December 20, 2012

December 20, 2012


Does HIV/AIDS Funding Undermine Health Systems?


Welcome to another day in my life. Today is Thursday and I hope you are having a beary safe and great week so far. If we listen to the doomsayers then this is the last day because the end of the world happens tomorrow per the end of the Mayan calendar. Hopefully, they are wrong.

But while I can still blog, does HIV/AIDS funding undermine health systems?

Perhaps UNDERMINE is the wrong term for what has happened to many health systems under PEPFAR and Global Fund influence, but others such as DISTORT, DISTRACT, SKEW, DISRUPT come to mind. Certainly the net impact of these two monster funding sources on HIV/AIDS and adjacent sectors has been measurably positive, but at a cost on several levels including: The creation of new figurehead structures ( CCMs and NACs) have most often failed to engender more than a shallow, top down impression of ownership fraught with dysfunction, attracting new opportunism around the glut-level funding streams; the disruption of natural coalitions manipulated by new caste of powerbrokers in control of program money; the historic levels of wasted resources as a result of corruption and pressures to spend, and the creation of parallel service systems attracting the most qualified personnel out of the national systems with the lure of increased salaries. While some lateral impact has been seen into TB, RH, MCH program efforts linked to the HIV efforts, the disproportion in funding has indeed pulled talent from the underfunded sectors into HIV and away from arguably equally (or more?) important health priorities.

So....yes.....these all contribute to UNDERMINING the health systems. The the systems need much more than even the colossal GF/PEPFAR funding levels of the past might fix even if implemented in a more balanced way. A new set of donor supported efforts continue to tweak the many systemic issues within the Global Fund mechanism, but ultimately the dynamic tension between true country ownership ( driven by a deeper national commitment than the annointed bureaucracies that have evolved around CCMs) and the more cynical form of COUNTRY DONORSHIP (driven by outside agendas and inside powerbrokers) will likely continue in the absence of the mythical levels of replacement funding from stressed national budgets.

It is not the HIV/AIDS funding or the many programs; itís the method of implementation. Few would doubt the skewing effect PEPFAR had on public health world-wide. The upside is that we made a huge dent in the spread and treatment of HIV/AIDS. The downside is that it demanded unprecedented levels of commitment, especially HR, from resource strapped countries to address a disease in an insular and disconnected fashion. It is only in the past few years have we seen a gradual shift from a donor-recipient interventionist model of implementation where the donor essentially calls the shots, to one of participatory engagement where the country is regarded on equal footing and as partner in a strategy that underscores ownership and transition. Although Global Fund attempts this through country-coordinating mechanism one still doubts how much of that process is actually owned by the country. We need to look more closely if these new strategies, widely based on the Paris Declaration and Accra Call for Action, are attainable given the historical approach to international aid and case-hardened institutional behavior on both sides.

What do you think? Drop me a line and let me know. Hope you have a beary safe and great Thursday!

Until we meet again; here's wishing you health, hope, happiness and just enough.



big bear hug,



Daddy Dab