How long will we depend on the US for HIV money?
Jan 05, 2010
<b>By Dr. Freddie Ssengooba</b><br><br>If the best time to plant a tree is 200 years ago, the second best time is todayâ€. This was the concluding statement of the Newsweek article that highlights the missed opportunities of President’s Emergency Plan for AIDS Relief (PEPFAR) under president B
By Dr. Freddie Ssengooba
If the best time to plant a tree is 200 years ago, the second best time is todayâ€. This was the concluding statement of the Newsweek article that highlights the missed opportunities of President’s Emergency Plan for AIDS Relief (PEPFAR) under president Bush and the urgency that the Obama administration has put in to seize the opportunity to pass on the PEPFAR baton to governments.
PEPFAR, under president Bush, is claimed to have contributed about 60% to the current 188,000 people now receiving life-saving treatment commonly known as ART.
The programme has come to symbolise the biblical story of Lazarus — resurrecting the dead — by giving a lifeline to many Ugandans and millions around the world that would have died from HIV/AIDS.
With the economic crisis and domestic health reforms in the US that require billions of dollars, the Obama administration badly needs to wean the PEPFAR baby off American breast milk.
The two main successes of PEPFAR both come wrapped in major failures. The American success and problem is that PEPFAR has helped to enroll 2.4 million people around the world into a life-long dependence on ART.
These people have their lives in the direct hands of the American government as opposed to their national governments. For example, the news last August that PEPFAR programmes in Uganda were going to close raised a public uproar against the American Government instead of the Uganda government.
The reassurance of the Uganda public came from US embassy in form of a press release and a visit from Ambassador Erick Goosby the global coordinator of PEPFAR.
His visit was an indication that the US government will not abandon the HIV programmes. When news about shortages of ART drugs and closure of some ART centres surfaced, the slow transition from PEPFAR-Bush to PEPFAR-Obama was blamed on Ugandan officials.
Between 2004 and 2009, the Uganda Government allocated about $3m for HIV while the US government web-site indicates that $1.2b was allocated to Uganda. This is about 0% compared to PEPFAR allocations for HIV in Uganda.
The burden of financing a life-long entitlement to ART care for millions of people around the world worries the Americans.
The costs for PEPFAR are estimated to rise to $12b per year by 2016. A study by the Center for Global Development shows that this will be equivalent to 50% of all moneys the American government spends on foreign aid. Americans are the largest contributor to the Global Fund which also provides funds for HIV.
The second American success and problem is that non-government agencies have steered the work of PEPFAR in countries like Uganda — leaving the national governments as a bystander.
Building PEPFAR on a platform of international NGOs as its base and foundation has its advantages — such as moving fast to deliver results, maintaining control in the hands of the funder and some say (wrongly in view) that it reduces the misuse of funds. But building health care programmes for chronic illnesses like HIV/AIDS on a platform of international and local NGOs has an inbuilt trigger for self-destruction because of poor sustainability and weak national ownership.
In several of his speeches, Ambassador Goosby has made it clear that NGOs are not sustainable and not an option for the exit strategy of PEPFAR, but national governments are his target.
On December 4, 2009, Ambassador Goosby said: “It is not that we want to dismantle (NGOs), … we want to include a public strategy with it and hold the government(s) accountable to respond to their epidemic.â€
The implications for HIV programmes in Uganda and around the world are now laid out in the new PEPFAR strategy released before Christmas.
The new strategy can be summarised into three words – sustainability, government and health systems. This is a revolution from the PEPFAR policy of the last five years. “Emergency†and “non-governmental†and “service targets†were the modus operandi with the implications that national HIV programmes were planned and directed from Washington DC and the US Embassy in Kampala.
Officials of the Uganda government were a marginalised stakeholder as they looked on in envy as international agencies and a few national NGOs become more powerful and expanded in uncoordinated fashion to spend the PEPFAR dollars and harvest HIV results at supersonic speed for the reports to American Congress.
Indeed, PEPFAR programmes in Uganda are claimed to have overshot their ART enrollment targets set by the American Congress. This success did not come without adverse distortions in the health care systems.
Nurses, doctors and public health specialists all moved to work for NGOs where PEPFAR was putting its money. Our research at Makerere School of Public Health shows that the salaries of nurses and doctors working among PEPFAR funded programmes were more than twice that paid by the Government or faith-based health facilities.
The flood of ART drugs procured by NGOs with PEPFAR funds made ART drugs procured by other funders to expire in the national medical stores. Such developments led some researchers to conclude that the success of PEPFAR has drained the health systems that supports the poor communities with non-HIV health care needs.
The good news is that PEPFAR under President Obama, wants to fix these problems by handing the responsibility back to national governments, assist governments to take responsibility for sustaining the HIV programmes and contribute to rebuilding the weak health systems.
But as a health systems researcher in Uganda, my euphoria ends here and great apprehension starts. Are our governments ready to get back into steering of HIV programmes? Can the governments competently work with an emboldened NGO community to build on what has been achieved? Can the political tokenism (exchange of votes for salt and soap) work with the vocally powerful groups of ART beneficiaries whose life-line now depends, on efficiently run health systems?
In summary, how can the PEPFAR strategy of passing the responsibility to national governments be assisted to succeed?
Some governments like Uganda have made some humble, but insightful progress. Although little budget allocation is given, an HIV budget-line has been introduced into the national chart of accounts for every government ministry.
Government procuring systems for medicines including ARVs are being re-engineered and strengthened. But the weakest points in the chain of government-led sustainability of the HIV programmes are many.
For the PEPFAR exit strategy to succeed, governments must pick up the tools and run the difficult race because millions of citizens have a reason to seek real accountability. Succeed we must.
The writer is a lecturer at the Makerere University School of Public Health
If the best time to plant a tree is 200 years ago, the second best time is todayâ€. This was the concluding statement of the Newsweek article that highlights the missed opportunities of President’s Emergency Plan for AIDS Relief (PEPFAR) under president Bush and the urgency that the Obama administration has put in to seize the opportunity to pass on the PEPFAR baton to governments.
PEPFAR, under president Bush, is claimed to have contributed about 60% to the current 188,000 people now receiving life-saving treatment commonly known as ART.
The programme has come to symbolise the biblical story of Lazarus — resurrecting the dead — by giving a lifeline to many Ugandans and millions around the world that would have died from HIV/AIDS.
With the economic crisis and domestic health reforms in the US that require billions of dollars, the Obama administration badly needs to wean the PEPFAR baby off American breast milk.
The two main successes of PEPFAR both come wrapped in major failures. The American success and problem is that PEPFAR has helped to enroll 2.4 million people around the world into a life-long dependence on ART.
These people have their lives in the direct hands of the American government as opposed to their national governments. For example, the news last August that PEPFAR programmes in Uganda were going to close raised a public uproar against the American Government instead of the Uganda government.
The reassurance of the Uganda public came from US embassy in form of a press release and a visit from Ambassador Erick Goosby the global coordinator of PEPFAR.
His visit was an indication that the US government will not abandon the HIV programmes. When news about shortages of ART drugs and closure of some ART centres surfaced, the slow transition from PEPFAR-Bush to PEPFAR-Obama was blamed on Ugandan officials.
Between 2004 and 2009, the Uganda Government allocated about $3m for HIV while the US government web-site indicates that $1.2b was allocated to Uganda. This is about 0% compared to PEPFAR allocations for HIV in Uganda.
The burden of financing a life-long entitlement to ART care for millions of people around the world worries the Americans.
The costs for PEPFAR are estimated to rise to $12b per year by 2016. A study by the Center for Global Development shows that this will be equivalent to 50% of all moneys the American government spends on foreign aid. Americans are the largest contributor to the Global Fund which also provides funds for HIV.
The second American success and problem is that non-government agencies have steered the work of PEPFAR in countries like Uganda — leaving the national governments as a bystander.
Building PEPFAR on a platform of international NGOs as its base and foundation has its advantages — such as moving fast to deliver results, maintaining control in the hands of the funder and some say (wrongly in view) that it reduces the misuse of funds. But building health care programmes for chronic illnesses like HIV/AIDS on a platform of international and local NGOs has an inbuilt trigger for self-destruction because of poor sustainability and weak national ownership.
In several of his speeches, Ambassador Goosby has made it clear that NGOs are not sustainable and not an option for the exit strategy of PEPFAR, but national governments are his target.
On December 4, 2009, Ambassador Goosby said: “It is not that we want to dismantle (NGOs), … we want to include a public strategy with it and hold the government(s) accountable to respond to their epidemic.â€
The implications for HIV programmes in Uganda and around the world are now laid out in the new PEPFAR strategy released before Christmas.
The new strategy can be summarised into three words – sustainability, government and health systems. This is a revolution from the PEPFAR policy of the last five years. “Emergency†and “non-governmental†and “service targets†were the modus operandi with the implications that national HIV programmes were planned and directed from Washington DC and the US Embassy in Kampala.
Officials of the Uganda government were a marginalised stakeholder as they looked on in envy as international agencies and a few national NGOs become more powerful and expanded in uncoordinated fashion to spend the PEPFAR dollars and harvest HIV results at supersonic speed for the reports to American Congress.
Indeed, PEPFAR programmes in Uganda are claimed to have overshot their ART enrollment targets set by the American Congress. This success did not come without adverse distortions in the health care systems.
Nurses, doctors and public health specialists all moved to work for NGOs where PEPFAR was putting its money. Our research at Makerere School of Public Health shows that the salaries of nurses and doctors working among PEPFAR funded programmes were more than twice that paid by the Government or faith-based health facilities.
The flood of ART drugs procured by NGOs with PEPFAR funds made ART drugs procured by other funders to expire in the national medical stores. Such developments led some researchers to conclude that the success of PEPFAR has drained the health systems that supports the poor communities with non-HIV health care needs.
The good news is that PEPFAR under President Obama, wants to fix these problems by handing the responsibility back to national governments, assist governments to take responsibility for sustaining the HIV programmes and contribute to rebuilding the weak health systems.
But as a health systems researcher in Uganda, my euphoria ends here and great apprehension starts. Are our governments ready to get back into steering of HIV programmes? Can the governments competently work with an emboldened NGO community to build on what has been achieved? Can the political tokenism (exchange of votes for salt and soap) work with the vocally powerful groups of ART beneficiaries whose life-line now depends, on efficiently run health systems?
In summary, how can the PEPFAR strategy of passing the responsibility to national governments be assisted to succeed?
Some governments like Uganda have made some humble, but insightful progress. Although little budget allocation is given, an HIV budget-line has been introduced into the national chart of accounts for every government ministry.
Government procuring systems for medicines including ARVs are being re-engineered and strengthened. But the weakest points in the chain of government-led sustainability of the HIV programmes are many.
For the PEPFAR exit strategy to succeed, governments must pick up the tools and run the difficult race because millions of citizens have a reason to seek real accountability. Succeed we must.
The writer is a lecturer at the Makerere University School of Public Health