Q & A: Ambassador Goosby
12/04/2009
Ambassador Goosby talks to John Donnelly about health systems, building capacity and the Global Health Initiative
Ambassador Eric Goosby, U.S. Global AIDS Coordinator. Photo courtesy of John Donnelly.
Ambassador Eric Goosby, MD, became the U.S. Global AIDS Coordinator in June. He talked with GLOBAL HEALTH magazine in late October about the fragility of health systems, the need to build capacity in ministries of health in the developing world, and what the Obama administration's Global Health Initiative will look like. Here is an edited excerpt of his interview with journalist John Donnelly.
Q: What are you spending most of your time on now?
A: The main focus has been in understanding what we've done in the first five years in the PEPFAR programs (and) in each location how our response in both prevention and treatment do or do not relate to the demographics of the epidemic in each of these settings. In each city, there are multiple epidemics. Each has their own population, and movement of the virus through that population. And we're looking at how well our prevention programs understand that movement of the virus, and if they have indeed positioned themselves in front of it.
A second focus ... has been appreciating the complexity of our partnering network within the country, in the NGO community in particular. It's been astonishing to see how well we have done in urban populations.
But now the fragility of these health systems is what I'm most concerned about it. They are as fragile as the NGO who is involved in the delivery, and that is dependent on continued resources from us to support them in that effort.
Q: What do you do about that fragility?
A: We need to move toward a public-sector strengthening exercise that tries to move these capabilities that we have created largely in the NGO community into the public sector. If those capabilities move into the ministries of health, we will have better assured these services remain in place for the duration of the patients' lives.
We are talking about one program's ability, or inability, to sustain itself as a service delivery site into the future. We're looking at 25 to 30 years ahead. ... I think we need to look for strategies that allow us to move these services into the public sector without giving up quality of care, and which, by design, will decrease cost. I kind of want my cake and eat it, too. I want the cost to drop, and I want the quality to stay up. I think we can do that.
Q: How would you strengthen ministries of health?
A: We are trying to engage the country in a dialogue around what they are willing to do, what they need to do in light of their epidemics. We want to start a relationship, if it isn't already started, with ministries of health that positions them at the national level to orchestrate divergent funding lines - vertical funding lines from Global Fund, PEPFAR, UNITAID, World Bank, WHO to some degree, other bilateral activities - multiple funding lines that come into a country for an HIV/AIDS-TB related response.
Q: Are you talking about shifting PEPFAR's decision making from the U.S. ambassador in countries to the ministry of health?
A: I'm talking about increasing the dialogue and partnership between the U.S. government activities and the ministry of health. ... The United States government cannot be the Department of Health in these countries. We need to have a different strategy that positions the ministry of health to play that role and puts us in a supportive relationship. We have the same goals, same outcomes, but a different kind of process. I don't see it as an abdication of ambassador control, or involvement; I actually see it as an increase of ambassador involvement and thinking, planning strategically, with the ministry of health in a collegial dialogue to try to respond to their epidemics.
I think this is a harder task. It's a task that will have a different trajectory and implementation from an NGO-based response. It will have different barriers to care and understanding access points, and barriers to access will become a real part of the dialogue.
We also need to address the problems of not paying a living wage to health-care workers. Countries need support and have the courage to engage in something that could be disruptive and cause radical transformations under their social services. Without that, though, we will not be able to retain health workers in these positions. It doesn't need to be in competition with an NGO salary, but it definitely needs to be able to say that health workers can live a life, pay for housing, pay for school fees, get uniforms and books for their kids.
Q: Do you see some of the funding in the future to help supplement salaries?
A: I think incentive programs are going to be a critical pillar of the success of our response.
Q: Many advocates note that under the Obama administration plan, global AIDS will be flat-funded for the next six years. How are you going to continue adding people on treatment and expand prevention efforts with flat funding?
A: We are in an economic crisis. The reality is that a flat or slightly rising PEPFAR allocation is what we are looking at for at least two years, maybe longer. This puts us in a position where we need to look for efficiencies. We need to be clear about redundancies and ineffective program focus. There is a lot of overlap in catchment areas. If we've got two NGOs in the same city overlapping in their catchment areas for treatment or prevention focus, we have to ask is that necessary, is that added value, or is it redundant?
Second, cost of care is going down as we move all of our countries from brand to generic (drugs), we are significantly lowering the cost per patient.
Starting treatment when a patient reaches 350 CD4 count or lower, from the current 200 level), is going to be a tough one. When we look at patients now, their first CD4 counts are about 130 to 140 on average. That is later-stage disease, people are more ill, they usually are co-infected with tuberculosis, and with injecting drug user populations with hepatitis C and B. ... We are not getting to a 350 trigger until we have addressed the patients who are more advanced in their disease. Our system should favor the sicker patients to go on the drugs first. I'm not anticipating a 350 change on a recommendation level (from the World Health Organization) will impact our programmatic approach worldwide. It's clear 350 is better than 200. It's always been clear. WHO saying it's clear now and changing the recommendation is really years after the data has determined that. I think triaging is still our approach; it always has been our approach.
Q: Do you see a time ahead in which countries will ration antiretroviral drugs?
A: I think that if countries go to 350 (CD4 count), there will have to be rationing because they do not have enough resources to cover people below 200 or people below 150. If they now say anybody 350 and down are eligible, they are going to have to figure out a way responsibly to put those people who are most ill on drugs first.
I think the challenge globally to us at this moment is to acknowledge this unmet need in treatment - we've gotten about a third of the way there. It's (time) for the world dialogue to change and start to engage around our shared responsibility in response to this epidemic. Is it just the responsibility of one country to mount a treatment response, or is it something that we really as all countries on the planet should try to share as a responsibility? I'm very interested in facilitating that dialogue before we get into rationing.
Q: What will the Obama administration's Global Health Initiative (GHI) look like, and how will that change your mission?
A: I think GHI will take advantage of pre-existing programs such as PEPFAR. The idea is to use existing delivery services, and off of those expand into targeting women as the entry point to access children and husbands-partners. That is designed to make available services that allow and enhance the woman's ability to control her family's needs with family planning, reproductive health services, and an immunization strategy. ... Nutrition will probably be another central element of this.
The United States will continue its vertical programs. We understand the medical ethics of that relationship already having begun with PEPFAR or other disease-specific activities. That will be honored. ... I think the GHI means that instead of starting from scratch and engage new systems, we want to build on what has already been done.
Learn More
Watch a webcast featuring Ambassador Goosby at a Town Hall hosted by the Kaiser Family Foundation.
John Donnelly is a freelance writer based in Washington, D.C. He can be reached at (JavaScript must be enabled to view this email address).
Thanks for this article regarding the direction of PEPFAR and the long term effect to Africa, Asia and other international groups. What is not addressed in this interview is the ill use of the PEPFAR funds from international US-based organizations. Who because they are part of the beltway bandits seeking to expand their bank accounts at the expense of the country needs, now they are to move towards working with the MOH, was this not what they were suppose to do? It is most upsetting that Amb Goosby will remain to support such organizations who have rape and taken the funds for their own growth and not capacitating the African and Asian countries health systems. I have worked with various US based NGO organizations and even so call US advocacy and FBO groups, none have the commitment to the mission just how to expand thier bank accounts. I was recently in a meeting where the CEO said we need to get some of this PEPFAR money since our IRAQ funds are being redistributed. It amazes me when I recently read an article from the South Africa Citzen newspaper such as Ms. Graca Machel will support civil societies to strengthen their ability to shift national governments funds towards HIV health related programs. This again is lead by a US group call Global AIDS Alliance. The US continues to fund and support groups who have no historical connection, only have recently purchased a building to call an office. this will show they have a country presence right/ Abosolutely, not, just another way to continue this onslaught of countries not able to take the lead and be responsible for their country people’s health. PEPFAR does not provide monitoring oversight of these US based programs only open up the bank doors. I hope this Amb Goosby takes a closer look at some of his friends.
— Denise on 2009-11-17
it is fine.
— urama bertrand chijioke on 2010-01-09
The US new global AIDS policy plans to prioritize strengthening health systems before funding more HIV treatment and this is correct in principle. As the health care systems in developing nations were already overburdened and under resourced even before HIV came. If we are just adding thousands of HIV cases on treatment to be taken care of by the clinics without helping the clinics with resource mobilization, that can be the last straw to tip the systems to total collapse. However again we shouldn’t be planning to rebuild the whole system. Local resources and task shifting to rebuild the HR and community involvement to assist in patient followups should be utilized. The risk of the new policy is if the funds are trying to cure every ail of the health systems, the diluted effects will have no significant change in the whole system recovery and catastrophic effect in the HIV programs with loss of all the previous PEPFAR gains! (This happened when malaria control programs which were initially vertically structured and funded were integrated in many developing countries like Ethiopia and the almost eradicated malaria was left completely unmanaged by the weaker public health systems and caused the surgeback of malaria. I am a witness)
— Tewodros teketel(DrTeddy) on 2010-01-15