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Africa: AIDS Resources Gaps

AfricaFocus Bulletin
Apr 15, 2005 (050415)
(Reposted from sources cited below)

Editor's Note

Despite increases in recent years, funding to fight the global AIDS pandemic is still only approximately half the minimum of more than $12 billion a year estimated to be needed. But the gaps are not only financial. Activists are increasingly emphasizing the even larger gaps in adequate human resources and upgraded health systems, that are essential for turning small-scale successes into sustainable larger programs.

This AfricaFocus Bulletin contains an organizational sign-on letter initiated by HealthGap and addressed to the G8 leaders who will be meeting in July. This will be half-way through the year that the World Health Organization has designated as the target for increasing the number of people being treated with anti-retrovirals to three million from less than 700,000 at the end of 2004. (http://www.who.int/3by5/coverage/en). In the last six months of 2004, the number on treatment in Africa increased from 150,000 to 310,000. But for such advances to continue, the G-8 and affected countries as well must both provide more money and address other obstacles to sustaining new programs.

Also included below are excerpts from the April 13 testimony before the U.S. House of Representatives Committee on International Relations by Holly Burkhalter, of Physicians for Human Rights, focused on the critical issue of human resources for health.

For earlier AfricaFocus Bulletins on human resources for health, see http://www.africafocus.org/docs05/migr0503.php and http://www.africafocus.org/docs04/acc0407b.php

For a full archive of AfricaFocus Bulletins on health issues, see http://www.africafocus.org/healthexp.php

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

Healthgap Sign-on Letter to G8 Leaders

Dear all,

Please add your organizational endorsement to this call to action on global AIDS targeting the heads of state of the G8 countries, in the run-up to the July Summit of the G8 in Scotland. Note: we are asking for organizational endorsement from groups from all countries, not only those in G8 countries.

Please reply with

--the name of your organization, --the country location, --and your website (if applicable) to asia@healthgap.org. The deadline for signing is April 24, 2005. The platform is also available as a pdf file from asia@healthgap.org..

Best

Asia Russell

The G8 Must Take Action to Make AIDS History

We, the undersigned organizations, call on leaders of the G8 nations to make good on their existing promises and to commit additional resources to make AIDS, tuberculosis and malaria history through commitments on these key issues:

FUNDING THE FIGHT AGAINST HIV/AIDS

G8 countries have endorsed funding for a Global AIDS Vaccine Enterprise, and are debating mechanisms to increase overall donor aid, such as the International Finance Facility (IFF). But a G8 focus on vaccine research and development with no commitment to closing the massive funding gap is unacceptable. Likewise, discussion of a mechanism for increasing donor aid is not a substitute for immediate increases in donor country spending in order to fully fund the fight against AIDS, and address the needs of the 40 million people living with HIV around the world.

G8 leaders must:

• Immediately provide the funding needed to meet the goals of the WHO-led campaign to treat 3 million of the estimated 6 million HIVpositive people who are in urgent clinical need of HIV treatment by 2005 ( 3 by 5ý).
• Increase funding for HIV prevention, treatment, care and support, including palliative care, to reach a total of at least $12 billion in 2005 and at least $19.9 billion by 2007. Provide an additional $6 billion annually to fund the fight against tuberculosis and malaria and $4.4 billion to address the needs of orphaned and vulnerable children in sub-Saharan Africa.
• Fully fund the Global Fund to Fight AIDS, TB, and Malaria (GFATM) and commit to predictable annual financing based on donor country income and the GFATM's need. The GFATM requires more than $2.3 billion in 2005 and $3.5 billion in 2006 to finance grant rounds five and six, as well as grant renewals.

DEBT CANCELLATION TO FIGHT AIDS

The massive external debts owed by poor countries are greatly hindering the fight against HIV/AIDS. Billions of dollars are redirected to servicing debts, when these funds should be used to focus on urgent domestic issues, including addressing the AIDS crisis.

G8 leaders must:

• Immediately commit to 100% cancellation of the debts owed to the IMF and World Bank for all impoverished countries, without harmful or externally imposed economic conditions. Cancellation should be financed through the use of IMF gold reserves. As necessary, World Bank accumulated profits, provided that these do not penalize other developing countries, and additional voluntary contributions from wealthy countries should be considered for financing debt cancellation.
• The funding freed up from cancelled debt must be additional to donor funding needed to fight AIDS, tuberculosis and malaria.

HIV/AIDS TREATMENT AND ACCESS TO MEDICINES

Lack of access to HIV treatment and care results in 8500 deaths each day worldwide. G8 countries must lead the world s response to this catastrophe.

G8 leaders must:

• Ensure the treatment targets of the "3x5" campaign are met: 3 million people on treatment by the end of 2005.
• Commit to a timetable for expanding access to HIV/AIDS care in order to achieve universal access to free treatment by 2010.
• At minimum, change existing and pending bilateral and regional Free Trade Agreements to comply with the Doha Declaration on the TRIPS Agreement and Public Health to ensure that such agreements protect public health and promote access to medicines for all.
• Urge developing countries to use all available flexibilities to protect public health and promote access to medicines for all as reaffirmed by the Doha Declaration on the TRIPS Agreement and Public Health.

SUPPORT FOR HEALTH CARE WORKERS

An immediate obstacle preventing the scale up of access to HIV treatment, as well as tuberculosis and malaria, is the lack of trained health care workers in developing countries, particularly in African countries.

G8 leaders must:

• Commit sufficient resources, including funding for salary support and other recurrent costs, to ensure recruitment and retention of an adequate number of trained health care workers to deliver essential health interventions, including HIV prevention, treatment and care to all who need it, especially in remote and rural areas. Community-based approaches to health care delivery, led by women and men living with HIV/AIDS and their peers, should be given particular support and attention.
• Provide long-term investments to develop sufficient education capacity in developing countries to train needed numbers of health care workers, particularly to meet needs in remote and rural areas.
• Change the macroeconomic policies promoted by the IMF to ensure that IMF policies enable countries to allocate adequate funds to develop health systems necessary to recruit, train, and retain health workers, including through providing sufficient retention packages.

HIV PREVENTION

Comprehensive, accurate, science-based HIV prevention saves lives and should work in conjunction with treatment scale up efforts.

G8 leaders must:

• Support comprehensive HIV prevention interventions that are driven by scientific evidence and best practice, not ideology. End attacks on prevention interventions that are effective in fighting HIV, such as condom use and access to sterile syringes.
• Stop pitting funding and other support for HIV prevention against funding and support for HIV treatment. The success of the fight against the AIDS pandemic is dependent upon a massive scale up of both prevention and treatment efforts.

Signed by:

<list in formation>

Human Resources for Health And the Global HIV/AIDS Pandemic

Testimony of Holly J. Burkhalter
Physicians for Human Rights

House International Relations Committee

Wednesday, April 13, 2005

[excerpts only; for full text visit http://www.phrusa.org/campaigns/aids ]

... Just a few years ago the concept of providing antiretroviral drugs, which at the time cost more per capita per day than poor governments spent on health per capita in a year, was largely a fantasy. But the drop in the price of antiretroviral drugs and development of generic medicines of the past five years, the extraordinary commitment of resources by President Bush and the United States Congress, and the creation of a major new international financing mechanism to confront the pandemic, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, have transformed HIV/AIDS for some in sub-Saharan Africa, Asia, and the Caribbean into a manageable disease.

If access to treatment had been withheld from poor countries until they secured the health infrastructure they needed to provide basic primary health care to all, as well as manage an immense HIV/AIDS case load with medicines largely unknown to them, those countries would be waiting for antiretrovirals to this day. Fortunately, the vision of treatment activists and now major donors as well has been to "build it as we go." ...

That approach has helped enlarge the number of people receiving anti-retroviral treatment in sub-Saharan Africa from 50,000 in the end of 2002 to 310,000 in December 2004. But it has become increasingly clear that donors and national governments must simultaneously confront, ameliorate, and eventually remedy Africa's disastrous shortage of trained health care workers. ...

While the dearth of health workers is undermining the huge scale up of HIV/AIDS prevention, care, and treatment that Africa needs so desperately, conversely the emphasis on HIV/AIDS services is drawing resources away from other vital health services that are also in short supply. For example, at the 970-bed the Lilongwe Central Hospital in Malawi, only 169 nurses were practicing in mid-2004, compared to the 520 nurses whom the hospital was authorized to employ. The hospital's former staff of 38 laboratory technicians had fallen to only six. The nurses and laboratory technicians were moving to HIV/AIDS programs sponsored by NGOs and overseas universities, precipitating a staffing crisis at this major national referral hospital.

... Adding new duties such as AIDS counseling, testing, and treatment to an overburdened health work force without a commitment to dramatically enlarge their numbers will not only undermine new AIDS treatments initiatives, it has the potential to weaken fragile public health systems and erode other primary health activities. ...

Durable solutions to the health worker shortage must include investing in African health professionals and giving them incentives to stay home where they are needed most. It means empowering African medical and nursing schools to recruit, train, and provide continuing education. And it will require that the U.S. and other Western countries that recruit African health workers adopt an ethical approach to the brain drain.

Background: Africa's Health Worker Shortage:

... The health worker shortage in Africa that is now in the public eye because of the AIDS pandemic has also been a key factor in other health emergencies, including the continent's tragically high rate of maternal mortality. In subSaharan Africa, a woman's lifetime risk of maternal death is 1 in 16, compared to 1 in 2,800 in rich countries. According to the World Health Report 2005 - Make Every Child and Mother Count, "Putting in place the health workforce needed for scaling up maternal, newborn and child health services towards universal access is the first and most pressing task."

The United Kingdom's Commission for Africa, noting this disparity in its recent report, recommends that African countries and donors unite to add 1 million health care workers to Africa within a decade, nearly tripling Africa's health workforce. The Commission estimates that Africa requires an immediate annual increase of $10 billion, rising to at least $20 billion, in donor assistance to the health sector, including health worker specific needs such as pre-service training and salary.

The health worker shortage has multiple origins, including massive underinvestment in health systems, inadequate attention to human resource policies, the death of health workers and enormous burden of care created by the HIV/AIDS pandemic, and deficits in the health worker education system. These problems, in turn, underlie the large-scale migration of health professionals from Africa to wealthier countries, such as the United States and United Kingdom. In some countries, the majority of physicians are leaving, and the number of nurses emigrating has skyrocketed in the past decade.

In the absence of comprehensive data, country examples and anecdotes highlight the scope of this "brain drain." As of 2001, only 360 of the 1200 physicians trained in Zimbabwe during the 1990s were still practicing in the country. In 2002/2003, more than 3,000 nurses trained in South Africa, Zimbabwe, Nigeria, Ghana, Zambia, and Kenya registered in the United Kingdom. In 1999, about as many nurses left Ghana as were trained there. It is frequently stated that more Malawian doctors practice in Manchester, England, than in all of Malawi. Brain drain is accelerated as wealthy nations, facing shortages in their own health workforces, actively and aggressively recruit health professionals from some of the countries that can least afford to lose them.

This migration, or brain drain, is part of a more complex flow of health workers from poorer to wealthier developing countries, from the public sector to the private sector, including for-profits as well as NGOs and vertical AIDS programs, and from rural to urban areas. ...

Health workers are leaving, in large part, because they are unable to meet their own needs or those of their patients. Their wages are inadequate, sometimes not even enough to cover their basic living expenses. They have few opportunities to develop themselves professionally, and fear contracting HIV and other infections on the job, especially because they often lack the gloves and other protective gear. Poor management and planning, leading to including inadequate supervision, enormous workloads, late paychecks, and inadequate training, further harms health worker morale. Health workers are trained to heal, but because they lack sufficient medicines, supplies, and equipment, all too often they can do little more than minister to death.

A key factor in the continent's brain drain of skilled health workers is the fact that hospitals and clinics in much of sub-Saharan Africa lack basic infection control, sanitation, and occupational safety. A survey by Physicians for Human Rights of more than 1,000 health workers in Nigeria suggested that fear of occupational exposure to HIV/AIDS contributes to stigma and discrimination against people with AIDS because health workers are afraid they will contract the virus from them. Even in Free State, South Africa, a recent survey conducted at children and maternity units, including labor and pediatric wards, in 30 hospitals found that 49% of health workers reported shortages of protective gear at some point during the course of the year. ...

Responding to the Shortage: Training Health Professionals Is Not Enough

Ambassador Tobias and his associates are attempting to address the health worker shortage and have made some innovative grants, such as supporting a Zambian scheme to offer incentives for urban doctors to relocate to underserved rural areas. But to the best of our knowledge, the American contribution to the African health work force has largely been limited to the training of health workers. ...

But training alone is not the answer to the health work force crisis in Africa; indeed, it may even accelerate health worker flight. If working conditions, salaries, benefits, management and opportunities for health workers in their own countries are not also addressed, additional training simply makes it more likely that the newly skilled nurse or doctor will be recruited or seek out a job in the U.S., Canada, or Europe at a vastly higher salary. ...

To recruit the vast numbers of students to nursing and medical school and prevent new graduates from leaving, national governments, donors, and international institutions must join forces to eliminate the "push factors" that discourage trained workers from staying home - the unsafe working conditions, low pay, poor supervision, absence of benefits, staggering work loads, and dearth of supplies, medicines, and equipment that sabotages worker satisfaction and patient health.

Even with substantial investments, the recruitment and retention of hundreds of thousands of nurses, pharmacists, technicians and doctors is at best a multi-year project, and poor people need health services today. We urge the Administration and Congress to make the training of and assistance not only to skilled health professionals but also to community health workers and home care givers an essential component of a Global Health Workforce Initiative. ...

At the same time that both community health workers and family and volunteer caregivers can provide important health services, both community health workers and caregivers require significant support structures. The study on Uganda and South Africa warned that without substantial investment in the home-based care, the approach could exacerbate gender and poverty inequalities among families and communities. Providing stipends, micro-credit or salaries to women engaged in this work would help them, and offering them training, supplies, and drugs will help the adults and children with AIDS who rely on them. Compensation is also important to maintaining the motivation of community health workers, who are also likely to be poor and require financial or material support. ...

Recommendations: The Next Phase of US Support for Health in Africa

Greatly increased spending by national governments and by foreign donors and international organizations is required to enable countries to meet AIDS prevention, care, and especially treatment targets and to sustain a high level of coverage for these interventions. These systemic improvements to what is typically the weakest part of health systems in Africa - personnel - will greatly enhance countries' capacity to improve health in all areas, from combating other major diseases such as tuberculosis and malaria to improving child survival and driving down unspeakable levels of maternal mortality that plague much of Africa.

We envision an initiative with four main pillars:

First, the United States should provide technical assistance to countries in assessing their current health workforce situations, in determining their health workforce needs to achieve health targets, such as the Millennium Development Goals, and in developing strategies to achieve those goals.

The strategies should be linked to overall health system development strategies so that health worker strengthening occurs in concert with the other aspects of health system strengthening require to achieve Millennium Development. So as to guide both national budgets and donor assistance, the strategies should include costing estimates. The strategies should also include coordination among donors and the national government to ensure that the full cost of implementing these strategies is covered. ...

Second, the United States should help fund the implementation of these strategies. The activities funded should be determined by national strategies, by the needs as expressed by the people of those countries. Based on strategies that countries have already begun to implement, as well as the needs common to the region that will determine the strategies, elements that will likely be in most or all of these strategies include:

• Higher salaries for health workers
• Incentives for health workers to serve in rural areas
• Improved health worker safety, including full implementation of universal safety precautions, post-exposure prophylaxis for health workers potentially exposed to HIV, tuberculosis infection control, and hepatitis B vaccination
• Improved human resource management, including improving human resource policies and enhancing management skills of local health managers
• Increased capacity of health training institutions, such as medical, nursing, and pharmacy schools
• Providing continuous learning opportunities to health workers
• Support for community health workers, including compensation, training, supervision, supplies, and linkages to health professional support and referral systems. Training, supporting and deploying people living with AIDS as counselors, prevention advocates, and care givers should be a priority.
• Re-hiring and rational deployment of retired or unemployed health professionals
• Health system improvements not specifically related to human resources for health, such as assuring adequate and dependable provision of supplies and essential drugs.

Third, while it is necessary for countries to have human resources for health strategies, enough is known about what is needed to begin funding many interventions immediately, and indeed, the urgency of the crisis demands this. ... [for example] As of 2003, Kenya had 4,000 nurses, 1,000 clinical officers, 2,000 laboratory staff, and 160 pharmacists or pharmacy technicians who were unemployed not because they were not needed, but because the government could not afford to pay them. These workers need to be hired.

...

Fourth, the United States should support efforts by the World Health Organization and others to collect and disseminate country lessons and experiences in human resource policies and efforts to recruit, retain, and equitably deploy their health workers.

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