Development and Cooperation


	Contributions from the Column Focus Fragmented goals E“We do not sit down and wait for assistance” Squaring the accountability triangle “We need coherent national strategies” Drugs are not enough 8-9/2005		“We need coherent national strategies” Donor and recipient countries, private-sector firms as well as civil-society actors are all involved in the Global Fund to Fight Aids, Tuberculosis and Malaria. As the name indicates, the Fund aims to fulfil the sixth Millennium Goal: mitigating the three most dangerous diseases. Bernhard Schwartländer, Director of Strategy and Evaluation at the Global Fund, spoke to D+C/E+Z about how important antiretroviral AIDS treatment is. [ Interview with Bernhard Schwartländer ] To what extent do the treatment and prevention of AIDS compete with other Millennium health goals? Antiretroviral treatment is very expensive and attracts more attention than do campaigns to combat maternal death and child mortality. In principle, the various programmes should not be seen as pitted against each other. Indeed, they fit in quite well because they all are about strengthening national health systems. But let’s face it: the people who implement such programmes are competing for the same funds. They have their own institutions and procedures. Tension and disputes do occur, but well designed, overarching concepts can minimise frictions. But antiretroviral treatment is very demanding and ties up capacities that are then no longer available for other purposes. We must definitely keep an eye on what happens when international funds are invested in a specific health programme. Are we providing incentives for all doctors and nurses currently involved in immunisation to move on to combating HIV/AIDS because that is where they can make more money or find more secure employment? That is problematic, especially because poor countries have poor capacities. But the problem is not insurmountable. Those trained for HIV/AIDS can use their knowledge profitably in all other areas. We are not talking about a separate field of medicine completely unrelated to others. We crucially need coherent national strategies for the entire health sector. That is well understood and the donor community is cooperating more closely than ever before in order to make sure that the chosen approaches do not compete but rather complement each other. But if an African country only has an average per capita income of 300 dollars, even relatively cheap generic antiretroviral drugs are exorbitantly expensive. After all, when you have to pay one dollar per patient and day, you need 365 dollars a year – only for the drugs. There can be no doubt that the Millennium Development Goals will not be reached by only relying on poor countries’ revenues. Antiretroviral treatment is indeed relatively expensive. But it is also very effective and extends the lives of those infected. That means they can work longer, which in turn has important economic consequences. And prices have fallen drastically. We are now down to 50 cents per day for first-line treatments. This is a figure that is manageable, especially when so much money is available from international donors – such as the Global Fund. But there are also bilateral programmes. The USA alone provides 15 billion dollars with a focus on antiretroviral treatment. But the US government also rejects the promotion of condoms. And it makes its support of national programmes contingent upon the exclusion of such practices. Doesn’t that mean that treatment comes at the cost of prevention? Prevention and therapy go together. As far as the USA is concerned, there often is more excited rhetoric than action. In practical terms, the US is working towards reasonable programmes just like other donors do. It is true that the US administration is having a hard time with some issues, but we do not feel that this has had any untenable consequences so far. We worry more about a more fundamental problem. The fact that treatment is possible means that people are losing interest in prevention. We know that, for this reason, infection rates in the industrialised nations have gone up again since the late 1980s. If something like that were to happen in developing countries, it would be a complete disaster. But the availability of antiretroviral medicine seems to make HIV/AIDS less of a threat everywhere. Exactly. If you are healthy, you don’t want to deal with diseases. But as soon as we feel pain, we all run off to the doctor. Therefore, we have to take advantage of all the possibilities antiretroviral treatment offers and use them to promote prevention. It is possible to do so – not least, because treatment helps to reduce the fear of the tests necessary to diagnose infections. In the end, it is clear that we can neither design prevention without treatment nor afford treatment without prevention. It is said that the great progress made by India and China, with more than a billion people each, ensures that the Millennium Goals will be met in global terms. On the other hand, it is said that both countries face major AIDS pandemics. Can HIV/AIDS still foil the plans of MDG optimists? It is very difficult to predict the spread of AIDS in Asia. India and China both have twice the number of people that live in all of sub-Saharan Africa. People tend to forget the dimensions. Moreover, both countries have very heterogeneous societies. It is very hard to make long-term projections. But we can influence what happens. The countries themselves have the most influence, but the international community also has some. We certainly do not expect India to one day end up with 20 percent of its adult population infected with AIDS, the rate we are witnessing in southern Africa now. On the other hand, there are some serious risks and we should not play them down. Private donors have gained a major role in the treatment and prevention of AIDS. This is especially true of the Bill and Melinda Gates Foundation, with its penchant to invest three digit million dollar sums wherever it gets involved. The Gates Foundation is also a major participant in the Global Fund. Have such agencies become more important than governments? Private agencies certainly make a significant contribution to the overall volume. There are niches where they are particularly important – for instance in research and development, an expensive area with uncertain results. This is where private donors – first and foremost the Bill and Melinda Gates Foundation – play a special role. In general, however, private funds for health issues still only add up to a rather small share of total international development aid. It’s just a drop in the ocean. If we really want to reach the entire population of any given country, public donors and public organisations remain the key players. Questions by Hans Dembowski. Dr. Bernhard Schwartländer is the Director for Strategy and Evaluation at the Global Fund to Fight AIDS, Tuberculosis and Malaria. He lives in Geneva. bernhard.schwartlander@theglobalfund.org