The next advocacy campaign
There is an emerging debate in healthy advocacy about the wisdom of focusing funding so much on fighting a few diseases. Is AIDS money truly additional money that would not have gone for other purposes or is AIDS taking money out of child survival, maternal health and other worthy areas of expenditure? (Jeremy Shiffman of the Center for Global Development and Laurie Garrett have both made this argument in recent months as we blogged about here, here).
CGD’s Nandini Ooman takes up this argument again in a recent post:
So, what is it that drives HIV/AIDS funding at the expense of other health priorities? If this is a result of phenomenally heroic and unprecedented health advocacy efforts, and active participation of civil society in driving priorities, isn’t it time for health advocates to reconsider their advocacy strategies? The relative disease burdens faced by low and middle income countries are from more than just HIV/AIDS. As fabulous as it will be, if we get to the point that AIDS, TB and Malaria don’t kill, there’s a lot more that will…
If this is a call for more catch-all funding for health systems, I think campaigners may face barriers to achieving significant results, though they may be able to package the need for “health systems” as part and parcel of a broader AIDS effort. As we saw in the budget the Democrats in the House supported last week, they put more money into AIDS and malaria than they did in to the Millennium Challenge Corporation. There appears to be much more interest in getting results now than efforts to build systems and institutions that may yield results but not for a while.
Francis Fukuyama highlighted this problem well in his recent book State-Building:
For example, everyone would agree that a program designed to provide antiretroviral drugs to AIDS victims in sub-Saharan Africa would be desirable to implement. An outside donor has two possible approaches to treating victims. It can work entirely through the country’s public health infrastructure, expanding its reach by training bureaucrats, doctors, and other health care workers and providing the government with massively greater resources. Alternatively, it can take over important parts of the drug distribution program itself, directly providing doctors and other health care workers, drugs, and most important, the administrative capacity to get the health care workers out into the field. Working through the local government inevitably means that fewer AIDS victims will be treated….But when the external aid agency bypasses the local government..the local bureaucracy leans the wrong kind of skills, never takes ownership of the heath care activity, and often sees many of its most skilled people leaving to work for the outside donor (40-41).
Donors want results and thus politicians favor the direct provision of aid and services, largely in a way that inevitably means that local capacity-building and broader health care problems remain under-funded. I understand that the Global Fund initially was envisioned as having a health systems capacity tranche but this was eliminated. While the Global Fund did diseases, the WHO and bilateral donors were supposed to focus on health care system development. It hasn’t worked out like that as yet.
While there are possibilities for synergistic effects between AIDS programs that lift all boats of other services in the health sector, this doesn’t always happen. That said, as Paul Farmer suggested, the distortionary effects of AIDS programs mostly occur in badly designed programs. Are most donor programs badly designed?
Certainly, Garrett’s recent Foreign Affairs piece was sobering. That said, I think advocates need to carefully consider how to craft their campaigns for long-run sustainability of donor funding. What does it mean to have extended this commitment of ARVs to poor people suffering from AIDS? Can this commitment be extended indefinitely? What would universal coverage of all HIV+ people cost now and forever?
Without a conscious choice, donors have committed themselves to an entitlement program to those with HIV for as long as they live, unless they and their home countries can come to afford all or part of the drugs themselves. I think this is a morally admirable effort, but I also worry that if it were to cease at any point, the recision of such funding could be as morally appalling as the current build-up is noble.
Filed under: Politics and Policy