A Los Angeles Times article on HIV/AIDS funding, particularly by the Gates Foundation and through the Global Fund to fight against AIDS, TB and Malaria (GFATM), has sparked a furor. The authors question whether the large and focused support for one disease reduces support for basic health systems issues and needs including nutrition, staffing, other infectious diseases and essential supplies and equipment.
An internal brain drain is described wherein staff migrate to HIV-related positions that attract supplemental salary. What could be termed replacement mortality is discussed when people survive HIV because of ART (anti-retroviral therapy) but die of other diseases because they are poor and malnourished. It is not a pretty picture.
Responses have been strong with some criticizing the audacity of the authors to question the good will of the donors while others questioning the academic and scientific qualifications of the donors to make intelligent decisions about channeling aid. Overall it is interesting that the malaria portion of such funding appears to have escaped the most scathing complaints.
When the Roll Bank Malaria Partnership got underway in 1998 one of the key components of discussion was the premise that malaria control must be pursued in the context of health system reform. The assumption was that all major malaria interventions required a strong health system for their effective delivery. Malaria care was already part of Integrated Management of Childhood Illness (IMCI). We certainly havenâ€™t heard of special malaria clinicians receiving salary supplements for dispensing ACTs.
We are aware, as is the GFATM that one of the major problems in delivering malaria interventions are basic health systems bottlenecks such as weaknesses in forecasting and procurement, supply chain disruptions and inadequate dissemination of current malaria care policies and guidelines to frontline health staff. What was not mentioned in the Los Angeles Times article is that GFATM encourages countries to include â€˜Health System Strengtheningâ€™ components in their proposals, although this has not been a major component to date.
Finally we are also aware as we have recently shared that malaria prevention efforts have positive benefits on nutritional status. Use of bednets/ITNs has helped reduce all cause infant and child mortality. Are we herein defending the special attention being given to malaria after years of neglect? Maybe readers would like to comment from their own experiences?