Access for All?

Science  25 Jun 2004:
Vol. 304, Issue 5679, pp. 1875
DOI: 10.1126/science.304.5679.1875

When the 15th International AIDS Conference convenes on 11 July 2004 in Bangkok, Thailand, the prevalence of adult HIV infection in parts of sub- Saharan Africa will be over 30%: an unprecedented scale of human suffering. Yet this has been poorly understood in the rest of the world, simply because what happens there currently has a small impact on the global economy. How different will it be when the epidemic in populated Asian countries such as China, India, and Indonesia grows by “just” a few percent? It is not too late to avoid the disaster that is likely to follow, but prevention will depend on mobilization of the necessary forces.

Science has certainly delivered tools to do the job and to repair policy misunderstandings, but the few success stories of countries turning the tide have involved strong commitments and sound strategies, supported by the national leadership at the highest level. Thailand and Uganda are deservedly cited as worth emulating. Brazil, with its universal access to antiretroviral therapy, can claim to be the greatest success story of all so far; it provides a good example of what community mobilization and a strong civil society can accomplish. After all, the Brazilian government was reluctantly drawn in at first. Community will play an even larger role in the scale-up of treatment as its efforts extend beyond advocacy and HIV prevention efforts to the delivery of medical care.

The good news is that the scale-up has been spurred by new funding mechanisms such as the World Bank Multicountry AIDS Programme and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Antiretroviral drug prices have come down, and multiple organizations are providing technical assistance to the poorest countries. The World Health Organization (WHO) has also set the ambitious goal of providing drug therapy for 3 million people in resource-poor settings by the end of 2005.


Sadly, despite these positive developments, we are still very far from meeting the WHO target. We need to move beyond the rhetoric and traditional ways of working to achieve sustainable provision of adequate therapy for millions. One of the biggest problems is that many of the hardest-hit countries in sub-Saharan Africa are “failed states” in which the public sector is unable to offer basic health services to the masses. Multilateral institutions such as WHO can only work within the constraints of such poorly functioning systems, and therefore cannot be expected to take the lead. The current U.S. unilateralism does not help to mend the situation.

Donors and technical assistance agencies are falling over each other, often in clear competition, without addressing the essentials. One pivotal element in strengthening public-sector health care, often conveniently forgotten, is the need to motivate and retain skilled personnel through sufficient remuneration and attractive career prospects. Likewise, robust mechanisms for distributing drugs and medical supplies can be set up only if those involved are sufficiently rewarded. Why is it that we are always talking about the problem of drug distribution when there is virtually no place in Africa where one cannot get a cold beer or Coca Cola?

Introducing antiretroviral therapy in developing countries on an adequate scale requires a more solid partnership. A global network of relevant institutions and organizations will be required, with a clear division of tasks among them and clear accountability. That is what it took to eradicate smallpox, and addressing the HIV epidemic globally requires an organized mechanism that recognizes economic realities on the ground. People in both underdeveloped and developed countries need to make a decent living out of their activities, even if that activity involves laudable goals such as providing HIV therapy to millions. The principle of what works should prevail over what constitutes an ideal society. In the end, the scale-up of treatment in resource-poor countries and minimizing the impact of HIV in developed nations will only succeed and prevail if sustainable financing of comprehensive health care for the masses has been solved through the establishment of robust insurance schemes. Health care “access for all” means much more than just providing drugs. We have to look at comprehensive solutions. The naïvety lies with those who think we can settle for less.

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