Insufficient coordination of health-care resources in developing countries—not simply a shortage of funding—is the primary reason the incidence of HIV/AIDS is still so high, particularly in Africa, speakers told the fourth annual Stanford Conference on International Development on February 26. "It's true that we haven't had adequate resources to address this epidemic," said Debrework Zewdie, director of the Global AIDS/HIV Program at the World Bank. "But it is impossible to use resources effectively if we pull countries in too many different directions," she explained.

Improved coordination among donors at the country level is one of the most critical tasks that policymakers face, said Zewdie, the keynote speaker for the conference that addressed improving health care in developing countries.

Vidya Prakash, a global public health practice expert at McKinsey & Co, agreed with Zewdie. "Unprecedented levels of aid are flowing into health-care-related programs," she said. "On one hand, it's heartening; on the other hand, we wonder if we're setting ourselves up for failure." According to Prakash, securing funding from public and private sources is not sufficient to address the health-care needs of developing countries. Instead, policymakers must focus on increasing these countries' "absorption capacity"— their ability to distribute aid to those who need it the most. "Most of the aid from the World Bank and other agencies goes to the governments of developing countries, and it doesn't always trickle down," Prakash observed.

According to conference participants, distributing aid in the form of therapeutic drugs—rather than cash grants—is one way to avoid the administrative burden of allocating resources effectively. "This strategy is often more effective because you're almost immediately getting drugs in the hands of the people who need them," Prakash said.

Distributing aid in the form of therapeutic drugs—rather than cash grants—is one way to avoid the administrative burden of allocating resources effectively. This is not without risks, however. Some governments raise barriers to this type of aid by imposing duties and tariffs on donated drugs.

Pharmaceutical giants like Pfizer have put this strategy into practice, developing donation programs that provide patients in developing countries with access to potentially life-saving therapeutic drugs. Timothy Goodman, assistant director of global policy at Pfizer, explained the company's ongoing efforts to distribute Diflucan—used to treat esophageal candidiasis and cryptococcal meningitis, two AIDS-related infections—in countries where the virus is the most prevalent. "Since the program was launched in 2000, we've made Diflucan available to about 83,000 people in 23 countries," Goodman said. "Our goal is to continue to make the drug available—free of charge—to as many people as need it for as long as they need it," he explained.

Distributing drugs in lieu of monetary aid is not without risks, however. Goodman said some governments raise barriers to this type of aid by imposing duties and tariffs on donated drugs. Perhaps more significantly, many countries whose need for this type of assistance is the most urgent do not have sufficient health-care resources to provide treatment safely and effectively. According to Goodman, drug donation programs such as Pfizer's are "useless or even harmful without well-functioning health systems."

Dr. Jack Higgins, president and medical director of the HouseCall Foundation, called for taking a holistic approach to improving access to health care in developing countries. "You can't just drop drugs in Nairobi," Higgins said, stressing the need to understand the underlying social factors that affect the success of any health-care intervention. "You have to know what's there: what belief system is there, how they think about health care."

To develop a sufficiently comprehensive understanding of countries and communities in need, panelists called for working within the communities themselves, interacting directly with patients to understand their most pressing needs. Ophelia Dahl, president and executive director of Partners in Health, a nonprofit health organization, explained how this approach shaped her organization's work in Haiti in the early 1980s. "In Haiti, we asked patients to tell us what they needed, what was ailing them," Dahl said. "Patients with infectious diseases had a difficult time actually getting to clinics that could provide them with the treatment that they needed. So we worked on providing a community health-care model. As soon as we started sending community health workers out into the communities—rather than asking patients to travel to the clinic—the situation improved dramatically," Dahl explained.

Limited training and low pay for qualified health workers in many developing countries means that countries experiencing the highest incidence of infectious disease often have the lowest number of health-care workers per capita.

Panelists agreed, however, that community health workers—like all health-care personnel—are in short supply in developing countries, presenting one of the most significant challenges to distributing resources effectively. Limited training and low pay for qualified health workers in many developing countries means that countries experiencing the highest incidence of infectious disease often have the lowest number of health-care workers per capita. "This is an epidemic that could be dealt with if we had the right resources in the right places," said Zewdie, referring to the HIV/AIDS epidemic specifically.

Higgins said this type of "brain drain" is hitting developing countries particularly hard. Today there are more Malawian nurses in London than there are in Malawi. Higgins described the severity of the health-care worker shortage in many sub-Saharan African countries. To address such shortages, Higgins founded the HouseCall Foundation to eliminate the geographic, economic, and cultural barriers to health-care access through telemedicine technology. "It occurred to me that perhaps distance doesn't have to be that much of a barrier if you can use technology to fill that gap," Higgins said. "I wanted to create a mechanism where people in developed countries could volunteer their time and expertise to treat disease all over the world," he explained.

"If you look at the life expectancy of the average person in Zambia versus the average person in the U.S., we have two lives for every life that a person in Zambia has. It behooves us to spend at least one of our two lives working on interesting and important problems."

Like Higgins, many other panelists described the ways that their organizations use innovative thinking to improve access to health care in developing countries. Dr. Vikram Kumar, president and CEO of Dimagi, explained how his 3-year-old start-up company developed software allowing health-care workers in South Africa to report HIV test results to patients confidentially. "People didn't want to get tested for HIV because they were afraid that their results would be made public," Kumar said, describing a common obstacle to effective diagnosis and treatment of infectious disease in developing countries. "With the right technology, we can provide a rapid, low-cost, and completely confidential diagnostic," he said.

For Kumar, the opportunity to apply innovative, creative thinking to issues of such global importance was uniquely compelling. When a student in the audience asked about the professional opportunities available to those interested in health-care policy development, Kumar's response reflected not only his own professional passions but the human scope of the health-care access issues he works to confront on a daily basis. "If you look at the life expectancy of the average person in Zambia versus the average person in the U.S., we have two lives for every life that a person in Zambia has," Kumar said. "It behooves us to spend at least one of our two lives working on interesting and important problems."




Contributed by Lisa Vollmer, Stanford Graduate School of Business. Reprinted with permission from Stanford Graduate School of Business.

To read another Global Envision article about much needed drug distribution, see Brazil Reaches AIDS Drug Deal With Abbott.



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