At the end of 2022 what are the big health sector issues left over and going forward?
Alan WhitesideArticle Type:
Article Number: 3
A retrospective to enable us to look forward to 2023
ABSTRACT Alan Whiteside discusses the two big issues in the health sector which, in his opinion, remain unresolved as we leave 2022 and go into 2023.
This will be my last commentary for a while. For these pieces to be interesting and relevant, I need to know what is going on, and what is important. For the next six weeks I will not be scanning the news, and so it is unlikely that I will have much worthwhile to say.
In this commentary I’m going to focus on two things that really trouble me, but which are somewhat niche areas of interest. The first is data, how we get it and how we use it. The second is how we should respond to dysfunctional and/or oppressive governments. There are no easy answers to these conundra.
I recently had the good fortune to attend a one-day training given by a British-based charity Full Fact. They are a self-described team of independent fact checkers and campaigners who find, expose and counter harmful bad data, because “bad information promotes hate, damages people’s health, and hurts democracy”.
The course was intense but limited. We were taught how to manipulate data sets and, effectively, make them sing and dance. I would recommend this group and their training to anyone. However, for people working in public health it does not go far enough. Where do the data come from? How reliable are they? What are the biases and the politics? As Louis Pasteur said, “the pathogen is nothing, the terrain is everything”.
In the early years of the AIDS pandemic the only data available were the number of AIDS cases (in the tens, hundreds and thousands at the time). With the advent of testing, it became possible to assess the levels of infection. Initially this was HIV prevalence (the number of infections in a population) and later incidence (the number of new infections over a given period of time).
Even then these data were political. The first and most egregious example I came across was the politicization of data in Zimbabwe. In 1987 the government reported, to the WHO’s Global Programme on AIDS in Geneva, that they had several hundred AIDS cases. A few weeks later the South African authorities, still the odious apartheid government, reported 120 cases. Within days Zimbabwe announced they had made a mistake, and, in fact, there were only 119 AIDS cases in the country. We reported this in a newsletter AIDS Analysis Africa: Southern Africa (Vol 1, No 1 6 June/July 1990 page 6). Currently data debates and politicization are seen in the COVID pandemic. For example, how many cases are there in China? Who is concealing the information and why?
As we have seen funding for HIV and AIDS stagnate and decline, many have looked for new ways to maintain global attention on this pandemic and keep resources flowing. This includes talking up the data. Is this the right thing to do? I am always disturbed by the fact that, at the replenishments, the Global Fund gives a big number for the amount of money that will enable the pandemic to be halted and reversed. If this target is not reached does this imply a failure? Clearly not because the same thing happens from replenishment to replenishment.
The Seventh Replenishment was pushed as: “the world’s opportunity to rise to the challenge and take bold action to protect everyone, everywhere from the deadliest infectious diseases” the goal was to raise at least $18 billion. The Global Fund said it was the minimum to get the world back on track toward ending HIV, TB and malaria. The replenishment said that from 2024 to 2026 the world needs a total of $130.2 billion, of which $18.6 billion is projected to come from the Global Fund, $25.2 from other funders, and $58.6 billion from domestic sources. The gap in funding is estimated at $24.4 billion. At the time of writing, pledges stand at S15,668,980. It seems unlikely that the goal will be met: so what does that mean?
The context at the end of 2022 is a faltering global economy and changing political landscape. For example, Sweden was a leader in setting the agenda for funding for HIV and AIDS. Indeed, the International AIDS Society was originally headquartered in Stockholm. The recent change of Government saw the new Prime Minister announce a reduction in the country’s international aid by 7.3 billion kronor ($673 million) in 2023, and another 2.2 billion kronor in 2024. This is a 15% reduction from what had had been planned. The target of 1% of gross national income in overseas development assistance (ODA) has been abandoned and Sweden, the eighth-biggest international aid donor in terms of absolute value, will slide down the table.
Fortunately, the world’s biggest donor, the United States, actually increased its international funding from $35.182 million to $40.485 million. However, this is dependent on the political situation in Congress, and the results of the next presidential election. In addition, the US is committed to supporting Ukraine. In November 2022, an additional $4.5 billion in assistance was announced. The US has committed $13 billion in assistance to the Ukrainian Government since February 2022. There are not infinite resources and something may have to give.
Here I will use the example of Eswatini. I grew up in Swaziland, (now Eswatini), in the 1960s and 1970s. There was great excitement when the country gained independence in 1968. In 1975 I left to study and have not lived there since. It is, however, very close to my heart. I joined the University of Natal in 1983 and built many professional links with the country. In 1992 we prepared the first report on the ‘Socio-Economic Impact of AIDS’ for the Government. I subsequently worked closely with the Government producing many other reports and documents.
I have watched as over the past few years, the levels of protest and violence in the country have grown in number and the State response is increasingly violent. There are frequent national strikes and protests. This is barely reported in the national, South African and international media. There is one independent outlet reporting from South Africa. It chronicles increasing (and increasingly violent) repression. On 30 November there was an unheard-of attack on a military camp.
This is the country with the highest level of HIV prevalence in the world. In 2019, the last year for which there were data, the adult prevalence levels stood at 27.1 % (next highest is Lesotho at 23.1 %).
Eswatini had one of the best national responses globally. The Ministry of Health set up the Swaziland National AIDS Programme (SNAP) early in the epidemic. As AIDS was seen as a crisis, in 2001 ‘The National Emergency Response Council on HIV and AIDS (NERCHA)’, a government parastatal, was established by Parliament. It is charged with providing leadership in the multi-sectoral emergency response to HIV and AIDS in Eswatini. This experience lead to a quick and informed response to COVID, with ‘The Economic Situation Report #1—COVID-19’ produced on 30 March 2020 and an economic recovery plan in 2021. However, this is at risk due to the political and economic situation.
In our work on HIV in the 1990s and early 2000s we wondered about the links between the HIV epidemic and political stability (Whiteside, A., A. de Waal and T. Gebre-Tensae. 2006. ‘AIDS, security and the military in Africa: A sober appraisal’. African Affairs 105 (419): 201–18. And Mattes, R., & Manning, R. (2004). ‘The Impact of HIV/AIDS on Democracy in Southern Africa: What We Know, What We Need to Know and Why?’ In N. Poku, & A. Whiteside (Eds.), The Political Economy of AIDS in Africa (pp. 191-214). Most of this was purely speculative, although we drew on the data from the Afro-Barometer. It is probable that it took time for the impact to develop and be measured and analyzed. AIDS is, I believe, a contributor to the political crisis.
And in conclusion
The data issues are not new, what is new though is the increased quantity of information and ability to analyze it. Sadly, this is creating ever more ‘noise’ and sorting the information is complex. There need to be more organizations like Full Fact and we at Aidspan. We all need to work out how to better communicate our findings, especially in the face of ‘alternative facts’.
The politics of the pandemic and its responses are becoming increasingly important. The days of AIDS being the primary public health issue are over. The reality is that the three diseases, and now pandemic preparedness and health system strengthening, funded by the Global Fund are competing for resources. They are also competing with other health challenges and the consequences of COVID. What is the right mix between prevention and treatment? Where do AIDS, TB and Malaria fit into the priorities of the Ministries of Health and donor agencies, where does health fit in government priorities? These questions are not new but answering them is more urgent than ever. There is a need for a ‘deeper dive’, but who will do it and who will fund it?
And finally, Alan Paton’s famous book ‘Cry, beloved county,’ published in 1948, was set in Natal. It is how I feel as I look at the unfolding crisis in Swaziland. I am filled with admiration for the Government and NGO workers who battle to deliver services. They deserve our support, the kleptocratic regime does not. There is the conundrum.
* Professor Alan Whiteside, OBE, is an Aidspan Board member.