The AIDS crisis in sub-Saharan Africa has received copious media attention in recent years, with unprecedented fund raising efforts, generous government donations and major celebrity endorsements. The effort has proven to be successful in finally curbing the trend in the AIDS epidemic for the first time since its discovery, yet the disease continues to spread as a pandemic in sub-Saharan Africa. Even the most optimistic estimates recognize additional funds are required to maintain the efforts and to avoid a global disaster. While we must meet this challenge and responsibility to eradicate AIDS, we must also carefully examine whether current efforts are addressing the root causes of the epidemic and are able to create a long-term solution. We will outline the current crisis, bring to light the challenges neglected by today's efforts and discuss how building infrastructure will result in a healthier work force and yield long-term benefits.
The sub-Saharan population suffers disproportionately from AIDS in comparison to both the developed and other developing regions of the world. The worldwide spread of HIV has seen exponential growth with the global infected population swelling from 8 million people in 1993, to an estimated 33 million today. Although only 11% of the world's population lives in sub-Saharan Africa, 67% of the global AIDS population lives in the region. The global AIDS death tolls have started to decline after rigorous antiretroviral therapy programs but 72% of the 2 million AIDS deaths in 2007 took place in the region. Infection rates are projected to climb in sub-Saharan Africa where 1.9 of the 2.7 million new infections in 2007 occurred and an overwhelming 90% of children with AIDS live in sub-Saharan Africa.i
Facing the magnitude and urgency of the epidemic, the poor state of the health systems in the region is not only unable to meet the demands but is exacerbated by the challenge. A major obstacle in the efforts to combat AIDS is rooted in the lack of health care personnel to deliver ARV therapies and administer care to AIDS patients, particularly in the rural areas. This dire need is currently met with a strategy used by MSF and others known as task shifting, or allocation of work to lower cadre health workers and to lay workers. MSF reports that despite maximizing capacity by task shifting, a vast number of people in need do not have access to care.ii
In part, the AIDS crisis can be understood as a problem of human resources. The World Health Organization made the link between the weak HIV response and weak health systems and outlined the vicious cycle.iii Additionally, they have suggested that the Global Fund emphasize efforts toward strengthening host country heath systems. iv The delicate health force is further jeopardized by burnout from increased workload, limited ability to respond to HIVAIDS, and risk of transmission in the healthcare setting.
The breadth and scope of the brain drain from sub-Saharan Africa is well known. In Malawi, a country of 13 million people, the public health system is served by only 165 doctors. Emigration of health professionals from countries in sub-Saharan Africa far exceeds that from any other region on the globe.v One fifth of African born doctors and one tenth of nurses were documented to have been working in the developed world in 2000.vi While some argue that the brain drain can be used as a financial advantage to the "exporter" nations of health professionals,vii the financial loss of public investment in educating the workers,viii in addition to the desperate situation the countries face from the dearth of health workers, do not make such arguments unreasonable.
Various social, economic, and political reasons behind the brain drain of doctors and nurses have been studied, but the trend continues with little signs of change. One major cause of the brain drain is the migration of workers to countries that provide better wages and living conditions. The demand for these doctors to fill the growing need for primary care physicians in the US facilitates the migration of the highly educated from impoverished countries. However, the motivation for the migration is not based solely on economic or social incentives. Some studies suggest that many prefer to stay in home countries, close to family and friends, but leave due to frustration caused by the lack of support and resources necessary to perform their duties.ix The driving forces are low moral, subordinate wages, lack of assistance, and inadequate resources to carry out the work, as well as political or social unrest in home countries.
Evaluating the current efforts to fight AIDS taking place in sub-Saharan Africa reveals that a minimal portion of the funding is directed towards building a strong local health system. The funding practices of three major donors with different ideological approaches to the crisis were analyzed by the Center for Global Development in 2007. The three organizations examined, PEPFAR (President's Emergency Plan for AIDS Response), the Global Fund to fight AIDS, Tuberculosis and Malaria, and the World Bank's Multi-Country AIDS Program for Africa (MAP), jointly contributed over half of the global funding for AIDS. Even though MAP was specifically designed by the World Bank to "strengthen a country's capacity to develop a national response to the AIDS epidemic," much of the funding was lost in the administration and only a portion was implemented towards the intended purpose.x
Suggestions made to the three organizations were to work with the host government as steward of the national response, to build local capacity, and to keep the funding flexible by supporting host country priorities. Analysis in three representative countries revealed that a only small proportion of the funding was directed at building up local infrastructure, but instead focused mainly on providing treatment and direct patient care. The donors were also encouraged to disclose their financial data to the public and make their funding practices more transparent.
Development of a cohesive health system structure will have a lasting effect on the health of the country's population not only in combating the AIDS epidemic but improving public health in general. A stronger national health system will be able to better attract and retain local health professionals to fulfill their needs. There will also be immediate benefit of more efficient and effective use of foreign aid funds by replacing foreign workers with local workers who do not require the overhead of transportation costs, a cultural and language adjustment period, and western cost of living.
A well-developed health system will allow preventive methods to increase health, by preventing and treating HIV infections. Furthermore, it will also be able to better prevent and treat other diseases to improve public health of the population. Prevention is superior, as it incurs lower costs and is more humane than treatment of existing illness. Also, many AIDS deaths that result from preventable co-infections and illnesses can easily be eliminated with proper sanitation and preventative care. Raising public health standards will decrease the death toll significantly.
Although lack of human resource is repeatedly discovered to be an obstacle to a strong health system, there are other factors that inhibit its creation. The interrelation between the availability of workers and infrastructure in developing countries appear to be trapped in a viscous cycle, but could potentially be exploited to a positive end. A concerted effort to build a robust health system could reverse the current trend and trigger a positive feedback that encourages workers to stay and potentially migrate back to their home countries. However, before such a health care system can be implemented, one needs to examine the readiness of the country to adopt the system.
Prior to an effective expansion of a government health system, certain macroeconomic preconditions must be met. A developing country's capacity to build up an effective health care structure depends on an adequately developed formal wage, ability to pay, and other socio-economic factorsxi that many countries in sub-Saharan Africa lack. In the long-term view of building up the health system, we must first fight poverty, improve living conditions, and create peace. Overall social wellbeing is interrelated but must begin with health. Without health it is impossible to function or enjoy the benefits society can offer.
Some immediate solutions can be proposed, both practical and ideological. Organizations that work in foreign countries should respect the host country's autonomous efforts and aid in the process whenever possible. They should take care to not overstep their roles and potentially harm or burden the host country through their practices. In recent efforts to address this need, the NGO Code of Conduct for Health Systems Strengthening has been drafted. This committee of concerned organizations, with the goal of minimizing harm to the host country's health system and encouraging cooperation with national governments, included Partners in Health, Physicians for Human Rights among many others.xii Numerous organizations have signed on but many have yet to adopt the Code.
Secondly, retaining a healthy work force in developing countries must be a priority in order to build up the country's efforts to fight AIDS. Allocating some of the increasing donations for AIDS relief towards a long-term project to build up infrastructure could serve as a potential solution. There is some evidence that suggests the recent surge of funding for AIDS has in fact squeezed out other health priorities in the region and shifted attention away from support for the overall health structure.xiii Efficient methods of management and application to meet this end still need to be examined. There also is potential for more to be done in the developed countries to minimize the brain drain from the "exporter" countries.
Focus of our aid programs must be balanced to meet the immediate needs and to work on long-term goals. Humanitarian aid must not be limited to objectives narrowly set forth to cure the sick, but to prevent disease and bring social justice. The causes and solutions to the problem are entangled and we must move towards addressing the problem of AIDS as stemming from poverty and general non-welfare.
As we are currently facing in the US, increasing health care dollars and doctors in a fragmented system will be a very expensive solution, if it can be considered a solution at all. There needs to be proper infrastructure to pipeline the resources, particularly emphasizing the role of preventive primary health care and education. The long-term and priceless benefits of healthier, thriving lives for the populations in autonomous nations can be achieved in developing countries if the current momentum in funding we observe today is employed effectively.xiv
The ultimate goal of foreign aid should be to make itself obsolete by equipping the host country to take control of its own needs. The foreign workers have a responsibility to not only meet the immediate needs of the country but to leave the country with adequate infrastructure to be able to sustain itself in the future. More of the existing foreign aid should be directed at building infrastructure, particularly health systems in countries affected by the AIDS epidemic, by helping them train and retain health workers. An ancient Chinese proverb states: "Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime." The burden lies with foreign aid to teach, and not merely give.
i UNAIDS. 2008 Report on the global AIDS epidemic. (Accessed November 22, 2008, at http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp.)
ii Medicins Sans Frontieres. Briefing Document on HIV/AIDS XVII International AIDS Conference. Mexico City 2008.
iii World Health Organization. Health worker shortages and the response to AIDS. 2006 (Accessed December 1, 2008, at http://www.who.int/healthsystems/task_shifting/en/)
iv World Health Organization Secretariat. The Global Fund Strategic Approach to Health Systems Strengthening. 2007.
v Mullan F. The metrics of a physician brain drain. N Engl J Med 2005; 353:1810-8.
vi Clemens M, Petterson G. New data on African health professionals abroad. Human Resources for Health 2008; 6:1.
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viii Kirigia J, Gbary A, Muthuri L, Nyoni J, Seddoh A. The cost of health professionals' brain drain in Kenya. BMC Health Services Research 2006; 6:89.
ix Mathauer I, Imhoff I. Health worker motivation in Africa: the role of non-financial incentives and human resource management tools. Human Resources for Health 2006; 4:24.
x Oomman N, Bernstein M, Rosenzweig S; Center for Global Development. Following the funding for HIV/AIDS: a comparative analysis of the funding practices of PEPFAR, the Global Fund and World Bank MAP in Mozambique, Uganda and Zambia. (Accessed November 22, 2008, at http://www.cgdev.org/content/publications/detail/14569.)
xi Luck J, Peabody JW. When do developing countries adopt managed care policies and technologies? Part I: policies, experience, and a framework of preconditions. American Journal of Managed Care 2002 Nov;8(11):997-1007.
xii Health Alliance International. The NGO Code of Conduct for Health Systems Strengthening. May 2008. (www.ngocodeofconduct.org)
xiii Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other health issues? Health Policy and Planning 2008; 23(2): 95-100.
xiv Farmer P. From "marvelous momentum" to health care for all: success is possible with the right programs. Foreign Affairs 2007. (Accessed December 2, 2008, at http://www.foreignaffairs.org/special/global_health/farmer)