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A Question of Will or Doing the Right Things and Doing them Right? |
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The Washington Post's lead editorial following the White House Summit on Malaria, titled Fighting scourges such as Malaria and AIDS requires strong institutions (December 18) correctly noted the disarray at the Global Fund for AIDS, TB and Malaria, and stressed the importance of leadership, direction and funds for the Global Fund. Arguing that perhaps more than half of the $8 billion-plus that is needed for these three diseases will have to come from the Global Fund, it acknowledged the need for funds as well as a balance between hands off and hand on approach in aid recipient countries by the future Global Fund. Clearly what it could not say in a short editorial is that not just the strength, but the institutional design of donor aid for public health more generally will have profound impact on the speed, efficiency and effectiveness with which the scourge of the three diseases afflicting developing countries is eliminated.
An institutional redesign of donor aid calls for long term predictable support for a total health systems approach for a coherent health sector strategy in each recipient country. Regrettably there is still less willingness on the part of the donor community to learn from its collective experience and to adhere to the “Three Ones” principle it has adopted: one action program, one national authority and one monitoring and evaluation system. Lacking confidence in the traditional international organizations such as the World Bank and WHO donors established new initiatives such as the Global Fund and PEPFAR (President’s Emergency Plan for HIV/AIDS Relief). They believed with some reason that the slow response of WHO and the World Bank reflected their institutional lethargy, rather more than insufficient open debate on the choices facing the donor community and the developing world on the control and prevention of communicable diseases. Rapid response of the kind the Global Fund provided was needed to open debate and learn lessons when there was great deal of inhibition and little past experience to go by. But that is not the case any longer. Independent evaluations of various donor initiatives suggest that focus on prevention is of supreme importance as the only long term solution to the diseases. Prevention did not receive the attention that it deserves. Similarly multiplicity of strategies and approaches by various donors to treatment including by the Global Fund through different initiatives is highly taxing of the very limited institutional capacity in developing countries.
Lack of agreement and coordination among donors prevents rather than helps develop cohesive national strategies and delivery systems of health services in developing countries. It results in recipient country responses which could be best described as “Robbing Peter to Pay Paul” to show results. Indeed, some times strong leadership and political will backed by money in donor countries can have the unintended paradoxical adverse impact of weakening the already frail institutional fabric of developing countries to address health system problems to which there are no easy and short term solutions. While bed nets, drugs, condoms and circumcision are all good and desirable technical solutions developed and exported by donor countries, what developing countries now most need but lack are effective institutional approaches to deliver these goods and ideas within their own highly diverse socio-economic and cultural contexts. Ultimately it is the leadership and institutional strength in developing countries and not at the global fund that will determine results, as the successful control of HIVAIDS in Brazil and Thailand or of tuberculosis in China and India demonstrate. To foster such leadership calls for a different highly sensitive leadership in the donor community than simply a focus on money, technologies and we know best approach.
Will the Center For Global Development’s new $10 million grant from the Gates Foundation help develop more effective in-country approaches to help redesign donor aid to global health?
Recommended reading:
Health System Capacities in Developing Countries and Global Health Initiatives on Communicable Diseases
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