Professor J. Brunet-Jailly,
Director of Research at ORSTOM:
ORSTOM 04 BP 293 Abidjan 04 Côte d’Ivoire
Fax: 225 354015
I. The First Decade: AIDS -- a Ministry of Health Priority?
II. The First Decade: Activities
III. Care Provided for AIDS Patients under the Existing System
IV. The UNAIDS Initiative in Côte d’Ivoire
V. A Fundamentally Discriminatory Health Strategy
VI. What Conclusions Can be Drawn from a Consideration of the Initiative’s Effectiveness?
In this article we deal with two questions. The first can be stated as follows: To what extent are anti-AIDS measures consistent with other aspects of health strategy? The second relates to issues of equity: Are the choices revealed by an examination of the health strategy really ethical?
The two questions are interrelated, because -- resources being limited -- equity demands that all the measures adopted be equally cost-effective. We will therefore begin by examining the most obvious aspects of the problem, which show that the reasoning underlying the AIDS strategy is quite different, after which we will identify the various elements upon which a new approach could be based.
"From 1987 to 1992, direct and indirect contributions by the Ivorian Government to the PNLS (National Program for Control of AIDS) essentially consisted of paying the salaries of government employees assigned to the Program, together with the maintenance costs of the premises provided. Thus, it provided CFAF 11.4 million (US$22,800) in 1997 for the salaries of seven staff members in the Program.
"From 1993, the Government added a specific item to the General Operating Budget of the Ministry of Public Health. This was intended to cover expenditures on operating costs, IEC (information-education-communication) and prevention, training, publications, and support for NGOs and ministries. Although originally launched to support the AIDS and STD control program, the item was extended in 1995 to include the tuberculosis program." ([1] page 48.)
The funding increased from CFAF 60 million in 1993 to CFAF 450 million in 1995 (with the inclusion of antituberculosis activities), CFAF 650 million in 1996, and about CFAF 800 million in 1997. Its share of the Health Ministry’s General Operating Budget was 0.15% in 1993 (38 billion) and 1.25% in 1996 (52 billion) ([1] page 48).
In fact, this item was financed to a considerable degree by EDF. This Fund provided the entire amount of financing from 1993 to 1995, and more than half in 1996 (CFAF 350 million, out of the total CFAF 650 million -- [1] page 48). The total for this line item is not sufficient to finance large-scale activities. In 1996, the grant to the NGO Espoir-CI alone amounted to CFAF 100 million ([1] page 49).
Obviously, the total operating costs of CNTS (the National Blood Transfusion Center) could be added to the list of activities financed under this special line item, given that the Center was rehabilitated in 1990/91 because of the problem of blood safety. (The cost of rehabilitation -- CFAF 900 million -- was met by EDF; in 1996, EDF also financed the conversion of blood banks into blood deposits, the cost being CFAF 145 million.) Operating CNTS costs the Government about CFAF 650 million ([1] page 49).
To these expenditures by the Ministry of Health can be added the spending of other ministries that were invited to submit sectoral plans as part of the preparation of the Second Medium-Term AIDS Plan. Overall, their total for 1994/95 is equal to the amount shown in the "AIDS" line item of the Ministry of Health’s General Operating Budget ([1] page 50). The annual grand total for all ministries is about US$2.5 million, on paper, because the other ministries have been waiting for the Health Ministry to subsidize them, and therefore not all sectoral plans have been implemented ([1] page 51) !
In practice, therefore, the operating costs of the PNLS were financed by WHO from 1987 to 1995, and thereafter by UNAIDS. WHO’s contribution over the 1987-95 period totaled about US$4 million (an annual average of US$400,000, or CFAF 200 million). In 1996/97, UNAIDS will have provided US$200,000 (equivalent to CFAF 100 million) ([1] page 52).
AIDS-control activities have also been financed by donors. "The first substantial AIDS-control initiatives were implemented as part of the 1987/88 Short-Term Plan, and were mainly concerned with blood safety. The European Union (EDF) financed rehabilitation of CNTS (...), at least in the capital and two other large cities (i.e. the Bouaké and Korhogo Regional Blood Transfusion Centers), providing CFAF 900 million between 1989 and 1992, while the French Cooperation Agency financed technical assistance for CNTS, equipment for serological diagnosis, and a number of prevention and AIDS-awareness initiatives." ([1] page 52.)
An initial meeting for mobilizing donors was held on June 20 and 21, 1989. They were asked to finance the first Medium-Term Program, with each of them developing "projects managed on the basis of agreements entered into with the Government." ([1] page 44.)
"The main donors contributed US$13,833,000 over the 1993-95 period (US$4,611,000 per year) toward control of the HIV/AIDS epidemic" ([1] page 53), the annual figure being equivalent to CFAF 2.3 billion. In 1996, donors provided a total of US$9.8 million (CFAF 4.9 billion) for AIDS, STD, and tuberculosis programs ([1] page 47).
1994 saw the launching of the 1994-98 Strategic Plan, prepared in cooperation with the World Bank and UNAIDS, and immediately -- at the suggestion of the World Bank -- preparations began to be made for a National Health Development Plan (PNDS) for the 1996-2005 period.[1] Over its first three years, this latter Plan will cost CFAF 132 billion, with CFAF 13.6 billion (10.3%) devoted to AIDS, STDs, and tuberculosis (6.8% in 1997, 3.3% in 1998, and 3.5% in 1999). (See [1] page 57: The table contains at least one error; the share of total financing allocated to AIDS, STDs, and tuberculosis is not 12%, but only 10%.) In short, expenditures are tending to decline (except for the first year), and donors are still being called upon to provide most of the financing; more specifically, the figure for the Ivorian Government’s contribution (CFAF 51 billion over three years) is completely unrealistic.
To summarize, AIDS-control activities are now perfectly integrated into a strategy specifically designed for obtaining assistance. It could be claimed that the parties are simply acting as is to be expected: faced with donors who are looking for someone to give their money to, the beneficiaries hone the skills necessary for acquiring it. (The donors even organize courses to train them in preparing their applications!) Nevertheless, if all this is to have any real impact on public health, the projects for which assistance is requested must be properly designed and selected.
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