At the same time, another issue is affecting how some donors are now approaching support of global health. Over the last few years, international agencies and academics have been embroiled in an ongoing debate about the wisdom of disease-specific aid (e.g. for HIV/AIDS) versus funding for general health systems strengthening.
Last week an extensive review of the evidence on the effects of global health initiatives published in The Lancet (the WHO-led Maximising Synergies project) concluded that global health initiatives have had both positive and negative effects on health systems. The authors, a group of more than 60 academics, programme chiefs and global policy makers, made five recommendations, based on their analysis of over one hundred studies:
- Infuse the health systems strengthening agenda with sense of ambition, the scale, the speed and the increased resources that have characterized the GHIIs
- Agree on clear targets and indicators for health systems strengthening;
- Promote country capacity for strong national planning processes and better alignment of resources with national planning processes;
- Promote the meaningful involvement of civil society organizations in the governance of health systems and the delivery of health services;
- Improve evidence-based decision making in health by building the capacity of countries to generate and use knowledge.
These nuanced and careful conclusions are likely to be used by both sides of the debate to justify their positions. Unfortunately the Maximising Synergies report does not provide much HIV-specific information.
However an independent review by the Global HIV/AIDS Initiatives Network, a global network of health systems researchers based at London School of Hygiene and Tropical Medicine, published this month in the journal Health Policy and Planning, provides some useful analysis. They note that while PEPFAR, the Global Fund and the World Bank Multi-country AIDS Program have been successful in supporting scale-up, in channelling funds to the non-governmental sector and in getting more stakeholders involved, they have also distorted national health systems priorities in some settings and created vertical systems.
But the researchers also point out that global HIV/AIDS initiatives should not be dismissed, and make some constructive recommendations about how to address current problems:
- Global HIV/AIDS initiatives could do more to align with national health priorities, and should coordinate investment to strengthen national health systems;
- Global initiatives should give countries sufficient flexibility to address health system weaknesses and strengthen implementation, espeically in human resources;
- Better coordination of donor investment to meet national health priorities, with flexibility to allow global initiatives to support the areas they can fund, allowing other resources to flow elsewhere;
- Global HIV/AIDS initiatives must provide long-term funding to address the shortage of public health sector staff;
- Global HIV/AIDS initiatives must continue to fund the non-governmental sector, but should require NGOs to utilise and contribute data to national health information systems, to ensure a joined-up approach.
It should be a false dichotomy — health systems strengthening is essential for the optimal success of HIV/AIDS programmes, and HIV/AIDS support should and could be designed and delivered in a responsible way that strengthens health systems. Occasionally, it was necessary to pilot a service vertically to demonstrate it was possible in a setting, but the goal has long been to mainstream HIV/AIDS services into the public health system as soon as possible. Indeed, WHO launched the 3 x 5 initiative in 2003 specifically to promote the delivery of antiretroviral treatment through the public health system through standardised protocols that would eventually allow delivery through primary care.
Services have been shown to be most effective when delivered locally — as close to where the patient lives as possible — through the primary health clinic, community-based and home-based care. This has been the public health approach that HATIP has been describing for the last five years, and universal access is impossible without a generalised scale-up of the capacity of primary care.
“You can reach a certain level of coverage without addressing the health system’s weaknesses, but when you go to scale up, as we all want to with universal access, then the health systems become particularly critical,” said Dr Abdullah.
The critics of HIV/AIDS funding frequently point to dated examples of the early HIV/AIDS response as a separate vertical system — suggesting that this will go on indefinitely and that “far too much is spent on HIV relative to other needs and this is damaging health systems.” But the critics forget that AIDS services are also rescuing health systems that were (and would be) inundated with people ill or dying of AIDS and TB. And they ignore the dynamic nature of the HIV/AIDS response and that HIV implementers have demonstrated capacity to adapt their practices and integrate services to make them more effective.
But the accusation that HIV/AIDS is getting too large a share of international aid for health seems to have taken hold and in an important sense, has helped the critics of HIV/AIDS funding win the rhetorical debate.
One indicator of the shift is how funding is being redirected from HIV/AIDS to general health systems strengthening. According to sources at WHO, the HIV Department has suffered a dramatic reduction in funding, with donors such as the Scandinavian countries now redirecting their funds to general health systems strengthening. But there is a real danger that, in the current economic climate, the debate will simply provide a convenient excuse for industrialised countries not to honour their commitments to supporting universal access.
PEPFAR insiders have told HATIP off the record that they are extremely worried that the debate is beginning to diffuse PEPFAR's focus on HIV/AIDS.
HIV/AIDS funding critics have adopted one particularly insidious tactic by pitting the needs of ‘innocent children’ against people living with HIV, arguing that infant mortality is receiving insufficient attention due to the emphasis on AIDS, and that many lives could be saved with inexpensive measures to prevent or treat diarrhoea and pneumonia.
Ezekiel Emanuel, brother of White House chief of staff Rahm Emanuel, while accepting that the US must continue to meet its responsibilities to people already on treatment, explicitly criticised further increases in PEPFAR spending on HIV/AIDS in a recent commentary in the Journal of the American Medical Association, arguing that "doubling or tripling PEPFAR's funding is not the best use of international health funding ... By focusing so heavily on HIV/AIDS treatments, the United States misses huge opportunities. By extending funds to simple but more deadly diseases, such as respiratory and diarrheal illnesses, the U.S. government could save more lives - especially young lives - at substantially lower cost."
“They have more DALYS,” a PEPFAR insider told HATIP, referring to Disability Adjusted Life Years or the sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability — meaning many more years of life could be saved with MCH interventions than by the relatively expensive HIV/AIDS interventions.
“But they forget that HIV/AIDS is striking adults at the prime of their lives. These are the workers, the family providers. HIV/AIDS threatens the security of families and the economic system —and it disproportionately affects teachers and healthcare workers upon which the educational system and health system relies.”
Low-cost interventions to save the lives of children from easily treatable and preventable illnesses should of course be made more widely available.
However, it is important to point out that maternal-child health is a perennial issue for which host governments must be held directly responsible. The health systems in these countries have indeed been weakened, but the main culprits for this were the disinvestment in health systems dictated by the structural adjustment policies of international financial institutions (such as the IMF) in the 1970s, 80s and 90s, and the subsequent failure of developing countries to allocate sufficient resources to health.
Debt forgiveness and policies that enable developing countries to invest in their own health systems may be the best way to strengthen general health systems in a way that is ‘home-grown’ and sustainable.
But it is another issue entirely whether funding should be directed away from the HIV/AIDS pandemic, which is indeed an unprecedented emergency that many high-burden countries are poorly equipped to manage and which does in fact require an exceptional response.
But has the debate affected US government policy?
“A big priority for the Obama administration is to continue our support for HIV/AIDS but to look at it in a broader context of public health issues around the world. So he recently launched something called the global health initiative, committing to spend $63 billion over the next 6 years (70% of which is for HIV/AIDS, TB and malaria),” said Michelle Moloney-Kitts, Assistant Global AIDS Coordinator for the US government at the opening press conference. “He is hoping that we can use the platforms PEPFAR has developed to look at other issues that affect families such as diarrhoeal diseases in children, maternal mortality, neglected tropical diseases, and that this comprehensive approach will in fact be more responsive to what people really need in the field and in the country and that will also contribute to the long-term sustainability of our programmes.”