Investing in change
With only a few exceptions, HIV/AIDS epidemics have hit hardest the countries whose health systems are least able to cope. Chronic underfunding and poor management largely explain their precarious position. Efforts to reform the public health sector have tended to focus on underfunding, centralized decision-making, and inefficient delivery of services. Responses have included the introduction of user fees, decentralization and contracting with the private sector. The limited successes - and frequent unintended adverse effects - of these reform initiatives have left public health providers in great need of capacity strengthening. Two broad strategies have been proposed: increased spending to overcome deficiencies of inputs and strengthen management systems; and the use of alternative delivery systems and health service providers from outside government (2).
New investments in capacity building, especially in human resources, need considerable time to mature. The alternative strategy of bypassing the public sector provider network offers the possibility of quicker benefits. This strategy has already been widely employed in a series of interventions, particularly in prevention efforts such as peer educator programmes, school education, social marketing of condoms, and mass media campaigns.
Most of the early experience with HIV/AIDS treatment in developing countries has been gained in private practice and in sites managed by nongovernmental organizations and research institutions, which are free of the bureaucracy and severe resource limitations that constrain the public system. Such providers have been prominent in demonstrating the feasibility of the treatment in resource-limited settings. However, scale-up will inevitably require a large number of treatment sites and therefore much larger participation by the public sector, which has the largest network of service delivery points. This is already apparent in many national plans, and it is inevitable that expanding treatment will entail the strengthening of public provider systems.
However, the treatment initiative will benefit from the experience of earlier disease programmes that have led to improved health system practice: collaboration between international, national and local authorities in the context of poliomyelitis eradication and SARS control; the value of monitoring systems based on outcome measures in the case of the DOTS strategy for tuberculosis control; and effective partnerships with parties outside government, also in the context of tuberculosis control. There are fewer examples of specific programmes enhancing the capacity to deliver other services, but improved disease surveillance and infection control measures for SARS (3) have wider application, and it has been possible to add the distribution of vitamin A supplements to polio eradication activities. There is little evidence that categorical programmes have undermined wider systems capacity. Synergistic benefits will occur if they are planned in advance and, equally, any adverse effects need to be anticipated so that their impact can be mitigated (4).
It is therefore important that treatment scale-up is designed not to undermine the capacity of health systems to reach broader health goals by, for example, avoiding disproportionate diversion of existing resources into antiretroviral therapy, or refraining from the use of incentives only for staff directly engaged in HIV programmes. While the public sector will be the largest single provider of antiretroviral therapy in future, various other providers have pioneered treatment delivery and will continue to have an expanding role. The following sections indicate their potential.