Article
from
The Boston Globe
More than 100 Harvard professors have signed the Africa AIDS plan, which proposes to treat patients in Africa with the same drugs that have been effective in rich countries. But the report glosses over major issues. Three of these are: how far does the proposal reflect African government priorities; can it be implemented on the ground quickly enough to serve a million patients in three years and three million in five years; and how will beneficiaries be chosen among a much larger population of AIDS victims?
The plan cites no requests for the proposed assistance from African governments. The call for selecting countries where government support is forthcoming implies (correctly) that such support is far from universal. But would not even some supporting governments say: If the donors are willing to provide us (collectively) with over a billion dollars of additional grant money each year, let us allocate it according to our own priorities. Sure, we will be happy to save as many of our AIDS sufferers as we can, but we have other pressing social and economic needs whose satisfaction will accelerate our economic growth and strengthen our own efforts toward both cure and prevention of AIDS.
Many Africa leaders understand the principle of equating marginal social returns to different uses of public resources. As regards implementation, the plan concedes the shortage of facilities to deliver the proposed treatment, and calls on aid donors to fund more infrastructure. But then it recommends use of existing infrastructures, such as networks that have been developed for directly observed therapy for the treatment of tuberculosis, and networks in development for treatment of maternal to child HIV transmission.
This raises the question: If in most countries these networks are incipient or exist as pilot projects, how long will it take to build facilities that can meet existing tasks, not to mention the burden of the new AIDS control effort? Over the years the World Bank and other donors have spent billions expanding health infrastructure in Africa. Many of the investments were abject failures. Where do we stand now?
By way of demonstrating the need for rich countries to pay the cost, the plan cites low per capita public health expenditure. For Ghana, Nigeria, and Tanzania, it is below $8 per year. But this cuts two ways: If it shows that Africa can''t pay for the plan, it also suggests absence of the infrastructure needed to administer it. Infrastructure comprises trained people as well as structures and equipment. The plan will require health personnel to administer for free to late-stage AIDS patients pills costing $500 per patient per year. Many of the personnel on whom the program will rely don''t earn much more than $500 equivalent per year. Most African public health systems we have seen maintain the fiction that patients are entitled to low-cost or even free drugs, but in fact the stores in clinics are often empty and patients have to pay full price to care providers or at private or state-owned pharmacies. Don''t call it corruption. It is simply a way for public health staff to avoid starvation. Also, many drug imports are pilfered before they leave the port. In the late 1980s, this was measured at about 40 percent.
Now suppose the new plan furnishes pills that care providers know are worth a hundred times anything they have dealt with hitherto. What proportion of the pills will reach intended recipients? HIV-positive individuals who are well-connected or of above-average means but not in the late stages of AIDS will bid for them and appropriate a large share. Assuming that the pills arrive at delivery points, who can prevent them from being smuggled out to higher bidders abroad, in Asia or the West?
The plan cites Haiti''s Clinique Bon Sauveur as a model that can be replicated. One should be cautious about predicting the speed at which a single experiment, the focus of intensive oversight by foreign experts, can be replicated to serve one to three million patients. Donors have funded many primary health-care projects in Africa that were designed as pilot projects to be replicated nationwide, but instead their nonfeasibility became apparent early on and they petered out.
The plan calls for simultaneous large-scale pilot projects and multiple pilot projects, and to rapid expansion of pilot projects. One is tempted to ask whether a large-scale pilot project is not a contradiction in terms, especially given the many hurdles that face implementation. There is a compelling case for establishing pilot projects in Africa, but we find the proposed scale overly ambitious and worry that it risks casting a shadow on the whole exercise. If after three years the press reports a large share of the pills being stolen, sold to ineligible persons and/or smuggled abroad, it would undermine public support in donor countries for future AIDS control initiatives.
Some years ago the World Bank adopted a policy that all project proposal documents had to contain a section containing subsections on sustainability, critical risks, and possible controversial aspects. As it stands, the new AIDS plan carries a strong tone of advocacy. Would it not be better if, coming from an academic community, it included such a section, acknowledging the kinds of issues we have mentioned?