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Funding health sector reform and disease-specific programs concurrently promise better health outcomes in developing countries
- A/Prof. Niyi Awofeso (17 September 2007)
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The dangers of attacking disease-programmes for developing countries
- Simon Collins, International Treatment Preparedness Coalition; Professor Brook K. Baker, Northeastern U. School of Law, Health GAP; Simon Collins, HIV i-Base; Gregg Gonsales, AIDS and Rights Alliance for Southern Africa; Marco Gomes, Global Youth Coalition on HIV/AIDS; (21 September 2007)
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A/Prof. Niyi Awofeso, School Of Public Health and Community Medicine University of New South Wales, Sydney 2052, Australia
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England’s1 perspective that funding disease-specific programs without first addressing national health systems hampers the achievement of better health in developing countries requires qualification. While a long-term goal of sustainable healthcare delivery through functioning health systems is obviously important2, there are sick people for whom revitalization of health systems will be too late, and for such people disease-specific aid programs are lifesaving. Non-governmental organizations like Medecins Sans Frontieres have specific mandates that govern their fundraising and healthcare activities, and they cannot be expected to divert such funds to augmenting salaries of competent national healthcare workers. My experience with operating vertical leprosy programs in northern Nigeria indicates that these programs provide ‘homegrown’ best-practice benchmarks for stimulating health system reform, including the integration of mature vertical programs into general health services.3 The benefits of disease-specific aid programs have been shown with regards to effective short-term efforts to control polio, measles and leprosy epidemics in specific regions in spite of their poor health systems. Chronic poverty of most developing countries compound efforts to promptly revitalize health systems. In Kyrgyzstan, where I worked earlier this year, the Government’s WHO-supported (MANAS) health reform program has been on-going since 1996 with good results. However, the maximum government annual budget for tuberculosis control has remained at $US1 million since 1996. The World Bank estimates that the country needs at least $US5 million yearly for TB control.4 Ongoing tuberculosis- specific aid programs in Kyrgyzstan are appropriate and have been producing positive dividends with regards to tuberculosis control as well as influencing the revitalization of the health system. Let’s not throw away the baby with the bathwater. References 1) England R. The dangers of disease-specific aid programs. BMJ, 2007; 335: 565 2) Jha P, Mills A, Hanson K et al. Improving the health of the global poor. Science, 2000; 295: 2036-2039. 3) Awofeso N. Life after Multidrug therapy: the managerial implications in leprosy control in Kaduna state, Nigeria. Tropical Doctor 1997; 27(4): 196-8. 4) Godinho J, Veen J, Dara M, Cercone J, Pacheco J. Stopping tuberculosis in central Asia: priorities for action. Washington, World bank, 2005. Competing interests: None declared |
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Simon Collins, Treatment advocate HIV i-Base, 44-46 Southwark St, London SE11UN, International Treatment Preparedness Coalition; Professor Brook K. Baker, Northeastern U. School of Law, Health GAP; Simon Collins, HIV i-Base; Gregg Gonsales, AIDS and Rights Alliance for Southern Africa; Marco Gomes, Global Youth Coalition on HIV/AIDS;
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The Dangers of Attacking Disease-Programmes for Developing Countries Roger England has launched yet another broadside attack on priority disease programmes in developing countries (England, BMJ 2007;335:565; England, 334 BMJ 2007;334: 344). In his latest BMJ “Personal View,” he claims that “disease specific global programmes [are] not the way to help Africa,” instead that they cause “big problems for recipients,” and that money for HIV/AIDS is “the worst.” He claims that off-budget money leads to distortions, that there are duplications of plans, operations, and monitoring, and that priority disease programs are neither cost effective nor sustainable. His evidence that little is being achieved is one statistic: HIV prophylaxis is reaching only 9% [sic – 11%] of pregnancies of HIV-positive women. He blames the warped prioritization of disease-programmes on international lobby groups from rich countries. England’s prescription for change includes: (1) governments must stop funding global programs that do not go through countries’ planning and budgeting processes; (2) the Global Fund to Fight AIDS, TB, and Malaria must disband and be reconstituted as a Global Health Fund, (3) countries must reform their systems and outsource service provision from the government to the private sector, and (4) everyone should drop the Millennium Development Goals because they are more trouble than they are worth. The evidence on hand rebuts or at least moderates many of England’s claims and recommendations: 1. Contrary to England’s claims, priority disease programmes have shown significant progress in a relatively short period of time. Currently, for example, the Global Fund contributes two thirds of international funding for tuberculosis and malaria, and approximately 20% of global resources for HIV/ AIDS. During its short life, the Global Fund has funded programs that have already saved more than 1.8 million lives; providing antiretroviral treatment to 770,000 people; distributing over 18 million bed nets, and treating 2 million new TB patients. However, no one should be satisfied with the piecemeal progress to date, and it is true, as England suggests, that health care capacity is now becoming the limiting factor in further scale-up of priority disease programs. 2. England discounts the growing evidence from the Global Fund, PEPFAR, and even that World Bank MAP initiative that priority disease programs, especially AIDS programming, can simultaneously strengthen health systems and delivery of primary health care. For example, approximately 22% of the Global Fund’s portfolio is devoted to human resources, training, and supporting the capacity building required to deliver key services. Likewise, 25% of all PEPFAR activities have components that directly support sustainable network development. Nearly 40% of World Bank MAP expenditures 2000-2006 were devoted to systems strengthening, including community systems. 3. Certainly there are instances where priority disease programming can be critiqued for draining human resources from other health programs, for being under-attentive to imperatives of service integration and coordination, and for neglecting broad based efforts to strengthen underlying health systems. However, there are growing calls for more effective, transverse use of priority disease funds so as to simultaneously strengthen system-wide health care delivery. HIV/AIDS programming should increase its integration with co- morbid disease programmes, e.g., malaria, tuberculosis, sexually transmitted infections, and others. Likewise, it should integrate service delivery with maternal and child health, sexual and reproductive health, and the primary care system. Finally, HIV/AIDS financing can and should be used to strengthen underlying health systems – planning and management, commodity procurement and supply, laboratory systems, education and training systems, and patient information and programme monitoring systems. That programming could be done better, does not mean that priority disease programs cannot continue to help lead the way for health system reform and capacity building. 4. England overemphasizes the problem of programme proliferation and the transactional costs of programme coordination, monitoring, and reporting, though there is certainly much that can and should be done to reduce transactional costs and to rationalize planning, spending, and reporting systems. The new International Health Partnership may very well have a positive role to play in this regard, and donors should undoubtedly reduce some of their idiosyncratic conditionalities. Despite the heightened transactional costs, however, priority disease programmes are often result - oriented, pro-active, and adaptive – they have shown that improved health outcomes are possible in an era of global health pessimism. 5. England overemphasizes the benefits of using the country’s budget processes. Although efforts are being made, and should be intensified, governance of health in much of the developing world is still weak and relatively unaccountable. Ministries of Health have difficulty fighting for prioritization in an era of scarce revenues and multiple needs. Moreover, with sector funding for health, it is sometimes hard to track expenditures, and there are increased opportunities for corruption and patronage. 6. Using countries’ budget processes and basket funding are also problematic when on-budget financing is subject to fiscal restraint policies mediated by the International Monetary Fund and national finance ministries. Recent studies at the IMF indicate that the vast majority of on-budget aid is being diverted to currency reserves and debt repayment and that only 27% is being spent. In contrast, off-budget, project aid, though far from perfect, is spent at a much, much higher rate. Admittedly, in the long run, it will be increasingly preferable for countries to own and budget their own health programs, but there is a danger in placing all aid in sector budgets when the IMF continues to put its big macroeconomic foot on the brake so as to restrict budget expansion for health and education. 7. England over-romanticizes service delivery by the private sector, just as the World Bank has done for decades. The overwhelming evidence is that private health care delivery is inequitable and that it rarely serves the poor. Accordingly, the backbone of health service delivery should be public sector even while the public sector plays a stronger role in regulating and harmonizing health care delivery in private, NGO/CSO/FGO, and workplace sectors. 8. England’s attacks on international, rich-country lobbyists denies the reality that there are international coalitions of AIDS activists, Southern and Northern, who are pressuring their governments, international institutions, and donors to respond to the greatest public health and human rights crisis of our time – the AIDS pandemic. Who exactly is bossing around the Treatment Action Campaign in its effort to force the South African government to draft, prioritize, and implement a national AIDS plan? What Northerners forced Brazilian activists and Brazilian Health Ministry officials to adopt the first free, universal access program in the Global South? Blaming outside agitators misrepresents the real balance of leadership in the global AIDS movement and ignores the history of theoretical and strategic contributions by our Southern allies. 9. HIV/AIDS is an emergency and should be treated as such. The prioritization of HIV, tuberculosis, and malaria has not been based on who screams the loudest, but rather on epidemiology – the excess morbidity, mortality, and other impacts that threaten individuals, families, communities, and countries. Several authors of this report are alive today because they fought for the right of access to live-saving drugs and medical care and because they fought to create global response to the pandemic. More recently, the existence of global priority disease programs has helped to build solidarity and efficacy for those who might otherwise become marginalized or silenced in isolated country context. Attacking priority disease programmes and calling for the dismantling of the Global Fund and the decommission of the Millennium Development goals is a prescription for returning global health and priority diseases to the backwater of broken promises and failed development. Instead of critiquing the movement and activities that form the leading edge of the driving wedge for global health reform, England, and more particularly planners, donors, and developing countries, should focus on rationalizing increasingly robust priority disease programmes so that they work laterally to strengthen health systems. By all means, those same policy makers should work much more vigorously to provide sustainable financing for health in quantities sufficient for expanding human resources for health and strengthening the health systems that deliver prevention, treatment, and care for all health needs. We realize that integration of priority disease programs within revitalized health systems over the long term is important. But, we also know that suspending priority programs prematurely will sacrifice millions on the altar of a health systems theory that made little progress post-Alma Ata until the AIDS movement became the high-speed engine on the train of health systems development. Competing interests: None declared |
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