AIDS Billions and Health Systems: Q&A with Nandini Oomman

Are the billions of dollars spent on HIV/AIDS in developing countries missing out on opportunities to strengthen national health systems? To find out, CGD’s HIV/AIDS Monitor asked researchers in three countries with high levels of donor AIDS spending -- Mozambique, Uganda, and Zambia -- to assess the interaction between health systems and the three big AIDS donor programs: the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the World Bank’s Multi-County AIDS Program (MAP) in Africa, and the Global Fund for AIDS, TB and Malaria. The resulting report, Seizing the Opportunity on AIDS and Health Systems, is being released this week at the international AIDS conference in Mexico City. Nandini Oomman, director of the HIV/AIDS Monitor and the lead author of the report, explains the key findings:

Q: Why did you do this study?

A: A decade ago, donors barely provided $500 million annually to respond to AIDS. Last year the total available funding for AIDS was $10 billion and donors provided the bulk of this funding. Globally, AIDS donors have spent more than than $20 billion to fight AIDS since 2000. In many recipient countries, donor funding for AIDS is almost as large as the total for all other health spending. This is the first time that so much international aid been dedicated to global health, let alone to a specific disease. What’s the impact of all this money? Can it be used better, both in responding to the AIDS epidemic itself and in addressing other health problems? This is a contentious topic where so far there has been little systematic research. We believe that our country case studies have shed some light.

Q: What did you find?

A: Delivering AIDS services increases the demands on harried health workers and further stretches already weak health infrastructure. With the massive increase in AIDS financing, these tensions will increase unless donors and recipients exploit potential synergies. AIDS donors should look for opportunities to strengthen the host country health system in addition to achieving their own program objectives. We offer specific recommendations in three crucial areas: information systems, the supply chain for essential medicines and other health commodities, and human resources for health, that is, doctors, nurses, technicians, and health service managers.

Q: That sounds like a lot to worry about. What if donors are able to focus on just one aspect of your recommendations, what should it be?

A: Information systems. Integration and coordination of information provides a platform from which other components of the health system can also be strengthened. For example, information about the procurement and distribution of AIDS drugs can be integrated with supply chain systems for other essential drugs. Similarly, improved information systems for managing health workers involved with HIV/AIDS can be utilized for managing health workers involved with other diseases.

Q: Isn’t that happening already?

A: Not so much. In the countries we studied, the donors stipulate different information requirements to satisfy their own reporting needs, often with little coordination across programs or with the host government. This creates additional burdens for health workers who then spend a lot of time feeding similar information into multiple systems. On the other hand, the donor AIDS systems often are more efficient than existing national information systems, so there is an opportunity to apply these successful approaches to national health systems over time.

Q: Besides information systems, what are some of the areas donors should tackle?

A: Look for untapped synergies in supply chains. Effective supply chains deliver health commodities—including antiretroviral drugs and essential medicines—to the right places at the right times and in the right quantities. Because supply chains for antiretroviral drugs and for essential medicines rely on many of the same resources—such as physical infrastructure, information systems, and health sector staff—HIV/AIDS programs must take care to avoid using those resources in ways that undermine a country’s ability to also operate a well-functioning supply chain for other health needs. In situations where the processes and the technical knowledge needed are quite similar, integrating functions for AIDS drugs supply chains and other medicines might make it possible to reduce costs and use resources more efficiently.

Q: What about shortages of health workers?

A: The shortage of workers in the most severely affected countries in Africa is a major barrier to improving health and to scaling up HIV/AIDS programs. Donors should be part of the solution rather than part of the problem. To do this they need to work with host governments to train new health workers and managers. They should also champion a more flexible labor management approach that pays workers for their performance for all health services provided, not just for AIDS services.

Q: How did you conduct the study?

A: Our team in Washington and the project field director based in Nairobi, William Okedi, worked closely with three country research teams: Freddie Ssengooba

and his team at the University of Makerere, Uganda; Dirce Costa and her team at Austral-Cowi, Mozambique; and Caesar Cheelo and his team at the University of Zambia. The country teams conducted extensive document reviews and interviewed many senior officials: at the donor agencies in country, in the ministries of health, in NGOs and other organizations that receive AIDS funding and with other key stakeholders. Drawing on all this information, we created a detailed picture of how donor programs interact with country health systems in the three countries across the three operational areas: information systems, supply chains, and human resources management.

Q: Why should the donors follow your advice?

A: Donors are interested not only in responding to the AIDS epidemic but also in improving health more broadly. Given the emergency nature of the initial global response to AIDS, it is not surprising that donors circumvented existing but weak components of national health systems and instead created their own systems devoted to achieving immediate and demonstrable results. Now there is time to take stock of the effects.

Certainly, global AIDS financing cannot be held solely responsible for fixing these systems. Many other stakeholders have important roles to play—especially the recipient governments, which must lead by making strong commitments and acting on them to improve health systems. But the donors can, and should, take advantage of opportunities to strengthen health systems while implementing and expanding their AIDS programs. Because AIDS donors care about saving lives, we are hopeful that they will carefully consider our recommendations.