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An article published in the British Medical Journal questioned whether HIV/AIDS was an exceptional disease requiring billions of dollars in international aid annually, and argued for strengthening public healthcare systems of affected countries instead. It has caused a storm of protest from those working in the field of HIV/AIDS |
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Voices questioning the pre-eminence of AIDS in the health sector and the amount of money being spent on combating it are rare. But this is just what an article in the British Medical Journal (May 10, 2008), has done. Roger England, chairman, Health Systems Workshop, Grenada, makes the case for putting the disease in perspective, and combating it by strengthening the public health systems in affected countries. He argues that AIDS diverts attention and resources from other health priorities and that AIDS financing builds aid dependency. In ‘Is the writing on the wall of UNAIDS’ England says that the creation of a UN agency devoted to AIDS – UNAIDS -- was justified on the grounds that HIV was exceptional (gay men – the first to be targeted in large numbers in the United States -- adopted a rights-based approach which succeeded in making HIV a “special case that demanded confidentiality and informed consent and discouraged routine testing and tracing of contacts, contrary to proved experience in public health.” The ‘exceptionality’ status of AIDS gradually grew to encompass poverty – in developing countries it became a development issue and this approach was successful in mobilising large resources from the international community involving, also, political commitment. “With its own UN agency, HIV has been treated like an economic sector rather than a disease,” England writes. He says that the poverty argument no longer holds water because demographic and health surveys in countries such as Ethiopia, Kenya, and Tanzania have shown than prevalence is higher in the relatively better-off sections of society. The threat from HIV is no greater than that from many other diseases. While HIV is a major disease in southern Africa, for instance, it is not “a global catastrophe” as it is often made out to be. Worldwide it claims as many lives annually as does malnutrition in children under 5 in India. He also criticises the large multisectoral programmes for being “misguided” and says they “have got nowhere slowly and expensively. Some small projects of non-governmental organisations (NGOs) have successfully integrated sectoral efforts, but government ministries such as agriculture and education have not succeeded in the HIV roles imposed on them.” The large sums of money expended on HIV programmes could have been better channelled into beefing up public health capacity that could have controlled transmission. “Only 10% of the $9 billion (£4.5 billion) a year dedicated to fighting HIV is needed for the free treatment programme for the two million people taking those treatments. Much of the rest funds ineffective activities outside the health sector.” Although HIV causes 3.7% of mortality, it receives 25% of international healthcare aid and a big chunk of domestic expenditure. England accuses the “massive off-budget funding dedicated to HIV” for providing no incentives for countries to create sustainable systems. “It also entrenches bad planning and budgeting practices, undermines sensible reforms such as sector-wide approaches and basket funding (where different donors contribute funds to a central "basket", from which a separate body distributes money to various projects), achieves poor value for money, and increases dependency on aid.” Though UNAIDS is calling for huge increases in aid from $9 billion today to $42 billion by 2010 and $54 billion by 2015, England says that the demand is increasing for better healthcare systems, not funding for HIV. He quotes a statement by Mozambique's health minister: “The reality in many countries is that funds are not needed specifically for AIDS, tuberculosis, or malaria. Funds are firstly and mostly needed to strengthen national health systems so that a range of diseases and health conditions can be managed effectively.” Guyana’s health ministry too has asked international donors to allocate some of the funds they allot to HIV, to improving general health services so that all diseases can be handled better. A special UN body for AIDS is unnecessary, the article says, but acknowledges that it will be hard to scale down the global HIV industry. “We have created a monster with too many vested interests and reputations at stake, too many single issue NGOs (in Mozambique, 100 NGOs are devoted to HIV for every one concerned with maternal and child health), too many relatively well paid HIV staff in affected countries, and too many rock stars with AIDS support as a fashion accessory.” The article has triggered a huge response on BMJ’s website, much of it critical of England’s view. Paul De Lay, Director, Evidence, Monitoring and Policy Department, UNAIDS, wrote in to say that the suggestion that “the AIDS epidemic is like every other health problem and doesn’t deserve an exceptional response” is wrong. “HIV was and still is an emergency requiring an unprecedented response. AIDS doesn’t fit neatly into a health box. Yes, AIDS is a disease and there are specific health needs, but AIDS has its tentacles in all sectors. “AIDS is mostly about sensitive issues—sex, gender inequality, sex work, homosexuality, drug use, stigma and discrimination—all have proved to be enormous barriers to government and civil society.” Therefore the need for the United Nations Joint Programme on HIV/AIDS to coordinate the UN’s response in an innovative way. The co-ordinated response from UN agencies has begun to show some success, De Lay writes. For example “Namibia enacted legislation to guide greater effort on HIV by a broad array of national ministries and sectors. This work is paying off with improved coverage for prevention and treatment initiatives, and favourable behavioural and epidemiological trends. Knowledge of HIV, and condom use have increased, while sex before the age of 15 and sex with more than one partner in the last 12 months have decreased. Adult HIV prevalence appears to have stabilised, while HIV prevalence in young women declined from 18% in 2003 to 14% in 2007.” De Lay responds to the accusation that too much money is spent on AIDS and not enough on improving general public health responses by pointing out that “in low- and middle-income countries total health expenditure was estimated at just $644 billion in 2006. The percentage spent on HIV from all sources including donors, governments, international foundations and from the pockets of people affected was a mere 1.4% of these health expenditures in low- and middle-income countries. “Despite the relatively small percentage of available funds spent on HIV, funding does provide an opportunity and entry point for health and social service systems strengthening. In many African countries, HIV services and treatment keep desperately needed health workers alive, well, and able to work. And in countries where a large proportion of hospital beds are occupied by patients with AIDS, HIV treatment is reducing hospitalisations, freeing up health workers and valuable resources to dedicate to other health care.” Besides, however strong, no national health service can tackle AIDS alone. “They certainly play a major role in providing HIV treatment, but health ministries do not cover other vital elements of the AIDS response such as working directly with vulnerable populations to reduce their risk of HIV infection, caring for orphans, providing food support and social welfare, and tackling gender inequities.” Lesley-Anne Knight, Secretary General of the global faith-based Caritas Internationalis, Rome, stoutly defends UNAIDS as “a model for a coordinated approach to an otherwise overwhelming threat to the human family.” She writes that it should be celebrated “as a model to tackle other global health and development emergencies, not only because UNAIDS promotes a unified programme and budget among its ten co-sponsor UN agencies but also because it stands out as a shining example of collaboration with civil society responses to HIV, including those of faith-based organisations. Mr England should not be posing an ‘either/or’ scenario for AIDS care vs strengthening of health care infrastructure but should advocate for adequate funding of both.” Mariangela Simao, Director, National STD/AIDS Programme, Ministry of Health, Brazil, argues in favour of the coordinated approach without which, she writes, AIDS cases in Brazil would have doubled. “It may sound repetitive, but clearly AIDS cannot be fought only by the health sector. It brought us, health professionals in Brazil, working on building up our national health system for the past 20 years, the need to act in a concerted manner with other governmental sectors, as fighting AIDS means also promoting human rights of vulnerable groups and discussing the implementation of public health policies with civil society organisations. Had we not treated AIDS as exceptionality in my country, and that does not mean resources were ‘siphoned’ from other health priorities, we would have more than double the estimated number of infected people. And this would certainly burden even more our national health system.” Read the full article by Roger England here: Read responses to the article here: InfoChange News & Features, May 2008 |
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