Wednesday, December 19, 2007

Does the Global Fund *really* save 3000 lives a day?

The LA Times has a long piece on the Global Fund, which looks at a lot of the complexities of providing solutions to global health problems. In particular, the article highlights a lot of the unintended consequences of the Global Fund’s focus on specific health issues, and questions the overall success claims of the fund. I came across the piece via an article on Valleywag of all places, which takes the article’s findings a step further by labelling the Gates’ work “Failanthropy.” I think Valleywag is a bit harsh in its analysis, but the Times article definitely had me thinking about some of the issues beneath the surface which are often not talked about when the director of the Global Fund says “Global Fund programmes are saving 3000 lives a day”

The main issues the Times brings up?
• The Fund’s focus on specific diseases is causing an internal ‘brain-drain’ in
country health systems as underpaid health professionals are drawn from basic
healthcare to jobs working on these better-funded diseases.
• There isn’t enough of a focus on support systems, so some of the very
expensive interventions are ineffective. A micro case if you want of ‘for want of
a nail the kingdom was lost’
As well as a slightly more serious allegation:
• Health workers are instructed not to discuss health conditions that the funded
vaccination programs cannot prevent, often the more serious concerns that the
patients have
– something which seems to go against all common sense in basic healthcare.

The LA Times piece comes across as a pretty scathing expose, a revelation of elements of paternalism in the Gates’ approach to global health care, and an indictment once again of Western interventions in developing world issues which fail to look at the bigger picture, and to work with other stakeholders in addressing the complete problem.

A little more digging however revealed a few things that the Times article neglected to mention. For instance, that health officials in Zambia have praised the Global Fund initiative for being largely country-driven. Also praise for the fact that Global Fund representatives are willing to listen to suggestions and adjust policies to be more relevant to the ways in which countries have chosen to address health issues ( sector-wide approaches versus a vertical focus on specific diseases.) There is also no mention of the fact that the Fund has admitted that countries have not always been clear on how funds can be channelled, and they are working to improve this, as well as looking at interventions in agriculture and nutrition, and give 1% of funds to support health systems more broadly (info from two Lancet pieces on the Global Fund).

In balance though, a lot more thinking needs to be done about the overall place of the Global Fund and other international health interventions, and how effective they are overall. One of the Lancet articles talks about the Zambian government’s frustration with the many different organizations they have to deal with. “7 months on the Global Fund, 8 months on the Clinton Foundation and 3 months on MAP.” Perhaps more time co-ordinating these different efforts than actually attacking the problem.

One thing which struck me about the article was the statement of Tadataka Yamada, president of the Gates Foundation’s global health program "We're a catalyzer. What we can't do is fill the gaps in government budgets…It's not sustainable.” True enough. Even more striking to me – his statement that Africans need to do more themselves to improve public health, and that they should spend less on weapons and more on doctors before they demand increased assistance. Sure, the likes of Dr. Yamada have no obligation to African countries and African health systems, and I’ve been a pretty vocal critic of some government spending choices, such as this one in Ghana. That being said, if the foundation has taken upon itself to intervene, I expect slightly more nuanced statements from Yamada. Sure, the governments could probably spend more on the health sector. But wouldn’t one of the results be accelerating the development of health systems in other parts of the world? It would take much more than the 15% of GDP that Yamada proposes African countries spend on health care (only 13 countries in the world spend as much as 10%) to come close to comparable conditions for health professionals in developing countries. Perhaps a little work on looking at how the poaching can be discouraged, or how developing and developed governments could cone up with mutually beneficial solutions could help. Just a thought…

As someone firmly in the camp of ‘the only way things will change is if we change them ourselves’ this was mostly a reminder to keep focusing on being impactful in developing the capacity of Africans to solve some of these problems ourselves. Also a reminder of how important leadership initiatives are. Maybe a few entrepreneurial health ministers in these countries could be more successful at coming up with solutions which take the whole picture into consideration. After all, they know the systems best, and they have to deal with the broader consequences of some of these spot interventions.

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