The Lancet, Volume 373, Issue 9681, Page 2110, 20 June 2009
doi:10.1016/S0140-6736(09)61148-X Cite or Link Using DOI

Towards a global fund for the health MDGs?
Alvaro Bermejo a

Giorgio Cometto and colleagues (May 2, p 1500)1 propose an expanded remit for
the Global Fund in order to achieve all the health Millennium Development Goals
(MDGs). The International HIV/AIDS Alliance welcomes this new and innovative
thinking, particularly given the poor progress on maternal health and the fact
that the current financial crisis is expected to cause an additional 200 000—400
000 children to die before their fifth birthday. But this proposal also raises
serious concerns.

The efficiency of health systems is positively related to health expenditure per
head. Performance increases greatly with expenditure up to about US$80 per head
per year. There is a minimum level of health expenditure below which the system
simply cannot work well,2 and much of sub-Saharan Africa is well below these
levels.

Without the necessary additional funding, this proposition will just water down
the Global Fund's current ability to deliver effectively and make an impact. It
will reverse the gains made in HIV, tuberculosis, and malaria before they can be
consolidated.

The Global Fund has produced some spectacular results delivering funding for the
three diseases. More than 2 million people are on antiretroviral treatment, 4•6
million people are under treatment for tuberculosis, and 70 million bednets have
been distributed. However, the Global Fund currently faces a funding shortfall
of $4—5 billion.

Expanding its remit even further would require a very significant upfront
funding commitment if it is to deliver tangible results.
The Global Fund is a model of successful health financing that is delivering for
those most vulnerable to HIV, tuberculosis, and malaria. Jeopardising its
ability to do this well would be a tragedy for the millions who rely on its
support.

I declare that I have no conflicts of interest.

References
1 Cometto G, Ooms G, Starrs A, Zeitz P. A global fund for the health MDGs?.
Lancet 2009; 373: 1500-1502. Full Text | PDF(63KB) | CrossRef | PubMed
2 Evans DB, Tandon A, Murray CJ, Lauer JA. Comparative efficiency of national
health systems: cross national econometric analysis. BMJ 2001; 323: 307-310.
PubMed
a Executive Director, International HIV/AIDS Alliance, Hove BN3 1RE, UK
________________________


The Lancet, Volume 373, Issue 9681, Page 2111, 20 June 2009
<Previous Article|Next Article>
doi:10.1016/S0140-6736(09)61150-8 Cite or Link Using DOI

Towards a global fund for the health MDGs?
Jeffrey D Sachs a, Paul M Pronyk a

In line with Giorgio Cometto and colleagues' Comment,1 we suggest that the
Global Fund should open three additional funding windows.
First, a health systems window would finance training and salaries of community
health workers and other professionals, alongside construction, equipping, and
maintenance of primary health facilities.

Second, a maternal and child survival window would enhance facility-based
services for antenatal care, safe delivery (including emergency obstetric
interventions), and newborn care,2 and structural interventions to address major
causes of child mortality including diarrhoea, respiratory infections, and
undernutrition.3

Finally, a neglected tropical disease window would finance an integrated
delivery package to control soil-transmitted helminths, lymphatic filariasis,
schistosomiasis, onchocerciasis, and trachoma.4

The Comment, however, misrepresented the perspective of the Harvard Consensus
Statement, suggesting it assumed that Africa's health systems "were working
reasonable well". The dismal state of public health in Africa was in fact well
known. Expanding antiretroviral treatment was advocated because of the
possibility to stop mass deaths from a treatable disease. Furthermore, the
Commission on Macroeconomics and Health advocated a general scale-up of support
for primary health, including AIDS and other disorders.

The Commission called for donor support of 0•1% of donor gross national product
(roughly US$36 billion in current dollars).5 Actual donor aid lags at around
0•04% ($12 billion). We are not overspending on AIDS but underspending on the
rest.

These needed sums are paltry relative to military spending or the bank bailouts.
The Global Fund offers an effective financing mechanism. The choice is not
between AIDS, health systems, and other Millennium Development Goals. We can and
must support them all.
We declare that we have no conflicts of interest.

References
1 Cometto G, Ooms G, Starrs A, Zeitz P. A global fund for the health MDGs?.
Lancet 2009; 373: 1500-1502. Full Text | PDF(63KB) | CrossRef | PubMed
2 Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong PAS, Lawn JE. Continuum of
care for maternal, newborn, and child health: from slogan to service delivery.
Lancet 2007; 370: 1358-1369. Summary | Full Text | PDF(209KB) | CrossRef |
PubMed
3 Ekman B, Pathmanathan I, Liljestrand J. Integrating health interventions for
women, newborn babies, and children: a framework for action. Lancet 2008; 372:
990-1000. Summary | Full Text | PDF(239KB) | CrossRef | PubMed
4 Hotez P, Molyneux DH, Fenwick A, Savioli L, Takeuchi T. A Global Fund to fight
neglected tropical diseases: is the G8 Hokkaido Toyako 2008 Summit ready?. PloS
Neglect Trop Dis 2008; 2: e220. PubMed
5 Commission on Macroeconomics and Health. Macroeconomics and health: investing
in health for economic development. Geneva: World Health Organization, 2001.
a The Earth Institute, Columbia University, Broadway and 116th, New York, NY
10027, USA