AIDS Funds: Rwanda

In their Policy Forum “Global HIV/AIDS policy in transition” (11 June, p. [1359][1]), J. Bongaarts and M. Over conclude that antiretroviral therapy for AIDS is not a cost-effective use of donor funding for global health. We believe that Bongaarts and Over omitted key aspects of a complete cost-effectiveness assessment: numerous positive spinoffs to other services, the effect on increased attention on global health, and the ability to mobilize resources that would not otherwise have been available for global health. The situation in Rwanda serves as an example. Rwanda's total health expenditure declined from 1998 through 2002, but because of advocacy for HIV resources, total health expenditure doubled between 2002 and 2003 ([ 1 ][2]). HIV funding, even before the current focus on integration, provided resources for the renovation of health facilities, equipment, training, and management, as well as a culture of openness for best practices. With integration of HIV services into other health services, resources have had an even wider benefit, especially for maternal health services. Integration is still in progress, but successful steps have been made ([ 2 ][3], [ 3 ][4]). Rwanda's 2006 National Health Accounts reported that although reproductive health spending did not grow as rapidly as overall spending, it increased by 15% between 2002 and 2006 ([ 4 ][5]), and maternal mortality rate decreased from 1071 (in 2000) to 750 per 100,000 births (in 2005) and is expected to fall to about 350 in 2010. Rates of assisted deliveries, use of family planning, and receipt of four standard prenatal care services have seen a marked increase ([ 4 ][5]–[ 6 ][6]). Consistent with the results in Rwanda, a recent Lancet article correlated maternal mortality with HIV mortality in women ([ 7 ][7]). These improvements cannot be attributed to reproductive health spending alone; major health initiatives made possible by HIV funding are largely responsible. HIV resources also paid for the community-based health insurance premiums of many of the poorest segments of the population; the funding thus contributed to the increase in community-based health insurance enrollment rate from 7% in 2003 to 85% in 2008. The literature cited by Bongaarts and Over failed to consider all benefits gained beyond direct HIV services, including the value of saving a mother and its contribution to quality of life for her children and family and societal productivity. In doing so, Bongaarts and Over have greatly underestimated the impact of HIV funding on both HIV and non-HIV health results. 1. [↵][8] Rwanda Ministry of Health, “National health accounts 2006” (2008). 2. [↵][9] National AIDS Commission, “National strategic plan 2009–2012” (2009). 3. [↵][10] UNAIDS, “Rwanda country progress report 2008–2009” (UNAIDS, Geneva, 2010). 4. [↵][11] Rwanda Ministry of Health, “Rwanda demographic and health survey 2000” (2001). 5. Rwanda Ministry of Health, “Rwanda demographic and health survey 2005” (2006). 6. [↵][12] Rwanda Ministry of Health, “Rwanda demographic and health survey 2007–2008” (2009). 7. [↵][13] 1. M. C. Hogan 2. et al ., Lancet 375, 1967 (2010). [OpenUrl][14][CrossRef][15][PubMed][16][Web of Science][17] [1]: /lookup/doi/10.1126/science.1191804 [2]: #ref-1 [3]: #ref-2 [4]: #ref-3 [5]: #ref-4 [6]: #ref-6 [7]: #ref-7 [8]: #xref-ref-1-1 "View reference 1 in text" [9]: #xref-ref-2-1 "View reference 2 in text" [10]: #xref-ref-3-1 "View reference 3 in text" [11]: #xref-ref-4-1 "View reference 4 in text" [12]: #xref-ref-6-1 "View reference 6 in text" [13]: #xref-ref-7-1 "View reference 7 in text" [14]: {openurl}?query=rft.jtitle%253DLancet%26rft.stitle%253DLancet%26rft.aulast%253DMcCaw-Binns%26rft.auinit1%253DA.%26rft.volume%253D375%26rft.issue%253D9730%26rft.spage%253D1967%26rft.epage%253D1968%26rft.atitle%253DNew%2Bmodelled%2Bestimates%2Bof%2Bmaternal%2Bmortality.%26rft_id%253Dinfo%253Adoi%252F10.1016%252FS0140-6736%252810%252960924-5%26rft_id%253Dinfo%253Apmid%252F20569839%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [15]: /lookup/external-ref?access_num=10.1016/S0140-6736(10)60924-5&link_type=DOI [16]: /lookup/external-ref?access_num=20569839&link_type=MED&atom=%2Fsci%2F330%2F6001%2F176.1.atom [17]: /lookup/external-ref?access_num=000278689600024&link_type=ISI