the Global Fund to Fight Aids, Tuberculosis and Malaria, outlined what he said was spectacular progress made on all three fronts. He noted that in 2000, no one in the developing world was receiving antiretroviral therapy from their public health system, whereas in 2012, some seven million people with HIV/Aids have access to affordable medication.
Feachem said this progress has been driven by "new money" that had come through groups such as the Global Fund and the United States' President's Emergency Fund for Aids Relief (Pepfar).
It had also been spurred by the development of new, more effective medicines. "Ten years ago, one pill a day was undreamed of nirvana," said Feachem, referring to the daily single dose of Tenofovir that has revolutionised Aids treatment.
In the past decade, many countries have also reduced their malaria burden by more than half. In addition to new money, technology, such as long-lasting impregnated bed nets, improved treatment, rapid diagnostic tests and political commitment have helped spur progress.
Feachem, who is the director of the Global Health Group at the University of California, San Francisco, said there were still "huge opportunities" to control malaria better in many countries, and even to add to the list of countries that have eradicated it.
Thirty-six of the 100 countries where malaria was still present had set a target to eliminate the disease completely. Among these were four countries in sub-Saharan Africa: Namibia, Botswana, Swaziland and South Africa.
"It's a horse race; we'll see who gets there first," said Feachem, but added that his bet was on Swaziland which looked likely to eliminate malaria by 2016.
He warned that new insecticides were needed, but welcomed the fact that new drugs were in the pipeline and should be available within five years. Feachem also predicted that by 2016 the world would have its first-ever anti-malaria vaccine.
Against the backdrop of the past golden decade of funding for health, Feachem cautioned that there were three sources of "jeopardy and vulnerability" - all of them financial.
In the current global financial crisis, almost all donor countries that had provided the lion's share of support for global health faced large domestic deficits. There were just two exceptions - Norway and Australia. This had already impacted on their aid and assistance budgets, said Feachem, and the knock-on effect on the Global Fund was already evident from the cancellation of Round 11 of funding.
He said a third cause for concern was the behaviour of "two thirds" of African governments that had, during the past "decade of largesse", reduced their own healthcare budgets, preferring to rely on donor funding which, by its very nature, "is not reliable and not predictable".
What should have happened, said Feachem, is that African governments should have been increasing their domestic expenditure during this time, to enable them to raise their domestic baseline for healthcare. "We have to rapidly address that situation," said Feachem, adding that it required a "grown-up discussion that we have been reluctant to have".
He said that only one donor country - the United States - and one recipient - South Africa - had engaged in that negotiation. "For all the others there is just the hope that international money will flow," he said. He warned that in this context, if funding did not materialise, people would die quickly from Aids-related illnesses. And, in the case of malaria, "after a few rainy seasons we will be back to where we were 10 years ago".
Sharing the platform with Feachem, was the international president of Médecins Sans Frontières (MSF), Dr. Unni Karunakara who also raised the alarm about the worrying new trend that was emerging after a decade of progress in global health. "Donor countries are nickel and diming HIV/Aids, TB and malaria programmes," he said. "They are asking developing countries to do more with less."
Karunakara said that MSF had witnessed first-hand what the funding crisis means in certain countries. Citing the example of the Democratic Republic of Congo (DRC) he said that only 12 percent of people who needed antiretroviral treatment were receiving it, but because of the cancellation of Round 11 of the Global Fund, the DRC would receive no new money to treat more people until 2014.
"Now is the not the time to retreat," said Karunakara. He said the treatment of chronic diseases such as HIV/Aids, TB and malaria was not just a moral question, but also a question of good economics. "It's a matter of pay now or pay forever," said Karunakara, quoting the head of the United Nations Aids Programme, Michel Sidibe.
Another key factor that had enabled the world to make such good progress in the treatment of HIV/Aids was the drop in price of antiretroviral therapy made possible by competition from generic pharmaceutical companies in India. "In 2000, ARVs cost between U.S.$10,000 and $12,000 per person per year. In 2012, the cost of antiretroviral therapy for one person is $75 a year," said Karunakara.
However, he warned that recent efforts by the European Union and the United States sought to limit generic production by countries such as India. This he said this would have serious consequences for people in poor countries who needed ARVs. "Eighty percent of the drugs we use to treat patients in Africa come from India. The same is true for Pepfar."
Pointing to the significant progress made over the past decade, Karunakara said health workers had the tools to fight and called on donor and recipient governments to provide leadership at this "worrying moment".
"We can choose to treat HIV and to move towards the eradication of these diseases, or we can choose to pull out of funding," he said. "It's a choice we have to make."