2009年5月9日星期六

【China AIDS:4054】 愿意做北京爱知行研究所万延海的推荐人

选民姓名

 

陆军

选民所在组织名称

 

北京益仁平中心

联络电话

 

 

010-51917981

电子邮件

 

 

yi.ren.ping@hotmail.com

 

支持理由

 

 

长期在国内NGO社群进行全球基金相关知识的推广,长期致力于全球基金在国内项目实施状况的监督,长期致力于推动促进CCM选举的公开、透明、有记录。

 
----- Original Message -----
From: WanYanhai
Sent: Friday, May 08, 2009 1:11 AM
Subject: 【China AIDS:4043】 万延海CCM社群组织代表参选宣言

各位社群组织同仁:大家好!
 

今天,我珍重宣布,我代表北京爱知行研究所,竞选中国全球基金项目国家协调委员会(CCM)以社区为基础的组织或其它非政府组织代表或列席代表。我的选区在3.3)综合性组织及其他组织。我希望本选区内的组织可以投票支持我!欢迎大家到综合类报名参加选举!请支持万延海!

 
我是一个直言不讳的人,但还不够勇敢;面对警察的时候,我会退却。我愿意为大家做事情。我选上了,我为大家做事;别人选上了,需要我帮忙,我也一定效劳。
 
作为候选人,我需要大家来推荐我,来给我捧场。如果您愿意作为我的推荐人,需要您所在组织到3.3综合类组织中报名参加选举(选民登记),同时可以给我来信,提供推荐下列信息我的信箱是:wanyanhai@gmail.com
 
以下是我的竞选宣言和选举组织者发布的选举通知。附件是北京爱知行研究所选民登记表、万延海参选报名表、爱知行章程和2008年度报告、选民报名表
 
万延海
 
 
万延海CCM社群组织代表竞选宣言
 

我代表北京爱知行研究所,竞选中国全球基金项目国家协调委员会(CCM)以社区为基础的组织或其它非政府组织代表或列席代表。我的选区在3.3)综合性组织及其他组织。我希望本选区内的组织可以投票支持我!谢谢!

 

如果我当选,根据需要,我将每周提供1-2个工作日为中国参与艾滋病、结核病和疟疾防治工作的社群组织服务,把大家的意见带到CCM会议和各个工作组的会议上,带领社群组织以负责任和敢于面对挑战的方式参与全球基金工作。

 

如果我当选代表或有机会协助代表工作,我将致力于中国全球基金项目的改革,要点如下:

1、修改中国CCM章程,主要意见如下:

1CCM增加社群组织和感染者代表名额,确保CCM成员40%以上来自公民社会;

2CCM增加会议次数和每次会议时间,确保重要事务得到关注和充分讨论,来自社群意见得到表达和尊重;

3)明确CCM对全球基金项目的监督职责和操作细则;

4)明确CCM各个部类成员对代表的监督权限。

2、对中国CCM艾滋病、结核病和疟疾三个疾病专题工作组进行改革,确保工作组具有广泛代表性,成员具备基本的专业能力,明确工作组职责和工作机制,实现工作组对全球基金项目的技术支持和监督职能。

3、筹集资源,对社群组织进行全球基金项目执行和管理能力的培训,实现社群组织可以下列方式参与全球基金项目:

1)不仅支持项目活动,也获得行政经费,支持工资和房租;

2)成为主要(PR)或次级(SR)资金接受单位,而不只是基层执行组织(SSR);

3)参与对项目评审和项目执行的监督和评估工作。

 

同时,本人将致力于全球基金项目的监督和评估工作,确保项目资金以社群参与和对社群敏感的方式执行,确保资金不被贪污,确保项目可以实现艾滋病、结核病和疟疾防治目的。

 

本人主张开放非政府组织工作委员会(非工委)的工作机制,允许更多组织以不同方式参与非工委工作,特别是那些在非工委缺乏声音的组织,比如妇女组织、宗教组织、少数民族组织、跨性别人组织、血友病人组织、青年和学生组织。

 

本人将致力于非工委团结合作。在非工委工作中,我更加愿意发挥本人在公共卫生计划和评估中的专业特长和对公共政策和全球基金规则的能力,做好大伙的参谋作用。

 

欢迎到综合类报名参加选举!请投我一票!支持万延海!让全球基金真正服务中国艾滋病、结核病和疟疾防治工作!谢谢大家!

 

这个附件是关于非政府组织/以社区为基础组织的相关信息。提醒大家报名时间515日结束,所以要注意时间有限!

中国全球基金项目国家协调委员会(CCM

以社区为基础的组织或其他非政府组织类别组换届选举

关于开始换届选举选民和候选人报名的通知

中国全球抗击艾滋病、结核病和疟疾基金项目国家协调委员会(China Country Coordination Mechanism for the Global Fund to Fight AIDS, Tuberculosis and Malaria Project,以下简称CCM ),是根据全球抗击艾滋病、结核病和疟疾基金(以下简称全球基金)的有关要求,为审议、批准和协调申请全球基金项目,监督和指导经全球基金批准在中国境内实施的项目而建立的协调机制。CCM坚持"公开透明、广泛参与、高效运作"的原则,积极为全球基金项目在中国的顺利实施做出贡献。

目前有13个轮次渠道项目和2个持续滚动资助项目获得全球基金批准,分别是第三、四、五、六、八轮艾滋病项目和第三轮艾滋病项目持续滚动资助,第一、四、五、七、八轮结核病项目和第一轮结核病项目持续滚动资助,以及第一、五、六轮疟疾项目。申请的全球基金资助总额约达12亿美元。

中国全球基金项目国家协调委员会(CCM)于2006220日第15次全体会议通过了新修订的《中国全球抗击艾滋病、结核病和疟疾基金项目国家协调委员会工作章程(试行)》。该章程规定,CCM 类别组成员任期为2 年。各类别组自己推选其类别组CCM成员。代表应通过公开透明、有记录的程序从其本组中产生。每名CCM 成员可与本类别组其它2 人(即列席代表)共同参加CCM 会议。CCM类别组成员的权利、责任等也在CCM章程中有明确的规定-请参见附件1。(如果您想了解更多关于全球基金和CCM的信息,请登录CCM网站:http://www.chinaccm.org.cn/ 。)

200931415日,CCM以社区为基础的组织或其他非政府组织类别组(以下简称CBO/NGO类别组)通过了本类别组的换届选举方案。该选举方案对换届选举的原则、选民和候选人的资格进行了界定,详情请参见附件2-《中国全球基金项目国家协调委员会成员换届方案》

根据该选举方案,独立选举委员会制定了CBO/NGO类别组的换届选举时间表并征求了类别组的意见。CBO/NGO类别组选择了在630日之前完成换届选举的时间表,并要求增加选民及候选人的报名时间。独立选举委员会尊重类别组的意见并对时间表进行了相应的修改--请参见附件3-《CCM以社区为基础的组织或其他非政府组织类别组代表选举时间表》。整个选举将按照此时间表进行,若出现临时情况,独立选举委员会将酌情修改,但整个选举将在2009630日之前完成。


 

注意

              1. 有意愿参与选举的个人请于200951624时前,通过电子邮件或邮寄方式(邮戳以2009516日当地时间为准)将信息完整的选民或候选人报名表及报名所要求的相关附件,发送到指定电子邮箱或邮政地址-请参见附件4-《以社区为基础的组织或其他非政府组织类别组选民报名表》和附件5-《以社区为基础的组织或其他非政府组织类别组候选人报名表》。

              2. 请在填写报名表前认真阅读注意事项,确保报名人已经了解报名表中部分信息将在指定的选举网站上公布。

              3. 独立选举委员会在收到以电子邮件或邮寄方式发来的选民或候选人报名表后3个工作日内回函确认,并发给选民报名人一个唯一的选举号,只有持选举号的选民才能参与投票。若选民报名人经独立选举委员会确认不符合选民资格,则其所持选举号将相应作废。若报名人在报名表发出后5天后仍收不到回复和确认,请主动与独立选举委员会联系。

              4. 本次选举所有信息都将按照本类别组换届选举时间表及时在CCM网站(http://www.chinaccm.org.cn )和中国红丝带网(http://www.chain.net.cn/ )上公布。

              5. 在报名过程中如果有任何问题,可以通过以下方式联系独立选举委员会:

电子邮箱:ccm2009cbo@gmail.com ccm2009cbo@yahoo.cn (请同时发送到两个邮箱地址,以防止邮件的丢失)

电话:010-8532 4230 或者 010-8532 4250

传真:010-8532 2261

通信地址:北京市朝阳区亮马河南路14号塔园外交办公大楼 2-8-2

邮编:100600

 

中国全球基金项目以社区为基础的组织或其他

非政府组织类别组独立选举委员会

200952

附件:

              1. 《中国全球抗击艾滋病、结核病和疟疾基金项目国家协调委员会工作章程(试行)》

              2. 《中国全球基金项目国家协调委员会成员换届方案》

              3. CCM以社区为基础的组织或其他非政府组织类别组代表换届选举时间表》

              4. 《以社区为基础的组织或其他非政府组织类别组选民报名表》

              5. 《以社区为基础的组织或其他非政府组织类别组候选人报名表》

 

 


"China AIDS Group中国艾滋病网络 论坛"
A:要加入:★中国艾滋病网络 http://www.chinaaidsgroup.org
B:要在此论坛发帖,请发电子邮件到 chinaaidsgroup@googlegroups.com
C:要退订此论坛,请发邮件至 chinaaidsgroup-unsubscribe@googlegroups.com
D:Contact us:  chinaaidsgroup@gmail.com

★中国艾滋病网络/China AIDS Group             http://www.chinaaidsgroup.org
★中国艾滋病博物馆/China AIDS Museum      http://www.aidsmuseum.cn
★艾博维客 AIDS Wiki                                  http://www.aidswiki.cn
★艾滋人权 AIDS Rights:                               http://www.aidsrights.net
★常坤:为艾滋病防治努力一生                     Http://www.changkun.org

-~----------~----~----~----~------~----~------~--~---


--~--~---------~--~----~------------~-------~--~----~
★★关宝英,不容你把官场蠹毒之气弥散民间社区,请引咎辞职,扼住以项目资金挟持非政府组织的邪恶之风,维护草根NGO的尊严、维护全球基金的尊严!!!
https://sites.google.com/site/guanbaoyingcizhi

-~----------~----~----~----~------~----~------~--~----~----------~----~----~----~------~----
"China AIDS Group中国艾滋病网络 论坛"
A:要加入:★中国艾滋病网络 http://www.chinaaidsgroup.org
B:要在此论坛发帖,请发电子邮件到 chinaaidsgroup@googlegroups.com
C:要退订此论坛,请发邮件至 chinaaidsgroup-unsubscribe@googlegroups.com
D:Contact us:  chinaaidsgroup@gmail.com

★中国艾滋病网络/China AIDS Group             http://www.chinaaidsgroup.org
★中国艾滋病博物馆/China AIDS Museum      http://www.aidsmuseum.cn
★艾博维客 AIDS Wiki                                  http://www.aidswiki.cn
★艾滋人权 AIDS Rights:                               http://www.aidsrights.net
★常坤:为艾滋病防治努力一生                     Http://www.changkun.org

-~----------~----~----~----~------~----~------~--~---

【China AIDS:4053】 Fw:关于延长感染者类别组换届选举选民和候选人报名时间的通知

 

中国全球基金项目国家协调委员会(CCM

艾滋病、结核病和疟疾患者或感染者类别组换届选举

 

关于延长换届选举选民和候选人报名时间的通知

 

    2009430CCM艾滋病、结核病和疟疾患者或感染者类别组独立选举委员会发出《艾滋病、结核病和疟疾患者或感染者类别组换届选举关于开始换届选举选民和候选人报名的通知》,截止20095824时,共收到选民报名表643份。截止5913时,共收到候选人报名表14份,其中七大区分布如下:

   华北:4名(山西1,河北1,北京1,天津1

   华中:3名(河南3

   华东:5名(浙江2,上海2,山东1

   东北:1名(辽宁1

   西南:1名(四川1

   西北和华南目前没有候选人报名。

   考虑到某些大区可能没有候选人的情况,独立选举委员会决定延长选民和候选人的报名时间至200951224,之后的选举步骤将相应后延。特提请广大有意向参与换届选举的社区同仁注意报名截止时间及后续选举活动时间表—请参见附件1艾滋病、结核病和疟疾患者或感染者类别组代表换届选举时间表-修改版》。

注意:

1.        有意愿参与选举的个人请于200951224时前,将信息完整的选民或候选人报名表及报名所要求的相关附件-请参见附件2和附件3,通过电子邮件或邮寄方式(若邮寄,请一律采用邮政快递方式以确保选举委员会能及时收到报名表,邮戳当地时间为准,截止日期之后寄送均视为无效),发送到如下电子邮箱或通信地址:

电子邮箱ccm2009plwd@gmail.com ccm2009plwd@yahoo.cn

(请同时发送到两个邮箱地址,以防止邮件的丢失)

通信地址:北京市朝阳区亮马河南路14号塔园外交办公大楼 2-8-2

邮编100600

·           参加此次换届选举的选民或获选人必须提交填写信息完整的报名表。表上必须写明真实姓名以及可公布的化名、身份证号、联系方式和详细通讯地址,可以合用一个邮箱或统一邮寄, 但报名者必须一人一表。每份表上必须写明报名者的具体联系方式和通信地址(不能合用一个通讯地址),以便于核实选民资格。集体签名报名无效。其他报名方式也无效。

·           无论通过何种方式报名,独立选举委员会将在收到选民报名表后3个工作日内,把唯一的选举号通过邮件或通信地址直接发送或邮寄到报名人本人手中

·           请报名人在填写报名表前仔细阅读注意事项,认真填写。信息填写是否完整将直接影响独立选举委员会对其选民身份的确认以及是否能及时收到选举号参与选举。

2.        报名人在填写候选人报名表附表二时需要注意:该处要求的候选人的支持者必须是具有选民身份的本选区选民,即支持者均已经参与本选区选民报名并经独立选举委员会确认符合选民身份。若某些支持者经独立选举委员会确认不符合选民资格,独立选举委员会将及时联系候选人告知这一信息。

3.        选民和候选人应只报名参加CCM一个类别组换届选举。若已报名参与两个类别组选举,请于200951224时之前做出选择,并通知独立选举委员会,否则将取消其参与换届选举的资格。

4.        200951224时,无论选民、候选人报名情况如何独立选举委员会将不再延长报名时间,直接进入下一个选举步骤。独立选举委员会将根据实际情况调整选举步骤的安排,并将提前发出通知提醒广大选民注意。

5.        本次选举第一阶段2009430日至5924时)报名情况将同第二阶段一起公布。在第二阶段结束之前,独立选举委员会将视请公布各选区选民人和候选人报名人数。

6.        独立选举委员会联系方式:

电子邮箱ccm2009plwd@gmail.com ccm2009plwd@yahoo.cn

电话:010-8532 4230  或者 010-8532 4250

传真:010-8532 2261

 

 

中国全球基金项目感染者类别组独立选举委员会

                                                             200959

附件:

1.        艾滋病、结核病和疟疾患者或感染者类别组代表换届选举时间表-修改版

2.        《艾滋病、结核病和疟疾患者或感染者类别组选民报名表》

3.        《艾滋病、结核病和疟疾患者或感染者类别组候选人报名表》

 

 
 
---------- 转发邮件信息 ----------
发件人:"chenhuan <chenhuan@chinaglobalfund.org>"
发送日期:2009-05-10 09:01:35
收件人:"'国亮'" <rgl88@126.com>
抄送:lingyunyao@chinaglobalfund.org
 
主题: 关于延长感染者类别组换届选举选民和候选人报名时间的通知

国亮:

 

附件请见关于延长感染者类别组换届选举选民和候选人报名时间的通知。烦请写著我们尽快在各大邮件组里转发,谢谢!

 

祝好!

 

 

陈华



__________ Information from ESET NOD32 Antivirus, version of virus signature database 4063 (20090508) __________

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穿越地震带 纪念汶川地震一周年 --~--~---------~--~----~------------~-------~--~----~
★★关宝英,不容你把官场蠹毒之气弥散民间社区,请引咎辞职,扼住以项目资金挟持非政府组织的邪恶之风,维护草根NGO的尊严、维护全球基金的尊严!!!
https://sites.google.com/site/guanbaoyingcizhi

-~----------~----~----~----~------~----~------~--~----~----------~----~----~----~------~----
"China AIDS Group中国艾滋病网络 论坛"
A:要加入:★中国艾滋病网络 http://www.chinaaidsgroup.org
B:要在此论坛发帖,请发电子邮件到 chinaaidsgroup@googlegroups.com
C:要退订此论坛,请发邮件至 chinaaidsgroup-unsubscribe@googlegroups.com
D:Contact us:  chinaaidsgroup@gmail.com

★中国艾滋病网络/China AIDS Group             http://www.chinaaidsgroup.org
★中国艾滋病博物馆/China AIDS Museum      http://www.aidsmuseum.cn
★艾博维客 AIDS Wiki                                  http://www.aidswiki.cn
★艾滋人权 AIDS Rights:                               http://www.aidsrights.net
★常坤:为艾滋病防治努力一生                     Http://www.changkun.org

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【China AIDS:4052】 Fwd: 【权利:1930】 Internet 安全建议



---------- Forwarded message ----------
From: wanghx <wanghx@gmail.com>
Date: 2009/5/10
Subject: 【权利:1930】 Internet 安全建议
To: ChinaRights@googlegroups.com, "lihlii@googlegroups.com" <lihlii@googlegroups.com>


在 gmail web 阅读这个 PDF 文件《H1N1型豬流感預防手册》,发现显示一页空白。
如果用 gmail 收信,在 gmail web 界面可以选择将附件 doc, xls, ppt, pdf 等文件在 google doc 界面浏览,避免被恶意代码攻击。

看此 PDF 文件源代码的作者信息如下:

<</Author (Felipe Andres Manzano)
/email (felipe.andres.manzano@gmail.com)
/web (felipe.andres.manzano.googlepages.com)

看他的网站[4]内容,涉及软件安全[2]。他还提供一个 python lib 来动态生成 PDF 文件。可能是有人利用他的安全研究成果,反而用于传播木马。

PDF 文件中的 JavaScript 可以用文本编辑器删除:
<</S /JavaScript
[删除这里一段代码]
>>
endobj

为防止 PDF 文件中插入恶意 Javascript 代码,可以在打开外来的 PDF 文件前,禁止 PDF reader 的 Javascript 功能:



Zola 等提供了一些 Internet 安全建议 [1]。技术专家支持的人权组织 Tactical Technology Collective 制作了一系列 NGO 指南 NGO In A Box (NGO 宝盒)[5],所有的指南都非常实用。其中有一份指南是关于信息安全的 Security In A Box (安全宝盒)。另外还有教程指导如何制作视觉精美的印刷品,如何开设网站,如何进行网络出版等等。

Zola 介绍说:
第三件事,我在公盟做奶粉受害者索赔法律援助团的志原者,我帮他们创立了一个Google Group用于工作进度讨论,把一个受害者家长赵联海也加进来了,结果发现zhaolianhai72@gmail.com冒充zhaolianhai1972@gmail.com发过 一封邮件,并在邮件里添加了四个doc附件,还不知道是否有病毒。幸好我从来对附件都是Open as a Google document ,并且我安装的是免费的OpenOffice和WPS个人版,即便 我下载并直接打开了有Wold病毒的文档也少了些可能性。看来国安和国保的工作强度和技术应用程度不底啊,但从他们干这些下三滥的活,也不知道他们是不是 真的为了国家利益。
  1. 慎重下载邮件附件。最好是开始使用在线的EMAIL程序,如Gmail。病毒和木马针对 OutLook设 计,改用在线EMAIL,可以减少风险,我认为Gmail足够好了。对于别人发来的Doc附件,建议用Google docs来打开。
但是请注意,gmail webmail 一样有安全风险,多次被发现有安全漏洞可以用于窃取信息和密码[1]。请立刻采用如下建议[1]:
  1. 千万不要相信 google 会给你发任何邮件要你输入你的帐号和密码!你的银行也不会这样做!

  2. 平时总是用 https://mail.google.com 访问 gmail 全程加密连接,中恶意代码的可能会低一些,拒绝一切不安全连接。
    但是恶意的钓鱼邮件,广告,浏览的一些恶意网站依然可能导致问题。

  3. 用 Firefox 访问 gmail webmail。在 gmail webmail 设置选项中选择总是用 https 加密连接方式[4]。

  4. 在 Firefox 中安装 NoScript 扩展包 (Addon) [5] 以防范恶意网站的 XSS 脚本攻击。这是一种对 gmail webmail 具有很大威胁性的攻击手段,并且大量网站上也有此类恶意代码可以跟踪监视窃取用户信息,诱导安装恶意软件。安装 NoScript 以后,你看许多网页也会过滤到很多广告和干扰性的 flash, 漂浮窗口之类。

  5. 如果你采用 gmail webmail 最新版本的界面,在邮件列表的下方,可以看到一段文字:

    You are currently using xxx MB (xx%) of your xxxx MB.
    Last account activity: 6 minutes ago at this IP (xxx.xxx.xxx.xxx).  Details

    您目前使用了 xxxx MB 配額中的 xxx MB (xx%)。
    目前此帳戶正在此 IP 的另 1 個位置使用 (xxx.xxx.xxx.xxx)。   最近帳戶活動: 0 分鐘以前.  詳細資料

    点击 “Details” 或者 “详细资料”可以查看你的 email 邮箱登录来源地址信息。
    每次登录后,请立刻查看这一登录历史信息,看是否有其他可疑地址登录你的邮箱,防范邮箱密码泄露被入侵盗用。

  6. 谨慎设置邮箱密码更改的机密问题并牢记,记在脑子里而不要写在任何地方。实在觉得难以记住,可以用 keepass 软件来加密保存这类私密信息。当密码被他人篡改,或者邮箱被 google 锁定时,需要这个信息来解锁。

    选取难以猜到的密码的一个简单方法,是选用一句名言或者对你容易记忆的广告词之类句子,然后选取每个字拼音的第一个字母来组成密码。容易记而 他人很难猜到。

  7. 3721实名,360安全卫士,上网助手, QQ,Tom.com 版本 Skype 这类流氓和反流氓软件绝对不要用。暴风影音这类国产软件曾经捆绑恶意软件,现在也难说是否潜藏木马代码,未确认。推荐用 k-lite mega codec pack 代替。flashget, 迅雷这类中共国人做的下载软件也无法保证安全,并且有隐私泄露问题。替代可以用 free download manager 或者 Firefox 扩展 DownThemAll。

  8. 不要让浏览器或者 Outlook Express, Thunderbird 记住你的密码。这些被记住的密码很容易被他人获取。为了方便一定要记住的话,Firefox 和 Thunderbird 提供一个功能,用一个主密码加密保存所有记住的密码。但是该加密算法的安全性未查考。

  9. 你要学会看邮件源码来识别虚假邮件[9]。如果你用 thunderbird,它也有一定的帮助防范的能力。
    信息隐私安全最脆弱的一点是可以用社会工程(social engineering)手段进行攻击,也就是说,只要突破你的社交网络中任何一个脆弱的人,就可以逐步获取关于你的信息。所以,请通知所有和你有联系的 朋友都警惕欺诈骗局,认真检查自己的密码是否被盗用,机器是否安全。
参考:
  1. Internet 安全建议 http://tr.im/kP2k
    防范 邮件钓鱼欺诈窃取密码
    https://groups.google.com/group/lihlii/t/da931bd593a1f776
    给做公益事业的人的病毒防范建议
    https://groups.google.com/group/lihlii/t/4e9ebc548a456c2d
    中共用钓鱼邮件黑客手段对付海外网站
    https://groups.google.com/group/lihlii/t/72a38681bc18940c
  2. Felipe Andres Manzano reported this vulnerability. http://securitytracker.com/alerts/2008/Jul/1020435.html
  3. http://forums.cnet.com/5208-6132_102-0.html?threadID=300414
  4. http://felipe.andres.manzano.googlepages.com
  5. 安 全软件工具指南 Security-in-a-Box: tools & tactics for your digital security [NGO In A Box][engagemedia][Tactical Tech Collective][frontline defenders] http://tr.im/kVDR
w wrote:
可以用在线病毒多重扫描来检查一个文件是否有恶意代码,比如这个 PDF 的检查 结果: http://www.virustotal.com/analisis/24e81560f0064bcfd84f9901ef211821  这是个 javascript 木马,利用了 Adobe Acrobat Reader 的缺陷。 http://www.bitdefender.com/VIRUS-1000487-en--Exploit.PDF-JS.Gen.html 究竟什么样的人会干这种恶毒事情,需要追查一下这个 PDF 文件的来源,才能更 好地防范阴险恶毒的勾当。  常坤 Chang Kun wrote:   
对不起,各位,我刚刚转发的《世界卫生组织中国调查组敬告《H1N1型豬流感預防 手册》》是附件带有木门程序病毒,非常歉意! 我将引以为戒,前事不忘!  常坤





--
常坤 Chang Kun
为艾滋病防治努力一生!
Devote my life to AIDS prevention and care work!

Office Phone: 010-51917982
手机:13810726838 (短信)

★北京益仁平中心http://www.yirenping.org

★博客http://www.changkun.org  http://aidsrights.spaces.live.com

★中国艾滋病博物馆/China AIDS Museum
http://www.aidsmuseum.cn

★中国艾滋病网络/China AIDS Group:http://www.chinaaidsgroup.org

★艾滋人权 AIDS RIGHTS:http://www.aidsrights.net

★艾博维客 http://www.aidswiki.cn
~~~~~~~~~~~~~~~~~~~~~~~~~~~
2009让我们发扬对父母对民族对人类这无比巨大的爱,以坦荡沉稳的胸怀用社会运动的方式推动中国艾滋病防治事业,抗击艾滋病及其所带来的一切邪恶!


--~--~---------~--~----~------------~-------~--~----~
★★关宝英,不容你把官场蠹毒之气弥散民间社区,请引咎辞职,扼住以项目资金挟持非政府组织的邪恶之风,维护草根NGO的尊严、维护全球基金的尊严!!!
https://sites.google.com/site/guanbaoyingcizhi

-~----------~----~----~----~------~----~------~--~----~----------~----~----~----~------~----
"China AIDS Group中国艾滋病网络 论坛"
A:要加入:★中国艾滋病网络 http://www.chinaaidsgroup.org
B:要在此论坛发帖,请发电子邮件到 chinaaidsgroup@googlegroups.com
C:要退订此论坛,请发邮件至 chinaaidsgroup-unsubscribe@googlegroups.com
D:Contact us:  chinaaidsgroup@gmail.com

★中国艾滋病网络/China AIDS Group             http://www.chinaaidsgroup.org
★中国艾滋病博物馆/China AIDS Museum      http://www.aidsmuseum.cn
★艾博维客 AIDS Wiki                                  http://www.aidswiki.cn
★艾滋人权 AIDS Rights:                               http://www.aidsrights.net
★常坤:为艾滋病防治努力一生                     Http://www.changkun.org

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【China AIDS:4051】 经济学及其对艾滋病专用资金的反对意见

经济学及其对艾滋病专用资金的反对意见

 

Nicoli Nattrass

开普顿大学(University of Cape Town)

 

Gregg Gonsalves

耶鲁

 

给世界卫生组织/世界银行/联合国艾滋病规划署经济学顾问小组(WHO/World Bank/UNAIDS Economics Reference Group)文件

2009年4月14日

 

    本文讨论了对有利于支持综合卫生系统的艾滋病专用资金的反对意见。我们认为这些反对意见更多是由花言巧语而不是由证据推动的,其缺点是没有认识到艾滋病应对措施的交叉性、公民社会组织在向政府问责上能够起到的有力作用、和在特别针对艾滋病的干预措施的支持下建设更好的卫生系统的可能。我们还主张:经济学家威廉·伊斯特利(William Easterly,2006)和Mead Over(2008)已经通过其反对抗逆转录病毒治疗在发展中国家首展的花言巧语和有缺陷的分析,对这些反对意见做出了贡献。本文总结道:当经济学家提供信息而不是抢先做出社会选择,广泛而不是狭窄地撒下自己的分析网,并且更多采用政治经济观点时,做出的贡献最有建设性。

 

反对意见

    世界经济处于危机之中。国际信贷市场垂死挣扎,战后全球生产首次收缩,估计2009年将有5300万人陷入贫困(世界银行,2009)。需要全球应对的观点得到了普遍接受,世界银行正在要求富国将其一揽子经济刺激计划中的0.7%捐献给脆弱性基金(Vulnerability Fund),以帮助遭受重创的国家。这些国家多数位于非洲,包括所有HIV疫情严重的国家。然而世界银行关于需要做哪些事的评估中没有出现HIV和艾滋病的字样,也没有区分有重大健康危机的国家和其余的国家(世界银行,2009)。奥巴马政府正在计划把健康领域新的大规模国内投资(6.34亿美元)作为美国的一揽子经济刺激计划的一部分,而国际援助议程却似乎相当不同。

    这暗示了HIV/AIDS资金猛增的时代结束了。来自某些捐赠者的令人担忧的信号是外援会收缩(世界银行,2009),已经出现的事实是美国正在削减其总统防治艾滋病紧急救援计划(President's Emergency Fund for AIDS Relief,PEPFAR)委员会。联合国艾滋病规划署执行主任米歇尔·西迪贝(Michel Sidibe)可能会发现,要从捐赠者那里得到所需的170亿美元和从受影响国家政府那里拿到80亿美元来满足今后两年的HIV预防和抗逆转录病毒治疗目标,是一场艰巨的斗争。

    西迪贝的任务由于普遍持有的认为艾滋病专用资金已经超出了它在发展资源中应得的份额的观点而变得更加困难。全球艾滋病资金从2001年的14亿美元上升到2007年的100亿美元,2009年上升到137亿美元(联合国艾滋病规划署,2008:188;西迪贝,2009:4)。最初的动力——2003年世界卫生组织的"三五"运动和全球抗击艾滋病、肺结核(TB)和疟疾基金的创建对此有很大的推动作用——来自对艾滋病危机的"例外"性和它给世界带来的社会经济危险的担忧(联合国艾滋病规划署 2006:5)。美国政府通过总统防治艾滋病紧急救援计划进一步给"资金池"增压。这——与前所未有的来自私营基金会(尤其是盖茨)的捐款和克林顿基金会(Clinton Foundation)的动员工作一道——戏剧性地把HIV预防和治疗服务扩大到了发展中国家。估计现在发展中国家中约有四百万人的生命可以归功于这一扩大抗逆转录病毒治疗规模的国际努力(西迪贝,2009)。

    但是,即使是在全球经济危机之前,在支撑全球艾滋病资金增长的长期繁荣的顶点上,反对意见也很明显。常见的主题是"艾滋病游说"已经获得了"不公平"的大量资源,这些资源被浪费在社会效果不确定的支出上,这些钱应该分配到其他目标上(例如见Garrett,2007)。有些人声称联合国艾滋病规划署故意夸大HIV估计数字(Chin, 2006; Pisani, 2007)。这导致高层呼吁"彻底修改国际艾滋病应对措施"(Lewis and Donovan, 2007: 532)及联合国艾滋病规划署与世界卫生组织的防御性反应(De Lay and De Kock, 2007)。另一些人认为,联合国艾滋病规划署错误地领导了其项目工作,虽然他们在资源是否应该用于对付贫困和解决发展问题上(Stillwaggon,2006)或更加积极地用于性行为改变上(Epstein 2007, 2008; Pisani 2007; Chin, 2006)意见不一。

    但是,核心的反对意见来自那些声称艾滋病相关资助破坏了发展中国家的卫生系统的人。这一论点——阐述这一论点最积极(也最善辩)的人是Roger England——认为:向艾滋病领域注入大量的资金不仅是毫无根据的,而且实际上是损害卫生系统的。他在发表于《英国医学杂志》(British Medical Journal England,2007a, 2007b, 2008)上的一系列观点中认为,艾滋病不是"艾滋病例外主义者"所称的全球大灾难,捐赠者对艾滋病的援助超过了艾滋病在所有疾病负担中所占的比例,把钱花在蚊帐、免疫和儿童疾病上更有成本效益。他指控联合国艾滋病规划署创造和强加了"历史上最大的垂直项目",它已经(通过转移人力资源)腐蚀了公共健康部门,(用额外的报告要求和协调很差的捐赠活动)损害了政府的效率,还有效地取消了国家对开支重点的控制。他提议关闭联合国艾滋病规划署,扣住给全球基金的钱,直到它参加全部门的一揽子资助安排,好把捐赠资金和国内资金放到一起(2008: 1072)。按照他的观点,给卫生系统的资助和给HIV的资助相当于一个零和游戏:"只要我们上马HIV项目,国家就得不到所需的服务供应系统。"(2007b: 1073)。

    但是,与England的论断相反,大部分证据显示艾滋病资金没有过多,也没有牺牲其他健康项目。世界卫生组织的HIV资金与艾滋病导致的疾病负担相符(De Lay et al, 2007; Stuckler et al, 2008: 1565),虽然艾滋病专用资金从20世纪90年代初的不到健康相关援助的10%上升到2003年的超过三分之一,到2005年稳定在四分之一左右,但这一时期的健康总预算按实际价格计算是原来的四倍,这个事实意味着各种健康开支都能够增加(Shiffman, 2007: 97; Yu et al, 2008)。因此艾滋病开销没有挤出其他健康相关开销。

    此外,如果考虑到抗击艾滋病的工作扩展到针对HIV的健康干预措施之外的方式,艾滋病应对措施似乎就不那么像"历史上最大的垂直项目",而是更像历史上最大的平行项目了。首先,艾滋病与肺结核的关系——二者在世界上多数地区都可以被认为是共同流行病——意味着艾滋病和肺结核是不可分割的。事实上,过去大约十年中人们重新对肺结核感兴趣主要是由于这个。吸毒者中艾滋病与丙肝感染之间的联系、HIV阳性的妇女中人类乳头状瘤病毒和子宫颈癌与普通性传播疾病之间的联系都意味着:当我们谈论艾滋病时,我们是在谈论一个大得多、需要协调应对的传染病网络。除了健康问题之外,艾滋病还涉及跨学科、跨部门和跨越人的生命的多部门应对,以便包括进与教育、人权和工业实践有关的问题。艾滋病推动资金和资源进入一系列广泛的健康和发展领域,在多数地方,这一现象已经产生了跨越各个部门和项目,平行管理艾滋病和相关工作的需要。

    然而,有些反对意见是有基础的,尤其是在某些情况下,艾滋病项目可能把人力资源从基本卫生部门中吸引出来(例如在马拉维);艾滋病开销可能挤出政府在其他领域内的开销(虽然似乎只在赞比亚、莫桑比克和乌干达等面临由国际货币基金组织(IMF)施加的财政限制的国家是这样);外国捐赠者的报告要求给已经不堪重负的服务提供者增加了管理负担;捐赠者的文化价值不适当地决定了发展中国家的艾滋病项目;而且如果捐赠者与公共卫生系统之间更好地协调HIV干预措施,就能实现更好的协作(见Yu et al, 2008; Shakow, 2006; Epstein, 2007)。但即使如此,大部分证据仍然显示:艾滋病项目很可能加强了整体的健康应对措施——尤其是在海地(Walton et al, 2004; Koenig et al, 2004)、墨西哥、莱索托和埃塞俄比亚(Kifle et al, 2008; Yu et al, 2008)。

    艾滋病项目和整个卫生系统的能力之间的关系上需要进行更多的研究;要在针对特定疾病的干预措施和卫生系统支持之间建立更好的协作,就需要更多的努力。这两点现在已经得到了普遍的接受(Ooms et al, 2007; Yu et al, 2008)。但这对联合国艾滋病规划署/世界卫生组织来说简直不是新闻,它们长期以来一直在强调需要处理在针对特定疾病的干预措施上的系统性约束的问题(例如 WHO 2006; UNAIDS 2007)。引进反对意见没有给桌子上带来新的洞察,反而刺激了捐赠者、发展机构和非政府组织之间对外国援助的政治斗争,使那些希望为支持综合卫生系统抽取资源和通过国家政府来分配资金,让公民社会组织在这一过程中靠边站的人拥有权力。

    对使抗逆转录病毒治疗在发展中国家的首展成为可能的创新的艾滋病项目来说,这是个严重的问题。从抗击艾滋病的工作中获得的经验——尤其是社群动员和让医疗保健服务消费者参与决策的重要性——已经被"国家所有"(读作政府控制)和"全部门途径"的新话语所淹没。这已经通过16个国家的国际卫生伙伴计划(International Health Partnership,,IHP,2007年9月启动)造成了重大影响,该计划把主要来自欧洲的捐赠资金分配给发展中国家政府。虽然创办时的"合同"没有明确反对艾滋病资助(事实上提到了艾滋病,文件也有联合国艾滋病规划署的签署),但它为修订议程奠定了基础,在修订后的议程中,《千年发展目标》(MDG)第4和第5条(促进母亲和儿童健康)在与艾滋病竞争(《千年发展目标》第6条),支持更大的卫生系统在与艾滋病相关干预措施竞争,而不是建立在后者的成功之上。

    2008年9月,戈登·布朗(英国首相和国际卫生伙伴计划的主要成员和提议者)与世界银行一道宣布了一个新计划:国际健康医疗资助改革小组(Task Force for Innovative International Financing for Health Systems)。该文件把反对意见当作程式化的事实来重复,说相对于艾滋病来说,《千年发展目标》第4和第5条被"忽视"了,重点应该放在全部门途径和支持综合卫生系统上(TIIFHS, 2009)。作为这一时代精神的具体表现,全球基金没有被包括在小组中——尽管它正在开发各种创新的资助机制,尽管它把艾滋病相关资助作为国家资助的一部分投入到支持综合卫生系统中。

    在某些方面,我们正在目击基本医疗保健议程——1978年在阿拉木图的阐述最为著名——的复兴。但这似乎没有考虑中间这些年里的重要经验教训。首先,使"垂直""平行"途径相竞争是无益的,因为某些医疗干预措施更适合于垂直的项目(例如消灭天花),而另一些(例如控制疟疾)被纳入更大的公共健康计划时工作得更好(Mills, 2005)。艾滋病应对工作的经验还告诉了我们把针对特定疾病的方案纳入更大的供应链管理、人力资源开发和预防筛查的"倾斜"的健康干预措施的价值。

    失败的基本医疗保健议程的第二个教训,是对健康计划采用了老式的公共管理途径,而没有注意到影响实施的"问责和激励的潜在方式"(世界银行,2004:316),这注定要失败。阿拉木图议程的主要缺点,是对政府决策的政治经济成分和国家一级的制度与政治约束破坏捐赠者和计划者意图的方式给予的注意不够(Easterly, 2006)。缺乏易于测量的结果和明确、政治上可行和可持续的向政府问责的机制,支持综合预算的资金可能很容易就会消失在卫生系统之外,把优先干预措施完全消灭。正如赞比亚的经验所显示的,20世纪90年代末,当捐赠者从支持垂直的肺结核项目转向支持"综合"途径时,肺结核项目慢慢停止了(Bosman, 2000)。在考虑不充分的情况下从特别资助艾滋病转向综合资助,可能会有同样的结果。

    总之,我们认为:

    1)对艾滋病相关资助日益增长的失望,似乎更多是由花言巧语的反对意见,而不是由对目前关于艾滋病资助的水平和对卫生系统的影响的证据的周密思考推动的。

    2)转向全部门途径的做法(远离特别针对艾滋病的干预措施,即使是在这给更大的卫生系统带来益处的情况下)对政治经济约束给予的注意不够。

    我们的主张还有:经济学家通过其花言巧语和有缺陷的分析,对反对意见做出了贡献。虽然同样的批评也可能来自其他社会学家,但在这里我们集中于经济学,因为它包含了一系列强有力的分析权衡取舍和影响公共决策的工具。事实上,我们中的一个(Nicoli Nattrass)就曾使用这些工具来证明预防母婴传播在南非是有成本效益的,从而帮助治疗行动运动(Treatment Action Campaign)对政府的政策提出了成功的法律挑战(Nattrass, 2004)。但是经济建模——虽然似乎是"技术的""科学的"——常常建立在远非不证自明或被事实或社会价值证明为合理的假设之上。本文的另一名作者(Gregg Gonsalves)是国际艾滋病活动家,他同样面临被定型为提倡"部门"利益的鼓吹者这一挑战。然而经济学家很少考虑他们可能存在偏见的方式。与Gregg不同——他的活动家角色和身份是明确的——我们在下文中关注的经济学家也是鼓吹者——但他们是偷偷摸摸地这样做,因为他们这样做是藏在经济学的外衣和权威之下。

    恰好因为经济学有经验科学的名声和为公共政策提供帮助的强有力工具,经济学家在进入公共讨论时有一定的权威。然而当经济学家以"经济"分析为幌子提出有政治意味的论点时,这种名声可能被滥用。我们尤其强调了以下三种"谬误"

    1)认为"最理想的"经济分析/结论对社会来说一定是最好的——而不顾人们可能的愿望或想法。我们把这叫"全知的经济学家谬误"

    2)认为狭隘地使用经济学技术一定适合于政策问题——考虑到一系列更广泛的信息和因素可能能够更好地(至少是不同地)处理这些问题。我们把这叫"近视的经济学家谬误"

    3)得出结论说因为政策A有缺点,政策B一定更好,虽然政策B没有受到同样严格的质疑。这是"诉诸无知"谬误的一个版本,因此我们把这叫"无知的经济学家谬误"

    本文其余部分讨论了经济学家对反对为抗逆转录病毒治疗提供艾滋病专用资助的意见做出的两大重要贡献。第一,威廉·伊斯特利(2006)用许多方法表达了反对意见,并给了反对意见以合法性。第二,Mead Over最近的介入(2008),他提出的给美国新总统的建议明明是政治的,却利用了许多经济学的技术和推论当武器。我们认为二人都是诉诸于上述谬误。

 

伊斯特利的探索者和抗逆转录病毒治疗政治经济学

    根据威廉·伊斯特利在他有影响的书《白人的负担》(The White Man's Burden)中的说法,"经济学家的工作是指出权衡取舍",而不是做出关于"无论什么代价"都要付的"乌托邦"声明(2006: 256)。他指控世界卫生组织2001年宏观经济学与健康委员会(Commission on Macroeconomics and Health,CMH)建议发展中国家的健康预算增加国民生产总值的2%,捐赠国的健康援助增加其国民生产总值的0.1%,以改进基本医疗保健、母亲和儿童健康,并且与艾滋病、疟疾和肺结核作斗争(宏观经济学与健康委员会, 2001: 6-12)就是这种乌托邦思想。伊斯特利抱怨宏观经济学与健康委员会报告"在为穷国治疗艾滋病赢得支持者上是有影响的"——按他的观点这是坏事,因为他认为如果扩大的预算被用在其他重点事项上,可以预防更多的死亡(ibid: 258)。

    他特别责备宏观经济学与健康委员会不正视权衡取舍:"在报告的一个不起眼的注释中,委员会提到:人们常问如果只有很少的资金可用,重点应该是什么,但它说这在'道德和政治上'是无法选择的事。最仁慈的观点是:这一声明是委员会得到它所需要的钱的策略。否则,这种拒绝做出选择的做法是不可原谅的。公共政策是用有限的资源尽量做得最好的科学——专业经济学家面对权衡取舍时退缩是玩忽职守。即使你得到了新的资源,你仍然必须决定怎样最好地使用"(2006: 256-7)。

    但是考虑到委员会实际说的话(注释24):"许多人问委员会如果得不到捐款该怎么办——实际上是如何选择把较少的钱用在什么地方。我们被要求给每年数百万很容易预防的死亡分出优先顺序,既然我们已经把我们的重点缩小到少数带来巨大的社会负担而预防——至少是部分有效——成本很低的疾病。这类选择不仅在道德和政治上超出了我们的能力,而且也很难用合理的方法来解决。那些希望有一个简单的答案的人——例如集中于便宜的干预措施(免疫)而把昂贵的干预措施(抗击艾滋病所需的成本较高的预防项目和抗逆转录病毒治疗)推迟到以后——错误地判断了我们所面临的实际选择。除非艾滋病得到控制,否则艾滋病流行会破坏非洲的经济发展;抗击麻疹而不是艾滋病不会开始满足非洲的人类和经济需要。走向另一个极端,让抗击艾滋病的合法需要牺牲急需的较便宜的干预措施,同样也是错误的,因此我们两个都提倡。此外,抗击艾滋病的基础建设发展也会支持抗击麻疹所需的基础建设,尤其是如果加强这种互补性明确成为艾滋病控制工作的组成部分的话。设计和资助一个处理许多重要的健康需要的综合项目,而不是挑选看起来便宜的项目,要有成效得多"(宏观经济学与健康委员会, 2001: 113-4)。

    与伊斯特利对其主张的讽刺相反,宏观经济学与健康委员会没有逃避其做经济分析的职责——它只是考虑了更多因素,而不是只对孤立的干预措施做标准的成本效益比较。此外,宏观经济学与健康委员会明确地通过选择低成本、高收益的干预措施考虑了成本效益问题,还从更大的发展角度出发,认为资助HIV预防和抗逆转录病毒治疗是有意义的,并且认为抗击艾滋病的基础建设和促进基本医疗保健的基础建设之间是互为补充的。一个人当然可以质疑该假设——但不理会它们(像伊斯特利所做的那样)或认为它们不包含可接受的经济分析当然是不公平的。换句话说,伊斯特利的批评不理解或不承认在经济分析中包括进一系列更广泛的信息和关切背后的逻辑,犯了"近视的经济学家谬误"

    在发展领域内从事工作的经济学家所面临的最大困难是明白如何使手中的问题溶入背景和使用哪些工具/经验。经济学学生们知道成本效益和宏观经济学建模等工具可以帮助找到最理想的结果。但公共选择理论和政治经济学的经验是:这种计划可能被质疑、破坏和误导。这可能导致一种"认知不和谐",使经济学家从理想主义地促进最理想结果转向对为什么这些最理想战略不可能有效实施——如果得到实施的话——进行冷嘲热讽的评价。伊斯特利的《白人的负担》是经典的例子:在劝经济学家做好工作的同时,多数内容放在他关于"探索者"——例如应对当地情况的创新者——与政府和援助机构中的"计划者"——他们把自己的重点强加于他人,不激励人们执行自己的计划,也从不核实穷人是否真正从他们的行动中获益——的差异上(2006: 5-6)。他在计划者面前遇到的挫折是如此之大,以至于他竟然总结道"正确的计划就是没有计划"(2006: 5)。然而,正如我们在他对宏观经济学与健康委员会的批评中已经看到的,他似乎认为应该拟订一个不同的计划——而且不知怎么的,神秘地,这个计划会更成功。

    在试图论证另外的计划应该是什么和它为什么会更加管用时,伊斯特利陷入了标准的沼泽。他抱怨说:

    "没人问过非洲的穷人是否愿意看到多数''钱被花在治疗艾滋病上而不是花在他们所面对其他许多危险上。艾滋病活动家所面对的问题不应该是'他们该死吗?',而应该是'我们应该决定让谁去死吗?'"(2006: 258)。

    注意,伊斯特利现在想让我们"问穷人"他们想要什么——一种与他之前鼓吹的使用成本效益工具的技术决策方法非常不同的分配资源方法。因此,我们应该选哪个呢?问穷人;还是让成本效益分析来决定需要做什么,不管他们想要什么?伊斯特利没有言明的回答是穷人实际上不知道他们想要什么,而一位仁慈的经济学家考虑几个拇指规则就能代表他们指出他们想要的东西(这里我们看到了走向"全知的经济学家谬误"的步伐)。根据他的书判断,伊斯特利认为穷人应该/确实想要的东西是:便宜的干预措施(像蚊帐和预防接种),因为"探索者较容易找到提供它们的方法",而艾滋病治疗却复杂得多,要取决于链条中多得多的环节(检测、药物供应、管理副作用等等),因此官僚机构更可能失败(ibid: 260)。换句话说,因为穷人不知道他们想要什么(或者如果他们知道,他们想要的东西会与发展经济学家使用成本效益分析方法认为他们想要的一致),而且受到有着无效率的卫生系统和政府官僚机构的国家的限制,目前分配给艾滋病治疗的钱应该改变方向……

    除了不合逻辑的推论和逻辑跳跃之外,该途径还有三个明显问题。

    ·第一,因为宏观经济学与健康委员会(2001)认可将成本效益计算扩大到包括宏观经济影响和由提供抗逆转录病毒治疗导致的在健康部门中其他地方节约的成本,这可以改变我们给不同的干预措施评级的方法。没有像经济学家认为的那样唯一、视而不见的明显的处理问题的方法。

    ·第二个问题是伊斯特利也没有问穷人他们想要什么——他只是假定如果他们问过,穷人想要的不会是抗逆转录病毒治疗。这公然不顾对来自穷人的治疗行动运动等公民社会组织的实质性支持和非洲指标调查(Afrobarometer)在南非所做的调查,该调查经常显示出对健康——包括艾滋病——开销优先的强烈偏好(Nattrass, 2004: 63-5)。虽然伊斯特利把抗逆转录病毒治疗捏造成是北方国家NGO和"计划者"的发明,但事实上是巴西、泰国和南非等地的穷人支持了使抗逆转录病毒治疗在发展中世界的扩大成为可能的行动。

    ·第三个问题是伊斯特利没有提供他的替代抗逆转录病毒治疗的议程如何和为什么能够成功的分析。他假设远离据称是由外部推动的、计划者导向的抗逆转录病毒治疗措施,就能自动带来更好的、"由探索者推动的"替代措施,这似乎犯了"无知的经济学家谬误"

    当然,伊斯特利正确地强调了自私自利、无效率的官僚主义者的问题。每个人——包括国际卫生伙伴计划——都愿意看到大胆和精力充沛的改革者/探索者承担起发展中国家濒临崩溃的卫生系统,向政府官员问责,要求所有人都能获得基本医疗保健。因此问题变成了:我们如何培养和支持这种勇士?我们的答案是:艾滋病治疗行动的历史指出,社群组织和活动家能够为我们需要的探索者提供所需的肥沃土壤和支持性的组织。具有讽刺意义的是,这恰恰是因为艾滋病问题能够在受艾滋病影响的国家里制造坚定积极的骨干(他们正在日益全球联网),我们已经——首次——看到了支持艾滋病治疗和更好的医疗保健的协调一致的社群行动。正如Yu等人最近在关于艾滋病开销与卫生系统的关系的证据评估中提到的:

    "艾滋病活动家正在越来越多地为获得全面的基本医疗保健的权利而进行倡导。他们也改变了医疗保健服务提供者与顾客之间的动态,从而帮助卫生系统为提供长期护理做好准备,比起提供急性病治疗来,这更需要医疗保健服务提供者与其顾客交换意见。事实上,是艾滋病活动导致人们在健康问题上团结一致,健康问题既是一种人道关切,也是全球化的演化范式的一部分"(2008: 6)。

    换句话说,开发支持艾滋病干预措施和其他基本医疗保健目标的健康基础设施(正如宏观经济学与健康委员会所建议的那样)不仅在技术上是有意义的,而且其政治动态是:一个人更有可能看到发展中国家政府被由于其疾病的性质而正在寻求艾滋病治疗和更好的医疗保健服务的活动家问责。由于没有医务人员、实验室服务、诊断工具、安全可靠的药物供应、基本医疗保健设施和中心医院等等,HIV疾病就不可能得到有效控制,因此成功的抗逆转录病毒治疗首展必定需要加强医疗保健系统。由于抗逆转录病毒治疗的出现,艾滋病变成了慢性可控的疾病,它越来越多地变成了基本医疗疾病而不是专家的关切,这要求发展中国家的卫生系统从强调急性治疗转向慢性病模式,在这种模式中,寻求更好的综合基本医疗保健的活动家和寻求艾滋病治疗的活动家有着共同的利益。

    重复我们前面提到的论点:需要将加强卫生系统作为艾滋病应对措施的一部分,这已经得到了联合国艾滋病规划署和全球基金的长期承认。公民社会组织签署和贯彻这一议程也有一段时间了(例如治疗行动运动动员纳入母婴传播预防和生殖健康服务,以及纳入肺结核和抗逆转录病毒治疗)。由花言巧语的反对意见导致的认为艾滋病干预措施一定是孤立的、破坏公共卫生系统的干预措施,艾滋病活动家不关心更大的公共健康问题,这是神话。显然需要加强卫生系统,但我们应该与艾滋病活动家一起做,通过找到利用公民社会能量的新方法来要求更好的公共卫生系统和向政府问责。

    由于目前国际卫生伙伴计划内部正在推动给国家政府的综合预算支持,因此现在的关键问题是需要确保问责和效率。然而国际卫生伙伴计划尚未从含糊不清地呼吁"良好管理"转向开发"技术完善"的健康战略和"高效实际的服务供应安排"。(资助改革)小组承认,这必须改变政府目前提供医疗保健的方式——但该分析最后以一个保守(和非常联合国)的立场作为结束:任何改变和能力创建都必须回应"由国内推动的改革事项"(TIIFHS, 2009: 4)。因此完全避开了政治经济障碍给有意义的制度改革带来的基本问题——正如伊斯特利自己最中肯地阐述的那样。小组承认向官员问责是有益的,但对如何最好地实现这一点保持沉默。与"艾滋病部门"建设性地合作,而不是让综合健康议程与艾滋病议程相竞争,显然是前进的方法。

    现在我们开始讨论一位经济学家最近对反对意见所做的贡献:Mead Over的贡献(2008)。

 

Mead Over:抗逆转录病毒治疗是一种新的依赖

    Mead Over最近一篇文章的标题《预防的失败:美国全球艾滋病治疗开销日益膨胀的津贴负担及我们对此能做些什么》说了很多。一言以蔽之,该文告诉我们:美国在抗逆转录病毒治疗上的开销不仅是"负担"(坏事),而且正在"膨胀"(坏事而且失去控制),还是一项津贴(另一件坏事,因为必须对此做点什么)。与宏观经济学与健康委员会认为抗逆转录病毒治疗是投资于人力资本和发展相对照,Over把总统防治艾滋病紧急救援计划描述为"国际转移支付项目,或许比得上美国粮食援助"(2008: 6)。Over注意到问题是复杂的,因为:

    "这些受益者非常依赖于继续接受艾滋病治疗,并且与联系艾滋病治疗倡导者的国际网络有联系,任何威胁他们生命的撤回治疗资金的做法都会使美国和其他捐赠国政府在国内和国外遭遇信誉风险,还可能在选票箱中威胁美国的政治家"(ibid: 14)。

    当然,Over是正确的:是富国的转移支付让发展中国家的穷人依靠抗逆转录病毒治疗活下去。在这里我们关心的是他的论述,和他的论点构成对全球团结的新(但是脆弱)形式的破坏的方式。在美国的政治辩论的背景下——他的文章明确地介入了美国的政治辩论——福利是一个高度紧张的话题:从罗纳德·里根到比尔·克林顿之后,"福利"是一个脏词,让人想起懒惰、贫穷的人的形象,通常有非洲裔美国人血统(例如罗纳德·里根的"福利女王"),他们不应得到社会或经济支持,福利项目成为"改革"或消灭(例如克林顿的福利改革计划)的目标。Over把总统防治艾滋病紧急救援计划诬陷为用美国纳税人的钱支持的"新福利项目"的一个例子,反映和加强了这一政治意识形态。

    Over担忧这个事实:美国负责全部外国艾滋病资助负担的大约四分之三,因此承担了大多数的津贴负担(ibid: 14-5)。他报告说,假定治疗人数按现在的比例扩大,到2016年美国资助的抗逆转录病毒治疗人数将会上升到540万(花费45亿美元——大约是美国全部海外援助预算的五分之一),如果我们假设覆盖率扩大到95%,到2016年将上升到1500万人(花费116亿美元)(ibid: 16)。这将占海外援助预算的一半(ibid: 17)。对Over来说,这非常成问题,因为:

    "那些目前依靠艾滋病治疗捐款维持生命的人可能感到他们有权继续治疗,他们的捐赠者签署了一个提供维持生命的药物以交换对良心的信仰的不言自明的合同。此外,国际和国内舆论会让捐赠者负责向已经开始治疗的人们持续提供治疗津贴"(ibid: 18)。

    注意,Over承认:"国际和国内舆论"可能会给捐赠者施加继续治疗的压力。但他不把这看作应该严肃对待的社会偏好,他的论点明确暗示其他议程会更好。这里我们看到了"全知的经济学家谬误"的又一个例子:公共舆论是一回事,但经济学家知道社会(在Over的例子里,是美国社会)的"真实"利益。

    Over制造了一个引人注目的案例:对抗逆转录病毒治疗资助的投入会缩小其他"无条件的"发展资助的余地——然后继续制造了一个不那么引人注目(我们会说是异乎寻常)的案例:这种情况对接受抗逆转录病毒治疗的人来说也同样不是好事:"从接受者一方来说,津贴的负面作用是依赖。那些获得津贴的人一般会依赖津贴,没有比在昂贵的救命药物的案例中更明显的了(ibid: 18)"。人们当然一定要"依赖"让他们维持生命的药物,但是这怎么可能比不依赖——例如死去——更糟?他试图证明依赖对发展中国家来说也是件坏事(依赖使发展中国家通过"后现代殖民关系"与美国绑在一起(ibid: 21))——但他的论点最终是关于美国的政治利益的。

    Over的解决方案有两个层面:美国应该放弃对抗逆转录病毒治疗的双边资助,代之以通过全球基金等多边机构来为治疗提供帮助;以及应该把更多的资金指定给HIV预防而不是治疗。虽然他也提出了一系列无可争议的政策,例如支持促进坚持的项目,创建志愿服务机构,以便为发展中国家的卫生事业提供人力资源,以及促进获得非专利药物,但他把治疗和预防对立起来,让我们回到了抗逆转录病毒治疗首展之前的日子里,当时没有可用的研究来给讨论提供信息。Over认为由于行为去抑制,抗逆转录病毒治疗可能恶化疫情——尽管事实是,与抗逆转录病毒治疗有关的病例的行为去抑制较弱,被大量相反的研究所淹没——他没有注意到抗逆转录病毒治疗通过降低传染性起到的预防作用。

    Over对抗逆转录病毒治疗对HIV预防的影响的过度悲观,与他对抗逆转录病毒治疗首展对卫生系统的影响表现出来的悲观相匹配——该分析同样没有考虑到由于与艾滋病有关的机会感染减少导致的成本节约和对卫生系统的压力减小(ibid: 24-5)。正如巴西(Levi and Vitória, 2002)和南非(Badri et al, 2006)的研究已经显示的,在这方面,抗逆转录病毒治疗首展真的可以节约成本。这里我们看到了"近视的经济学家谬误"——分析中没有考虑一系列更加广泛的关切(在本案例中是节约成本)。

    与伊斯特利一样,Over认为应该把更多的钱分配给HIV预防(ibid: 30)。但他们都没有使用任何证据来支持为什么在与HIV疫情做斗争上,预防会比抗逆转录病毒治疗更成功(因此他们都犯了"无知的经济学家谬误")。事实上,他们支持预防基本上是一相情愿,即他们所拥护的HIV预防是一个理想的理论构想,它似乎假定存在一套在族群水平上有效的强有力、以证据为基础的干预设施,我们所需的所有东西就是使其得到更广泛应用的资源和政治意愿。

    事实上,除了为吸毒者提供的针具交换和其他少数在性工作者等特定的高危群体中进行的干预措施之外,HIV预防项目缺乏在族群水平上有作用的明确证据,可以提出的我们在其他国家和社群中已经看到的发生率发生大的变化的例子可能是由于自发的社群动员,而不是遏止疫情趋势的公共健康项目(e.g. Epstein, 2007)。事实上,预防措施的记录是如此令人失望,以至于继续对抗逆转录病毒治疗感兴趣的原因之一就是它是HIV预防的核心(e.g. Granich et al, 2009)。

    Over通过呼吁对HIV预防进行更多研究承认了这个问题(ibid: 14, 32)。但是,预防研究目前主要集中于生物医学干预措施,例如疫苗和杀菌剂,由于科学上的障碍,这些可能要花几十年才能实现。HIV预防项目的失败不仅仅是由于缺乏资源,也是由于目前使用的干预措施科学基础薄弱;强调生物医学途径的预防概念狭窄;非生物医学途径在强调个人心理而不是导致风险的结构性因素的行为改变模型上的溃败;以及HIV预防的拥护者在批判性地评价自己的工作上的失败。捏造案例把HIV预防说成仅仅是与资源有关的事,为持续"预防失败"铺平了道路,这不符合任何人的利益,而且会阻碍为即将到来的讨论寻找有效的HIV预防战略。

 

结论

    我们已经论证了反对艾滋病相关资助——尤其是抗逆转录病毒治疗——的意见有着放弃最可能给卫生系统带来积极改变的机制——例如动员公民社会——的危险。 Roger England对艾滋病的批评是基于对卫生系统发展的理想化观念,主要是基于理论,而没有面对历史或政治现实,这些历史或政治现实阻碍了我们探索载入《阿拉木图宣言》《Alma Ata Declaration》中的所有崇高的健康观念。

    钟摆正在摆回支持卫生系统而不是针对特定疾病的干预措施,这在国际卫生伙伴计划内部(如上所述)、英国海外开发署(DFID)最近的发言和行动以及英国牛津饥荒救援委员会(Oxfam UK)呼吁"暂停"新的垂直健康计划中显而易见。南方国家的艾滋病活动家——其中多数是基本医疗保健和建设更加有效、负责和再分配的发展型国家的强烈支持者——现在发现自己与以前的盟友和捐赠者发生了矛盾。他们承认更好的卫生系统是可持续和有效的艾滋病应对的关键——但他们合理地怀疑把资源从专用项目转向综合的"能力建设"的要求。正如伊斯特利自己提醒我们的,没有目标的捐款太容易被浪费、转移——在接受国际货币基金组织的调整项目的国家的案例中——或仅仅被用来支持外汇储备。

    自从20世纪40年代殖民官僚首次提到发展的思想以来,我们已经走过了很长的路。我们已经学到:通过公共管理而不是政治经济的眼镜来处理发展政策,注定要失败。除非发展政策可以与对公务员的政治激励相配合,否则这些政策就不会得到成功实施——无论捐赠者和发展计划者把它们设计得多么理性或有效。这就是为什么发展话语——除非稳固地位于一个更大的战略中,以确保国家政府一方有具体、令人满意的行动——有变成花言巧语的危险。更糟的是,由于经验向我们证明的,一次又一次,"能力建设""综合预算支持"的钱太容易得到和被改变用途,发展话语有可能变成偾世嫉俗的花言巧语。参加国际卫生伙伴计划的公民社会代表已经在抱怨让政府对他们所计划的为支持综合卫生系统支付资金的方法负责有多难。

    国际卫生伙伴计划承诺加强卫生系统是值得赞赏的,但我们需要一个更加强调差异的途径来与艾滋病和肺结核等流行病,甚至还有其他确实在发展中世界带来了较高的发病率和死亡率的优先领域——例如儿童腹泻和其他传染病——做斗争。我们需要用承认这些流行病和另一些健康问题需要某些垂直做法的方法来加强卫生系统。削弱全球基金或扩大其权限使其变得过于综合化(例如将其改为全球健康基金)的改变可能既会破坏艾滋病干预措施,也会破坏产生和支持争取更好的艾滋病干预措施和更好的医疗保健的行动的公民社会动员。

    艾滋病在发展中世界中非常成功地推翻了关于国际援助和公共健康干预措施的假设。Ooms(2008)甚至认为捐赠者思想中有从短期、与急救相关的健康援助转向更多接纳发展中国家长期依赖外国援助的"范式转换"。他认为这一范式转换可以被用作建设富国无限期为穷国支付基本医疗保健和艾滋病治疗的全球化形式的"健康团结"的跳板。

    这一论点的一个明显的问题是所谓的范式转换既不普遍也不稳定——正如反对意见明确证明的。艾滋病资金增长如此之快,以至于艾滋病资金的份额与艾滋病在全球疾病负担中的份额大致一致(Stuckler et al, 2008: 1565),这个事实意味着艾滋病资金现在特别易于遇到伊斯特利在2006年提出的权衡取舍问题。除非直截了当地提出这些问题并且系统和理性地处理它们,否则有利于艾滋病和健康工作的"范式转换"会像晨雾一样消失。而且由于权衡取舍问题以这种方式被提了出来,因此我们需要切断综合——全球——级别的关于援助的道德化论述,留下更加针对具体国家的关于实际需要什么的分析。在这方面,批判性的政治经济观点必不可少。

    因此,经济学家怎样才能提供帮助呢?我们认为重要的研究要包括:

    1.对具体国家的健康和发展重点,以及其他经济政策——尤其是国际货币基金组织施加的财政限制——是否成为恰当使用捐款的障碍的研究。经济学家可以通过以下方式提供帮助:宏观经济建模;批判性地分析公共财政和捐款财政;研究社会优先事项(例如实际与人们交谈,批判性地调查政治优先事项,以及用对既定的政治和经济精英的权力敏感的方式来构建发展议程);以及动手实际评估健康和发展问题。

    2.设计不会被寻租者偷窃、被不负责任的官僚政治破坏或用不能得到NGO、活动家等等的监督和斗争的方式实施的健康干预措施。换句话说,这意味着设计能够被伊斯特利的改革者/探索者拥护、监督和实施的干预措施。这需要成本效益分析,但要用吸收进关于"有效"的干预措施是否能够引进和持续,以及如何才能引进和持续的详尽的制度和政治分析的方式来进行。

    3.探索如何利用公民社会组织的力量来进行监督和向政府问责。艾滋病治疗活动家在监督医疗保健供应和促进为更好的医疗保健而斗争上是潜在的有力量的盟友。但不是所有的公民社会计划都一样成功,我们显然需要创新评估方式。

    4.探索如何使健康和发展开销的协同作用最大化。反对艾滋病资金的意见已经产生了使疾病与疾病相竞争、健康与发展相竞争、"平行"的干预措施与"垂直"的干预措施相竞争的无益话语。这使精力和注意从确保艾滋病干预措施、基本医疗保健和发展项目的协同合作的重要——但要困难得多——任务上移开。这意味着促进对新的领域进行经济分析和鼓励经济学家不仅与狭窄的经济学变量打交道,还与制度设计、政治进程和更大的社会/经济目标打交道。

    回到我们开头对全球危机的影响的观察;今天的世界是一个收缩预算和面临困难的权衡取舍的世界。对与艾滋病有关的资金来说,政治和经济环境正在日益变得严酷。但这并不意味着继续抗击HIV是不可能的,也不意味着艾滋病资助议程一定要向其他财政和发展重点割让领土。成本效益分析可以帮助形成关于如何为发展干预措施确定优先顺序的公共讨论。但这种计算应该为讨论提供信息,而不是预先决定讨论的结果。真正的政治和制度动态决定所有可能决定的东西,社会对价值和优先事项的争论深深地影响政策的排序和设计。

 

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>
 

 
> From: wanyanhai@hotmail.com
> To: slm_mouse@hotmail.com
> Subject: 尽快翻译这个文件,5日之前给我?
> Date: Fri, 1 May 2009 07:28:07 +0800
>
> Economics and the Backlash against AIDS-Specific Funding
>
> Nicoli Nattrass
> (University of Cape Town)
>
> Gregg Gonsalves
> (Yale)
>
> Paper for the WHO/World Bank/UNAIDS Economics Reference Group
> 14 April 2009
>
>
> Introduction
>
> This paper discusses the backlash against AIDS-specific funding in
> favour of general health systems support. We argue that this has been
> driven more by rhetoric than evidence and is flawed by its failure to
> recognise the cross-cutting nature of the AIDS response, the powerful
> role that civil society organisations can play in holding governments
> to account and the potential for building better health systems on the
> back of AIDS-specific interventions. We also contend that economists
> William Easterly (2006) and Mead Over (2008) have contributed to the
> backlash through their rhetoric against, and flawed analysis of, the
> rollout of antiretroviral treatment (ART) in developing countries. The
> paper concludes that economists can contribute most constructively
> when they inform rather than pre-empt social choice, cast their
> analytical nets broadly rather than narrowly, and adopt a more
> political-economic perspective.
>
>
> The Backlash
>
> The world economy is in a crisis. International credit markets are
> moribund, global output is shrinking for the first time since the war
> and an estimated 53 million people will sink into poverty in 2009
> (World Bank, 2009). The need for a global response is widely accepted
> and the World Bank is requesting that rich countries devote 0.7% of
> their stimulus packages to a Vulnerability Fund to support hard-hit
> countries. Most of these countries are in Africa and include all the
> HIV hyper-epidemic countries. Yet in the World Bank's assessment of
> what needs to be done, the words HIV and AIDS do not appear and no
> differentiation is made between countries with major health crises and
> the rest (World Bank, 2009). Whereas the Obama Administration is
> planning new massive domestic investments (US$634 million) in health
> as part of the US stimulus package, the international aid agenda seems
> rather different.
>
> The indications are that the era of sharply increasing funding for
> HIV/AIDS is over. There are worrying signals from some donors that
> foreign aid will contract (World Bank 2009) and it already appears
> that the US is falling short on its President's Emergency Fund for
> AIDS Relief (PEPFAR) commitments. Michel Sidibé, the Executive
> Director of UNAIDS, is likely to find it an uphill struggle to get the
> $17 billion needed from donors, and the $8 billion needed from
> affected country governments to meet HIV prevention and ART targets
> over the next two years.
>
> Sidibé's task has been made harder by the widely-held view that
> AIDS-specific funding has had more than its fair share of development
> resources already. Global funding for AIDS rose from $1.6 billion in
> 2001 to $10 billion in 2007 and to $13.7 billion in 2009 (UNAIDS,
> 2008: 188; Sidibé, 2009: 4). The initial impetus, boosted
> significantly in 2003 by the World Health Organisation's '3 by 5'
> campaign and the creation of the Global Fund to Fight AIDS,
> Tuberculosis (TB) and Malaria, was driven by concern about the
> 'exceptional' nature of the AIDS crisis and the socio-economic dangers
> it posed for the world (UNAIDS 2006: 5). The US government
> turbo-charged the funding pool further with PEPFAR. This, together
> with unprecedented contributions from private foundations (notably
> Gates) and the mobilising efforts of the Clinton Foundation
> dramatically expanded HIV prevention and treatment services into
> developing countries. An estimated four million people in developing
> countries now owe their lives to this international effort to scale up
> ART (Sidibé, 2009).
>
> However, even before the global economic crisis, and at the height of
> the long boom which underpinned the increase in global funding for
> AIDS, a backlash was evident. The common theme was that the 'AIDS
> lobby' had garnered an 'unfair' amount of resources, was wasting it on
> socially dubious expenditure and that the money should rather be
> allocated to other objectives (see e.g. Garrett, 2007). Some claimed
> that UNAIDS had deliberately inflated HIV estimates (Chin, 2006;
> Pisani, 2007). This resulted in high-level calls for a 'major
> over-haul of the international AIDS response' (Lewis and Donovan,
> 2007: 532) and defensive responses from UNAIDS and the WHO (De Lay and
> De Kock, 2007). Others argued that UNAIDS had misdirected its program
> efforts, although they differed over whether the resources should
> rather have gone into addressing poverty and development (Stillwaggon,
> 2006) or more aggressively into sexual behaviour change (Epstein
> 2007, 2008; Pisani 2007; Chin, 2006).
>
> The core of the backlash, however, has come from those asserting that
> AIDS-related funding has undermined health systems in developing
> countries. This argument, articulated most aggressively (and
> polemically) by Roger England, holds that the amount of money poured
> into AIDS was not only unwarranted, but actually harmed health
> systems. In a series of opinion pieces in the British Medical Journal
> England (2007a, 2007b, 2008) he argued that AIDS is not the 'global
> catastrophe' claimed by 'AIDS exceptionalists', that donor aid for
> AIDS is out of proportion to the contribution of AIDS to overall
> disease burden and that it would have been more cost-effective to put
> the money into bed nets, immunisations and childhood diseases. He
> accuses UNAIDS of creating and imposing 'the biggest vertical
> programme in history' which has eroded the public health sector (by
> diverting human resources), undermined government efficiency (with
> additional reporting requirements and poorly co-ordinated donor
> activities) and effectively removed national control over spending
> priorities. He proposes that UNAIDS be shut down and that money be
> withheld from the Global Fund until it joins sector-wide basket fund
> arrangements to combine donor and domestic funding (2008: 1072). In
> his view, funding for health systems and funding for HIV amounts to a
> zero-sum game: 'until we do put HIV in its place, countries will not
> get the delivery systems they need.' (2007b: 1073).
>
> However, contrary to England's assertions, the balance of evidence
> suggests that AIDS funding has not been excessive nor at the cost of
> other health programs. WHO funding for HIV is in line with the burden
> of disease caused by AIDS (De Lay et al, 2007; Stuckler et al, 2008:
> 1565) and even though AIDS-specific funding rose from less than 10% of
> health-related aid in the early 1990s to over a third in 2003,
> stabilising back down to about a quarter in 2005, the fact that the
> total health budget quadrupled in real terms over the period meant
> that all categories of health expenditure were able to rise (Shiffman,
> 2007: 97; Yu et al, 2008). AIDS spending thus did not crowd out other
> health-related spending.
>
> In addition, if one takes into account the way in which the fight
> against AIDS has broadened beyond health interventions targeted at
> HIV, the AIDS response looks less like "the biggest vertical programme
> in history", and more like the biggest horizontal programme in
> history. To begin with, the relationship between AIDS and TB, which
> in most parts of the world can be considered a co-epidemic, means that
> AIDS and TB programming are inextricably linked. In fact, the
> resurgence in interest in TB in the last decade or so has largely
> arisen because of this. The linkage between AIDS and hepatitis C
> infection in drug users, the link between human papilloma virus and
> cervical cancer in HIV-positive women and sexually transmitted
> diseases in general, means that when talking about AIDS, one is
> talking about a far larger network of infectious diseases, which has
> required a coordinated response. Moving beyond health, AIDS has
> involved a multi-sectoral response which has cut across disciplines,
> ministries and people's lives to involve issues around education,
> human rights, and industrial practices. AIDS has driven money and
> resources into a wide set of health and development areas and that
> this phenomenon has driven a need to manage AIDS and related efforts
> horizontally in most places, across ministries and programmes.
>
> There is, nevertheless, a basis for some of the backlash concerns,
> notably: that in some cases AIDS programs may have attracted human
> resources away from the primary health sector (e.g. in Malawi); that
> AIDS spending may have crowded out government spending in other areas
> (though this appears to be the case only in countries like Zambia,
> Mozambique and Uganda facing IMF-imposed fiscal ceilings); that the
> reporting requirements of foreign donors have increased administrative
> burdens on already-over burdened service providers; that the cultural
> values of donors have inappropriately shaped AIDS programs in
> developing countries; and that greater synergies could have been
> achieved if HIV interventions had been better co-ordinated between
> donors and with the public health system (see Yu et al, 2008; Shakow,
> 2006; Epstein, 2007). Even so, the balance of evidence suggests that
> AIDS programs probably strengthened the overall health response –
> notably in Haiti (Walton et al, 2004; Koenig et al, 2004), Mexico,
> Lesotho and Ethiopia (Kifle et al, 2008; Yu et al, 2008).
>
> It is now widely accepted that more research is needed into the
> relationship between AIDS programming and overall health systems
> capacity, and that more effort is required to build better synergies
> between disease-specific interventions and health systems support
> (Ooms et al, 2007; Yu et al, 2008). But this is hardly news for
> UNAIDS/WHO which has long stressed the need to address systemic
> constraints on disease-specific interventions (e.g. WHO 2006; UNAIDS
> 2007). The import of the backlash has not been to put new insights on
> the table, but rather to fuel a political struggle between donors,
> development agencies and non-governmental organisations over foreign
> aid and to empower those wishing to extract resources for general
> health systems support and to channel that money through
> country-governments, sidelining civil society organisations in the
> process.
>
> This is serious problem for the innovative AIDS programming which made
> the roll-out of ART possible in developing countries. The lessons
> learned from the fight against AIDS, notably the importance of
> community mobilisation and involving health-care consumers in
> decision-making, has been drowned by a new discourse of 'country
> ownership' (read 'government control') and 'sector wide approaches'.
> This has already had a major impact via the International Health
> Partnership (IHP) of 16 countries (launched in September 2007) which
> channels donor funding primarily from Europe to developing country
> governments. Although the founding 'compact' is not explicitly hostile
> to AIDS funding (indeed, AIDS is mentioned and the document is signed
> by UNAIDS), it set the stage for what has become a revisionist agenda
> where Millennium Development Goals (MDGs) 4 and 5 (to promote maternal
> and child health) have been pitted against AIDS (MDG 6) and where
> broader health systems support has been pitted against, rather than
> built on the success of, AIDS-related interventions.
>
> In September 2008, Gordon Brown (the Prime Minister of the UK and
> leading member and proponent of the IHP) announced a new initiative
> with the World Bank: the Task Force for Innovative International
> Financing for Health Systems. Echoing backlash claims as if they were
> stylized facts, the document states that MDGs 4 and 5 have been
> 'neglected' relative to AIDS and that priority should be given to
> sector-wide approaches and general health systems support (TIIFHS,
> 2009). In a concrete manifestation of the mood of the times, the
> Global Fund was not included in the Task Force – despite it having
> developed various innovative funding mechanisms, and despite
> committing AIDS-related funding to general health systems support as
> part of country grants.
>
> In some respects we are witnessing a revival of the primary health
> care agenda articulated most famously in 1978 at Alma Ata. But this
> appears to be happening without taking on board the key lessons of the
> intervening decades. The first is that pitting 'vertical' against
> 'horizontal' approaches is unhelpful because some health interventions
> were better suited to vertical programs (e.g. the eradication of small
> pox) whereas others (such as malaria control) work better when
> integrated within broader public health initiatives (Mills, 2005). The
> experience of the AIDS response has also taught us the value of
> 'diagonal' health interventions which integrate disease-specific
> protocols with broader supply chain management, human resource
> development and preventative screening.
>
> The second lesson of the failed primary health agenda is that adopting
> an old-style public administration approach to health planning without
> being alert to the 'underlying patterns of accountability and
> incentives' which affect implementation (World Bank, 2004: 316) is
> doomed to failure. The key weakness of the Alma Ata agenda was that
> insufficient attention was paid to the political-economy of
> decision-making within government, and to the ways in which
> institutional and political constraints at country-level undermine the
> intentions of donors and planners (Easterly, 2006). In the absence of
> easily measurable outputs and clear, politically feasible and
> sustainable mechanisms to hold government to account, funds for
> general budget support can all too easily vanish out of the health
> system, killing priority interventions entirely. As the Zambian
> experience shows, when donors in the late 1990s switched from
> supporting the vertical TB programme in favour of an 'integrated'
> approach, the TB program effectively ground to a halt (Bosman, 2000).
> An ill-considered shift from AIDS-specific to general funding could
> have the same result.
>
> In sum, we argue that:
> 1) The growing disenchantment with AIDS-related funding appears to be
> driven more by backlash rhetoric than careful reflection of the
> current evidence about the level and health systems impact of AIDS
> funding; and
> 2) The shift towards sector-wide approaches (and away from
> AIDS-specific interventions even where these have broader health
> systems benefits) pays insufficient attention to political-economic
> constraints.
>
> It is also our contention that economists have contributed to the
> backlash through their rhetoric and flawed analysis. While a similar
> critique could be made of other social scientists, we focus here on
> economics because it comprises a powerful set of tools for analysing
> trade-offs and influencing public policy. Indeed, one of us (Nicoli
> Nattrass) has used these tools to demonstrate the cost-effectiveness
> of mother to child transmission prevention in South Africa, thereby
> assisting the Treatment Action Campaign in its successful legal
> challenge against government policy (Nattrass, 2004). But economic
> modelling, whilst appearing to be 'technical' and 'scientific', is
> often built on assumptions which are far from self-evident, or even
> justified by the facts or social values. The other author of this
> paper (Gregg Gonsalves) is an international AIDS activist and as such
> faces the challenge of being typecast as an advocate promoting
> 'sectional' interests. Yet economists rarely consider the ways in
> which they too may be partisans. Unlike Gregg, whose activist role and
> identity is clear, the economists we focus on below are also advocates
> – but sneakily so because they do so under the cloak and authority of
> economics.
>
> Precisely because economics has a reputation as an empirical science
> with powerful tools to assist public policy, economists enter the
> public debate with a certain authority. Yet this can be abused when
> politically charged arguments are made in the guise of 'economic'
> analysis. In particular, we highlight the following three 'fallacies':
>
> 1) Assuming that 'optimal' economic estimates/conclusions are
> necessarily best for society – irrespective of what people may want or
> think. We call this the 'omniscient economist fallacy'.
> 2) Assuming that the narrow application of economic techniques is
> necessarily appropriate to policy questions which may be better (or at
> least differently) addressed taking into account a broader range of
> inputs and factors. We call this the 'myopic economist fallacy'.
> 3) Concluding that because Policy A has faults, Policy B is
> necessarily better even though Policy B has not been interrogated to
> the same level of rigour. This is a version of the fallacious
> 'argument from ignorance' so we call it the 'ignorant economist
> fallacy'.
>
> The rest of the paper discusses two important contributions by
> economists to the backlash against AIDS-specific funding for ART. The
> first, by William Easterly (2006) in many ways shaped the backlash and
> gave it legitimacy. The second, more recent, intervention by Mead Over
> (2008), is explicitly political in that it is framed as advice for the
> new US President, but employs much of the technical and discursive
> armoury of economics. We contend that both commit the fallacies
> outlined above.
>
> Easterly's 'Searchers' and the Political-Economy of ART
>
> According to William Easterly in his influential book, The White Man's
> Burden, 'it is the job of economists to point out trade-offs' and not
> to make 'utopian' claims about spending 'whatever it takes' (2006:
> 256). He accuses the WHO 2001 Commission on Macroeconomics and Health
> (CMH) of such utopianism for recommending an increase in developing
> country health budgets of 2% of GNP, and in donor country health
> assistance by 0.1% of their GNP, to improve primary health care,
> maternal and childhood health and to combat AIDS, malaria and TB (CMH,
> 2001: 6-12). Easterly complains that the CMH report was 'influential
> in gaining adherents for AIDS treatment in poor countries' – a bad
> thing in his opinion because, he believes, more deaths could be
> prevented if the expanded budget had been allocated to other
> priorities (ibid: 258).
>
> He specifically takes the CMH to task for not confronting trade-offs:
> "In an obscure footnote to the report, the commission notes that
> people often asked it what its priorities would be if only a lower sum
> were forthcoming, but it says it was "ethically and politically"
> unable to choose. The most charitable view is that this statement is
> the commission's strategy to get the money it wants. Otherwise, this
> refusal to make choices is inexcusable. Public policy is the science
> of doing the best you can with limited resources – it is a dereliction
> of duty for professional economists to shrink from confronting
> trade-offs. Even when you get new resources, you still have to decide
> where they would be best used" (2006: 256-7).
>
> But consider what the Commission actually said (footnote 24):
> "Many have asked the Commission what to do if the donor money is not
> made available – in essence, how to triage with less money. We are
> asked to prioritize millions of readily preventable deaths per year,
> since we have already narrowed our focus to a small number of
> conditions that have an enormous social burden and that have low-cost
> interventions that are at least partially effective. Not only is this
> kind of triaging ethically and politically beyond our capacity, but it
> is also exceedingly hard to do in a sensible way. Those who hope for a
> simple answer, for example to focus on the cheap interventions
> (immunizations) while putting off the expensive interventions (higher
> cost prevention programs and antiretroviral therapy needed to fight
> AIDS) to a later date, misjudge the practical choices we face. The
> AIDS pandemic will destroy African economic development unless
> controlled; to fight measles, but not AIDS, will not begin to meet
> Africa's human and economic needs. It would be wrong to go to the
> other extreme as well, and let the legitimate need to fight AIDS end
> up starving the cheaper interventions, so we advocate both. Moreover,
> the infrastructure developed to fight AIDS will support the
> infrastructure needed to fight measles, especially if strengthening
> such complementarities is explicitly built into the AIDS control
> effort. It is vastly more fruitful to design and finance a
> comprehensive program that addresses many critical health needs than
> to pick and choose the apparently inexpensive items" (CMH, 2001:
> 113-4).
>
> Contrary to Easterly's caricature of its argument, the CMH was not
> shirking its duty to do economic analysis – it was simply taking more
> factors into account than is the case with standard cost-effectiveness
> comparisons of isolated interventions. Furthermore, the CMH clearly
> had taken cost-effectiveness considerations into account by selecting
> low-cost, high benefit interventions and was assuming that funding HIV
> prevention and ART made sense from a broader developmental perspective
> and that there were complementarities between building the
> infrastructure to fight AIDS and the infrastructure to promote primary
> health. One can of course contest the assumptions – but it is
> certainly unfair to disregard them (as Easterly does) or assume they
> do not comprise acceptable economic analysis. Put differently,
> Easterly commits the 'myopic economist fallacy' in his critique by
> failing to grasp or recognise the logic behind including a broader set
> of inputs and concerns into an economic analysis.
>
> One of the great difficulties facing economists working in the
> development field is figuring out how to contextualise the question at
> hand, and which tools/lessons to apply. Economics students learn that
> tools such as cost-effectiveness and macroeconomic modelling can
> assist in finding optimal outcomes. But the lessons of public choice
> theory and political-economy are that such plans can be contested,
> subverted and misdirected. This can lead to a form of 'cognitive
> dissonance' in which economists veer from the idealistic promotion of
> optimal outcomes to cynical assessments of why these optimal
> strategies are unlikely to be implemented effectively, if at all.
> Easterly's The White Man's Burden, is a classic example: whist
> exhorting economists to do good work, most of the volume rests on his
> distinction between 'searchers', i.e. innovative agents who respond to
> local conditions, and 'planners' in governments and aid agencies who
> impose their priorities on others, fail to motivate people to carry
> out their plans and never check to see if the poor actually benefitted
> from them (2006: 5-6). His frustration with planners is so great that
> he actually concludes that 'the right plan is to have no plan' (2006:
> 5). Yet, as we have seen in his critique of the CMH, he seems to
> believe that a different plan should have been drawn up – and that
> somehow, mysteriously, this plan would have been more successful.
>
> In attempting to argue for what that different plan should have been,
> and why it would have worked better, Easterly sinks into a normative
> quagmire. He complains that:
> 'Nobody asks the poor in Africa whether they would like to see most
> "new" money spent on AIDS treatment as opposed to the many other
> dangers they face. The question facing AIDS campaigners should not be
> "Do they deserve to die?" but "Do we deserve to decide who dies?"'
> (2006: 258).
> Notice that Easterly now wants us to 'ask the poor' what they want – a
> methodology for allocating resources very different to the technical
> decision-making using cost-effectiveness tools he was previously
> punting. So, which is it? Ask the poor; or let cost-effectiveness
> analysis dictate what is needed irrespective of what they want?
> Easterly's implicit answer is that the poor do not actually know what
> they want, and that a benevolent economist will be able to figure it
> out on their behalf by taking a few rules of thumb into account (i.e.
> we see a move here towards the 'omniscient economist fallacy').
> Judging from his book, Easterly believes that what the poor should/do
> want are: cheap interventions (like bed nets and vaccinations) because
> 'they are simpler for searchers to find ways to administer' whereas
> AIDS treatment is vastly more complicated, depends on many more links
> in the chain (tests, supply of drugs, managing side-effects etc) and
> hence bureaucratic failure is more likely (ibid: 260). In other
> words, because the poor do not know what they want (or if they do, it
> will be in line with what development economists using
> cost-effectiveness analysis think) and are trapped in countries with
> inefficient health systems and government bureaucracy, the money
> currently allocated to AIDS treatment should be redirected….
>
> Aside from the non sequitur and leaps of logic, there are three
> obvious problems with this approach.
> • The first, as recognised by the CMH (2001) is that expanding
> cost-effectiveness calculations to include macroeconomic impacts and
> cost-savings elsewhere in the health sector resulting from ARV
> provision, can change the way we rank different interventions. There
> is not one single, blindingly obvious, way of approaching the issue as
> an economist.
> • The second problem is that Easterly did not ask the poor what they
> wanted either – he just assumed that if they had been asked, it would
> not be ART. This flies in the face of substantial support for civil
> society organizations like the Treatment Action Campaign from poor
> people and the 'Afrobarometer' surveys in Southern Africa which
> routinely show strong preferences for prioritising health spending,
> including on AIDS (Nattrass, 2004: 63-5). Although Easterly frames ART
> as an invention of Northern NGOs and 'planners', it was the poor in
> places like Brazil, Thailand and South Africa that underpinned the
> activism that made the expansion of ART in the developing world
> possible.
> • The third problem is that Easterly provides no analysis of how and
> why his alternative agenda to ART will be successful. He appears to be
> committing the 'ignorant economist fallacy' by assuming that moving
> away from a supposedly externally driven and planner oriented ART
> intervention, will automatically result in a better, 'searcher driven'
> alternative.
>
> Easterly, of course, is correct to highlight the problems of
> self-interested inefficient bureaucrats. Everyone, including the IHP,
> would like to see bold and energetic innovators/searchers taking on
> the crumbling health systems in developing countries, holding
> government officials to account and demanding access to basic health
> care for all. So, the question then becomes: how do we nurture and
> support such champions? Our answer is that the history of AIDS
> treatment activism suggests that community organisations and activists
> can provide the necessary fertile ground and support structures for
> the searchers we need. Ironically, then, it is precisely because AIDS
> is an issue that produces cadres of committed and motivated activists
> in AIDS affected countries (and which are increasingly networked
> globally) that we have seen – for the first time – concerted community
> action in support of AIDS treatment and better health care. As Yu et
> al noted in a recent assessment of the evidence on the relationship
> between AIDS spending and health systems:
> 'AIDS activists increasingly advocate for the right of access to
> universal primary health care. They have also changed the dynamics
> between health care providers and clients, thus helping prepare health
> systems for the delivery of chronic care, which requires much more
> give-and-take between care providers and their clients than does the
> delivery of acute care. Indeed it is the activism for AIDS that has
> created solidarity about health as a concern for humanity, and as part
> of the evolving paradigm on globalization' (2008: 6).
>
> In other words, not only does it make sense technically to develop
> health infrastructure that supports AIDS interventions and other
> primary health care objectives (as suggested by the CMH), but the
> political dynamics are such that one is more likely to see developing
> country governments held to account by activists who are, by the very
> nature of their illness, seeking both AIDS treatment and better health
> care services. As it is impossible to manage HIV disease effectively
> without medical personnel, laboratory services, diagnostic tools, a
> safe and reliable supply of drugs, primary health care facilities and
> referral hospitals etc, a successful ART rollout necessarily requires
> health care strengthening. As AIDS become a chronic manageable illness
> with the advent of ART, it becomes more and more a disease of primary
> care rather than specialist concern, requiring health systems in
> developing countries to move from an emphasis on acute care to a
> chronic disease model, and one in which activists for better overall
> primary healthcare and AIDS treatment have a common stake.
>
> To reiterate the point we made earlier: the need to strengthen health
> systems as part of the AIDS response has long been recognised by
> UNAIDS and the Global Fund. Civil society organisations have also been
> endorsing and carrying through this agenda for some time (for example,
> the Treatment Action Campaign's mobilization to integrate mother to
> child transmission prevention and reproductive health services, and to
> integrate TB and ART services). It is a myth, driven by backlash
> rhetoric, that AIDS interventions are necessarily stand-alone,
> interventions that undermine the public health system and that AIDS
> activists are unconcerned about broader public health. There is
> clearly a need to strengthen health systems, but we should be doing
> this in partnership with AIDS activists and by finding new ways of
> harnessing the energies of civil society to demand better public
> health systems and to hold governments to account.
>
> Given the current push from within the IHP for general budgetary
> support to country governments, the need to ensure accountability and
> efficiency is now the key issue. Yet the IHP has yet to move beyond
> vague calls for 'good governance', for the development 'technically
> sound' health strategies and for 'efficient and effective service
> delivery arrangements'. The Task Team (on innovative finance)
> acknowledges that this entails changing the ways in which governments
> currently deliver health care – but the analysis ends with an
> ultimately conservative (and very UN) stance that any transformation
> and capacity creation must respond to 'domestically driven reform
> agendas' (TIIFHS, 2009: 4). The fundamental problem – as articulated
> most cogently by Easterly himself – of political-economic obstacles to
> meaningful institutional reform, is thus entirely side-stepped. The
> Task Team acknowledges the usefulness of holding officials to account,
> but is silent on how this is best achieved. Working constructively
> with the 'AIDS sector', rather than pitting the general health agenda
> against the AIDS agenda, is an obvious way forward.
>
> We now turn to a discussion of a more recent contribution by an
> economist to the backlash: that by Mead Over (2008).
>
>
> Mead Over: ART as the New Dependency
>
> The title of Mead Over's recent article, 'Prevention Failure: The
> Ballooning Entitlement Burden of US Global AIDS Treatment Spending and
> What to Do about It' speaks volumes. In one short line, we are told
> that US spending on ART is not only a 'burden' (a bad) but is
> 'ballooning' (i.e. bad and out of control) and an entitlement (another
> bad because something must be done about it). In contrast to the CMH
> which regarded ART as an investment in human capital and development,
> Over depicts PEPFAR as an 'international transfer program, comparable
> perhaps to US food assistance' (2008: 6). Over notes that the issue is
> complicated because '
> 'these beneficiaries are vitally dependent on continued receipt of
> AIDS treatment and linked to an international network of articulate
> AIDS treatment advocates, any withdrawal of treatment funding which
> threatens their lives will expose the governments of the US and other
> donor countries to reputational risk at home and abroad and may
> threaten US politicians at the ballot box' (ibid: 14).
>
> Over is, of course, correct in that transfers from rich countries are
> keeping poor people alive on ART in developing countries. Our concern
> here is with his discourse, and the way in which his argument has been
> constructed to undermine this new (but fragile) form of global
> solidarity. In the context of US political debate, and in which his
> piece is an explicit intervention, welfare is a highly charged
> subject: from Ronald Reagan to Bill Clinton and beyond, 'welfare' has
> been a dirty word, which conjures up the image of lazy, poor people,
> usually of African-American descent (e.g. Ronald Reagan's 'welfare
> queens'), who do not deserve social or economic support and welfare
> programs have been targeted for 'reform' or elimination (e.g.
> Clinton's welfare reform initiative). Over's framing of PEPFAR as an
> example of a 'new welfare program' supported with US taxpayer money
> reflects and reinforces this political ideology.
>
> Over worries about the fact that the US is responsible for about ¾ of
> the total external AIDS funding burden and hence bares most of the
> burden of entitlements (ibid: 14-5). He reports that depending on the
> scale up assumptions, the number of people on ART funded by the USA
> will rise to 5.4 million by 2016 (costing $4.5 billion – i.e. about a
> fifth of the USA entire overseas aid budget) or, if one assumes a
> scale up to 95% coverage, to 15 million (costing $11.6 billion) in
> 2016 (ibid: 16). This would take up half the overseas aid budget
> (ibid: 17). This, for Over, is highly problematic because:
> 'Those people whose lives currently are sustained by donor funding of
> their AIDS treatment may feel that they are entitled to continuation
> of that treatment, that their donor has entered into an implicit
> contract to provide life-sustaining drugs in exchange for their
> conscientious adherence. Furthermore, international and domestic
> opinion will hold donors responsible for maintaining treatment
> subsidies to individuals who have already started treatment' (ibid:
> 18).
>
> Note that Over acknowledges that 'international and domestic opinion'
> will probably put pressure on donors to continue treatment. But rather
> than seeing this as a social preference to be taken seriously, the
> clear implication of his argument is that some other agenda would be
> better. We see here another example of the 'omniscient economist
> fallacy': public opinion is one thing; but the economist knows the
> 'real' interests of society (which, in Over's case, pertains to the
> US).
>
> Over makes a compelling case that commitments to ART funding will
> reduce the space for other, 'discretionary' development funding – but
> then goes on to make the far less compelling (we would say, bizarre)
> case that the situation is bad for people on ART as well: 'From the
> recipient's side, the downside of entitlements is dependency. Those
> who receive entitlements typically become dependent on them, and never
> more starkly than in the case of expensive life-giving drugs (ibid:
> 18). Of course people are necessarily 'dependent' on medication that
> is keeping them alive but how could this possibly be worse than not
> being dependent – i.e. being dead? He tries to argue that dependency
> is bad for developing country governments too (in that it ties them to
> the US in a 'post-modern colonial relationship' (ibid: 21)) – but
> ultimately his argument is one about US political interests.
>
> Over's solution is two-fold: that the US should back away from
> bilateral funding of ART and should instead channel support for
> treatment through multilateral institutions like the Global Fund; and
> that more funding should be earmarked for HIV prevention rather than
> treatment. Although he also proposes a set of uncontroversial
> policies, such as supporting projects to promote adherence, creating a
> volunteer service to provide human resources for health to developing
> countries and promoting access to generic drugs, his juxtaposition of
> treatment versus prevention harks back to the pre-ART rollout days
> when no research was available to inform the debate. Over argues that
> ART will probably worsen the epidemic because of behavioural
> disinhibition – despite the fact that the case linking ART to
> behavioural disinhibition is weak and overwhelmed by studies to the
> contrary – and he pays no attention to the preventative impact of ART
> via reduced infectivity.
>
> Over's undue pessimism about the impact of ART on HIV prevention is
> matched by his gloomy take on the impact of the ART rollout on the
> health systems – an analysis which also fails to take into account any
> cost-savings and released pressure on the system resulting from fewer
> AIDS-related opportunistic infections (ibid: 24-5). As studies from
> Brazil (Levi and Vitória, 2002) and South Africa (Badri et al, 2006)
> have shown, rolling out ART can actually be cost-savings in this
> respect. Here we see the 'myopic economist fallacy' – i.e. failing to
> take into account a broader set of concerns (in this case
> cost-savings) in the analysis.
>
> Like Easterly, Over believes that more money should be allocated to
> HIV prevention (ibid: 30). But neither of them mobilise any evidence
> to support why prevention will be more successful at combating the HIV
> epidemic than ART (hence they both commit the 'ignorant economist
> fallacy'). Indeed, their support for prevention is based largely on
> wishful thinking, that is, the HIV prevention they champion is an
> ideal theoretical construct, which seems to assume that a powerful,
> evidence-based armamentarium of interventions with population-level
> efficacy exists and all we need are the resources and political will
> to make them available more widely.
>
> In fact, except for needle exchange for drug users and a few other
> interventions among certain risk groups such as sex workers, clear
> evidence of population level impact of HIV prevention programs is
> scarce and a case can be made that large shifts in incidence that have
> been seen in other countries and communities have probably been due to
> spontaneous community mobilization rather than public health
> programming to stem the tide of the epidemic (e.g. Epstein, 2007).
> Indeed, the record for prevention interventions is so disappointing
> that it is one of the reasons for continued interest in ART as a
> lynch-pin for HIV prevention (e.g. Granich et al, 2009).
>
> Over acknowledges the problem by calling for more research into HIV
> prevention (ibid: 14, 32). However, prevention research is currently
> largely focused on biomedical interventions, such as vaccines and
> microbicides, which due to scientific obstacles, may take decades to
> arrive. The failure of HIV prevention programming is not because of
> the lack of resources alone but a weak scientific basis for the
> interventions currently in use; a narrow conception of prevention
> which emphasizes biomedical approaches; the collapsing of
> non-biomedical approaches into behavior change models which emphasize
> individual psychology rather than the structural factors which drive
> risk; and a failure of HIV prevention proponents to evaluate their own
> work critically. Framing a case for HIV prevention simply as one about
> resources alone paves the way for continued 'prevention failure' which
> is in no one's interest and could set back the quest for effective HIV
> prevention strategies for decades to come.
>
>
> Conclusion
>
> We have argued that the backlash against AIDS-related funding,
> especially ART, runs the risk of abandoning the very mechanisms – i.e.
> a mobilised civil society – which made positive changes to health
> systems possible in the first place. Roger England's critique of AIDS
> is based on an idealized notion of health systems development largely
> based on theory without confronting the historical or political
> realities which have hampered the quest for the lofty notions of
> health for all enshrined in the Alma Ata Declaration.
>
> The pendulum swing back to supporting health systems rather than
> disease-specific interventions is evident within the IHP (as noted
> earlier), in recent DfiD statements and actions and in Oxfam UK's call
> for a 'moratorium' on new vertical health initiatives. AIDS activists
> in the South, most of whom are strong supporters of primary health
> care and of building more efficient, accountable and redistributive
> developmental states, now find themselves in conflict with their
> erstwhile allies and donors. They recognise that better health systems
> are key to a sustainable and effective AIDS response – but they are
> correctly suspicious of calls to divert resources from dedicated
> programmes to general 'capacity building'. As Easterly would himself
> remind us, non-targeted donor support is too easily wasted, diverted
> or – in the case of countries undergoing IMF adjustment programs –
> simply used to shore up foreign reserves.
>
> We have come a long way since the idea of development was first mooted
> by colonial bureaucrats in the 1940s. We have learned that approaching
> development policy through the lens of public administration rather
> than political-economy is doomed to failure. Unless development
> policies can be aligned with the political incentives facing public
> officials, they will not be implemented successfully – no matter how
> rationally or efficiently they are designed by donors and development
> planners. This is why developmental discourse, unless firmly located
> within a broader strategy to ensure concrete, desired action on the
> part of national governments, is in danger of becoming little more
> than rhetoric. Worse still, it may be a cynical rhetoric because
> experience has shown us, time and time again, that money for 'capacity
> building' and 'general budget support' is all too easily captured and
> redirected to other ends. Civil society representatives involved in
> IHP processes are already complaining about how difficult it is to
> hold governments to account for the way they intend to disburse funds
> for general health systems support.
>
> The IHP's commitment to strengthening health systems is commendable
> but we need a more nuanced approach to combating epidemics like AIDS
> and TB, indeed other priority areas which cause high morbidity and
> mortality in the developing world such as childhood diarrhoeal and
> other infectious diseases. We need to strengthen health systems in
> ways that acknowledge the need for some verticality for these
> epidemics and other health issues. A shift which weakens the Global
> Fund, or broadens its mandate to make it too general (i.e. transform
> it into a Global Health Fund) could undermine both AIDS interventions
> and the civil society mobilisation which generated and supported the
> push for better AIDS interventions and better health care.
>
> AIDS has been remarkably successful in overturning assumptions about
> international aid and public health interventions in the developing
> world. Ooms (2008) goes so far as arguing that there has been a
> 'paradigm shift' in the mind of donors away from short-term,
> emergency-related, aid for health towards greater acceptance of
> long-term dependence of developing countries on foreign aid flows. He
> believes that this paradigm shift can be used as a springboard for
> building a globalised form of health solidarity in which rich
> countries pay indefinitely for primary health care and AIDS treatment
> in poor countries.
>
> An obvious problem with this argument is that the so-called paradigm
> shift is neither universal, nor stable – as the backlash demonstrates
> clearly. The fact that AIDS funding has grown so fast, to the point
> where the share of funding for AIDS is broadly in line with the share
> of AIDS in the global burden of diseases (Stuckler et al, 2008: 1565)
> means that AIDS funding is now particularly vulnerable to the
> trade-off questions posed by Easterly back in 2006. Unless these are
> posed squarely and addressed systematically and reasonably, the
> 'paradigm shift' in favour of AIDS and health will disappear like the
> morning mist. And for the trade-off questions to be posed in this
> manner, we need to cut below the moralised discourse about aid flows
> at aggregate, global, level, to more country-specific analyses of what
> is actually needed. And in this respect, a critical, political-economy
> perspective is essential.
>
> So how can economists help? We argue that key research needs include:
> 1. Country-specific explorations of health and development priorities
> and whether other economic policies, notably IMF-imposed fiscal
> ceilings, are acting as impediments to the proper use of donor funds.
> Economists can assist with: macroeconomic modelling; critical analysis
> of public and donor finance; by exploring social priorities (i.e.
> actually talking to people, examining political priorities critically
> and in a way that is sensitive to the vested power of political and
> economic elites to structure the development agenda); and through
> hands-on practical assessment of the health and development.
> 2. Designing health interventions which will not get hijacked by
> rent-seekers, subverted by unaccountable bureaucracies or implemented
> in ways that cannot be monitored and fought for by NGOs, activists
> etc. Put differently, this means designing interventions which can be
> championed, monitored and implemented by Easterly's
> innovators/searchers. This entails cost-effectiveness analysis, but in
> a way that incorporates explicit institutional and political analysis
> of whether and how 'effective' interventions can be introduced and
> sustained.
> 3. Exploring how to harness the power of civil society organisations
> to monitor and hold governments to account. AIDS treatment activists
> are a potentially powerful ally for monitoring health care delivery
> and assisting in the fight for better health care. But not all civil
> society initiatives are as successful as others and there is a clear
> need for innovative forms of assessment.
> 4. Exploring how to maximise synergies in health and development
> spending. The backlash against AIDS funding has created an unhelpful
> discourse in which disease is pitted against disease, and health
> against development and 'horizontal' against 'vertical' interventions.
> This detracts energy and attention away from the crucial – but
> infinitely more difficult – task of ensuring synergies between AIDS
> interventions, primary health and development programs. This means
> pushing economic analysis into new territories and to encourage
> economists to engage not only with narrow economic variables, but also
> with institutional design, political process and broader
> social/economic objectives.
>
> To return to our opening observations about the impact of the global
> crisis; today's world is one of shrinking budgets and difficult
> trade-offs. The political and economic environment is becoming harsher
> by the day for AIDS-related funding. But this does not mean that it
> will be impossible to keep up the fight against HIV, and it does not
> mean that the AIDS funding agenda should necessarily cede ground to
> other financial or developmental priorities. Cost-effectiveness
> analysis can help shape the public debate about how to prioritize
> development interventions. But such calculations should inform such
> debate, not pre-empt it. Real political and institutional dynamics
> shape what is possible, and social contestation over values and
> priorities profoundly affects the rank-ordering and design of
> policies.
>
>
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>
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>
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>
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>
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>
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>
>
> --
> Gregg Gonsalves
> 100 York Street, 10-D
> New Haven, Connecticut 06511
> Email: gregg.gonsalves@gmail.com or gregg.gonsalves@yale.edu
> Mobile: 1-203-606-9149


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