Prioritize Fighting AIDS…or Health System Strengthening…Or Both?

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Last night I attended a session here in Cape Town that addressed the controversial issue of to what extent HIV/AIDS programs have helped strengthen the delivery of non-AIDS health services in developing countries.

This has been a hot topic in the global health debate, in the wake of last-month’s release of a WHO-led study of the impact of global health initiatives, such as PEPFAR. The WHO report indicated there was mixed evidence, mostly positive, but some negative, regarding the impact of disease-specific strategies.

Then the debate intensified when The Lancet claimed the study showed that the initiatives worsened inequalities in health services, with Health GAP and other groups stating that the report showed exactly the opposite.

To shed some light on the broader issue of health system impact, the presenters at last night’s satellite session, organized by the International AIDS Society, summarized the proceedings of a two day pre-meeting on the crisis facing health systems. (The IAS also included a brief summary of the latest research on the issue in their July 2009 newsletter.)

IDSA member Dr. Wafaa El-Sadr was one of the speakers. She said that while there was mixed evidence from qualitative studies of the issue, and more research was needed, she believes that the AIDS investment has pulled the overall health system forward. History has shown, she said, that you have to have passion and urgency to increase any investment in health, and nothing better provides that sense of urgency than a disease epidemic like AIDS. The challenge now, she said, is to learn from the experience of scaling up AIDS programs and focus on sustainability while at the same time preserving a sense of urgency.

El-Sadr called the scaled up AIDS response of recent years, especially in the area of treatment, a remarkable achievement and that in the course of implementation AIDS programs has pulled health systems in some positive directions. AIDS is a chronic condition that impacts throughout the life cycle, and this necessitates a transformation of the system toward a holistic, longer-term approach. To address HIV/AIDS, programs have had to activate the community and introduce new cadres of health workers, such as peer educators. The AIDS movement has also contributed by showing how to generate community demand for services and accountability, she said.

Economist Alan Whiteside also spoke on the panel. He emphasized the human resource crisis now confronting health systems, caused by attrition and out migration, and said, “We have a duty to do something about this.” The crisis is seen not only in a shortage of nurses, doctors and community health workers, but also in personnel needed to properly run procurement and distribution systems.

On whether to continue increasing investments in AIDS or instead invest in overall health system strengthening, Whiteside called this “a manufactured problem” and said both were needed and financially feasible. He said the way massive funding was mobilized to bailout wealthy banks has shown that money is available.

Whiteside called for innovative taxes to help finance health system strengthening and delivery of essential services, while at the same time demanding accountability. Citing the precedent of the airline tax, now generating millions of dollars for UNITAID, he called for a tax on foreign exchange transactions. Interestingly, this concept has recently been taken up by a wide range of health advocates, including groups focused on maternal and child health, reproductive health and AIDS, TB and malaria, in collaboration with Stamp Out Poverty.

Dr. Freddie Ssengooba, of the Makarere University School of Public Health in Uganda, who also spoke on the panel, said that global health initiatives can have a beneficial impact on the overall system. He said effective malaria prevention, for example, especially through the use of residual indoor spraying, is freeing up health care workers from dealing with malaria cases in the region’s already over-burdened clinics and hospitals. He said the shortage of health care workers was aggravated by the privatization of education and the difficulties medical students face in completing their educations. He said the use of global health initiative funds, such as from the Global Fund, to help defray the cost of training should be considered. He also called for the use of bonding mechanisms that would require health care workers to stay in their posts, along with better performance incentives and job contracts.

The World Bank’s Dr. Debrework Zewdie, who co-convened the session along with Noreen of TASO, said that “we should not apologize” for the AIDS investment. She said the solution was not to shift resources away from AIDS, the human cost of which she said would be monumental, but rather invest in health systems while continuing what has been started on AIDS.

One thing is clear, which is that AIDS services are benefitting efforts to combat other diseases. New research by Dr. Robin Wood has shown that AIDS treatment can significantly reduce the risk of TB disease. Plus, research from Uganda, released this week, showed that concurrent antiretroviral therapy and cotrimoxazole prophylaxis significantly reduced the risk of malaria among HIV-infected Ugandan patients.

But the broader system needs urgent attention. PEPFAR, after the successful reauthorization last year, is now required to recruit, train and retain 140,000 new health care personnel. Now, we at the Center for Global Health Policy, along with other groups are working hard to ensure PEPFAR gets the funding it needs to finance these and other improvements, which will benefit all health efforts. We will also issue our own examination of the health systems issue later this year.

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