Spending bottlenecks hamper anti-AIDS initiatives

The limited capacity of African countries to implement large- scale HIV/AIDS programmes should not be an excuse for donors to put the brakes on funding, activists said on Monday at the 15th International AIDS Conference in Bangkok, Thailand. Total global spending on AIDS has increased from US $1.2 billion in 2000 to an estimated $6 billion this year, according to UNAIDS. However, to finance a "comprehensive response to the epidemic", $12 billion would be needed in 2005 and $20 billion in 2007. There has been recognition that even when money is available, "in many heavily affected countries it is clear there are serious bottlenecks to spending it effectively," UNAIDS said in its 2004 report on the pandemic, released last week. These blockages include a lack of human and institutional capacity, "shortfalls in political commitment, slow transfer of funds from national to local and community levels, inadequate accounting and auditing mechanisms, and inconsistent bureaucratic funding processes of the global donor community", UNAIDS said. "It's not about money, but creating capacity at the ground level," a senior World Bank official in Uganda, Pradful Patel, said at the conference. "The issue of building capacity has become the biggest challenge we face - it's not just about access to treatment." Most African countries suffer human resource constraints in all sectors - public, private and civil society. Health services face personnel shortages, are burdened with weak institutional structures, and have problems recruiting and deploying staff to rural areas, noted the UNAIDS report. As a corollary to that grim reality, the issue of the "absorptive capacity" of African countries to put AIDS funding to effective use has become a debating issue in Bangkok. Bizwick Mwale, the head of Malawi's National AIDS Commission, acknowledged that his country was losing health workers at an alarming rate to better paid jobs abroad, but noted: "let's not use capacity as a scapegoat, let's build capacity as we scale up [the rollout of antiretroviral therapy - ART]". While international funding agencies have taken on board the need to help develop capacity, critics charge it is often "short-term investment, looking for a quick fix", said Dr Robert Pawinski of the Enhancing Care Initiative in KwaZulu-Natal (KZN) province, South Africa. "Every [donor] wants to write a report that says 'I trained 1,000 HIV workers' - it's high profile, but short term." Nursing staff are key to the rollout of national ART programmes, and "must be capacitated in the long term to ensure sustained quality of service", Pawinnski told IRIN. The KZN department of health has aimed to have at least 800 patients on ART by September, and 20,000 by March. However, health care workers in KZN, already under pressure due to staff shortages and the escalating AIDS burden, were further handicapped by a lack of training in treatment and care. In response, the Enhancing Care Initiative, with financing from the Global Fund to Fight AIDS, Tuberculosis and Malaria, has designed and implemented a comprehensive training strategy to complement the ARV rollout. Among the requirements for building capacity on a significant scale, Pawiinski said, was "investment in structures", in which partnerships with national departments of health are essential. But the health sector has been sapped by the brain drain of medical staff heading for donor capitals, and, according to UNAIDS, limitations on social spending urged on national governments by the International Monetary Fund (IMF) and World Bank. "If you are going to retain human resources in African countries you have to incentivise health workers, because they are leaving the public sector," Ruari Brugha, head of the Health Policy Unit at the London School of Hygiene and Tropical Medicine, told IRIN. "But Western countries speak with forked tongues [when noting a lack of absorptive capacity for scaling up]. The IMF are putting macroeconomic limits on how much public sector spending can go on salaries." A related problem, according to UNAIDS, is a "temptation" to direct funding to countries perceived as having greater capacity to spend it in the short term. "But this would leave out some countries that are most needy, precisely because of the greater impact of AIDS. A more equitable strategy is to address capacity problems in the countries with the greatest need through targeted investments in both human capital and physical infrastructure."