Treatment Issues: Newsletter of Current Issues in HIV/AIDS - Volume 19, Number 3 & 4, March / April 2005
Gregg Gonsalves

Many AIDS activists have been enraged by the export abroad of conservative American morality on sex, drugs and prostitution through HIV/AIDS programs funded by the U.S. government. Particularly galling is that it replaces accepted, evidence-based public health policies with ideology. But if there is one thing this U.S. government hates more than fags, junkies, hookers, condoms and clean needles, it's socialized medicine.

Quietly, the President's Emergency Plan for AIDS Relief (PEPFAR) and other bilateral initiatives are exporting the HMO-ization of AIDS in Africa and elsewhere on the planet, in which a network of private institutions are being built up to provide antiretroviral therapy (ART) to the millions who need it. In the short term, this will not be a bad thing. Circumventing crumbling or rudimentary public health systems in developing countries probably means that more people will get treated more quickly.

However, in the long run the vast investment in non-governmental and faith-based organizations to provide care will drain whatever resources are left in the public sector, take governments off the hook for providing care to their citizens and enforce a fee-for-service health sector system when the donors eventually tire and move on to other crises in these countries leaving only those who can pay for it with the care they need to survive.

If it's good enough for the United States, it must be good for Africa, Asia, and the Caribbean. Right? Sadly, the American model of health care will leave close to a third of the population of this country uninsured by 2013.

The sustainable scale-up of antiretroviral therapy in the developing world depends on the simultaneous scale-up of the public health sector in these countries, yet this is a task that repulses the United States and many other donor countries, as they try to pare down their own lavish welfare states. Furthermore, in 2005, demanding health care as a public right and a public good is virtually a revolutionary act. Most people are just too busy trying to survive to speak up and demand what they need.

The difficulty of the current moment is that there is no clearly described acceptable alternative to the vertical programs that are rolling out all across the globe. Although the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) is funding public sector programs against these diseases (which is a welcome relief from the American franchising of health care), it too has the potential to distort the health care landscape in these countries since it isn't a sector-wide approach.

I recently asked a health systems researcher in Mumbai to describe a middle ground between the short-term need to get as many people on ART as quickly as possible and the long-term need to strengthen health systems. I was told that these were incompatible goals. In fact, this is the mantra of many health systems researchers and this is as unhelpful as the privatization agenda being promulgated by the U.S. We need to find the middle ground and find it quickly.

In several reports over the past year, the drastic shortage of doctor, nurses, clinical officers, community health workers, has been described as one of the key factors in slowing the scale-up of antiretroviral therapy. But this shortage is also being acknowledged as one of the broader problems facing the health sector in developing countries. It is here that the twin needs to roll out ART quickly and to strengthen the overall health sector is being recognized.

The recommendations for dealing with the shortage of health care workers though are varied and some have the potential of once again distorting the health care environment in developing countries. In particular, a bill proposed by Senator Bill Frist would send doctors as U.S. federal employees and private sector professionals as volunteers to developing countries. This new Global Health Corps, instead of providing incentives for local health workers now migrating in droves to richer countries to stay home, is yet another way that the U.S. will further weaken local capacity. As UNAIDS' Peter Piot has said: "Isn't it a bit absurd that we then send nurses and doctors to fill slots in Africa that have been emptied by our recruitment policies?"

The dialogue on the shortage of health care workers in developing countries has put health systems and HIV/AIDS experts together to identify solutions to this problem. We now need a broader discussion on how to strengthen other aspects of health systems as we scale-up ART. HIV therapy is a lifetime commitment and so should our commitment to seeing that AIDS is the beginning of creating better health for all across the globe. It is only within functioning health systems that ART can be sustained over the long haul.

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