AIDS: the private sector is vital

Juan Pablo Gutierrez and colleagues (July 3, p 63)1 calculate the costs of achieving the WHO/UNAIDS "3 by 5" target at up to US$5•9 billion, and UNAIDS calls for US$20 billion a year by 2007.2 These estimates are for the additional costs for HIV/AIDS; they assume that public-sector infrastructure is capable of delivering those services. Sadly, this is not the case in countries where the money is needed. Countries of sub-Saharan Africa have many vacant posts through AIDS deaths and migration,3 and most suffer from chronic organisational weaknesses.2 What would the cost be of running health systems capable of delivering what is needed? For sub-Saharan Africa to achieve comparability on a per capita basis with South Africa would cost US$72 billion a year; currently, US$8•5 billion are spent, including aid.4 Clearly, to assume this extra funding will be forthcoming--and these are running costs not development costs--is not realistic. How public health systems will be able to absorb large amounts of HIV/AIDS money effectively, or indeed at all, without piles of antiretrovirals passing their expiry dates is, therefore, difficult to imagine.

Where large sums might get spent effectively is in the private sector. In financial terms, this area is already bigger than the public sector in all relevant countries. People use private drug shops, nurses, community health workers, and traditional care providers more than they use public services. Often, they provide the only care available. We urgently need to encourage large-scale social franchising and similar networks that link these private workers by supplying them with the right drugs, and insisting on the right protocols in return for a marketing edge through branding, training, and regular supplies. If they could access growth money, many competent non-governmental organisations (NGOs) would rapidly scale up in this way, avoiding the costs of employing all their health workers directly. Treatment plans for tuberculosis, other opportunistic infections, and HIV/AIDS could be built on existing reproductive-health and primary-care services.

The difficulty in getting money to NGOs is that government organisations handle it first. Experience from sector-wide approaches, from World Bank HIV/AIDS funding, and from early transfers from the Global Fund indicates little enthusiasm or capability by governments in directing money to the private sector.5 Many international agencies have to work with national governments, but the Global Fund does not, and it is good to see the role of Country Coordinating Mechanisms (dominated by government) now being questioned and interest in non-state programmes growing. Better yet would be to bypass government completely with money for private initiatives, provided these are working within national plans. This option might also reduce the risk of displacement of funding (reallocating planned HIV/AIDS money to other things).2 Public sectors have a vital part to play in the expansion of HIV/AIDS services, but they are not going to succeed on their own.

Roger England

roger.england@ihsd.org

Institute for Health Sector Development, London EC1V 9HL, UK

1 Gutierrez JP, Johns B, Adam T, et al. Achieving the WHO/UNAIDS antiretroviral treatment 3 by 5 goal: what will it cost? Lancet 2004; 364: 63-64. [Text]

2 UNAIDS. 2004 report on the global AIDS epidemic: 4th global report. http://www. unaids.org/bangkok2004/report.html (accessed July 28, 2004).

3 Freidman EA. An action plan to prevent brain drain: building equitable health systems in Africa. Boston: Physicians for Human Rights, 2004.

4 World Bank. World development indicactors 2003. http://www.worldbank.org/ data/wdi2003/ (accessed July 28, 2004).

5 Daly KS, Sellers T, Pimenta de Oliveira MC, et al. Meeting the challenges of providing financial and technical support to NGOs and CBOs in the context of increased funding (abstract MoOrE1040). XV International AIDS Conference, Bangkok, July 2004. http:// www.aids2004.org (accessed July 28, 2004).
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