Global Health Policy

The LA Times piece says that a baby died because Gates funds HIV-care but not postpartum care. If Gates funded postpartum care but not HIV-care, the LA Times could do a story on a baby that died from lack of HIV-care.

Yes it's true that when you fund one thing, you don't fund another. And when nurses care for one type of patient, they don't care for another type of patient. But what is the best use of existing personnel? It depends on our goals and on the productivity of different types of personnel in different places and different sectors. Whether or not "Gates kills babies" is impossible to tell without a very serious analysis of where resources have the greatest marginal impact on current and future morbidity and mortality. I don't know the answer but I do see that development practitioners and researchers show scant interest in this type of analysis, without which little that is meaningful can be said on the subject.

The invocation of 'Health Systems' as a solution to multiple problems (eg: lack of food among the general population, human resource needs, low MOH salaries, no oxygen tube for a newborn) is dangerously optimistic in the hands of people as naive as the LA Times authors. You raise very important points about an article which holds kernels of truth, but is essentially an argument against vertical programs, and for poverty alleviation and general western underwriting of health services. The truth of the article is that the attention to a few vertical programs means that in many instances the wrong things get supported to the exclusion and detriment of the right things. The $110M for HIV/AIDS in Rwanda, next to an MOH budget of $104M for everything else, is a good example.

One of the dangerous naivetes of the article is in assuming that GFATM or GAVI money would be available if appeals hadn't been made for clearly defined and rigidly delineated areas of work. $8 billion for something as vague as 'health system strengthening'? It would never have happened.

Gates, Rockefeller, the Global Fund, the Bank, and WHO are all now trying to make adjustments to focus on systemic issues in addition to the measurable, vertical program areas they work on already. This is extremely important, timely, and to be encouraged and pushed faster and farther. But it is worth keeping in mind that improving a health system, by its vague and amorphous nature, will inevitably mean both more and less than food supplements and more doctors. If PIH takes over primary care services for all of Rwanda, using the per-capita MOH budget for health services of $10 for non-HIV/AIDS and $10 for HIV/AIDS, they will surely provide high quality care and save many lives. But can PIH do the same in Nigeria for 140 miillion, in India for a billion? Should they?

Supporting a functioning effective health system that is able to do as well as PIH, MSF, or other high-level volunteer-driven initiatives, within the political realities of any developing country, is a goal we should all support but with open eyes. The same needs for accountability, vocal disease-specific advocates, and real-poltik decision making that created the Global Fund exists in spades in every ministry of health around the world. System improvements and increased productivity of health managers and providers are the long term goal, to be aimed for both by providing shining examples such as PIH, and by plodding through the long and imperfect process of working with the systems that exist and supporting them even when the local priorities are not those of a donor or an LA Times writer.

Vertical vs. Horizontal always means a trade off between efficiency and comprehensive system sustainability. There is a need for both types of program, whether one is a donor or a ministry of health. The great danger of the LA Times article and the kind of thinking it promotes is its willing blindness to this reality. In arguing that UNICEF's immunization program should provide HIV testing, and implying that next should be food supplements, obstetric care, and on to comprehensive care... the authors are ready to throw the baby out with the bathwater. Their goals are good, but their simplification of things which, sadly, just aren't simple, is dangerous.

The LA article has succeeded in bringing to fore a very important matter but has failed to proffer holistic solutions to dilemma caused by the vertically implemented health programs.

Dominic and Micheal have really touched the same views that I have about the matter and really recommned that who reads through April's blog should as well hear what these gentlemen have to say.

But I just wanted to add this. The regulation and management of health systems is primarily the responsibility of the government of the recipient developing countries. If not for any other reason, at least for the fact that any attempt at HSS or horizontal approach to implemetation of public health programs will definitely have to deal with the preavailing poilitical realities of these countries or else they would not just succeed.

I guess that may be one of the reasons why the GFATM from the onset avoided creating what it refered to as a "bottom less pit" where the funds will just go down the drain if they have started by trying to tackle these diseases horizontally. Another wisdom in that decision is that it ensures that government of the recipient countries do not run away from their responsiblities in ensuring that their health systems are working.

One of the major problems we have in Africa is poor leadership and the "failure" of vertically implemented public health programs lies squarely on the shoulders of the government of these countries. It is the government's responsiblity to provide a platform that can sustain or contain the pressure or distraction caused by vertically implemented programs. It has nothing to do with the good intentions of donor agencies, of which Gates Foundation and the GFTAM are just a few of them. Public health programs have been implemented vertically long before the establishment of the GFATM. The picture of the delipidated primary health care center painted by the LA article brings to fore the failure of the government of these countries and not that of the good gestures of development partners and donor agencies. And it is not even as issue of scarce resource but fundamentally an issue of poor leadership and poor management. At least, that is exactly the case for an oil-rich country like my own country, Nigeria.

The GFATM has succeeded so far, so have other agencies. Though I do not agree with its emphasis on performance but they may be excused because it may not be fair to judge the GFATM's impact from what they have been able to achieve within a short period of its establsihment. But it may as well not be too early to evaluate for impact.

The GFATM already has been able to wield her powers well to extent that she is indirectly infleuncing policy formulation and implementation in the recipient countries. What I will call a "carrot-and-big stick" kind of powers.

Health sysyems is primarily the responsibilty of the recipient countries and these countries should work out modalities to develop programs that will be implemented horizontally or provide a platfrom that will be very conducive for the implementation and success of the vertically implemented programs.

The GFATM should use its powers to set some set of rules that will require potential recipient countries show visible, tangible and concrete evidence that they have health systems that are working before they are qualified to get more grants. Other development agencies and donor should also toe such a line.

It would have been worse if these funds have not been poured into Africa and we cannot afford to stop now. When my organisation started receiving ARVs from the GFATM-sponsored National ARV program in Nigeria, we had our fears that with time these programs will stop. But for the program to still be running, two years down the road, its an a miracle in Nigeria where things are just beginning to work.