Getting science into international aid

Abstract

C P Snow once famously observed that there was a cultural divide between “literary intellectuals” and scientists. Now it appears that another cultural divide, that between international aid and science, may be emerging in the plans for the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), the public-private partnership fund of US$7–10 billion that is the brainchild of UN Secretary General Kofi Annan.Plans for this global health fund are moving forward quickly, perhaps too quickly. A Transitional Working Group, whose representatives come from more than 40 countries, UN agencies, the World Bank, private groups, and non-governmental organisations (NGOs), was established in July, with the aim of having an operational fund by the end of this year. Last weekend, negotiators in Brussels met to hammer out a governance structure for the fund, with input from several of the largest donor nations, including the UK, whose Department for International Development has often been thought sceptical of the workability of the effort. In June, Clare Short, the UK's Secretary of State for International Development, called the publicity around the fund “a piece of nonsense”, suggesting that such a project was unwieldy and impossible to administer.This latest meeting followed on from two others involving many stakeholders, including NGOs. A final meeting is to be held in mid-December, at which time the working group is expected to disband, handing over control of the fund to a governing board.The goals of the fund are laudable: it aims to be transparent and accountable, to involve active participation from persons living with HIV/AIDS, and to disburse monies in a streamlined and nimble manner, using countrywide approaches in projects that focus on measurable outcomes. The fund wants to use the national plans that countries already have in place, employing existing coordination mechanisms and without duplicating programmes. Part of the fund's premise is that “business as usual will not suffice”. Scientific peer review of proposals to the fund may be in danger of taking a back seat to plans for the structure and governance of the fund, making the situation look very much like little is changing. Although one of the fund's stated principles is the evaluation using “independent review processes based on the most appropriate scientific and technical standards that take into account local realities and priorities”, background materials are light on the details of what would constitute appropriate review. One proposed framework of responsibilities describes the job of a technical review panel, with members drawn from UN technical agencies, as advice-givers, but without specifying the level of expertise or scientific rigour needed. It further recommends that members be experts in all three diseases, and that the panel should take into account concerns other than technical ones, such as governance issues—recommendations that seem naïve and unfocused at best.Proposals to the fund should be subjected to a rigorous, systematic process of case-by-case peer review (see Lancet 2000; 356: 521), similar to the way proposals to the US National Institutes of Health are evaluated. This process should be led by an independent panel of medical and scientific experts from both North and South, who are committed to examining proposals in the light of the best available evidence and practices, without using cost-effectiveness as the highest criterion. Expert peer review would provide safeguards against funding proposals that are not scientifically sound, as has occurred in other disease-control programmes such as malaria eradication. And it should encourage projects that are grounded in real-world perspectives from people working in the countries involved. Developing countries would have important input into the direction of their own projects while being assured of the highest level of critique and advice. In such a system, donors would not be dictators, as has often been charged, and there would be no cultural divide between the international-aid community and scientists. Instead, proposal review would be left to those best prepared to do it—the academic scientific and research community. C P Snow once famously observed that there was a cultural divide between “literary intellectuals” and scientists. Now it appears that another cultural divide, that between international aid and science, may be emerging in the plans for the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), the public-private partnership fund of US$7–10 billion that is the brainchild of UN Secretary General Kofi Annan. Plans for this global health fund are moving forward quickly, perhaps too quickly. A Transitional Working Group, whose representatives come from more than 40 countries, UN agencies, the World Bank, private groups, and non-governmental organisations (NGOs), was established in July, with the aim of having an operational fund by the end of this year. Last weekend, negotiators in Brussels met to hammer out a governance structure for the fund, with input from several of the largest donor nations, including the UK, whose Department for International Development has often been thought sceptical of the workability of the effort. In June, Clare Short, the UK's Secretary of State for International Development, called the publicity around the fund “a piece of nonsense”, suggesting that such a project was unwieldy and impossible to administer. This latest meeting followed on from two others involving many stakeholders, including NGOs. A final meeting is to be held in mid-December, at which time the working group is expected to disband, handing over control of the fund to a governing board. The goals of the fund are laudable: it aims to be transparent and accountable, to involve active participation from persons living with HIV/AIDS, and to disburse monies in a streamlined and nimble manner, using countrywide approaches in projects that focus on measurable outcomes. The fund wants to use the national plans that countries already have in place, employing existing coordination mechanisms and without duplicating programmes. Part of the fund's premise is that “business as usual will not suffice”. Scientific peer review of proposals to the fund may be in danger of taking a back seat to plans for the structure and governance of the fund, making the situation look very much like little is changing. Although one of the fund's stated principles is the evaluation using “independent review processes based on the most appropriate scientific and technical standards that take into account local realities and priorities”, background materials are light on the details of what would constitute appropriate review. One proposed framework of responsibilities describes the job of a technical review panel, with members drawn from UN technical agencies, as advice-givers, but without specifying the level of expertise or scientific rigour needed. It further recommends that members be experts in all three diseases, and that the panel should take into account concerns other than technical ones, such as governance issues—recommendations that seem naïve and unfocused at best. Proposals to the fund should be subjected to a rigorous, systematic process of case-by-case peer review (see Lancet 2000; 356: 521), similar to the way proposals to the US National Institutes of Health are evaluated. This process should be led by an independent panel of medical and scientific experts from both North and South, who are committed to examining proposals in the light of the best available evidence and practices, without using cost-effectiveness as the highest criterion. Expert peer review would provide safeguards against funding proposals that are not scientifically sound, as has occurred in other disease-control programmes such as malaria eradication. And it should encourage projects that are grounded in real-world perspectives from people working in the countries involved. Developing countries would have important input into the direction of their own projects while being assured of the highest level of critique and advice. In such a system, donors would not be dictators, as has often been charged, and there would be no cultural divide between the international-aid community and scientists. Instead, proposal review would be left to those best prepared to do it—the academic scientific and research community. Donor responsibilities in rolling back malariaThe previous global campaign to eradicate malaria failed. This WHO-led campaign lasted from 1955 to 1969. A new campaign, Roll Back Malaria (RBM), was launched in October, 1998. It must not be allowed to fail. Malaria accounts for more than a million deaths annually. Since the mid-1960s malaria itself is estimated to have slowed economic growth in highly malarious areas by 1·3% per year. If not for this negative growth, Africa's gross domestic product would be US$100 billion greater than it is now. Full-Text PDF