THE DONOR DILEMMA

Millions of lives have been saved thanks to the generous donations of people and organizations around the world to fight HIV. Their efforts are making a difference in the war on HIV and AIDS.  Sadly, according to a recent report by the Center for Global Development, (CGD) many of these well-intentioned organizations are inadvertently undermining the very healthcare systems they are trying to aid.

The study focused on HIV initiatives in Mozambique, Uganda and Zambia. It reveals that in those three countries, because of the process requirements that come with the money; the programs initiated by major donors create a burden on already shaky healthcare infrastructures.

By specifying how the treatment is to be administered, the fund provider creates a treatment process for HIV that is separate from the rest of the healthcare system. Having another separate process to learn and run creates new complexity and burdens on already over-burdened systems.

Then there are the staffing issues. Instead of adding new workers for the HIV programs, they usually train existing staff in HIV/AIDS treatment and give them extra money for doing so. Since workers in the AIDS programs get paid more, it draws health and administrative workers away from other (generally already under-staffed) areas.

According to the report all this strengthens the nation’s ability to treat HIV, but weakens its overall ability to treat all other health issues — which are numerous.

I think the report did a good job at documenting the problem, but I was disappointed that it did not investigate or suggest a solution. It would be easy to conclude from the study that perhaps the money should just be handed over to the local health ministry.

The reason many HIV fund providers no longer do that is because they tried that approach and found it didn’t work. Other donors who support a sector approach through ministries get so bogged down with bureaucracy and politics that in many cases nothing happened and if it did, it simply took too long.

Generally, the American donor organizations favor the approach outlined in the report, although many do actually give directly to ministries as well. This results in fast action, but as the report says, can create other obstacles, i.e. sustainability issues and shortage of workforce in other areas.

One thing the CGD paper did not mention is the effort that donors are making to shore up local healthcare infrastructures. I think it’s important to mention that most donors do realize these problems exist and are trying to improve the situation. The World Bank used a whopping 40% of its HIV money for bolstering local infrastructures, and the new PEPFAR plan includes a program to train 140,000 health care workers.

Science recently addressed many of these issues in an investigation of how HIV funding is being used titled ‘HIV/AIDS: Follow the Money.’ In the feature, they call for the whole system to be re-thought and point out that many are questioning if all this money for HIV is only made possible by sacrificing treatment for other diseases.

The article also points out that many countries with poor infrastructures miss out on funding because donors realize much of the money will go to waste if they give it to them. The major contributors will not give more money to a country if they feel that country cannot handle it.  In most countries, that maximum capacity doesn’t provide enough money to treat everyone. So simply going around local health infrastructures is clearly not the way to make universal access a reality.

HIV is a long-term problem and clearly the current way of doing things is a short-term solution.  It’s fantastic that these programs have saved so many lives. It’s a shame the only way they can achieve these results is by circumnavigating the health ministries.  The bottom line is that millions are in need right now and they cannot afford to wait for efficient health care systems to develop. But develop they must. 

It is not the donors’ responsibility, but that of the governments who run the health ministries.

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