AIDS and Primary Health Care

[Guest guest]

THE AIDS ROAD TO COMPREHENSIVE PRIMARY HEALTH CARE FOR ALL?

Gorik Ooms, Wim Van Damme, Marie Laga,

Institute Of Tropical Medicine, Antwerp And

Ford, University Of Cape Town, South Africa

EDITORIAL

On 28 May 2008, the Institute of Tropical Medicine (ITM, Antwerp)

hosted a workshop at the World Health Organization (WHO, Geneva) to

review the evidence on positive and negative impacts of the global

AIDS response in low-income countries in sub-Saharan Africa on

general health systems and services. The workshop involved people

working in AIDS and health services, in civil society and in academia

with and from Sub-Saharan Africa.

The original question was simple and straightforward: what is the

evidence to support or refute recent claims that global resources

allocated to fight AIDS are over inflated and do little to support,

and may even undermine, health systems?

Discussions quickly moved beyond this original question. The Alma Ata

concept of Primary Health Care (PHC) – comprehensive PHC rather than

selective PHC – proved to be a uniting concept. The real question

became: how can the global AIDS response best contribute to the

realisation of Comprehensive PHC? Most participants agreed that there

are lessons to be learned – good and bad – from the global AIDS

response, that will help us move closer towards Comprehensive PHC for

all.

There is evidence of the global AIDS response strengthening general

health systems and services, and there is also evidence of the global

AIDS response weakening general health systems and services.

The most important point of stress identified related to the overall

shortage of health workers. In some countries, the AIDS response was

reported to have led to an `internal brain drain', with health

workers abandoning their previous occupations to work on AIDS

programmes. In other countries, the AIDS response enabled improved

working conditions of health workers across the board, helping to

attract and or retain more health workers.

Without systematic reviews, or an agreed score card allowing us to

add up the strengthening effects and to subtract the weakening, we

cannot conclude if the overall result is predominantly negative or

positive. However, the positive effects of strengthening general

health systems and services seem be more likely where national public

sector led strategies explicitly aimed for these positive synergies.

This finding suggests that if recipient countries want AIDS funding

to strengthen general health systems and services, they need to

negotiate the needed flexibility from donors for this.

Therefore, we felt it would be more productive to focus on what

measures promote positive synergies and avoid negative synergies - to

support this, rather than trying to make a conclusive statement on

whether the balance is currently positive or negative.

One key issue is the under-funding of health care in developing

countries. Whether the objective is Comprehensive PHC for all,

fulfilling the Right to Health obligation, or achieving the health-

related Millennium Development Goals (MDGs), neither national nor

international funding of health care measures up.

Scarcity of human and financial resources was observed to drive

competition and rivalry. At the same time, health funding should not

only increase, but also become more reliable in the long run. For

ministries of health to embark to an ambitious health workforce

programme, for example, a long term financing perspective is needed.

It doesn't make sense to increase training capacity today, if 10

years from now the additional health workers' salaries cannot be

secured to employ trained personnel. A new concept of sustainability

adopted for AIDS treatment – where sustainability is based on

domestic resources and sustained international funding – should be

expanded to health systems and services, including salaries of health

workers.

Most participants to the meeting acknowledged that AIDS activists

have been more successful than the proponents of PHC at getting their

priority high on the political and funding agendas. However, within

the spirit of Comprehensive PHC, they saw this could be an

opportunity rather than a threat, if this is used to equally raise

the profile on general health systems and services, not to depress

the profile given to AIDS responses.

Delegates felt the means to this was through renewed impetus for what

is fundamentally a shared and uniting paradigm of Comprehensive PHC,

including AIDS prevention and treatment, where:

• Health (and health care) is a human right, and an entitlement

• Programming and financing is adapted to needs and not to scarcity

of human and financial resources

• Macroeconomic policies are adjusted to vital needs and not the

other way around

• Concerns about the sustainability of health care is addressed as a

shared global responsibility, depending as much on sustained national

funding as on sustained international funding

• The people whose health is at stake are involved in the decision-

making process

Where the global AIDS response has made significant progress on these

issues, the benefits of this progress must be extended to general

health systems and services.

Therefore:

• Governments must live up to their promises: governments of low-

income countries must allocate 15% of their domestic government

revenue to health while governments of high-income countries must

allocate the equivalent of 0.7% of their Gross Domestic Product (GDP)

to global solidarity, and 15% of that (0.1% of GDP) to health.

• These commitments should be open-ended (as long as needed), without

aiming for national financial resources to replace international

financial resources as soon as possible, as this would undermine the

crafting of ambitious health plans, including workforce plans.

• Ceilings on health expenditure (included in policies imposed by the

International Monetary Fund) must not hamper the realisation of the

right to health or Comprehensive PHC for all.

• The people whose right to Comprehensive PHC is at stake have the

right and the duty to be involved in critical decisions that affect

their health.

• The global aid architecture must be reorganised in such a manner

that it supports Comprehensive PHC for all, not one part of

Comprehensive PHC at the expense of another; andGeneral health

systems and services not only need strengthening, but also

transforming: involving and working with communities as participants

of health systems and services, rather than merely `clients' or

passive recipients of health services.

We found that the global AIDS response created real challenges for

health systems and services, but also that there are ways to tackle

and minimise them. The global AIDS response also created real

opportunities, which should be maximized.

Comprehensive PHC is a uniting goal for all constituencies. It

demands a significant mobilisation of knowledge, experience and

additional funding. We cannot afford to repeat the mistake of three

decades ago, when the ideal of Comprehensive PHC was abandoned as

unaffordable, leaving us with the present health and health systems

deficit.

This oped is not intended to be an accurate record of the meeting

referred to which can be obtained from the authors located at

Institute of Tropical Medicine, Antwerp

[http://www.itg.be/itg/GeneralSite/Generalpage.asp].

EQUINET welcomes further opeds on the issues raised in this oped and

on Comprehensive PHC, particularly from an equity perspective. Please

send debate, comment or queries on the issues raised, or

communications for oped authors to the EQUINET secretariat, email

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