Twenty years ago today, former South African President Nelson Mandela and former US President Bill Clinton closed the International AIDS Conference in Barcelona. As they stepped off the stage, Mandela turned to Clinton and asked him to help get treatment for people living with HIV.
The Clinton HIV/AIDS Initiative (later, the Clinton Health Access Initiative, or CHAI) launched later that summer with Mandela’s words in mind. Co-founded by President Clinton and business strategy consultant Ira Magaziner, the organization helped turn the tide on the AIDS crisis. Over the last two decades, CHAI’s unique approach has been replicated to address many more health challenges.
Today, almost 2,000 staff support ministries of health in over 30 countries. The organization is led by CEO Dr. Neil Buddy Shah and a senior leadership team that has decades of collective experience tackling health system gaps in Africa, Asia, and the Caribbean.
In the summer of 2002, a handful of volunteers from CHAI stood by a bed in Nasau’s main hospital. They were in the Bahamas at the request of the prime minister, to meet AIDS patients and provide them with affordable drugs.
In the bed lay an 11-year-old girl and 12-year-old boy—sharing was common, the patients were filling up every available space. The boy had just had a stroke. The doctors said neither child had long to live.
CHAI managed to get the medicine into the hospital within a few weeks. The Bahamas were already using generic drugs, but they were going through a supplier that marked up the price, limiting what the government could afford to buy. CHAI cut out the middleman and made a deal directly with the manufacturer that dropped the price by 87 percent. In a few months, the kids who did not have long to live were out of hospital and back in school.
“CHAI’s ambition has always been to drive transformational impact,” says Dr. Neil Buddy Shah, who joined the organization as CEO in June.
At that time there were close to two million AIDS-related deaths globally every year, yet less than 10 percent of people living with HIV were on lifesaving treatment in low- and middle-income countries. Charity groups operating in the Caribbean and Africa provided HIV treatment to patients in their own clinics. While often successful, the efforts could not keep up with the demand presented by the AIDS crisis.
A few months earlier, President Clinton had addressed the International AIDS Conference in Barcelona, alongside President Mandela. In his address, President Clinton pledged, “I will do all I can in the United States and around the world to get more money, more action, and more understanding. And I ask you to hold me accountable for that commitment, and to give me your ideas on what more I can do.”
Dr. Denzil Douglas, Prime Minister of Saint Kitts and Nevis, immediately took him up on that offer. He told President Clinton in Barcelona, “We don’t have a denial problem, we don’t have a stigma problem. We have a money and an organizational problem.”
President Clinton and Magaziner took a business-minded approach to address the crisis on an international scale. HIV drugs and tests were too expensive to buy in quantities essential for treating the millions of people in need. Their idea was to work on the supply and demand side of the market to ensure the volumes were in place so that manufacturers could provide treatment at lower costs while remaining profitable.
“We were able to break through,” says President Clinton. “Because of the essential support of the governments, multilateral organizations, individual donors, and amazingly dedicated NGOs. When we began the effort in 2002, Canada and Ireland, soon joined by other nations, pledged multi-year assistance to African nations. Private donations got us started in the Caribbean. Generic ARV makers agreed to work with us to shift from a high-cost, low-volume, uncertain payment business to a low-cost, high-volume, certain payment one. Soon the prices began to drop dramatically.”
This approach “changed the way business was being done,” as one World Bank official told The Atlantic in 2007.
The model worked. At the beginning of the 2000s, treating HIV cost over US$10,000 per person per year. CHAI’s pioneering work in negotiating price reductions and generic licenses, together with critical efforts from partners like PEPFAR and the Global Fund, has dramatically reduced that to under US$60 per person per year in 2022.
Developing the CHAI approach
Later in the summer of 2002, CHAI volunteers were in Rwanda. Another hospital bed, another child. The goal was the same: to negotiate price reductions on antiretroviral (ARV) drugs and make them available to AIDS patients. But the negotiations took almost a year. Magaziner remembers returning to the same hospital bed every couple of months to find a new patient there. By the time the deal went through, all the patients he and his colleagues had met had died.
“It kept coming back to me that if we could have moved faster we could have saved their lives. It created a real imperative in my mind to move fast in everything we did,” says Magaziner.
The organization hired business and public health experts who could help governments maximize the impact of their limited funding, as well as HIV/AIDS specialists, analysts, and other advisors. Staff listened to what governments said they needed, and worked with ministries of health, state, and local leaders, as well as healthcare professionals to set up systems that would function without CHAI’s support.
CHAI was also on the ground, particularly in Africa, supporting government efforts to establish treatment protocols—which drugs would be used, which tests would be done—as well as laboratory systems to do the testing, distribution systems to deliver drugs, and care, and training for health workers. CHAI worked with health ministries to set up units, which could measure the impact of the programs and respond as needed.
“They don’t do the real job, but they help you to do your job where you have gaps,” says Dr. Agnes Binagwaho, Rwanda’s former Minister of Health.
“CHAI’s ambition has always been to drive transformational impact,” says Dr. Neil Buddy Shah, who joined the organization as CEO in June. “We look to drive change at each point in this entire value chain—from global price negotiations to national health system planning to last-mile delivery—in order to prevent as many unnecessary deaths and illnesses as possible.”
The organization’s strategy means governments lead the solutions and programs are designed to scale nationally with tactics that can be replicated in other countries. CHAI has always been deeply grounded in the countries where it works—85 percent of employees are based in program countries and 68 percent are nationals in the countries they are based—to work closely with ministries of health to develop and implement effective systems and provide on-the-ground support.
“They don’t do the real job, but they help you to do your job where you have gaps,” Dr. Agnes Binagwaho, Rwanda’s then-health minister, told the New York Times in 2015.
This model of cooperation is central to CHAI’s mission. “We only work in countries at the invitation of the government,” says President Clinton. “So this lifesaving impact really is the result of support and collaboration within a global network of advocates, governments, and NGOs.”
Applying the approach to new problems
Today, along with HIV, CHAI works with governments, donors, and other partners to apply this same approach to more than a dozen other health areas. Over the last two decades, CHAI has negotiated over 140 global deals to lower the prices of health products by 50 to 90 percent. The organization has also expanded its support to governments in over 30 countries across Africa, Asia, and Latin America to finance and deliver these products and support frontline workers and communities.
“Ultimately, we want to ensure that when a person comes into a health facility, they receive the healthcare they need to stay healthy,” says Mphu Ramatlapeng, a former Minister of Health in Lesotho, and current executive vice president at CHAI.
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Our track record
| 67% | We have helped reduce prices of vaccines such as rotavirus, polio, and pentavalent by 45-67%, while helping governments dramatically improve the cold chain systems needed to deliver the vaccines. |
| 40% | Reduction in mother and newborn mortality in three high burden Nigerian states in 18 months through targeted health interventions integrating across all levels of the health system in the 48 hours around delivery. |
| 55M | Increase in annual number of children with diarrhea using ORS and zinc from 1.2M to 55M across four high-burden countries (India, Kenya, Nigeria, Uganda) over 4 years. |
| 72% | Reduction in malaria cases across 9 countries with plans to eliminate the disease in Central America, Hispaniola, and Southeast Asia since CHAI began technical and operational support in 2015. |
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While global health has improved dramatically over the last 20 years, half the world still lacks basic health services. COVID-19 has only exacerbated pressures on health systems, threatening to set back progress.
Here CHAI continues to use its approach to tackle some of the world’s most pressing challenges. During the pandemic, the organization has partnered with governments as they respond to COVID-19, securing affordable personal protective equipment, rapid tests, and medical oxygen during global shortages, and supporting COVAX to drive more vaccines to low- and middle-income countries.
“CHAI today builds off an incredibly strong foundation,” says Shah. “We have 20 years of experience driving large-scale impact; deep and longstanding partnerships with ministries of health; and an incredibly talented, passionate team. Looking forward to our next 20 years, our aspiration is to use this foundation to dramatically reduce preventable deaths and illnesses and ultimately, work ourselves out of a job.”
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CHAI was founded on the principle that it was morally unacceptable that millions of people died each year of AIDS in Africa, Asia, and the Caribbean while those in wealthier countries were treated. Over the following two decades, CHAI has expanded its focus. Today, along with HIV, the organization works with partners to prevent and treat COVID-19, malaria, tuberculosis, hepatitis, and cancer, accelerate the rollout of lifesaving vaccines, reduce maternal and child mortality, combat chronic malnutrition, and strengthen health systems.
With each new program, the mission remains the same: to save lives and reduce the burden of disease in the regions in which CHAI works, while helping governments create sustainable, high-quality healthcare systems. Learn more about how we work.
