Health Alliance International (HAI), the organization I work for, started to get PEPFAR funding in 2004. And we have been working to integrate antiretroviral (ARV) treatment in the pre-existing network of public hospitals. This integration is making it possible to put AIDS therapies into the primary health system without having to resort to the vertical delivery system. Following the administrative province-wide logic of the public health system is very important. We want to strengthen existing health systems and avoid setting up duplicate labs and parallel services.

The term “structural adjustment” has not come up much in our discussions yet, but it is the dominant factor in why African health systems are so anemic. Structural adjustment is how neo-liberalism is operationalized on the ground: cutting government budgets, privatizing, opening borders for capital. For health systems, structural adjustment involves spending caps and hiring caps. IMF workers make sure that the health systems aren’t “exceeding their limits.” This is also true for education. “Poverty reduction strategy” is now the new euphemism for this operation.

I’d like to know more about Health Alliance International and its funding structures. How do you go about constructing the outcomes to show successes? One of the criticisms of vertical care is that it erases some kinds of outcomes. How do you manage these erasures?

I would like to use the opportunity to be skeptical. When I first arrived in Uganda in 1968, we had one of the only vehicles in the area, and we ended up running it as an ambulance. The system was miserable, and it’s still miserable. It still kills people, but it also saves people. I think you have to ask whether your basic premise here is tenable – the idea of trying to resurrect a national health system that was actually a fairly late colonial creation and that never really functioned to begin with. This is crucial because it leads to “What is global health?” and “What other approaches are possible?” Just because you buy into critiques of neoliberal policies and programs and the IMF, does not mean that you have to settle for what was there before. On the maps, there are health units, but you don’t even have roads. There is no infrastructure. How to get the system to work is not the point of all of this. The point is to get fewer sick people.

I’m wondering about how structural adjustment negates the possibility of creating and sustaining a middle class that would be positioned to institute some of these changes in care delivery that you mention. Being a nurse or a teacher is a profession that bridges the class spectrum. What does structural adjustment mean for the socio-economic profile of the nation? Is the whole economy structured in such a way that it only allows experts and dire poverty? How does this relate to health advocacy and social advocacy?

Also, with regard to the labs: They are a critical piece in making AIDS treatment work. I see in Botswana all the time that some of the labs are simply not fully functional. There is a tremendous difference between public labs and the Harvard lab or a CDC lab [U.S. Centers for Disease Control] – which facilitate some public programs. I wonder, at least in terms of the lab capacity, if people shouldn’t be allowed or even encouraged to build a separate system to produce really good, new technology.

On PEPFAR and the state. You might be overstating when you say that PEPFAR doesn’t have anything to do with the state. A lot of the drugs go through the state. And in different countries there are different political considerations. Take USAID in Haiti: It initially supported one hundred percent NGOs, and then dropped all of them, becoming one hundred percent support to the health ministry. The World Health Organization recently published a conceptual model of treating everyone and eradicating HIV and they are also developing a cost-based model. All of it is through the state. There is zero vision for the participation of community and nongovernmental organizations. I certainly agree philosophically that this is a state responsibility (from a human rights perspective, there are specific state obligations, and we don’t want to create unaccountable NGOs), but I do think that there has to be a discussion of the role of communities in holding states accountable. And within this, there has to be a discussion of donor accountability. Finally, the language of “lost to follow-up” is very interesting. People who are “lost” are sometimes dead, but sometimes they have moved due to seasonal migration. PEPFAR and other global donors often support ARV treatment in two countries side by side, but they don’t ensure that patients who spend time in both countries get treated in both.

What is the role of Brazil in the Mozambique AIDS treatment rollout? How do south-south collaborations and alliances matter and do they have any particular significance?

It’s important not only what the people who use the services think about government services vs. vertical services, but also what health workers think. Are they keen to have all the services go through the government?

Accountability is a huge issue with NGOs. Who are they accountable to? Their donors. We wrote an NGO code of conduct, arguing that they should be accountable to the countries in which they work. The on-the-ground system of accountability has to happen through the public sector, but that’s not how it’s structured now. It all comes down to African self determination. Brazil has been very important. Ironically, most Brazilians working in Mozambique are working for ICAP, the Columbia University project. In terms of constructing outcomes, PEPFAR comes with a prepackaged set of indicators that must be reported on. This is controversial because hunger and a myriad of other things are erased from the indicators. How do we handle those erasures? Everyone is very hungry.

As you write, ARVs make patients hungrier, but how does the rollout make the broad issue of food security more or less visible?

At our organization, we want to use HIV/AIDS funding to strengthen the broader system and to identify other problems. It is important to highlight how critical the problem of hunger is, and so we have been pushing for a food voucher system. This has raised the question. If everyone with HIV gets it, shouldn’t everyone with chronic disease get it, too? And everyone who suffers from hunger? But this is where you run up against structural adjustment constraints (such as no food subsidies). The idea of a right to food.

In response to Michael’s comments, what do we really want to do about health? There are obviously huge limitations. We’re just talking about biomedical care through a public health system, and that’s only a small piece of what improves health. But that expands out into the discussion of primary healthcare. How do you build this in reality, on the ground? In the end, especially in a place like Mozambique, which is so poor, you want to have some minimal provision of healthcare and you want that system to work well. The way that the millions of dollars in aid are funneled in is not working well. It’s better to use it through the public sector.