The dangers of disease specific programmes for developing countriesBMJ 2007; 335 doi: http://dx.doi.org/10.1136/bmj.39335.520463.94 (Published 13 September 2007) Cite this as: BMJ 2007;335:565
- Roger England, chairman, Health Systems Workshop, Grenada, West Indies
Last week saw the launch of the new International Health Partnership that Prime Minister Gordon Brown hopes will accelerate progress towards achieving the United Nations' millennium development goals for health (see News doi: 10.1136/bmj.39335.610394.DB). Will the partnership make a difference? Certainly, the joint press releases with Chancellor Merkel of Germany made the right noises (www.number-10.gov.uk/output/Page13047.asp). Politicians are realising, perhaps, that throwing money at countries through disease specific global programmes might make good press, but it is not the way to help Africa.
Although international aid to developing countries for health has doubled to $14bn (£7bn; €10bn) since 2000, much of the increase is tied to individual diseases and is delivered outside of recipient countries' planning and budgeting systems, causing big problems for the recipients. Money for combating HIV and AIDS is the worst. This now exceeds the whole health budget of many of the recipient countries, such as Uganda (figure).⇓ It distorts countries' efforts to deal with their problems, because most of this new aid is delivered “off budget,” resulting in separate plans, operations, and monitoring—all in parallel with government systems. Just as countries are strengthening their budgeting processes and linking planned expenditure to activities, donors are earmarking aid to their own priorities, led by lobby groups in rich countries and the acquiescence of compliant politicians.
The main providers of aid for HIV and AIDS are the US President's Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the World Bank's multi-country AIDS programme (MAP). Each imposes its own priorities, plans, and reporting requirements, thus massively increasing the administrative burden on countries. Much MAP money is channelled through national AIDS bodies operating independently from health services and indeed has encouraged the proliferation of these bodies. Global Fund money comes with complicated and inflexible procedures that start with the grant application. And PEPFAR operates largely independently of recipient countries and uses the large scale importation of US organisations.
Countries themselves know that until HIV and other disease specific services are integrated within general routine health services there will be duplications not synergies, and they will not be cost effective or sustainable. As it is, all this money is achieving little: HIV prophylaxis is used in only 9% of pregnancies among HIV positive women, for example.
What is missing is strengthened national healthcare systems that can deliver the range of services that countries need, according to their own priorities, not those of international lobby groups. No one is funding this adequately, and no international body is equipped to provide the technical support that countries need. The obvious candidate, the World Health Organization, suffers from serious constitutional and institutional flaws and is chronically under funded.
What can Mr Brown's new International Health Partnership do to redress this? Firstly, participating donor governments can stop funding global programmes that do not put their money through recipient countries' planning and budgeting processes—withholding money from the Global Fund, for example, until it joins the sector wide, basket fund arrangements that countries have established to combine donor and domestic financing.
Secondly, the partnership can press for the Global Fund to become a truly global health fund—not a three diseases fund—so that financing can be better coordinated even before funds get to countries and so that countries will have more predictable funding with which to invest in longer term plans.
Thirdly, it can provide real support to countries that are seriously reforming their systems. Such support must extend beyond encouragement and advice: it must start with paying for the extra costs of decentralisation and of moving services out of government to independent status under contract. Donors must face squarely the reality that staff shortages and low quality health care result from the miserable level of earnings in the public sector, and they should use aid money to pay staff more if they perform. It doesn't matter whether the staff are employed by public or private organisations or are self employed. Already, 60% of health expenditure in sub-Saharan Africa is private, and reform minded governments are looking at how purchasing those services can raise quality for public consumers.
Finally, the partnership can lead a complete rethink of the millennium development goals, not because we are not going to meet them, but because they are more trouble than they are worth—and always were. They were cobbled together to make politicians look grand for the UN millennium declaration in 2000. Targets were set in the absence of any idea of how they were going to be met, how much it would cost, or where the money was coming from. The “one size fits all” target percentage reductions mean that countries that have achieved a lot in the past have big difficulties in meeting the goals, and gains (or lack of them) take no account of distribution across socioeconomic groupings. They are a factor in the rise of disease specific global programmes instead of sector-wide reforms.
We will not achieve better health care for the world's poor people without better national health systems to fund and deliver it, and we will not achieve that without a better international system for aid. Disease specific programmes do a disservice to this ambition, and the International Health Partnership must not only recognise this but be bold enough to act.
What is missing is strengthened national healthcare systems that can deliver the range of services that countries need, according to their own priorities, not those of international lobby groups