A challenge to stop `wasteful spending’ in AIDS programs

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Stefano Bertozzi speaks Thursday in the plenary session at the 2009 HIV/AIDS Implementers' Meeting in Windhoek, Namibia

Stefano Bertozzi speaks Thursday in the plenary session at the 2009 HIV/AIDS Implementers' Meeting in Windhoek, Namibia

While many people at the 2009 HIV/AIDS Implementers’ Meeting have expressed concern about the global economic crisis hurting AIDS and health budgets, Stefano Bertozzi turned the focus back on AIDS programs today, which he said had too much “wasteful spending’’ and needed to be better run.

Bertozzi, executive director of the Center for Evaluation Research and Surveys at Mexico’s National Institute of Public Health, paraphrased a saying often used by his old boss, Julio Frenk, as his own “take-home message’’: “We need more money for AIDS, but we also need less AIDS for the money. For the last 27 or so years, we’ve paid much more attention to getting more money for AIDS, and we’ve paid much less attention to getting less AIDS for the money.’’

Speaking in today’s plenary session, Bertozzi challenged the leaders of PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, UNAIDS, UNICEF, the World Bank, and governments receiving AIDS funds to stop spending money on unproven interventions.

“There’s a silver lining in the economic crisis cloud: It’s an opportunity to improve the efficiency of our programs. When budgets are increasing, it’s easy to be sloppy with the money we have,’’ he said.

He urged those who run AIDS programs to invest in monitoring and evaluating the effectiveness of interventions.

“We need to stop implementing large-scale interventions of uncertain values without measuring their effectiveness,’’ Bertozzi said to applause.  “That means all of us – and I don’t care what side of political spectrum you are on – have to have humility to investigate what interventions work. We wouldn’t think to vaccinate people without evidence. And yet we are rolling out programs that we are not sure actually work. South Africa, for instance, has been working on several strategies to reduce concurrent partnerships, and while that is a worthy goal, it doesn’t mean we know how to implement programs that work.’’

Many AIDS programs were extremely inefficient, he said.

“I don’t care whether you are talking about shoes, or coffee, you need to find ways to produce them efficiently,’’ he said. “But it turns out in HIV you can stay in business even if you don’t produce your shoes efficiently.’’

Bertozzi cited a study that looked at the cost of voluntary counseling and testing centers in five countries – Mexico, Uganda, Russia, India, South Africa, and Mexico. The cost per client ranged between a couple of dollars and more than $800.

And he criticized AIDS programs planned year to year. Strategies, he said, needed 10-year horizons.

“We’re more than 27 years into the epidemic and we’re still talking about one year plans and one year goals. If we are talking about success for one year, we can’t achieve successes we need for this epidemic. We won’t empower women – you don’t do anything like that over the course of a year. We’ve seen extraordinary changes in social norms on tobacco, and I live in a country, Mexico, where people didn’t think about smoking 10 years ago. Now, Mexico has banned smoking in all public places. We need, in HIV, to have 10-year horizons that show we are working over the long term.’’


Michelle Maloney-Kitts, the assistant US global AIDS coordinator, said that the US government program also saw many opportunities in becoming more efficient and also in entering long-term plans with national governments.  She forecast a “period ahead where I believe we’ll see a leveling of funding, which does create some tensions.’’

“PEPFAR is now working on better partnering relationships with national governments and donors to better coordinate efforts. We need to have very good national plans and partnership frameworks that will be five-year working relationships, outlining shared commitments.’’

Elizabeth Lule, who oversees the World Bank’s HIV/AIDS programs in Africa, agreed with Bertozzi for the need to do more rigorous evaluation to determine what works. She also noted that the money for AIDS in many instances wasn’t spent for years.

“There’s a lot of wastage out there,’’ she said. “There are many projects sitting at the country level with undisbursed balances. The World Bank has had to extend projects for five to seven years and there still are unspent balances. I’m sure the Global Fund also has grants with money that is not spent. If the money is still there, how are you going to make the case for more money?’’

One thought on “A challenge to stop `wasteful spending’ in AIDS programs

  1. Jonathon Simon

    Though Dr. Bertozzi focused on the need to be more efficient (lesss wasteful)and evidence-driven in the our program interventions, one of the key policy changes that will need to occur to facilitate these changes is a re-focusing from annual plans to more realistic time frames for the programmatic interventions required to catalyze the changes in social norms that are required. Dr. Bertozzi said it…and it needs to be reiterated loudly and clearly if PEPFAR II is going to further the progress to date.


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