Of the 40 million people that are infected with HIV globally, approximately 95% live in severely resource-constrained settings. From a humanitarian perspective alone, not bringing antiretroviral therapy to those in need implies accepting a number of casualties that is difficult to imagine and impossible to accept. But there is another important argument to take up the challenge: HIV/AIDS mainly affects adults in their productive prime, leaving the very young and old to cope alone. This severely hampers economic growth and development of countries concerned. There is little doubt that poverty facilitates the spread of HIV/AIDS, but conversely HIV/AIDS perpetuates poverty. Generalizing HIV/AIDS into a problem of poverty will paralyze an effective and specific response to it, and conflicts with the "art of the soluble" principle that we should adhere to.
Resource allocation and health financing
This report authored by the Global HIV Prevention Working Group assesses the shortfall in access to HIV prevention services worldwide, detailing the specific shortfall in the regions of Sub-Saharan Africa, Asia and the Pacific, Eastern Europe and Central Asia, and North Africa and the Middle East. It discusses regional prevention priorities for each and identifies funding gaps. The document calls for the scale up of treatment and care programs, in coordination with prevention work. The authors finally call on political leaders, both nationally and in donor countries, to increase their commitment to effective prevention programmes.
Health care for all does not always mean increased health expenditure. This article looks at various strategies that may be employed to save costs and maximise resources. Health policy reforms alone have not been successful in containing health care cost. While lack of money is often a governing constraint, it does not mean that progress is not possible without the injection of money into the system. It is necessary to identify areas of wastage, inappropriate spending and strategies to contain health care cost while improving quality of health care provision. It makes sense to start by spending money on cost-effective interventions that save a lot of lives. A recent experiment in Tanzania illustrates the impact of rational spending. Researchers were sent to the rural districts of Morogoro and Rufiji. They carried out a door-to-door survey asking whether anyone had died or been laid low recently, and if so, with what symptoms. They found that the amount of money local authorities spent on each disease had no relation whatsoever to the harm it inflicted on local people.
Hospital costs are difficult to measure when there is limited or poor quality data. Current accounting methods may miss key aspects of inefficiency. Researchers from the London School of Hygiene and Tropical Medicine find that using ‘tracer’ illnesses is a more effective way to assess costs in Zimbabwe’s hospitals. Crude methods of hospital costing do not consider case mix or severity – both vital to understanding cost structures and differences between hospitals. They may miss unnecessary costs that stem from wasted staff time, over-prescription of drugs, needless diagnostic tests, inappropriate length of stay and other redundant activities. Using the tracer approach may resolve some of these problems.
Although a grossly disproportionate burden of disease from HIV/AIDS, TB and malaria remains in the Global South, these infectious diseases have finally risen to the top of the international agenda in recent years. Ideal strategies for combating these diseases must balance the advantages and disadvantages of 'vertical' disease control programs and 'horizontal' capacity-building approaches. Nevertheless, it is clear that significant structural changes are required in such domains as global spending priorities, debt relief, trade policy, and corporate responsibility. HIV/AIDS, tuberculosis and malaria are global problems borne of gross socio-economic inequality, and their solutions require correspondingly geopolitical solutions.
Fewer than one in five people at risk of HIV infection today have access to prevention programs, and annual global spending on prevention falls $3.8 billion short of what will be needed by 2005, according to a new report released by the Global HIV Prevention Working Group. The report, Access to HIV Prevention: Closing the Gap, is the first-ever analysis of the gap between HIV prevention needs and current efforts, and provides recommendations for expanding access to information and services that could help save lives and reverse the global epidemic.
In an informal address to the 4th International Conference on Priorities in Health (Oslo, 23 September 2002), Professor Jeffrey Sachs – Chairperson of the WHO Commission on Macroeconomics and Health – maintained that the real causes of the inability of the world's poorest people to receive help for the lethal diseases that burden them did not include the "usual suspects" (corruption, mismanagement, and wrong priorities). Rather, the root cause was argued to be an inherent lack of money, indicating that the burden of disease would be lifted only if rich countries gave more money to poor ones. Without taking exception to anything that Sachs said in his address, there nevertheless remain a number of justifications for efforts to improve priority setting in the face of severe shortages of resources, including the following three defences: prioritisation is needed if we are to know that prioritisation is insufficient; prioritisation is most important when there is little money; prioritisation can itself increase resources.
This posting from Africa Action contains a news update and excerpts from two recent reports documenting the wide gap between the consensus on the need for greater funding for fighting the HIV/AIDS pandemic and the failure in practice to provide that funding. First, a report from the IMF/World Bank released for the spring meetings, summarized by the Kaiser Daily HIV/AIDS Reports and excerpted briefly below, documents that "if current budgetary trends continue, donor support in 2003 will still be much less than the bare minimum required for basic prevention and care programs". Secondly, an article from the Global Fund Observer newsletter notes the failure of the Global Fund itself to develop a fundraising strategy.
The fight against AIDS will need more resources from the US, with faster delivery, than what the President is proposing," says Dr. Paul Zeitz, Executive Director of the Global AIDS Alliance. "We will need fast action by Republican and Democratic leaders in the US Congress to deliver on an appropriate package for 2003 and 2004. It's very disappointing the President (George W. Bush) is not calling for a more rapid increase in new funding. Plus, it's troubling that the President gives such short shrift to the Global Fund, which is fast running out of resources."
The WHO’s Commission on Macroeconomics and Health recommends a large increase in funding for health interventions in poor countries. But money alone is unlikely to be able to address the constraints facing health systems. What factors hamper the widespread implementation of health programmes for the poor and what options are available to tackle them? A relatively small number of health conditions are responsible for the majority of the burden of ill-health in poor countries. Effective interventions exist to prevent and treat most of these conditions, but these interventions are not available or accessible to the world's poor. A dramatic expansion in access to these priority services is urgently needed.