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Roger England has launched yet another broadside attack on programmes for priority diseases in poor countries (BMJ 2007;335:565 doi: 10.1136/bmj.39335.520463.94 and 2007;334:344 doi: 10.1136/bmj.39113.402361.94). In his latest 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 programmes are neither cost effective nor sustainable.
His evidence that little is being achieved is one statistic: HIV prophylaxis is reaching only 9% (actually it is 11%) of pregnancies of HIV positive women. He blames the warped prioritisation of disease programmes on international lobby groups from rich countries.
England's prescription for change says that (1) governments must stop funding global programmes that do not go through countries' planning and budgeting processes; (2) the Global Fund to Fight AIDS, Tuberculosis, 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 considerable progress in a relatively short period of time. Currently, the Global Fund contributes two thirds of international funding for tuberculosis and malaria, and about 20% of global resources for HIV/AIDS, for example. In its short life it has funded programmes that have already saved more than 1.8 million lives; provided antiretroviral treatment to 770000 people; distributed more than 18 million bed nets; and treated two million new patients with tuberculosis. However, no one should be satisfied with the piecemeal progress to date, and it is true, as England suggests, that healthcare capacity is now becoming the limiting factor in further scale-up of priority diseases programmes.
(2) England discounts the growing evidence from the Global Fund; the US President's Emergency Plan for AIDS Relief (PEPFAR); and even that World Bank's Multi-Country HIV/AIDS Program (MAP) that priority diseases programmes, especially AIDS, can simultaneously strengthen health systems and delivery of primary health care. For example, about 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 development of sustainable networks. Nearly 40% of spending by MAP in 2000-6 was devoted to strengthening systems, including community systems.
(3) Certainly there are instances in which priority disease programming can be criticised for draining human resources from other health programmes; being underattentive to imperatives of service integration and coordination; and neglecting broad based efforts to strengthen underlying health systems. However, there are growing calls for more effective, transverse use of priority disease funds to simultaneously strengthen system-wide healthcare delivery. Programming for HIV/AIDS should increase integration with programmes for comorbid diseases, such as malaria, tuberculosis, sexually transmitted infections. Likewise, it should integrate service delivery with maternal and child health, sexual and reproductive health, and the primary care system. Finally, financing for HIV/AIDS 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 diseases programmes cannot continue to help lead the way for reform of health systems and building capacity.
(4) England overemphasises the problem of proliferation of programmes and the transactional costs of coordination, monitoring, and reporting of programmes, although there is certainly much that can and should be done to reduce transactional costs and to rationalise planning, spending, and reporting systems. The new International Health Partnership may well have a positive role to play in this regard, and donors should undoubtedly reduce some of their idiosyncratic conditions. Despite the heightened transactional costs, however, priority diseases programmes are often result oriented, proactive, and adaptive. They have shown that improved health outcomes are possible in an era of global health pessimism.
(5) England overemphasises 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 prioritisation in an era of scarce revenues and multiple needs. Moreover, with funding for health by sector, 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 (IMF) and national finance ministries. Recent studies at the IMF indicate that most 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, although 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 programmes, 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-romanticises service delivery by the private sector, just as the World Bank has done for decades. The overwhelming evidence is that delivery of private health care is inequitable and 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 harmonising health care delivery in private organisations; non-governmental organisations, civil society organisations, and foreign government organisations; and workplace sectors.
(8) England's attacks on international lobbyists from rich countries denies the reality that there are international coalitions of AIDS activists, from rich and poor countries, 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, prioritise, and implement a national AIDS plan? Which rich forces made Brazilian activists and Brazilian Health Ministry officials to adopt the first free, universal access programme in the poor world? 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 allies in the poor world.
(9) HIV/AIDS is an emergency and should be treated as such. The prioritisation of HIV, tuberculosis, and malaria has not been based on who screams the loudest, but rather on epidemiology—the excess morbidity, mortality, and other effects that threaten individuals, families, communities, and countries. Several authors of this report are alive today because they fought for the right of access to life saving drugs and medical care and because they fought to create global response to the pandemic. More recently, the existence of global priority diseases programmes has helped to build solidarity and efficacy for people who might otherwise become marginalised or silenced in isolated country context.
Attacking priority diseases programmes and calling for the dismantling of the Global Fund and decommissioning 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 criticising 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 rationalising increasingly robust priority diseases programmes so that they work laterally to strengthen health systems.
By all means, these 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 realise that integration of priority diseases programmes in revitalised health systems in the long term is important. But we also know that suspending these programmes prematurely will sacrifice millions on the altar of a health systems theory that made little progress since Alma Ata until the AIDS movement became the high speed engine on the train of health systems development.
This is a short version of a rapid response on bmj.com. The full version is at www.bmj.com/cgi/eletters/335/7619/565#176912.
Competing interests: None declared.