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March 14, 2005
Scenes Behind the Scenes
A doctor holds a flow chart in front of me. It's nothing medical; it's the structure of Mozambique's Ministry of Health. It's a head and shoulders of little boxes with lines between them. Here's how it works.
If you're a woman who comes into a maternal health center in Mozambique, you can get tested for HIV. (Unlike for example a syphilis test, because of the stigma around AIDS, testing remains voluntary, not compulsory.) How many then make it to the next step of getting their levels checked so they can see whether they're sick enough to take antiretroviral drugs? "Not many," says the doctor with the chart. "How many sick people in regular hospital get an HIV test?" he asks. "They'd have to be physically taken to day hospitals."
The day hospital seems to be a term, if not a concept, unique to Mozambique. It's a facility designed to handle all facets of AIDS treatment - doctor visits, dispensing of drugs and so on. (Prevention is a separate story.) Day hospitals and the massive drug program that Mozambique is rolling out belong to an office called the Department of Medical Assistance, one arm of the ministry. The government's AIDS program, however, is in the Department of Epidemiology - a completely separate arm. You start to get the idea about how the ministry coordination that everyone praises in Maputo can break down in the field.
It's Epidemiology that handles tuberculosis, for example. That seems to make sense. But AIDS and TB often go hand in hand - many AIDS patients actually die of TB. Since the day hospitals are separate, a patient admitted to the hospital for TB may not get tested for HIV. Epidemiology doesn't have a monopoly on infectious diseases. The Community Health Department oversees maternal care and, by extension, programs designed to prevent mothers from passing HIV to their children.
External funding reinforces the divide. Money from the Global Fund goes to Epidemiology, while some World Bank and U.S. money goes to yet another department, Farmacia, where it is used to buy drugs. In fact, outside funding is one of the causes of the problem. If a donor or non-governmental organization comes in with a particular goal to solve a particular problem - eliminating cholera in an area, for example - it makes sense to tunnel in with that money and achieve the goal. "All evaluations suggest vertical programs get specific things done better," a public health worker told me. So the ministry adds limbs as it tries to deal with many problems, and help from many donors.
The ministry in is the process of implementing a five-year plan whose goal is to raise all of its boats on the tide of money to fight AIDS. Ministers, doctors and donors worked together on the plan, but at least two big obstacles await. First, last December's elections put a new health minister in office. His attitude toward the plan is positive, but his actions, including the firing of three key regional officials, have been tepid.
The other obstacle is the United States. With a promise to bring in about $48 million this year to fight AIDS, it's the 800-pound gorilla. While the U.S. consults with the government and other donors, most of its money goes directly to non-governmental groups. How do you make that part of a national health system? Particularly when U.S. policy on discussing condoms with youth, for example, is at odds with the government's? There is a fear that the U.S. is building itself another massive limb on the ministry. "I'll be leaving if it is," my doctor says.
Posted by Adam Graham-Silverman at March 14, 2005 05:30 PM
Comments
Wow, this is all great stuff.
Posted by: Pam at March 17, 2005 09:58 AM
Yeah, ditto, yo.
Posted by: JW at March 19, 2005 04:30 AM