WHO's numbers don't add up

Roger Bate | 24 May 2005
Business Day (South Africa)

THE 58th Annual World Health Assembly began last week in Geneva, the headquarters of the World Health Organisation (WHO). The killers of malaria and HIV/AIDS, and the fact that half the world does not have access to essential medicines, should not just be on the agenda, but should dominate it.

But the WHO is a bit sensitive about these issues because its efforts are falling short. The Roll Back Malaria campaign, which aimed at halving incidence of the disease in 12 years, is halfway through and has overseen an increase of 10% or more. The campaign to get 3-million on HIV antiretrovirals by the end of this year looks to be falling short by about 75%.

Despite reductions in the price of essential drugs and medical products, developing nations are still placing significant tariffs on these life-saving products — even those that have been donated. Our analysis shows that if these tariffs were removed, tens of millions of the poorest people in countries such as Nigeria, India and Tanzania would probably have access to medicines and other products that could save their lives.

However, with the imminent failure of its HIV/AIDS treatment programme, the WHO is getting busy with its exit strategy. The snappily named 3 by 5 campaign was always ambitious, especially since the WHO does not do health care itself. It meant getting other agencies and countries to ramp up their efforts, with advice, encouragement, some funding and, it seems, hectoring, from the WHO.

SA is feeling the pressure, perhaps because of its past views on antiretrovirals. Now, though, state facilities are treating more than 40000 HIV patients, most in a responsible and sustainable manner. However, it seems the WHO was expecting more; 750000 more, in fact, and by the end of the year. Not unreasonably, Health Minister Manto Tshabalala-Msimang is protesting. "It's not about chasing numbers, it's about the quality of health care we provide for our people," she says.

A recent issue of The Lancet blamed lack of political will in SA, Nigeria and India for the failure of 3 by 5, since only 720000 people were on antiretrovirals in the developing world in December last year, and only about 8% of the 4-million Africans targeted were being treated.

I've been looking at the problems of HIV treatment in Africa and agree with The Lancet's assessment: "Without SA on board, with its ... leadership position within Africa, 3 by 5 is but a pipe dream," and that only SA has the infrastructure to speed up provision of AIDS drugs. But the target was always a pipe dream: there isn't the infrastructure in most of Africa to treat that many people. Further, the WHO cannot afford to provide SA with funds to treat its arbitrary target, so it has no right to feel aggrieved.

For a wider appreciation of WHO's folly, take Lesotho. I was there in March, when 2000 people were receiving antiretrovirals. Of these, perhaps 800 were on sustainable treatment, the rest on a far from ideal mix of single or dual therapy with forced changes in drug regimens due to supply shortages. It takes specifically trained staff to deliver antiretrovirals and, in most of sub-Saharan Africa, they are thin on the ground. Against this background, the WHO set the target for this year at 28000, which is absurd. I spoke to staff at an HIV clinic in Maseru, who were shocked at the target. They thought that, if they had to treat patients with whatever drugs were in supply, maybe 5000 could be treated by the end of the year.

But there are other reasons why the target of 3 by 5 will not be hit.

There were not 720000 people on sustainable treatment at the end of last year, as The Lancet says. The WHO claimed 700000, but it is a matter of record that this is inflated by about 10%. Further, some drugs were withdrawn because WHO was overenthusiastic about their performance, and the price of these and others was higher than WHO assumed, so budgets are too low.

Perhaps most importantly, reallocating medical staff from immunisation, antimalarial, child health and other programmes to treat HIV patients would be a misallocation: HIV treatment has a high cost and a poor relative outcome.

The WHO must address its failures if it is ever to do a better job.

Bate is a resident fellow of the American Enterprise Institute.