Donor AIDS money weakening health systems

More international aid has been dedicated to fighting HIV/AIDS than any other disease, but what impact have all those donor dollars had in countries where HIV/AIDS funding often exceeds total domestic health budgets?

The three largest HIV/AIDS donors - the Global Fund to Fight AIDS, Tuberculosis and Malaria, the US President's Emergency Plan for AIDS Relief (PEPFAR) and the World Bank's Multi-Country AIDS Programme (MAP) - have spent US$20 billion on combating AIDS since 2000.

But a new report by the Washington-based Centre for Global Development, "Seizing the opportunity on AIDS and health systems", launched at the International AIDS Conference in Mexico City last week, suggests that AIDS donors may actually have weakened the health systems necessary for an effective AIDS response.

"The big HIV donors are creating AIDS-specific systems that compete for health workers and administrative talent, share the same inadequate infrastructure, and further complicate already complex flows of information," said Nandini Oomman, lead author of the report.

Noting that "The future of the global HIV/AIDS response cannot be considered independently from that of national health systems," the study examined interactions between the three donors and health systems in three countries where they work: Mozambique, Uganda and Zambia.

The future of the global HIV/AIDS response cannot be considered independently from that of national health systems

Focusing on three components of those health systems - health information systems, supply chains for essential drugs, and human resources - the researchers found that donors had developed AIDS-specific processes, often creating a drain on resources essential to the country's broader health system.

In the area of health information systems, for example, all three donors have their own reporting requirements, which burden already overstretched health facility staff with multiple record-keeping duties. "This extra effort takes away time from helping AIDS patients or providing other health services," Oomman pointed out.

With the goal of distributing antiretroviral drugs more efficiently, donors have also supported the development of procedures that are separate from those for other essential medicines.

The report warns that "As antiretrovirals come to be offered at more and more facilities, maintaining the separate systems will become increasingly complex," and recommends integrating the two systems.

All three countries covered in the report are experiencing severe shortages of qualified health workers, but instead of training additional workers, the three donors have funded specific training in HIV/AIDS for existing staff. In some cases, they have rewarded staff for the extra work administering their programmes with salary top-ups.

"Such top-ups ... focus the attention of clinical staff on HIV/AIDS - in some cases reducing the time they give to other health services," the report's authors argued.

PEPFAR has also funded the hiring of large numbers of non-governmental organisation (NGO) health workers, who often earn significantly more than their counterparts working for the state. A clerk working for a PEPFAR-funded programme in Zambia, for example, makes about twice as much as a registered nurse in the public sector, according to the study.

Not surprisingly, donor funding for better paying jobs with NGOs has sometimes pulled desperately needed staff away from the state sector.

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The report concludes that donors should shift their response from an initial emergency mode, in which they circumvented weak areas of national health systems to set up systems that could achieve quicker results.

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