Health

How Health Aid Undermines Health Systems

The FT is carrying a full page analysis on the impact that “vertically integrated” healthcare aid programs, such as for HIV/AIDS, have on public health systems in the developing world.

There are some startling statistics on just how much is being pumped into these fashionable diseases - HIV, malaria, and into vaccine research. For instance, in Rawanda, a third of all IDA for health (about USD 47m) went to HIV/AIDS. In comparison, malaria received USD 18million, and only USD 1 million was spent on integrated management of child illnesses - though both were judged more serious priorities by the authorities.

Is it any surprise then, that such massive aid programs as Pepfar, the GAVI alliance, the Global Fund, and the Gates Foundation, are reported to be creating dangerous collateral damage in the countries they hope to “serve”:

One concern is how far such programmes prove counter-productive by displacing resources from health threats that may be just as important or even more so. Roger England from Health Systems Workshop, an advisory group, argued in the British Medical Journal this year that HIV, which he dubbed “the biggest vertical programme in history”, was receiving too much money. HIV consumes more than one-fifth of all health aid around the world, he pointed out, but accounts for just one-twentieth of the burden of disease in low- and middle-income countries and causes lower mortality than stillbirths, infant deaths or diabetes.

Sophisticated equipment, heavy demands on medical staff and costly medicines mean HIV consumes large amounts of money for each patient treated. Alan Fenwick, a professor at Imperial College in London, argues that far more modest resources could transform the lives of millions of sufferers of such debilitating but “neglected” conditions as the hookworm parasite, trachoma (a bacterium that causes blindness) and schistosomiasis (bilharzia).

A second worry is that HIV and other vertical programmes funded by individual donors - each with their own different criteria and conditions for evaluation - create wasteful administrative burdens and encourage a brain drain of medical experts away from already weak state health systems. A study published last year on Rwanda showed that $47m of international assistance for health - or three-quarters of the total - went to HIV, while just $18m was for malaria and $1m for integrated management of child illnesses - although both alternatives were judged more serious priorities by the authorities.

Furthermore, the government controlled just 14 per cent of this aid, with 55 per cent channelled at the insistence of its 21 donors through non-governmental organisations instead. These groups hired many of the country’s best medical staff from the state health system, typically paying doctors six times as much.

Elaine Gallin from the Doris Duke Charitable Trust, who helped design a $100m African Health Initiative grant programme launched this week to strengthen fragile health systems, says: “There is so much money being poured into certain areas that it is skewing the delivery of primary healthcare. It’s as if you were fixing only one piece of the car and forgetting to put the wheels on.”

The FT does not conclude here, suggesting instead that a debate is on between those who favor vertical and horizontal programs. Yet, this finding by itself is not surprising. It is just a manifestation of the aid curse.

A related criticism of such health assistance has appeared previously suggesting how general health delivery systems are being completely ignored. Indeed, the BMJ recently criticisized the the Gates Foundation for ignoring how health delivery systems:

For although the foundation has given a huge boost to research and development into technologies against some of the world’s most devastating and neglected diseases, critics suggest that its reluctance to embrace research, demonstration, and capacity building in health delivery systems is worsening the gap between what technology can do and what is actually happening to health in poor communities. This situation, critics charge, is preventing the Gates’s grants from achieving their full potential. 

Development “experts” would do well to look beyond their narrow boxes to the environment in which they operate. Given the amounts involved, particularly in relation to the general budgets in most countries that receive HIV/AID assistance, these cash infusions cause serious damage to public health systems. Experts may, of course, argue that those systems are weak and the governments running them corrupt. But is that reason to undermine them further?

© 2007 The Discomfort Zone.