During the past decade, the growing prominence of AIDS in official development assistance for health has tipped the balance. Although a paltry $2 billion in donor aid was devoted annually for many years to health programs in developing countries, with an emphasis on basic reproductive, maternal, and child health, something on the order of $17 billion are now available, with about 60% of that allocated to programs to prevent HIV and to treat and care for those with AIDS. Global funding to combat HIV/AIDS has more than quadrupled since 2001 from US $2.1 billion to US $10 billion in 2007.1 Much of that money is concentrated on a relatively small number of countries where, because of high prevalence, generalized epidemics or other factors, HIV/AIDS constitutes a major threat to national welfare. In countries where the United States President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria devote the majority of their resources, budgeted funds for AIDS can equal those for all other health priorities. For example, in 2006, AIDS funding from donors and the government was about US $20.60 per capita in Zambia, compared with a national per capita health budget of US $26.2 In other words, we have moved from a low-level equilibrium to an overall higher level but one heavily skewed toward AIDS.
In the absence of prospects to move to an overall higher level equilibrium with more for all priorities, pressure is being placed on the AIDS monies to serve a broader set of health conditions-in particular to “strengthen health systems” in ways that have a sustained positive impact beyond treating individuals who currently have AIDS. The pressure also comes from within the AIDS donor organizations as they realize the limitations of weak health systems. An example of recent guidance issued by PEPFAR to partner countries states that “specific health system weaknesses pose critical barriers to achieving PEPFAR objectives and to ensuring country capacity to sustain the response to HIV/AIDS over time.”3
The imperative to use AIDS dollars for broader impact has three dimensions: First is the need to “do no harm.” Anecdotal reports and some systematic research highlight particular ways in which relatively large and rapid inflows of resources have shocked health systems. Although evidence is still lacking as to whether these shocks are positive or negative, a recurring observation from countries suggests that these large inflows are shifting different components of the health system, detracting attention and resources from existing programs to AIDS programs: skilled health workers and managers who otherwise would be deployed managing and implementing other types of health programs are attracted by salary “top-ups” and better working conditions to AIDS programs; supply chains that bring antiretrovirals (ARVs) and other AIDS program supplies are prioritized over those for other essential drugs; and AIDS information systems are systematically providing information to the AIDS donors but not necessarily to national health information systems or back to programs where the information is collected.4 These concerns, which emerge in virtually all donor-supported “vertical” initiatives, are amplified because of the sheer scale of AIDS programs.
The second dimension is the potential to “get more health from the money” by using AIDS monies in ways that confer broader benefits and capture “synergies.” To date, this has had an aspirational tenor with relatively little operational reality. Those responsible for advocating for and implementing AIDS programs are emphatic that they see on a daily basis the ways in which the influx of money improves otherwise crumbling health infrastructure, the quality and quantity of the health workforce, the availability of drugs, and the production and use of information. The funders themselves are quick to claim how investments from their programs have “exposed weaknesses in health systems,” and “funds for this disease are making a major contribution to the strengthening of health systems.”5 A much-cited study from Rwanda documents increases in the use of a range of non-AIDS health services in clinics that have been refurbished under the PEPFAR program.6
A recent study by the Center for Global Development identifies specific ways in which “health system strengthening” potential could be realized while maintaining the more-or-less vertical nature of the use of the monies and not jeopardizing the core objectives of AIDS prevention, treatment, and care: pursue strategies that will distribute both ARVs and essential medicines, monitored with the same logistics management information systems, and building on the efficiency of ARV supply chains; provide more support to train new health workers (preservice training) in addition to on-the-job short-term training and hire these workers into the work force while at the same time working with ministries to improve public sector human resource policies and planning; and coordinate government and donor health information needs through one system to minimize duplicative and burdensome reporting and to improve data quality.
An alternative approach, which would require significantly more adaptation in the way funds are provided and monitoring occurs, would pool a portion of the resources from AIDS, immunization, and other vertical programs and make it available if and when prespecified performance targets are met by health facilities, districts or other subnational units, or national governments. “Results-based financing” or the use of performance incentives would require both the establishment of feasible performance targets and monitoring of indicators and a willingness of donors to permit resources to be under the control of local decision makers, who are given the incentive to use them effectively (although not necessarily following some centrally defined blueprint).7
The third dimension of the relationship between AIDS monies and health systems is subtle but powerful. If the availability of funding for AIDS increases the confidence of communities in the ability of government health services to respond to their needs, and thereby changes health-seeking behavior, progress can be made against demand-side barriers that have often frustrated central planners' “build it and they will come” approaches. Again without confirmation by systematic research, many observers report that the availability of AIDS treatment and the consequent ability of health services to stay the death sentence has fostered major improvements in citizens' views of the formal health sector. There may be room to build on this momentum, with particular attention to health priorities where limited trust and demand have proven to be major obstacles-for example, in the areas of attended deliveries and other determinants of maternal mortality and poor birth outcomes. Communication campaigns that highlight the success in response to AIDS may be a valuable complement to efforts to improve the access to and quality of those services.
AIDS funding alone will not solve the problem of weak or dysfunctional health systems, but opportunities to use AIDS funding to achieve broader health impacts are manifold, and each of the major sources of HIV/AIDS support is exploring options. For example, according to a personal communication with the staff of the Office of the Global AIDS Coordinator in April 2009, PEPFAR is engaging in an in-depth process to solicit feedback on ideas about how to use the resources provided under the 2008 reauthorization and subsequent budget appropriations to achieve “intentional spillover” benefits. As noted in this short essay, possibilities range from ensuring that the funding does no harm to existing health system capabilities to actively using the money to promote better performance across the board in basic health services.
But although there are many ways the funding could be used for system strengthening, there is only one way to determine how it should be used: Those who are providing resources must find ways to align their actions with the priorities and approaches of partner governments and other national stakeholders. The trajectory of health system development is a function of social choices and political processes that are constructed at the national and local levels, not driven primarily by technocratic and/or supranational aims. The now long and difficult history of attempts by outside funders and technical agencies to effect changes in health policy in developing countries clearly demonstrates that this is possible only when governments are genuinely committed to health as a development priority and are able to use the aid within the context of their national conversation about the role of government and public sector management. Outside funding and technical expertise can inform fundamental choices about payments for services; the scope of practice of health workers, nurses, and doctors; and accountability mechanisms among others. But these are political questions in developing countries, just as they are in domestic debates in the countries from which donor funds originate. To have a sustained positive effect on the broader health system, the major challenge for AIDS funders is how to fit a priority that is well established and compellingly articulated at the international level into the realities of diverse countries with dynamic albeit underperforming health sectors. This will require patience, a willingness to engage in negotiations far above the technical and service delivery levels, and a commitment to adhere to principles of national sovereignty.
1. Kates J, Izazola JA, Lief E. Financing the Response to AIDS in Low- and Middle-Income Countries
[chartpack]. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Kaiser Family Foundation; 2008.
2. Oomman N, Bernstein M, Rosenzweig S, et al. Following the Funding: A Comparative Analysis of the Funding Practices of PEPFAR, the Global Fund and World Bank MAP in Mozambique, Uganda and Zambia
. Washington, DC: Center for Global Development; 2007.
3. Annex V: health system strengthening priority-setting of DRAFT guidance for PEPFAR partnership frameworks and partnership framework implementation plans, Version 1, March 11, 2009 [web page]. The United States President's Emergency Plan for AIDS Relief Web site. Available at: http://www.pepfar.gov/guidance/framework/120741.htm
. Accessed May 29, 2009.
4. Oomman N, Bernstein M, Rosenzweig S, et al. Seizing the Opportunity on AIDS and Health Systems: A Comparison of Donor Interactions With National Health Systems in Mozambique, Uganda and Zambia, Focusing on the President's Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the World Bank's Africa Multi-Country AIDS Program
. Washington, DC: Center for Global Development; 2008.
5. Piot P, Kazatchkine M, Dybul M, et al. AIDS: lessons learnt and myths dispelled [published online ahead of print March 29, 2009]. Lancet
6. Price JE, Leslie JA, Welsh M, et al. Integrating HIV clinical services into primary health care in Rwanda: a measure of quantitative effects. AIDS Care
7. Eichler R, Levine R; with the Performance-Based Incentives Working Group. Performance Incentives in Global Health: Potential and Pitfalls
. Washington, DC: Center for Global Development; 2009.