In his LA Times article on December 16, Charles Piller addresses the very real possibility that the extraordinary amount of funding now flowing to poor countries to combat individual diseases might undermine other health sector capabilities. Indeed I suggested as much in a 2004 book chapter entitled "Impact of the HIV/AIDS Epidemic on the Health Sectors of Developing Countries," where I proposed that an index of the ability of a country to absorb annual AIDS treatment expenditures might be the ratio of such expenditures to the number of physicians. But in order to take account of the fact that physicians in a higher income country might be able to manage the expenditure of more money per year than those in a low income country, I thought it useful to also control for the country's per capita income. The result was a figure like this:
In this figure, AIDS cost per physician is on the vertical axis and GDP per capita is on the horizontal. Countries are represented by circles in the chart, with larger circles representing more AIDS patients. Circles at the top of the graph represent countries with large numbers of AIDS cases and few physicians while those near the bottom have the reverse. Countries at the right are richer and those at the left are poorer. I have arbitrarily constructed a vertical line at $500 to divide the poorest countries from the richer one and inserted a diagonal at ten times per capita GDP.
The idea is that countries in the lower right or "southeast" quadrant would have the easiest time meeting their treatment needs. These countries include Brazil and Thailand for example. Countries in the upper right or "northeast" quadrant would have a harder time because their AIDS burden is greater relative to the size of their physician workforce. While they would face a substantial challenge, their relatively high per capita incomes would help them to adjust to the burden of AIDS care. Countries in the upper left or "northwest" quadrant would face the greatest challenge due to a combination of high burden, small supply of physicians and low per capita GDP. In these countries, we might expect resources to be sucked out of other health care services by the extraordinary inflow of financing to support AIDS care.
However, the story is not as simple as might be implied by these comparisons. One of the countries in the northwest quadrant which faces the "greatest challenge" is Rwanda. While benefiting from enormous inflows of money for AIDS treatment from the Global Fund and PEPFAR, Rwanda also has substantial complementary funds from the World Bank to strengthen its health system. Jessica Price of the consulting firm Family Health International gave a presentation at the Institute of Medicine which claims that the way international resources have been used in that country has substantially improved the performance of the health sector for all problems, not just for AIDS. I present below her before and after pictures of a maternity ward as evidence for how much improvement was accomplished in at least one of the health centers.
What may distinguish the Rwandan example from those cited in the LA Times article is the considerable attention paid by the Rwandan government to improving overall health care. For example, with World Bank support the government provided small grants of $60,000 each to each hospital which strengthened overall care in government and non-government facilities alike. A note in a World Bank newsletter quotes "a provider at the recently renovated Kiziguro Hospital run by a religious mission....MAP has assisted to improve the quality of care for both AIDS and non-AIDS patients." (p. 10)
Countries in which the current and future flow of funds for specific diseases are unaccompanied by other vigorous efforts to strengthen the overall system may indeed suffer the negative spillovers onto non-AIDS care that the LA Times article so vividly depicts. This is a reason to strengthen health systems, not to reverse course on recent accomplishments. The objective should be to assure that the poorest countries have financing and technical support for balanced growth of the health sectors.