Global Health Reform: BOT Model for Private Institution Building

Interesting analysis in today's FT: Roger England, who is "founder and director of HLSP, a specialist healthcare consultancy, and is forming a new institute on health policy in developing countries" (and most likely looking for funding for his new institute or consulting fees, and not related to Gordon England) writes that "The world spends too much on the fight against Aids".

In 2004, 21 per cent of all health aid was allocated to HIV, up from 8 per cent in 2000, according to the Organisation for Economic Co-operation and Development. It could now easily exceed one-quarter of all health aid, and is the only disease to have its own United Nations agency, UNAIDS. Is this justified? In 2001, HIV/Aids represented 5 per cent of the burden of disease in low- and middle-income countries as measured by disability-adjusted life years lost, a measure combining reduced life expectancy and quality of life. This compares with 3 per cent each for tuberculosis and malaria and 6 per cent each for respiratory infections and perinatal conditions. Are HIV interventions so much more cost-effective to justify this disproportionate spending? Probably not.

Now, I have no clue as to whether a) the numbers are correct (but FT probably fact checks), or b) how the disability-adjusted life years lost are estimated and if they include e.g. the dynamic effects of slowly damaging diseases as opposed to faster killing ones. Given that these are ok -- and even if they're not, then the point just gets restricted to the general level -- this column is a fine example of fact-based argumentation, which is a) the necessary basis for any kind of prioritization, b) pretty wanting at least in the public political debates surrounding almost any subject. Bjorn Lomborg's Copenhagen Consensus conference was one example of such an attempt at estimating which bigger issues to tackle first.

In principle any IGO, any NGO, any GO, should not only deliver annual reports showing how much they spent on what. They should also publish a formalized, externally conducted "what if" review of the strategic choices represented in the annual reports that should include uncovering factual bases for these choices -- and spell out alternative possibilities and their bases.

England's concrete reform proposals are quite sweeping, and interesting for the specific case:

Two big changes are needed if the rich world's recent concern with the health of Africa is to achieve results. First, there must be country mechanisms integrating all health funding and allocating it where it will do most good, whether to state or non-state service providers. There have been attempts at this with so-called sector-wide approaches in which all donor and government funding is pooled and spent according to an agreed strategy. They have had some success but have been weakened by lack of co-operation by some donors and management by health ministries with vested interests. But they have potential. A small Caribbean island, Anguilla, is engaged in a bold programme in which healthcare is no longer provided directly by government. An independent national purchasing agency will receive all health funding, combining government revenues and social health insurance contributions, to procure care for the population by contracting the best value-for-money services available.

The second big change needed is in the structure of aid. Independent national purchasing agencies would impose some discipline on donors, many of whom over-fund HIV programmes because it is fashionable. But the role of key players is unclear and their structures deficient. Some 75 global funds and partnerships target single communicable diseases, creating massive co-ordination challenges at country level. Along with these, the UN runs Aids-related projects (using donor funds). Vast swaths of the UN's Aids-related bureaucracy could be abolished or privatised. However, there is no international agency capable of supporting health-sector restructuring. The World Bank could shift its focus but this would require a structural shift from project funding to strategic support. Rationalisation of the UN and international agencies is needed and must be led by the donors, for the agencies have no incentive to reform themselves. After Toronto, donors could make a start by questioning why we have UNAIDS, the agency promoting HIV as exceptional instead of just another disease, resulting in distorted funding and weakening health systems. [Emphasis added.]

Probably the WHO does not agree with England's second point. And probably focusing on strengthening non-state or directly private health care institutional infrastructure is not the way forward in countries where the state building is part of the larger solution.

But what if OECD organizations -- private companies, IGOs, NGOs -- are better at building efficient corporate institutions -- both free of corruption and infused with esprit de corps -- than the local states? Then maybe one way to improve third world health care systems could be the BOT-model (build-operate-transfer) used in traffic infrastructure? This especially given that the private enterprises -- or IGOs or NGOs or a mix -- build on, educate and retain local/domestic personnel for the operations.