Op-Ed: Is global health industry too self-serving in the fight against AIDS?

Civil rights activists march in Durban, South Africa, Monday, July 18, 2016, at the start of the 21st World Aids Conference. U.N. Secretary-General Ban Ki-moon told reporters Monday that the gains the world has made against AIDS are "inadequate and fragile." He said more than half the people around the world infected with HIV, or 20 million people, still don't have access to treatment. (AP Photo)

By Scott Barnhart and Joanna Diallo, special to Humanosphere

Washington state’s global health community is a recognized leader in the fight against many diseases of poverty including HIV/AIDS.

No question about that. The question is whether our region’s leadership, the way we choose to fight the pandemic, is actually doing more for us than the people we claim to be helping.

At the closing ceremony of the International AIDs society Conference last July, South Africa’s Minister of Health Aaron Motsoaledi, said: “We must say no to complacency at this moment. There is no space for it.”

Complacency? What was Motsoaledi talking about, you may ask. Haven’t we achieved great progress in reducing deaths and disability from HIV/AIDS? Haven’t our scientists come up with life-saving drugs? Aren’t we spending tons of money trying to find an effective vaccine?

Yes, but at the same time we are not even close to reaching people in need of those life-saving drugs and treatments. Motsoaledi was talking about the fact that, of 36 million people infected with HIV, less than half (about 17 million) have reliable access to these life-saving treatment today and more than 2 million are newly infected every year.

These sobering numbers regarding the epidemic’s continued devastation of families and economies demand aggressive, expanded in-country service delivery and have led to a call by some for HIV funding aimed at addressing needs in the developing world to rise from $12 billion to $18 billion annually by 2020 (http://www.healthdata.org/policy-report/financing-global-health-2014-shifts-funding-mdg-era-closes) (http://www.unaids.org/en/resources/documents/2014/90-90-90).

At this rate, HIV funding alone will require more than 50 percent of development assistance dollars for health. This is arguably an unsustainable demand when other equally legitimate needs exist such as feeding the world’s 9 billion people by 2050, emerging diseases such as Zika, or massive refugee crises.

At the same time, a quick look at where the money actually goes to fight HIV today suggests that much if not most of it never reaches those most in need. Rather, much of the money we claim to be spending on the fight against HIV/AIDS in sub-Saharan Africa or elsewhere in the developing world appears to stay here at home, benefiting our own institutions and people.

Emphasis on global health development, in particular the fight against HIV/AIDS, has fueled a huge industry in wealthy nations in general and specifically in Washington state. We need to look at how much is actually spent in the countries of need and how much remains in the hands the large foundations, private firms, NGOs, faith-based organizations and universities that deliver development programs.

Often the amount allegedly spent on fighting the pandemic in poor countries that actually never leaves the donor nation can range be as high as 50 percent. In a 2015 report, the Washington Global Health Alliance showed the statewide economic impact of global health work in Washington state as more than $9 billion in business revenues including more than 12,000 global health sector jobs with average annual salaries $71,000. This represents an army of development workers flying half way across the globe to help implement programs.

Think of the impact if those 12,000 well-paying jobs were located in low-income countries. Think of what good could be accomplished if a greater proportion of that $9 billion was spent on improving health access in the poorest parts of sub-Saharan Africa.

A look at the tax filings of humanitarian nongovernmental organizations (NGOs) shows that some executive salaries exceed a half a million dollars (Guidestar Major NGO and Foundation IRS 990 Tax Filings). In addition, many NGOs, universities and U.S. development agencies such as USAID and CDC maintain large expatriate staffs in these countries where annual expenses per staff member can easily range from $250,000 per year to much higher. Further, the University of Washington charges up to 54 percent overhead on direct costs; when one includes the costs of the project team, often only half or less of the money is spent on in-country activities.

USAID, wishing to put more of its funding into projects run in and by people in the developing world, nearly met its modest goal of 30 percent of funds spent in-country. This was progress made in demonstrating that such an effort can be accomplished. Yet it still left the bulk of funds controlled by U.S.-based development organizations.

Is this a sensible way to approach development when funds are tight? We don’t think so.

This approach disrespects and ignores the capacity and resiliency of the people whom the programs are intended to serve. Unfortunately, there is little incentive by the United States and other wealthy nations’ to move away from this lucrative, self-serving model of development. Viewing development as an economic engine has created a dangerous conflict of interest that pits those who claim to want to help people against the people they say they want to help.

Despite a lot of lip-service by the development and humanitarian community to “capacity building,” there is a powerful incentive to not create strong civil society organizations and strong ministries of health.

Washington state’s global health community must recognize the enormous unequal power relationship between wealthy donor and economically poor recipient countries. We should become the leader of shifting control of development from wealthy to poor nations. This shift must include funding for development of in-country leadership, technical and administrative experts, and a robust civil society in resource-constrained nations.

Yes, there will always be a need for high-end expertise based in Washington State. But every dollar expended here should be judged as well to determine if it might be better spent elsewhere.

Key steps, which would need to be phased in over a decade, include:

  1. Large donors such as the U.S. government and foundations such as the Bill & Melinda Gates Foundation resolving to steadily ratchet up the percent of funds controlled by and spent in resource-constrained countries to reach 80 percent in-country funding over the next decade.
  2. Prioritizing investments in local development infrastructure as a path to sustained results rather than emphasizing short-term outcomes.
  3. Fostering a healthy, large-scale, civil society in low-income countries capable of managing funds and program implementation that meet international standards for technical, administrative and financial skills.
  4. Shifting wealthy nation NGOs from delivery of programs and services to capacitating local NGOs to deliver those programs and services.
  5. Ensuring ministries of health are strengthened to provide the essential public health functions.
  6. Developing strong accreditation programs for both civil society and ministries.
  7. Focusing universities’ efforts on building strong in-country universities.

Taking the long view of global health development and making these changes will continue to spur local economic development while meeting global health goals. It will ultimately benefit wealthy nations as a part of a stronger global economy. No more should we cite corruption or absence of skills in the developing-nation NGO and public sector to justify the current wealthy-nation-centric development model without seeking to first reinforce these sectors.

Weak civil society and weak ministries of health represent job security for the expatriate global health community. We must not be complacent in our own self-interest by allowing these institutions to remain weak, countries to stay poor and HIV funding to be insufficient to serve both masters. Washington state should take the lead to truly shift development to be an economic engine and driver for better health in low income countries.

Scott Barnhart, M.D., M.P.H., is a professor of medicine and global health, University of Washington, Seattle.

Joanna Diallo, B.A., is a senior program manager, department of global health, University of Washington, Seattle.


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  • Amy Hagopian

    Terrific essay, thank you Dr. Barnhart. The systematic disinvestment in Africa, after decades of colonial extraction, has left weak systems. Paying American consultants and professionals to supplement for those weaknesses is no solution.

  • Elvira Beracochea

    I agree with the seven recommendations above and with the fact that the global health industry is an industry and must be accountable for effective and sustainable results. Having good charitable intentions is not enough. Charity is a way of funding global health programs not of ignoring lack of progress and lack of sustainable results. Everyone working in global health must demonstrate sustainable results and progress. Every project implemented in a country must demonstrate it strengthens the country’s health system, including services provided by public, private, civil society providers or all of the above. In fact, the Paris Declaration on Aid Effectiveness set principles for the donor community and recipient countries in 2005. In fact, the Declaration on the Right to Development of 1986 had already brought up the responsibilities of donors and recipient countries. We need not reinvent the wheel, here. Instead, since 2015 we are now in an era of results, in fact, it is the era of sustainable results. I refer to actually having a global plan to achieve SDG3 in which all the major players have a clear role and are accountable for their share. As global health professionals, we cannot ignore the agreements and commitments of the past like we ignored the MDGs and Health for All by the year 2000. It is time to change how we work in global health and start achieving and accounting for measurable progress by country and by SDG3 targets in real time. We, global health professionals, have the knowledge and technology to do so. Will we also have the will of donors and international organizations to actually develop effective and sustainable countries’ health programs and services?

  • Lisa Cohen and Kristen Tetteh of the Washington Global Health Alliance respond:

    The authors of the 12/1/16 Op-Ed, “Is global health industry too self-serving in the fight against AIDS?” make some important points about funding and supporting local countries and NGOs, but their argument presents an unfair characterization of a study we produced.

    The Washington Global Health Landscape Study 2015 was used as “evidence” that global health organizations in Washington State are keeping jobs and money within our state instead of building capacity in-country. That’s simply not true and takes our findings out of context.

    While a portion of the study does demonstrate the economic impact of global health organizations in Washington State, the report also highlights our academic, NGO and research institute leaders’ priorities. They specifically point to, “the identification and training of in-country partners” as a key global health challenge and point to restrictive 3-5 year project cycles for grants which bias action toward short-term milestones instead of the harder, long-term work of building local capacity.
    The Op-Ed cites the more than 12,000 global health jobs based in Washington.

    But the study did not reflect the number of jobs the 168 global health organizations have created in-country. We didn’t study that. The economic portion of the Study was intended to educate domestic lawmakers and businesses in order to support investment in the state’s global health community — and it worked.

    An earlier version of this Study inspired the Washington state legislature to allocate $1 million to create a Washington Global Health Fund which invested in organizations like PRONTO International which develops and implements innovative training strategies that act as a catalyst for health care providers to make individual, team, and systems changes. PRONTO International’s in-country staff is comprised primarily of nationals to the country.

    The article also states global health organizations based in Washington have, “an army of development workers flying half way across the globe to help implement programs.” In fact, the greatest number of our organizations work in research and technology development (54% of Study respondents) which, we can all agree, have global implications. And research institutes like Fred Hutchinson Cancer Research Center and the Infectious Disease Research Institute are shifting some of their research staffing to in-country labs and clinics in Uganda and South Africa.

    The Op-Ed writers assert, “Washington state’s global health community must recognize the enormous unequal power relationship between wealthy donor and economically poor recipient countries. We should become the leader of shifting control of development from wealthy to poor nations.”

    Washington State’s global health leaders agree. It is misleading to imply otherwise.

  • yovobonsoir

    I have to say I was disappointed with this “op-ed”.

    I would expect more detail and context from someone(s) who are supposed to understand the inner workings of international development projects in general, and international global health programs specifically.

    I don’t think it is helpful to state that 50 percent of funds dedicated to combatting HIV/AIDS in developing countries “never leaves the donor nation”, without talking about what that 50 percent is paying for (research, medications, etc), if in fact that 50 percent figure is correct. There is no citation of an external source for that figure.

    The hyperbole of linking the number of “global health sector jobs” (12,000) to the statement – “an army of development workers flying half way across the globe to help implement programs” is unnecessary. Again, he is providing no context or perspective.

    While it is true that some NGO executives make a half million dollars or more per year, the vast majority make considerably less than that. But to the casual reader the half million dollar figure is now linked to all NGO executives. How is that helpful? Again, no context or perspective provided.

    It is true that USAID and CDC have expatriate staff that can cost $250K or more per year. It is also true that USAID has reduced its expatriate staff numbers by 75% in the last 25 years. It would be interesting to include that fact and probe as to why USAID did that and where that money went. Again – need context and perspective.

    Finally, his statement – “there is little incentive by the United States and other wealthy nations to move away from this lucrative, self-serving model of development” – indicates an ignorance of several current behaviors being exhibited by both public and private sector donors. They are: reduction in overhead/indirect rates (usually 50 – 75 % equivalent of historical rates), public sector donors increasing the percentage of development project funds going directly to host country governments, and ever more donors insisting that international NGOs develop and transition to locally-based NGOs.

    This “op-ed” neither represents the informed opinion of an international health professional nor takes the time and effort to truly educate those who are much less knowledgeable about the financial realities and historical perspective on international development and assistance work.

    It is an op-ed-tunity wasted.