"AIDS Spending Harms Health Systems" -- Passionately Disputed but Hardly Refuted

Roger England's article on "AIDS exceptionality" in the British Medical Journal argues that AIDS has received a larger share of total health spending than its contribution to the burden of disease would justify and that this large increase is having negative effects on the rest of the health care system in recipient countries. His article has so far generated 17 often passionate and lengthy responses.

Some of the effort of responders is devoted to demonstrating that the effects of AIDS are worse than its burden of disease would indicate. This effort to justify donor spending on AIDS seems futile, since the same is true of many other diseases, including tuberculosis, motor vehicle deaths, smoking caused disease, etc. (In any case, the cost-effectiveness of public spending should play a larger role than the total burden of disease in guiding the allocation of public health spending). Much of the rest of this prodigious rhetorical effort asserts that AIDS spending is really helping, not harming, the rest of the health sector.

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Mead Over

Senior Fellow Emeritus

If Roger England's assertion that AIDS spending harms the health sector could have been refuted by data, one of those posting would have cited such data and the others would not have felt the need to post. The problem is that we really don't know, in any general way, what the extraordinary scale-up of AIDS spending has done to other parts of the health sector.

[For previous discussion of this issue on our blog, look here, here, and here]

An interview I had last November with the nurse who was responsible for managing a health center in Western Kenya is perhaps revealing. His district health center had tripled in size due to the addition of a clinic, lab, waiting and storage space for treating AIDS patients and for warehousing the fresh produce, cooking oil, flour and other groceries given to supplement the diets of many AIDS patients. The staff nominally reporting to him had increased by several young physicians, who had received special training in AIDS case management.

I asked this gentleman if he could compare the treatment his patients received in the two parts of his clinic. He said, "The patients who receive AIDS treatment leave with a smile. Those here for other problems do not. As I've told my ministry, we now have two systems of health care in Kenya."

Then I asked him, "As the manager of this particular center, is there anything you can do to redress this imbalance?"

He said, "I insist that all of my staff, including the physicians who have been specially trained in AIDS treatment, rotate through all parts of the clinic, taking their turns serving non-AIDS as well as AIDS patients. I hope that the specially trained AIDS personnel carry some of their motivation and skill from the AIDS treatment part of the clinic to the non-AIDS part."

On the one hand, this story supports Roger England's claim that the resources going to AIDS treatment are vastly greater relative to the burden of disease than the resources available for other health care problems.

On the other hand, the story suggests, especially to those of us who have known how poor have been the conditions of African district health centers, that the presence of AIDS spending has tended to improve non-AIDS care as well, even if by much less than it has improved AIDS care.