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Africa: Health Policy Reports
AfricaFocus Bulletin
Jul 17, 2004 (040717)
(Reposted from sources cited below)
Editor's Note
Health systems in Africa are being drained by an exodus of health
personnel to wealthy countries, even as the need for professionals
to implement new AIDS programs and reconstruct battered health
systems grows ever more urgent. A new report from Physicians for
Human Rights proposes new measures by both rich and poor countries
to address this crisis, including compensation by rich countries
for the immigrant professionals they are using to bolster their own
health personnel shortages.
The human resource shortage is one of the key structural obstacles
facing not only the war against the AIDS pandemic but also the more
general health crisis of which it is the most visible indicator.
Other obstacles still include funding shortfalls, the failure to
address the debt burden of affected countries, the continuing
resistance by the United States to the use of generic drugs, and
the widespread failure to move from words to action in addressing
the role of gender inequality in fueling the pandemic,
This AfricaFocus Bulletin contains (1) a press release from
Physicians for Human Rights on its new "Brain Drain" report, (2)
announcement of a new report on Women and HIV/AIDS from three UN
agencies, and (3) excerpts from an overview progress report on AIDS
treatment from the World Health Organization . Another AfricaFocus
Bulletin sent out today includes a roundup report on the
International AIDS Conference in Bangkok and brief excerpts
from a report on the U.S. Global AIDS program from the Government
Accountability Office.
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BRAIN DRAIN: The exodus of doctors and nurses from the
AIDS-affected countries of sub-Saharan Africa to wealthier
nations
Physicians for Human Rights (Boston)
http://www.phrusa.org/campaigns/aids/bangkok/braindrain.html
Press Release, July 15, 2004
Bangkok
We are paid so little that all of us in the medical profession
think about going overseas. I don't want to go, but I want to
work in modern conditions. I want to be paid enough to support my
family. That means I must go to Britain, or maybe Australia. -
New doctor, Zimbabwe
The severe shortage of health professionals in Africa is a huge
barrier to expanding AIDS treatment and care and other health
goals. African countries, donor governments, and international
institutions must link their responses to AIDS to a broader
initiative to build equitable health systems in Africa, with
special attention to strengthening human resources and ensuring
the right to health care for all, said a report released today by
Physicians for Human Rights (PHR) and its Health Action AIDS
campaign.
An Action Plan to Prevent Brain Drain: Building Equitable Health
Systems in Africa, was presented in Bangkok at the XV
International AIDS Conference today, with the theme, "Access for
All." The PHR report addresses such equity issues by offering a
series of recommendations to meet people's health care needs by
paying more attention to human resources. These proposals include
improvements in health infrastructure, higher salaries and
benefits for health workers, enhanced investment in training
institutions, reduced recruitment by wealthy nations and
capacity-building for human resources management.
Right now, some 38 countries in sub-Saharan Africa, more than 75%
of the region's countries, fall short of the World Health
Organization (WHO) minimum standard of 20 physicians per 100,000
population; 13 of these countries have five or fewer physicians
per 100,000 population. Countries are losing health professionals
to wealthier nations. Zambia's public sector retained only 50 of
the 600 physicians that have been trained in the country's
medical school from approximately 1978 to 1999. Nursing shortages
are severe too. Approximately 17 sub-Saharan countries do not
even have half of the WHO minimum standard for nurses, 100 nurses
per 100,000 population.
Health workers are leaving their countries because they refuse to
practice in second-class health systems, where they practice in
unsafe conditions, where they cannot begin to meet the needs of
their patients, and where their salaries can't meet their own
needs, the report said.
"Solutions exist," said Eric A. Friedman, Physicians for Human
Rights Policy Associate and author of the new PHR report. "If
governments commit the resources and if everyone involved in
health sector financing and planning recognizes the urgent need
to implement strategies that will bolster human resources, the
nations of the world can achieve their AIDS treatment and other
health goals. The primary response to brain drain must be to
redress second-class health systems that reflect widespread
violations of the right to health and other rights."
He continued, "Meeting these goals requires a renewed commitment
to equity. Just as intolerable gaps exist between health care in
rich and poor countries, the gaps between rich and poor, between
urban and rural areas within countries must be closed."
Shortages of health professionals and access to care are
especially acute in rural areas. With donor support, African
countries should increase investment in rural health
infrastructure, provide incentives to health professionals to
work in under-served areas, and re-orient health professional
training and recruitment practices to increase the number of new
health professionals who decide to work in rural areas.
While the health sector human resources crisis would exist even
without HIV/AIDS, the AIDS crisis is central to the shortages of
health professionals. Many health professionals die of HIV/AIDS
and HIV/AIDS is increasing the workload at health facilities.
Meanwhile efforts in countries that have begun to scale-up AIDS
treatment, such as Botswana and South Africa are being hampered
by the dearth of health professionals.
Other recommendations in the report include:
- African countries, with donors support as necessary, should
implement and fully fund infection control procedures, such as
ample supplies of gloves, syringes and sharps with safety
features to protect health workers.
- Donors should help African countries increase salaries and
benefits within a context of fair salary structures. Countries
should apply to the Global Fund to Fight AIDS, Tuberculosis and
Malaria for costs of increased salaries and benefits.
- African health training institutions should re-orient their
curricula to be more relevant to local circumstances and should
focus recruitment on students from rural areas, who will be more
likely to practice in these underserved areas upon their
graduation.
- Wealthy nations must address their own shortages of health
professionals, especially in rural areas.
- Health professionals need tools to do their jobs. African
countries, with the assistance of the United States and other
wealth countries, should rehabilitate their health facilities,
ensuring phone service, electricity and safe water, functioning
equipment, and a consistent supply of medicines and other key
items.
- African governments and the health profession must reassess the
roles of nurses, mid-level health workers, and community health
workers, and the potential for increasing their responsibilities.
As these workers receive new responsibilities, they will require
increases in salaries, supervision, and training.
- Wealthy countries and health training institutions in these
nations should develop programs to enable health professionals in
these countries to work in African countries that cannot meet
their human resource needs through native health professionals.
These foreign health professionals can help build capacity and
deliver services. Members of the African health professional
diaspora can make an important contribution to health care in
Africa.
- Low-income countries that are the source of health
professionals who migrate to wealthy nations should be reimbursed
by those nations.
- Budgetary spending caps driven by macroeconomic concerns often
result in limitations on the amount of money countries spend on
health and other social sectors. The International Monetary Fund
and donor and recipient governments must work together to remove
the ceilings on these sectors or make them more flexible.
At present, sub-Saharan Africa's health systems are dramatically
underfunded. The US State Department reports that "overall public
health spending is less than US $10 per capita in most African
countries." The Commission on Macroeconomics and Health urges
donors to contribute an additional $22 billion by 2007 to health
sectors of low- income countries to cover basic health care
intervention.
"The health consequences of brain drain are enormous and result
from practices of both developed and developing countries," said
Leonard S. Rubenstein, PHR Executive Director. "Rich and poor
nations each have responsibilities to secure people's right to
the highest attainable standard of health in Africa and other
regions of the developing world."
Action Against AIDS must Address Epidemic's Increasing Impact on
Women, Says UN Report
14 July 2004
UNAIDS, UNIFEM, UNFPA
Contact: Leigh Pasqual
leigh.pasqual@undp.org
BANGKOK, 14 July 2004 - Action against HIV/AIDS that does not
confront gender inequality is doomed to failure, according to a
report released today by the Joint United Nations Programme on
HIV/AIDS (UNAIDS), the United Nations Development Fund for Women
(UNIFEM) and UNFPA, the United Nations Population Fund.
[report available at
http://www.unfpa.org/publications/index.cfm?ID=190]
Noting that women are now nearly half of all people infected with
HIV, the report documents the devastating and often invisible
impact of AIDS on women and girls and highlights the ways
discrimination, poverty and gender-based violence help fuel the
epidemic.
The report, Women and HIV/AIDS: Confronting the Crisis , reveals
that 48% of all adults living with HIV are women, up from 35% in
1985. Today, 37.8 million people are infected worldwide: 17 million
of them are female. The situation is even more alarming in
sub-Saharan Africa, where women make up 57% of those living with
HIV, the virus that causes AIDS. Young African women aged 15-24 are
three times more likely to be infected than are their male
counterparts.
Without AIDS strategies that specifically focus on women, there can
be no global progress in fighting the disease. Women know less than
men about how to prevent infection, and what they do know is often
rendered useless by the discrimination and violence they face,
according to the report.
"Promoting concrete actions that address the reality of women's
lives and help decrease their vulnerability to HIV is the only way
forward," said Dr Kathleen Cravero, Deputy Executive Director of
UNAIDS. "We must reduce violence against women, ensure greater
access to HIV prevention and treatment services and protect their
property rights."
Confronting the Crisis focuses on key areas identified by the
Global Coalition on Women and AIDS - an international pressure
group - as critical to an effective AIDS response. The Coalition is
a broad-based initiative launched in 2004 to stimulate concrete
action to improve the daily lives of women and girls infected and
affected by HIV and AIDS.
These critical areas include HIV prevention, treatment,
care-giving, education, gender-based violence and women's rights.
Women have the right to education and information needed to protect
themselves, and to female-controlled protection methods. They have
the right to own or inherit land and property and to pursue
independent livelihoods. They have the right to be free from
harmful traditional practices and violence. They have the right to
exercise control over their own bodies and lives.
"The ABC approach - Abstain, Be faithful, use Condoms - is not a
sufficient means of prevention for women and adolescent girls,"
said UNFPA Executive Director Thoraya Obaid. "Abstinence is
meaningless to women who are coerced into sex. Faithfulness offers
little protection to wives whose husbands have several partners or
were infected before marriage. And condoms require the cooperation
of men."
"The social and economic empowerment of women is key. The epidemic
won't be reversed unless governments provide the resources needed
to ensure women's right to sexual and reproductive health," she
added.
[AfricaFocus note: The U.S., which places a high stress on
abstinence in its AIDS programs, announced yesterday that for the
third year in the row it will withhold $34 million in funding from
the UNFPA, for its alleged indirect support of abortion programs in
China. The amount the U.S. is not paying represents a little more
than 10 percent of the budget of the international agency, which is
a lead agency in support of women's reproductive health.]
Despite the odds stacked against them, many women have become
leaders in the battle against HIV/AIDS. Confronting the Crisis
offers a number of stories of women from across the globe who are
taking innovative action to face the epidemic. These women are
battling to change AIDS policies and strategies, and calling for
funding to be directed to meeting women's needs and circumstances.
Noeleen Heyzer, Executive Director of UNIFEM, said that "gender
inequality has turned a devastating disease - AIDS - into an
economic and social crisis."
"The crisis requires the infusion of serious resources into
programmes and policies that promote gender equality and women's
empowerment," she added. "These must be grounded in the knowledge
and experiences of women living and working in communities affected
by HIV/AIDS. Women are not just victims, they are agents of change.
Infected and affected women's voices must be heard and their
leadership invested in. To end this triple threat of HIV/AIDS,
gender inequality and poverty, women must have the right to
economic independence and equal access to land, property and
employment, and to a life free of stigma, violence and
discrimination."
"3 by 5" Progress Report
December 2003 through June 2004
[brief excerpts only; full report available on
http://www.who.int/3by5/en]
On World AIDS Day 2003 we announced a strategy to facilitate
reaching "3 by 5" 3 million people in developing and transitional
countries receiving antiretroviral therapy by the end of 2005. If
countries and the international community continue to intensify
their efforts, we will reach this target, and that will set us on
the road towards our ultimate goal of universal access to treatment
for all those who need it.
Since we published the "3 by 5" strategy, we have been working to
help break through obstacles and ensure that the people in need of
treatment can get it. We have established the AIDS Medicines and
Diagnostics Service to assist countries with the information and
technical assistance they need to purchase high-quality AIDS
medicines and diagnostic tools. WHO has strengthened the
antiretroviral pre-qualification project to assess the quality of
medicines against rigorous international criteria. We have sent
staff to more than 20 countries to respond to specific requests for
help. We have worked to build a network of partners who have joined
us in committing to the goal of delivering treatment to people
where and when they need it. We believe that the building blocks,
supported by many partners, are now in place to rapidly increase
the availability of antiretroviral therapy on a large scale.
Countries were quick to respond to the promise of "3 by 5". Forty
requested technical support almost immediately, and many more
followed. However, the funding needed to implement WHO's
contribution to the strategy did not become available as quickly as
we had expected. We therefore reviewed our options and focused on
using the staff and other resources already available within WHO as
effectively as possible.
More funding has recently been made available, particularly from
the Government of Canada, which made a generous pledge of CAD 100
million to fund the "3 by 5" initiative, and from the Governments
of the United Kingdom and Sweden. The combination of this new
funding and the political will needed to increase the availability
of treatment, prevention and care strongly improves prospects for
controlling the worst global epidemic the world has ever faced.
I am well aware that we and our partners have set an ambitious
goal. That is just what we needed: a difficult, time-limited
undertaking that would force us to change the way we work at WHO.
"3 by 5" is the best way to challenge ourselves to make the
contribution we should be making to the global effort against
HIV/AIDS.
We will continue to measure ourselves against specific targets to
assess the progress we are making. This progress report highlights
the achievements of the first six months of the initiative to
expand the availability of HIV/AIDS treatment as well as the many
challenges that remain. ,,,
LEE Jong-wook Director-General World Health Organization
...
Despite the increasing political attention paid to HIV/AIDS, more
than 8000 people are still dying every day from a disease that can
be treated and prevented. However, some important progress is being
made. Significant new resources are flowing to support the scaling
up of antiretroviral therapy and are not simply being diverted from
core prevention activities. More and more countries accept the need
to provide antiretroviral therapy to the people who need it, and
international and national partners across a diverse range of
groups and agencies are coming together to support scale-up in
accordance with "3 by 5" targets.
Key findings
[selected; more key findings in full report]
Number of men, women and children with advanced HIV infection
receiving antiretroviral therapy
As of 30 June 2004, 440 000 people with HIV/AIDS were receiving
antiretroviral therapy in developing and transitional countries.
This is 60 000 less than the target for the initial six months of
the "3 by 5" Initiative. Although this is disappointing, the
absolute increase of 40 000 people in a few months does indicate
that country and international efforts to scale up HIV/AIDS
treatment are resulting in progress. National and international
efforts related to "3 by 5" have advanced national planning for
antiretroviral therapy, reduced drug prices and increased political
will. Following intense work over the past six months, many of the
building blocks are now in place to facilitate a rapid increase in
the number of people on treatment over the next months.
Improving the supply and reducing the cost of necessary drugs and
diagnostics
The timely and uninterrupted supply at reasonable cost of the
required medicines and diagnostics including antiretroviral drugs,
laboratory equipment and reagents, HIV test kits and antibacterial
agents to treat opportunistic infections is clearly essential for
scaling up antiretroviral therapy. In addition to logistical
challenges, the costs involved in procurement and supply management
are considerable and may represent up to 65% of the total cost of
scaling up treatment.
Significant progress has been made in a variety of areas. The price
of first-line treatment with fixed-dose combination formulations
continues to decrease, with benchmark pricing now about US$ 150 per
person per year (a decrease of about US$ 150 in less than 12
months). However, not all countries have adopted these low-cost
regimens as their standard. Furthermore, generic antiretroviral
drugs have not yet been registered in many countries. Thus, despite
good progress on a number of fronts, the average price for
firstline treatment remains above target. Finally, the cost of
second-line treatments remains high.
Looking ahead to 2005, a number of countries and their partners are
heavily engaged in supporting the scaling up of treatment and
prevention. Their leadership and action are critical to achieving
the "3 by 5" target. The 34 countries with the highest burden of
people living with HIV needing access to treatment have an
estimated total treatment need of 4 677 000 by the end of 2005. Of
these 34 countries, 24 have already declared a cumulative target of
1 061 900 people on treatment by the end of 2005. ...
Some governments have begun to utilize the flexibility in
international trade agreements to make medicines more affordable
and accessible. In May 2004, Malaysia and Mozambique announced that
their national authorities had issued compulsory licences for
certain antiretroviral drugs, and Canada reformed its patent
legislation to allow its generic pharmaceutical producers to export
under World Trade Organization rules to countries without adequate
manufacturing capacity. More and more developing and transitional
countries are exploring the possibility of producing HIV-related
medicines locally, and a group of developing and industrialized
countries agreed to support technology transfer in this area at the
WHO Executive Board meeting in January 2004.
AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with
a particular focus on U.S. and international policies. AfricaFocus
Bulletin is edited by William Minter.
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