Can the Third World Spend the AIDS Money Well?

This week's Paris conference on Aids in the developing world is likely to be dominated by the rich countries arguing over who can promise the biggest spending commitment.

Behind the competitive compassion remain concerns about whether the wave of money about to hit Africa and other poor regions can be well spent - and particularly whether large-scale drug treatment is practical in a continent where basic health care remains out of reach for so many. But doctors and non-governmental organisations active in poor countries are pressing hard to show what is possible.

The slowness and difficulty of delivering aid money in countries dogged by corruption and weak governments is well known. The Geneva-based Global Fund against Aids, Tuberculosis and Malaria, which has now awarded around $1.5bn (€1.3bn, £917m) in grants, largely to sub_Saharan Africa, started off slowly as it developed its own mechanisms for receiving applications and monitoring spending.

With this in mind, a key US congressional committee tried last week to redirect more of the $2bn US Aids spending planned for next year away from US bilateral programmes - which as yet exist only on paper - and towards the global fund. "The global fund has in place the monitoring, the oversight, the control mechanisms, the procurement," says Jim Kolbe, the Republican congressman who chairs the committee. "I was frustrated for a while that it went slowly, but I think in retrospect it was done right."

The US is highly sensitive to aid money being misspent. And the global fund has run into its own problems during its short life, with bureaucratic squabbles in recipient countries about who manages its grants, along with the need to ensure that money is not embezzled. Though some of the initial caution about the fund has dissipated, some European governments question the wisdom of yet another aid mechanism for a continent already groaning under the the bureaucracy needed to deliver and account for money from many different sources.

There are also doubts about whether Aids treatment programmes can work in poor countries with weak health infrastructure. In its Aids initiative, the US administration has latched on to Uganda's "network model" - which US president George W. Bush visited last week - in which drug and preventative treatment is co-ordinated via a web of hospitals linked with smaller health centres and spreading out to local clinics.

Some development practitioners wrily note this is the sort of integrated European-style public health system that the Bush administration would never contemplate for the US. More substantively, they are concerned that the model will prove hard to replicate in other African countries with less-well-developed public health systems.

Rachel Cohen, US director of the international medicines access campaign for the non-governmental organisation Médécins Sans Frontières (MSF), says of the US administration: "They are giving the impression - and it may only be an impression - that there is a one-size-fits-all approach, whereas the one thing we have learned from working in Africa is that you have to adapt."

US officials counter that they are receptive to local conditions. "You have to adapt whatever system you have to an African system," says Anthony Fauci, director of the national institute of allergy and infectious diseases, who advised the White House on its Aids initiative. And whatever the bureaucratic challenges, Dr Fauci notes that most of the medical infrastructure required, both physical and human, is far less complex than the technology used for Aids treatment in rich countries.

Doctors and organisations such as MSF are working hard to overcome the worst fears about what is technically possible. They say that in a number of small-scale projects across Africa and other developing regions, low-tech Aids treatment programmes show initial success. They use cheaper assessments of patients' immune systems such as monitoring "CD4" blood cells rather than the more expensive laboratory-based viral load testing typical of Aids treatment in rich countries. And they say fears that experimental Aids treatment programmes could create drug resistance problems have largely been disproved.

The current patchwork of scattered pilot Aids treatment projects in the developing world does not prove beyond doubt that billions of dollars in aid can be spent well. There are too few and they have too short a track record. But advocates insist they show that blanket scepticism about Aids treatment in Africa is no longer justified.

Paul Farmer, a physician at Harvard University, helped to set up an Aids treatment programme in a poor and remote region of Haiti, whose antiretroviral drugs are purchased by a grant from the global fund. He says fears over infrastructure are much overdone.

"The most important infrastructure is human - community health workers to make sure the patients take the meds correctly," says Dr Farmer. Though doctors and high-technology labs would be nice to have, he says, "these are not the things that we need to save lives".