Gorik Ooms Institute of Tropical Medicine Antwerp, Belgium Strengthening Health Systems through the AIDS response: Report from the ‘Antwerp in Geneva’ workshop Gorik Ooms Institute of Tropical Medicine Antwerp, Belgium

‘Antwerp in Geneva’ workshop Organised by the Institute of Tropical Medicine (Antwerp, Belgium), hosted by the WHO, as a pre-meeting to the first expert consultation on ‘Positive Synergies’ Objective: To review the evidence of the effects of the AIDS response on health systems and services, particularly in high prevalence countries, and to discuss the way forward Participants: Research institutions, representatives of Ministries of Health, NGOs involved in the implementation of AIDS responses – trying to bring ‘two tribes’ together (under Chatham House rule)

Findings on funding International funding for AIDS responses has increased sharply, but has not decreased international funding for health sector development, on the contrary

Findings on funding However, there are indications that international funding (for disease-specific interventions) is crowding out domestic health financing (for general recurrent health expenditure) in some countries, probably because of health expenditure ceilings imposed by the International Monetary Fund This is a cause for alarm, but we should be careful about blaming those who deserve the blame

Findings on implementation AIDS responses contribute to increased investment in all the building blocks of health systems (health workforce, participation of communities in the provision of health services, supply systems, lab facilities, information systems,…)

Findings on implementation However, there are countries where this increased investment has been devoted exclusively to disease-specific outcomes: A missed opportunity, as potential positive spill-over effects for other health services have not been fully realised (yet); Other health services might have been weakened, as increased disease-specific investments are using the building blocks of the health system (Is the AIDS response not allowed to use the health system? It is the health system of people living with AIDS as well!)

Factors that make the difference between positive and negative synergies The health workforce crisis is the critical factor: wherever the AIDS response strengthens the health workforce, the spill-over effect for other health services is positive; wherever the AIDS response is using the present (and insufficient) health workforce without strengthening it, the impact on other health services seems to be negative National strategies make the difference: if they aim at using AIDS funding to strengthen the health workforce, Global Fund and PEPFAR grants can be used to strengthen the health workforce (there seem to be a lot of misconceptions about this)

The way forward The global AIDS response has created renewed momentum for what is fundamentally a shared and uniting paradigm of comprehensive primary healthcare (including AIDS prevention and treatment): no more selective primary healthcare! Comprehensive primary healthcare indeed brings the ‘two tribes’ together…

The way forward There are lessons from the fight against AIDS that can and should be applied in the fight for comprehensive primary healthcare: Health is a human right, and healthcare is an entitlement Programming and financing of healthcare should be adapted to needs, not to the alleged scarcity of resources Concerns about sustainability should be considered at a global level, not at a national level Macroeconomic policies must be adjusted to vital needs People have a right and a duty to be involved in decisions about their health

The way forward We are living in a world where the average economic product is about US$ 7,500 per person per year; the global economy could easily afford to spend US$ 300 per person per year on health (4%) In some countries, the government health budget is still less than US$ 15 per person per year The fight against AIDS created some kind of ‘Copernican revolution’ in health economy – if AIDS treatment is too expensive for low-income economies, it surely isn’t for the global economy: can we use this new perspective for comprehensive primary healthcare?

The way backward… Quote from a recent discussion about health sector salary reform in Mozambique: “Sustainability is an important issue in the sense that in the longer run the national economy should be able to pay for the increased level of salaries.” Why should it be the national economy, why can’t we rely on national and international funding? If health is a human right, there is a duty for all human beings to contribute to it, beyond borders!

The way forward Governments must live up to their promises: governments of high-income countries must allocate the equivalent of 0.7% of their Gross Domestic Product (GDP) to international solidarity (permanently), and 15% of that to international solidarity in health This would result in US$ 37 billion per year, for international solidarity in health

The way forward Governments must live up to their promises: governments of low-income countries and middle-income countries must increase government revenue, and allocate 15% of government revenue to health expenditure And let’s hope they won’t need as much time as high-income countries seem to need to live up to their promise

…when two tribes go to war (together) Comprehensive primary healthcare for all, including universal access to AIDS prevention and treatment, is possible, even in the poorest countries, within the new paradigm created by the fight against AIDS… …when two tribes go to war (together)