*This post is co-authored by Ruth Levine
In the Washington Post today, three doctors with sterling reputations in the AIDS world (Lola Daré, executive secretary of the African Council for Sustainable Health Development International and a member of CGD's working group on IMF programs and health spending; Paul Farmer, pioneer of new AIDS treatment programs in Haiti and Rwanda; and chief of Harvard Medical School's Department of Social Medicine Jim Kim, a member of CGD's working group on the Global Fund), call on the Bush Administration to spend $8 billion on training of community workers, nurses and doctors in Africa to deal with AIDS treatment.
Their proposition that many more community-level health workers be deployed to provide essential services, breaking the implicit and costly monopoly of health "professionals" on health delivery, makes eminent sense. But more money for training, without complementary institutional changes that fundamentally alter the incentives for workers at all levels, won't get the outcomes sought by those who are working on AIDS, or any other health challenges.
Fundamental reforms of health systems, such as eliminating ghost workers from public payrolls, reducing absenteeism rates of doctors from public clinics who resort to private practice to earn a decent living, salary incentives nurses and others willing to work in rural areas, development of health insurance programs for the poor, are admittedly more complex than setting up more pre-service and in-service training programs. But dysfunctional systems are the primary cause of the emigration of doctors and nurses and the low productivity of health workers, and functional systems will be the only real and lasting solution.
Yet, as CGD Visiting Fellow Jeremy Shiffman writes in the WHO Bulletin, U.S. funding in the health sector capacity category has "nearly vanished," falling from 20 to 1 percent of U.S. health aid budgets from 1998 to 2003. This may be due only to changes in the way aid is categorized, increasing the figures for highly-publicized problems like HIV/AIDS. But if it reflects a real movement of resources, such a shift would undermine - rather than prioritize - the effort to tackle AIDS, or any other purpose for which the money is earmarked.