health systems: finding new strength
The treatment initiative presents a tremendous challenge to the health systems of countries heavily burdened by HIV/AIDS. Ideally, those systems should function effectively, efficiently and serve the entire population. In most cases, however, they are poorly run, underfunded and sometimes barely able to function at all. This chapter examines what is necessary to strengthen them in order to implement the initiative, while also improving and expanding many other health interventions related to both communicable and chronic noncommunicable diseases. It shows that a major effort is urgently needed, requiring a massive increase in resource transfers from rich to poor countries.
Far from being a drain on resources, the 3 by 5 initiative has the potential to strengthen health systems in a number of ways. It can attract resources to the health system over and above those required for HIV/AIDS. It can spur investment in physical infrastructure, help develop procurement and distribution systems of generic products, and foster interaction with communities across a wide range of health interventions. Any possible adverse effects of the initiative on the wider health system must be anticipated so that they can be minimized.
Current levels of health expenditure in many poor countries are far below those needed to provide the bare minimum of services to their populations. In the years ahead, the financing gap will have to be filled largely by external donors. National governments and their economies are incapable of generating much more funding than they do already, while donors have still to live up to past collective undertakings.
The expansion of treatment should not divert resources and attention away from prevention and other forms of care. Indeed, the aim is for the initiative to become profoundly synergistic with those interventions (1) (see Chapter 2).
Antiretroviral therapy calls for a pattern of chronic care in which individual patients receive continuous follow-up treatment for the remainder of their lives, rather than the occasional acute interventions that characterize the response to most infectious diseases. If health systems can be strengthened to accommodate this new pattern, the management practices developed for antiretroviral therapy (appointment systems, integrated medical records, drug supply systems, and adherence support) can also be applied to the management of other common, chronic conditions such as diabetes and hypertension.
This chapter shows how both public and private providers within health systems have helped to combat HIV/AIDS in some developing countries. It then uses the conceptual framework of four principles of health systems - leadership, service delivery, resource provision and financing - to examine how health systems, and especially publicly funded systems, can be strengthened to implement the 3 by 5 initiative while continuing to improve and expand many other health interventions.