- Criticism is increasing against the many giant programmes to particularly tackle the HIV/AIDS pandemic in Africa, which are said to deplete other African health programmes that may have a much greater effect on public health.
So-called "vertical" health programmes - that is to say, programmes designed to target specific diseases such as AIDS rather than the "horizontal" strengthening of general health systems - are becoming dominant in Africa when it comes to health funding from external donors. Billion of dollars are poured into the AIDS epidemic in Africa, headed by large donations by the US President's Emergency Plan for AIDS Relief (PREPFAR), large private initiatives like the Gates Foundation, the Hewlett-Packard Foundation and others and the UN system.
This "vertical funding" targeting in particular HIV/AIDS treatment is now increasingly criticised by development cooperation professionals, but also specialists on the AIDS pandemic as not being cost-effective when it comes to improve public health in Africa. In some cases, it is even seen as counterproductive.
Dr Stewart Tyson, the head of the health professional group at the British development agency DFID, is emerging a leading critic of such vertical programmes. At a hearing in the London House of Lords, Mr Tyson described an example from Zambia, where PEPFAR works through contracting local NGOs, giving them short-term targets in the US-sponsored AIDS programmes.
"They have to get so many people on treatment by the end of Year Two, Year Three, Year Four. How do they do it? They put an advert in the paper in Lusaka and they hire 400 health workers. Where do they take them from? They move them from one part of the health system, where they are delivering children and providing general health services looking after kids, to work just on AIDS. This is a no-win/no-win situation; it is robbing Peter to pay Paul," Dr Tyson complained.
In Tanzania, a thorough analysis of the entire health sector and its funding was conducted in cooperation with the Danish development agency DANIDA a half year ago. As reported earlier in the development magazine 'African Future', vertical funding of AIDS treatment is leading to the channelling of more than half of Tanzania's total health expenditure towards HIV/AIDS while only around 6 percent of the population is HIV positive.
The Danish-Tanzanian evaluation turned sceptical towards the new and well-financed global health funds. "Because of the vast amounts of funding involved they have profound ramifications, as the continuing rapid and significant increase in resources for HIV/AIDS in Tanzania shows. Given the sheer volume of HIV/AIDS funding, almost US$ 350 million expected for 2006/07 – as compared to total public spending on health of US$ 561 million in 2005/06 - it is hardly surprising that HIV/AIDS funding also tends to distort priorities and draw staff away from, for example, maternal and child health services," the report says.
The evaluation goes further, issuing a warning: "The increasing number of and funding by Global Health Initiatives and large bilateral programmes threaten to destabilise health sector planning and prioritising as they remain largely outside established coordination and alignment mechanisms." Of the almost US$ 350 million budgeted for 2006/07 for HIV/AIDS, it was expected that almost US$ 300 million would remain outside government accounts.
Not only in Tanzania and Zambia do giant AIDS programmes threaten the entire public health system. In most Southern and East African nations, government and external funding for AIDS is greater or similar to all other public health spending. These countries additionally struggle with a "brain drain", seeing many of its best medics and nurses finding employment in Europe or America, while a great part of the remaining professionals are recruited into HIV/AIDS programmes that are secure better and more regular funding than other public health programmes.
But the over-funding of AIDS programmes is not confined to this region seen as the core of the AIDS epidemic. Even far-away countries such as Sahelian Niger with an HIV prevalence of around 1 percent have popped-up HIV/AIDS budgets. Impoverished Niger spends only around US$ 70 million on health annually, but the Global Fund to Fight AIDS alone has disbursed US$ 48 million to fight AIDS in Niger. In little affected West and Central Africa, the Fund alone has disbursed US$ 800 million to fight AIDS.
Global health experts are starting to react on this over-emphasis on AIDS spending in countries with fragile public health systems. The debate turned serious in February this year, after the 'British Medical Journal' published an article by Roger England of Health Systems Workshop, a health-policy charity, who pointed out that AIDS receives about a quarter of global health aid but constitutes only five percent of the disease burden in low- and middle-income countries.
This month, also the UN's media specialised on HIV/AIDS, 'PlusNews', entered the debate questioning whether AIDS should still be treated as an extraordinary emergency. John Bongaarts, Vice-President of the Population Council, in an interview with 'PlusNews' said that more African lives could be saved by investing in strengthening health systems and combating other diseases with inexpensive interventions like immunisations, mosquito nets and family planning.
"AIDS should now be treated like any other disease, and the world community should look at its investments in health and prepare the most cost-effective interventions," Mr Bongaarts said. "I am not advocating less money for AIDS treatment, but I want more spent on AIDS prevention and other diseases. We can save lives for a few dollars," he added.
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