International Development CommitteeWritten evidence submitted by Dr Patricia Nkansah-Asamoah
Submission to the International Development Select Committee One-off Evidence Session on the Global Fund to Fight AIDS, TB and Malaria
My experiences with the Global Fund started with the implementation of policies and services in the Prevention of Mother to Child Transmission of HIV in 2002 in a 200 bed hospital in Tema General Hospital (TGH) in Ghana. The planning and execution of an HIV service for pregnant women at that time has resulted in a structured and well tested programme. All pregnant mothers attending antenatal care in this hospital are offered HIV counselling and testing as part of routine care and more than 95% of them accept this service. Those identified to be positive are treated with medication to reduce the transmission of HIV to infants and enrolled into care.
This paved the way for the hospital to be accredited for comprehensive HIV services in 2006, comprising of educational and preventive as well as curative services. I managed the TGH out-patient HIV clinic with more than 3,000 clients, a workforce of about twenty including doctors, medical assistants, nurses, counsellors, pharmacists, and laboratory and data managers.
Tuberculosis was found to be the leading cause of death among people living with HIV in developing countries. Almost 25% of deaths among people with HIV are due to TB. In 2010 there were an estimated 1.1 million new cases of HIV-positive new TB cases, 82% of whom were living in Africa (WHO 2012). Ways to actively screen HIV positive persons for TB resulted in a screening tool designed with input from my HIV clinic and adopted by the National TB Programme of Ghana. Initiation, implementation and scale up of TB/HIV collaborative activities were funded by the Global Fund—resulting in TB patients being tested for HIV and HIV patients being screened for TB. Early diagnosis and free treatment for TB has resulted in improved health outcomes among TB/HIV patients.
However, at the end of 2011 the Global Fund announced that it would not be able to fund new projects until 2014 because of funding gaps.
The UK’s Aid Objectives and the Global Fund
Some of DFID’s developmental objectives from the Bilateral and Multilateral Aid Review were outlined by the Secretary of State for International Development in a statement he read a year ago.
We will dramatically increase our focus on tackling ill health and killer diseases in poor countries, with a particular effort on immunization, malaria, maternal and newborn health, extending choice to women and girls over when and whether they have children; and polio eradication.
We will do more to tackle malnutrition which stunts children’s development and destroys their life chances; and do more to get children—particularly girls—into school.
We will put wealth-creation at the heart of our efforts, with far more emphasis on giving poor people property rights and encouraging investment and trade in the poorest countries.
The Global Fund’s Financing Gap
The prospect of DFID achieving these objectives would not be possible with current funding gaps at the Global Fund. Interwoven with the objective of dramatically increasing maternal and newborn health, tacking malnutrition in children and wealth creation for the poor, are interventions to prevent HIV transmission from mother to child (PMTCT) and treatment of Persons Living with HIV (PLHIV) with medication. Children born with HIV are more prone to diseases, are more likely to present with malnutrition, failure to thrive, stunting and even death. PLHIV and AIDS who are not on treatment are among the poorest in the world. They get sick more often, spend huge sums of money on treatment and usually at the time of diagnosis are unable to work to look after their families and themselves. The gains made in the fight against HIV would be reversed.
Tuberculosis is interlinked with HIV. Reduced immunity makes people prone to all forms of diseases. Tuberculosis is the main cause death among persons with HIV/AIDS in developing countries. Free diagnosis and treatment of tuberculosis reduces death in PLHIV. In malaria endemic areas, HIV transmission from mother to child is enhanced when mothers are infected with malaria which affects the placenta and facilitates transmission.
High levels of community HIV counselling, and testing which promotes behaviour change for persons either HIV positive and negative, cannot be promoted. Few people want to know their HIV status if nothing can be done in terms of treatment. Few people would access treatment early; patients would come in bedridden, very sick and dying. This is demotivating for health care workers and its effects spill-over to other areas of care. The same doctors attending to HIV cases see other medical conditions as well. When one is constantly confronted with a helpless situation, there could be depression.
Further delays in funding and approval of new grants means newly diagnosed patients cannot be treated. The anxiety of waiting, the constant fear of death and the increase in opportunistic infection would make these patients even poorer than they already are—defeating the objective of putting wealth-creation at the heart of DFID’s efforts. There is an increase in hospitalizations and frequent hospital visits, increased work load for Health Care Workers (HCW), decreased quality of care and increased workplace stress for HCW. Workplace stress is influenced by nature of work, work environment, volume of work and staffing levels. In such circumstances the volume of work increases (frequent hospital visits), the nature of work is depressing (constant death and a feeling of helplessness), and the work environment diminishes (crowded because of repeated hospital visits and hospitalization). Very few HCWs want to work in such depressing situations for a long time. High staff turnover for all HIV related programmes would be expected. Experienced staff finding more challenging jobs would leave. Hospitals seeing PLHIV will turn into hospices.
In treatment acceleration for Persons Living with HIV, developing countries have demonstrated commitment and resourcefulness in the administration of HIV drugs. The complications which were feared with the introduction of these drugs are not even considered now. What was hitherto considered impossible is now common place and it is as if it was never an issue.
The Global Fund to Fight AIDS, Tuberculosis and Malaria has strengthened health systems in developing countries. Laboratory equipment for AIDS/TB/Malaria is used for the diagnosis and monitoring of other infectious and chronic diseases. Training of health care workers provides other non-tangible benefits like team building, leadership skills, and communication skills.
What the UK can do?
The Secretary of State for International Development stated organisations that have been assessed as providing very good value for the British taxpayer in the aid reviews will have increase funding, because they have a proven track record of delivering excellent results for poor people. If UK now steps up and delivers new financing for the Global Fund it could influence other donors to undertake similar funding commitments.
May 2012