The dangers of disease specific programmes for developing countries

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