Category: HIV/AIDS

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Throwing aid at HIV

Some colleagues at APSA shared a new paper by Nunnenkamp and Öhler investigating the effect of official development assistance (ODA) on HIV-related health outcomes in developing countries. The authors write:

Optimally, ODA would help prevent new HIV infections as well as provide better care for the infected. Our results indicate that ODA-financed prevention has been insufficient to reduce the number of new HIV infections. By contrast, we find evidence of significant treatment effects on AIDS-related deaths for the major bilateral source of ODA, the United States.

However, the treatment effect proved to be insignificant when multilateral organizations represented the major source of ODA. In particular, our findings are in sharp conflict with claims of the most important organization in this field—the Global Fund to Fight AIDS, Tuberculosis, and Malaria—that its performance-based support has saved almost five million lives by the end of 2009.

It seems HIV/AIDS related foreign aid is coming under increasing scrutiny these days, at least by academics. Like Bendavid and Bhattacharya (2009), Nunnenkamp and Öhler find U.S.-funded PEPFAR associated with reduced deaths due to HIV/AIDS, but not reduced prevalence of HIV. The inability of billions of dollars to reduce new infections is troubling indeed.

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PEPFAR in Africa: Success or Failure?

My friend and co-author, Melissa Lee, is presenting our paper, “PEPFAR in Africa: Beyond HIV/AIDS”, today at the 2011 American Political Science Association annual conference. I have long wondered whether such a huge influx of health aid targeting a particular disease has a negative effect on the rest of the health sector. So, sometime earlier this year, Melissa and I decided to try to find out!

In our paper, we find that immunization and under-5 mortality rates in African PEPFAR recipient countries improved significantly less than in African non-recipient countries with HIV epidemics. The paper has not been uploaded yet, but I will share the link as soon as it is available.

The President’s Emergency Fund for AIDS Relief (PEPFAR) was initiated by President Bush in 2003, and is the largest bilateral aid program in the world that targets a single disease. By 2011, the U.S. government had committed $39 billion to the program, which often constitutes a large percentage, if not the majority, of health funding in PEPFAR recipient countries.

Empty corridors: rural hospital in Western Uganda, where PEPFAR spends more on HIV than the government spends on health

PEPFAR’s initial goals focused on prevention and treatment of HIV/AIDS, although they have recently expanded their strategy to include integrating PEPFAR into more general health programs. How successful has PEPFAR been in achieving these goals? They have helped provide anti-retroviral treatment to 3.2 million people, prophylaxis for 600,000 HIV+ pregnant women to prevent mother-to-child transmission, and supported 11 million people through other activities.

But a real evaluation of how well PEPFAR has performed must include a comparison to how well PEPFAR recipient countries would have performed in the absence of PEPFAR. Of course there is no way to go back in time and re-do history, but Eran Bendavid and Jay Bhattacharya in their 2009 paper use a difference-in-difference approach (as do Melissa and I) to evaluate the effect of PEPFAR on HIV outcomes such as HIV deaths, HIV prevalence, and the number of people living with HIV among African countries with an HIV epidemic. They find that while PEPFAR appears to have reduced deaths due to HIV/AIDS, HIV prevalence did not improve significantly in PEPFAR recipient countries when compared to non-recipient countries.

All told, the evidence on the effect of PEPFAR on both HIV and non-HIV health outcomes is mixed. Much more work needs to be done to determine why PEPFAR has been unable to reduce the prevalence of HIV, and the channels through which it negatively affects non-HIV related health outcomes such as child mortality and immunization rates.

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Is the AIDS industry hurting public health?

Is HIV/AIDS funding distorting health priorities in ways that actually harm efforts to improve public health? If so, how? These are questions I have wondered about for a long time. In 2008, the U.S. government spent $283 million dollars in Uganda on the HIV/AIDS sector via the President’s Emergency Plan for AIDS Relief (PEPFAR). In the same year, the Ugandan government spent approximately $180 million on the entire health sector. What impact does PEPFAR levels of donor funding for HIV/AIDS have on the recipient country’s health priorities? On the amount of money spent on other health issues? On the number of doctors that work in primary care?

Tapiwa Gomo of Newsday writes:
” … The UNAIDS projects that by 2015, the annual resource needs will reach $54-57 billion (a total of approximately $172 billion in three years) which could avert 2,6 million new infections and 1,3 million deaths. Still this is not enough to cater for the 33 million people living with the virus today.
As a result of the presence of such huge financial figures, the HIV and Aids industry has uncontrollably grown in size and budget, thanks to the generous donors who can finance anything or anyone as long as there is an HIV and Aids dimension in the proposals.
However, what concerns some experts is that the impact of this colossal and resource-guzzling industry is not parallelled by results on the ground, in addition to the damage it has caused on the public health sector especially in Third World countries...”

The article in full can be found here.

I only have speculative and anecdotal evidence pointing to negative side effects of gargantuan HIV funding, but I am currently working on a project that I hope will provide more quantitatively sound evidence. More on this as the project comes along.

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What do people care about?

I love knowledge for the sake of knowledge, but as I embark on this five-year journey otherwise known as grad school, one thing I don’t want to do is get stuck inside, both literally and figuratively. Literally, I don’t want to see the sky for only 20 minutes a day on the walk to and from the car, and figuratively (and more importantly), I don’t want to get stuck in a world where only other academics or econ-y types find my work interesting/palatable/intelligible. This has been on my mind a lot recently as I have been trying to home in on a specific research question for my first major research project/paper (which I will hereafter refer to as a field paper). I can think of lots of research questions, but certainly not all of equal pertinence to the lives of ordinary people. Which got me thinking, what would be of most pertinence? I am not a doctor, I am not a teacher (yet, anyway), I am not a civil engineer…there are many things I can’t do to improve people’s lives. So what can I do? Well, hopefully (and this is the goal anyway, I think), I will be able to provide some small insight or suggestion to help solve problems people care about.  So what do people care about?

Since Uganda is mostly on my mind, I remembered a recent Afrobarometer survey asked exactly this question. Ok, not exactly. The exact question was, “What are the most important problems facing this country that the government should address?” The answers? (according to % of people who listed this concern first)

Poverty/Destitution: 43%

Unemployment: 28%

Health: 27%

Food shortage: 20%

Infrastructure/Roads: 20%

Seems pretty obvious in retrospect. But what wasn’t in the top 5? Democracy/Political Rights (3%), Orphans (2%), Political Instability/Ethnic Tensions (2%), International War (0%), AIDS (5%), and Inequality (2%), among others. Less obvious now, right? This is not to say that no one cares about these things, just that they are not the most important things for most people. Of course these things are also related to the above “most important problems”, and it could be that democracy (or something else) will solve all of these problems (I am skeptical though). Still, I think it’s always good to keep in mind what people are struggling with on a daily basis even while trying to figure out what’s up with democratic peace (for example).

Now, back to that field paper…

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Why Don’t We Have a Global Fund for Maternal Health?

Well, cause someone would steal the money anyway. No? Ok, how about because the international community is preoccupied (is obsessed too strong a word?) by the much more exotic sounding tropical and infectious diseases (a virus that turns your insides to mush = exciting/terrifying, bleeding to death giving birth = boring). Not everyone gets Ebola or HIV or malaria, but most people either give birth or are the direct cause of someone else giving birth (and if nothing else, at least someone once gave birth to them). So maternal health is ordinary, banal, and just plain not-sexy. That is, unless it is tied to something exotic (see Prevention of Mother-to-Child Transmission of HIV — PMTCT)…

The wards described in the article of the Tanzanian hospital are not different from those in Uganda. In Mugalo Hospital, around 80 to 100 babies are delivered every day, and there are certainly not enough beds for all the mothers. One medical student working in the labour ward described to me how the “fluids” from one mother giving birth flowed into the ears of another mother who was sharing her mattress one night during his shift.

I don’t know what the solution is to the neglect of maternal health. In Uganda, maternal mortality statistics have barely budged in the past 20 years. The 2006 Uganda Demographic and Health Survey (depressingly) discusses the lack of improvement with regard to maternal mortality:

At first glance, it would appear that the maternal mortality ratio has declined significantly
over the last five years, from 527 maternal deaths per 100,000 live births for the ten-year period prior to the 1995 UDHS to 505 for the ten-year period before the 2000-01 UDHS, and to 435 for the ten- year period before the 2006 UDHS. However, the methodology used and the sample sizes implemented in these three surveys do not allow for precise estimates of maternal mortality. The sampling errors around each of the estimates are large and, consequently, the estimates are not significantly different; thus, it is impossible to say with confidence that maternal mortality has declined. Moreover, a decline in the maternal mortality ratio is not supported by the trends in related indicators, such as antenatal care coverage, delivery in health facilities, and medical assistance at delivery, all of which have increased only marginally over the last ten years.

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First do no harm. Ok, first do not-too-much harm…what? You don’t know how much you’re doing? Well in that case…

“…apart from questions over its investments, the Gates Foundation has received little external scrutiny. Last year, Devi Sridhar and Rajaie Batniji reported that the Foundation gave most of its grants to organisations in high-income countries. There was a heavy bias in its funding towards malaria and HIV/AIDS, with relatively little investment into tuberculosis, maternal and child health, and nutrition—with chronic diseases being entirely absent from its spending portfolio. In The Lancet today, David McCoy and colleagues extend these findings by evaluating the grants allocated by the Gates Foundation from 1998—2007. Their study shows even more robustly that the grants made by the Foundation do not reflect the burden of disease endured by those in deepest poverty. In an accompanying Comment, Robert Black and colleagues discuss the alarmingly poor correlation between the Foundation’s funding and childhood disease priorities.
The concern expressed to us by many scientists who have long worked in low-income settings is that important health programmes are being distorted by large grants from the Gates Foundation. For example, a focus on malaria in areas where other diseases cause more human harm creates damaging perverse incentives for politicians, policy makers, and health workers. In some countries, the valuable resources of the Foundation are being wasted and diverted from more urgent needs.”

Excerpt from 9 May 2009 Lancet editorial.

This is the same point I have tried to make with regard to HIV/AIDS funding in Uganda. But it is hard to tell/convince donors that their massive spending on HIV/AIDS may actually be hurting other healthcare programs (not to mention that the funding decisions are often made by those in Washington, etc who have no idea what is going on on the ground). The response of the program and project managers, of course, is that they believe they are helping more than hurting. There are at least two problems with this argument though. One, measuring how much one is helping or hurting a country/population/sector/etc is difficult, especially as unintended/unrecognized consequences abound (i.e. doctors migrating from cash-starved district health centers to donor-funded HIV clinics). Two, what happened to “first do no harm”? Should one even be involved if the consequences of one’s actions cause harm of unknown/unquantifiable amounts?

The good news is that the discussion regarding priorities/allocation of money within the health sector is emerging in policymaking circles — New Vision, for example, reports today that parliament has recommended sh36b earmarked to purchase anti-retrovirals (ARVs) be re-allocated to other pressing government programmes. (Although, reading through the article again, I am thoroughly confused as to what MPs are proposing…anyone have insight?)

Meanwhile, Easterly and Wronging Rights have an interesting (and related) discussion on aid and the Love Actually Test.

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No one cares about our nations more than we do

We appreciate support from the outside, but it should be support for what we intend to achieve ourselves. No one should pretend that they care about our nations more than we do; or assume that they know what is good for us better than we do ourselves. They should, in fact, respect us for wanting to decide our own fate.

Says Kagame in his op-ed last week in the Financial Times.

While I am concerned that certain individuals high up in the echelons of power actually care about themselves far more than their nations, I agree wholeheartedly with Kagame’s sentiment. Especially the bit about supporting a country’s own priorities, whether they be in health, education, infrastructure, etc., and not simply making up your own.

I wrote about donor distortions to Uganda’s health sector in this week’s Independent. I don’t think many U.S. taxpayers, for example, realise that they are contributing more to fighting HIV/AIDS in Uganda than the Ugandan government is contributing to Uganda’s health sector in its entirety. This is unacceptable on a number of levels. The current state of affairs is not the fault of only one party, but the donor/recipient relationship will never be equal and those involved should act/think accordingly, political correctness of “partnership” notwithstanding.

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Want a Condom? Think again in the land of ABC

Uganda has long been hailed for its success in fighting HIV/AIDS, bringing prevalence rates from a high of 20-30% (depending on estimates) to 6%, where it has remained for the past several years. The success was attributed, among other things, to the ABC campaign — abstinence, “be faithful” and condom use. Well, I’m not sure about either the abstinence or the being faithful bit (though a new effort is being pushed forward with the be red campaign), but condom use remains tricky around here.

New Vision ran a fascinating piece in their Sunday edition, sending out reporters around the city/country asking to buy a condom from various shops. Results were mixed, but in general most were ridiculed, laughed at, or looked down upon for their purchase, where they were able to make it. It seemed to me the women fared worse…The men’s accounts are here and here, the women’s here, here and here.

This combined with the not uncommon idea that using a condom during sex is like eating candy with the wrapper on…

In any case, for those who thought promoting condom use abroad would be as (relatively) easy as it has been in the U.S. (where you often have 12 year olds putting condoms on bananas during sex ed class) should seriously think again, even in countries that have been supposedly successful in the fight against HIV/AIDS….

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Condoms –> More AIDS

This is essentially what Pope Benedict XVI has suggested while on his current visit to Africa, where he will visit Cameroon and Angola. Regarding the HIV/AIDS epidemic, which has killed and affected millions, the vast majority living in sub-Saharan Africa, the Pope told reporters that it is “a tragedy that cannot be overcome by money alone, that cannot be overcome through the distribution of condoms, which even aggravates the problems.”

Criticism of condom use is an altogether unsurprising position from the Catholic church, which largely rejects the use of birth control. Nonetheless, the argument appears to have reached a new level, with the Pope actually suggesting that condoms are making the “problem” of HIV/AIDS worse. I disagree with the church’s position on condoms in general, though I recognize the valid point that condoms will not alone bring an end to the HIV/AIDS epidemic. Nonetheless, I find it incredibly irresponsible for such a powerful and influential leader to make a causal argument of this nature with little to no evidence to back it up. Millions of the devoted will be listening, and millions may thus come to the conclusion that condom use in and of itself may increase their chances of contracting HIV. This could obviously not be farther from the truth (if you are going to have sex anyway, wearing a condom will certainly not increase your chances of contracting HIV).

We can agree to disagree on ideology, but not on matters of scientific fact, especially when millions of lives are at stake. This kind of misinformation benefits no one.

For more thoughts on the subject, see the opinion by the Guardian‘s Ela Soyemi. Or yesterday’s NYT editorial. Or on Bill Easterly’s latest post.

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Who Cares About Cancer?

Cancer is not captivating. Or, at least, in sub-Saharan Africa it doesn’t seem to be when compared with, say HIV/AIDS or malaria. Why is that? Is it the sheer numbers? The assumption that you are more likely to die of a communicable disease before you will ever develop cancer in this region? Or maybe, like global warming, it’s a scary topic that it is easier to put off thinking about until tomorrow. Or the next day…Or the next day…

It seems like a lot of friends of friends are dying or have died from cancer recently in Kampala. On Sanyu FM this morning, a caller asked for advice on how to handle his relationship with a girl who had terminal cancer. While I have long been interested in health and healthcare in Uganda, I have never looked much into cancer prevalence or treatment. I assumed, at any rate, that treatment was prohibitively expensive for most people when available at all. But do we even have accurate figures on who has cancer and where? I went circles around the WHO Uganda site to find any figures. At best they have projections for 2005, based on 2002 burden of disease estimates. Not exactly what you might call up-to-date or very accurate.

I next went to Uganda’s most recent Demographic and Health Survey, from 2006. I was shocked to find that in searching “cancer”, there was a SINGLE result, out of 501 pages! It was a note on reproductive organ cancer made in reference to the Sexual and Reproductive Health Policy Guidelines that had been developed in 1994.

According to WHO’s stats, cervical cancer is the most common form of cancer in women, followed by breast cancer. In men, the most common is prostate cancer, followed by esophageal cancer. Lung cancer is surprisingly low on the list (9th for men, not even ranked for women), given the number of people I see smoking around Kampala (of course this is not indicative of the rest of the country, but still, Kampala-ites are more likely to be diagnosed anyway I would imagine).

Uganda does have a Cancer Institute, which is almost definitely underfunded, understaffed and ill-equipped, though I haven’t done much in-depth investigation of the place. While cancer may not yet be killing as many Ugandans as malaria or diarrheal disease (which primarily affects children), I have a strong suspicion that it is much more prevalent and pernicious than meets the eye. It may not be captivating, but it is killing. More on this to come…