From "Marvelous Momentum" to Health Care for All: Success Is Possible With the Right Programs

In 2005, PIH initiated, with the Rwandan Ministry of Health and the Clinton Foundation, a new rural AIDS initiative in Rwanda based on the Haitian model, and it is starting to have some success. More than 2,000 people with AIDS are now receiving therapy within two health districts in eastern Rwanda -- districts that, prior to 2005, were served by not a single doctor. Over 400,000 people live in these districts; 60 percent of them are resettled refugees or others displaced by war and genocide. PIH did bring in doctors at first, some of them Americans, but within months of our arrival, over 95 percent of our employees were African, most of them accompagnateurs. And most of what we do, in Rwanda as elsewhere, has more to do with primary health care than with HIV/AIDS. We also work within the public sector, so that the doctors, nurses, and paraprofessionals who work with us are not part of the brain drain at all.

Unfortunately, such practices -- and such results -- are the exception rather than the rule. "By one reliable estimate," notes Garrett, "there are now more than 60,000 AIDS-related NGOs [nongovernmental organizations] alone." Yet by 2006, after a global campaign to bring HIV/AIDS care to Africa, less than 25 percent of Africans who needed ARVs to survive were receiving them, with the fraction dwindling to less than five percent in rural areas. Worse, new infections continue apace. So what on earth, one might ask, are all these AIDS-focused NGOs doing? That is a very good question, and we should all be grateful to Garrett for posing it so provocatively.

As Garrett notes, it is not NGOs alone that suck up resources intended for the poor; corrupt governments divert many of these resources to the pockets of the nonpoor, including a huge international "helping class." Garrett cites a 2006 report by the World Bank estimating that, in Garrett's words, "about half of all funds donated for health efforts in sub-Saharan Africa never reach the clinics and hospitals at the end of the line," and this is surely true. But it is important to add that the same international financial institutions issuing such reports are contributors to the situation -- having for years suggested "capping" social expenditures on health and education and even having made such restructuring of public budgets a precondition for access to the credits and assistance on which poor governments depend for survival.

Garrett is correct to emphasize the importance of strengthening public-sector health institutions and to criticize vertical, or "stovepiped," approaches to health care. And she is to be lauded for describing the distortions that frequently ensue when large sums of money are introduced into cash-starved health systems. Our experiences at PIH, however, suggest that while her general thesis is right, Haiti is not a good example to support it. Garrett claims that former U.S. President Bill Clinton was wrong to suggest that HIV/AIDS initiatives would "end up helping all other health initiatives." "The experience of bringing ARV treatment to Haiti," she writes, "argues against Clinton's analysis. The past several years have witnessed the successful provision of antiretroviral treatment to more than 5,000 needy Haitians, and between 2002 and 2006, the prevalence of HIV in the country plummeted from six percent to three percent. But during the same period, Haiti actually went backward on every other health indicator."

There are three problems with the correlation and inferred claim of causality. First, is the correlation true? The reduction of HIV prevalence has been well documented. But has Haiti actually gone backward "on every other health indicator" between 2002 and 2006? This might be true in the chaos of present-day Haiti, but the national-level surveys that would provide such data have not been conducted, much less completed and analyzed.

Second, even were the correlation shown to be true, how would we know that the primary reason for such backsliding was too much AIDS funding rather than, say, the 2004 coup d'état, an event that led to great political upheaval, attacks on hospitals and clinics, the disruption of medical supply chains, and the effective dissolution of Haiti's National AIDS Commission (which had been ably chaired by First Lady Mildred Aristide, one of the primary architects of Haiti's successful application to the Global Fund)?

Third, I am confident, even without the results of national surveys, that Garrett's stovepiping hypothesis, manifestly true in most countries mentioned, does not hold true in central Haiti, where close to half of the Global Fund grant went and where half of those 5,000 "needy Haitians" on ARVs live. There, as PIH has documented, the increased AIDS funds were spent exactly as Garrett advocates: to strengthen the public health system in general. Even if we measure, as she suggests, by maternal mortality and life expectancy at birth (rather than the "short-term numerical targets" she deplores), we see that funds nominally slated for AIDS may be used to reduce maternal mortality and increase life expectancy.