By JONATHAN MUNDELL (1)

The first week of August saw approximately 22,000 people from around the world converging on the impressive Centro Banamex in Mexico City for the XVII International AIDS Conference. The conference, entitled ‘Universal Access Now’, brought together delegates ranging from policy makers to social scientists; health workers to the HIV-infected, from resource limited regions and developed nations alike. The primary aims of the conference were to evaluate progress that has been made in attempts to achieve goals put forward in 2005, of providing universal access to HIV prevention, treatment, care and support to all those in need by 2010, and additionally to strategise for the future. According to Dr. Pedro Cahn, President of the International AIDS Society (IAS) and co-chair for the conference, “AIDS 2008 is taking place at a unique moment in the epidemic, when there is widespread consensus on the urgency of ensuring universal access to HIV prevention, treatment, care and support by 2010”.

While the conference included more than 7,500 presentations, covering a wide range of topics associated with the epidemic, a theme that seemed to arise more often than most was the pressing need to strengthen health care systems in developing countries, specifically in Africa. The topic of health worker shortages, and the consequent negative impact on countries’ response to the epidemic, has increasingly received more attention at International AIDS Conferences over the past decade, and this year saw a number of major sessions and activist campaigns dedicated specifically to such issues.

GREENER PASTURES LEAVE HEALTH CARE SYSTEMS LACKING

Developing countries have been hit hardest by HIV & AIDS, and at the same time have progressively seen more and more of their health workers leaving for greener pastures in wealthier parts of the world. In Africa, health worker shortages are widespread. A World Health Organisation (WHO) report states that Africa possesses 14% of the world’s population, 25% of the global health load and a meagre 1.3% of global health workers (2). A striking example of such shortages can be seen in South Africa, where it has recently been confirmed that there are more than 4,000 doctor’s posts unfilled in the country’s state hospitals. This, while 3,000 and 2,000 South African doctors are currently working in the United Kingdom and the United States respectively. Currently, South Africa has 65 doctors per 100,000 citizens, most of who are in the private sector and in urban areas. It is estimated that the ratio for doctor-to-patient in the country’s rural areas is as low as three per 100,000. To put this in perspective, in the United States, it is estimated that there are as many as 550 doctors per 100,000 citizens.

The issue of health worker shortages is mirrored across the African continent. Similar statistics can be seen in countries such as Malawi, where only 10% of physician slots are filled; in Zimbabwe, where less than a third of physicians trained in the country between 1990 and 2001 remained; in Ghana, where 69% of physicians, 25% of nurses, and 42% of pharmacists who graduated between 1993 and 2002, left the country; and in Ethiopia, where the private healthcare sector and other countries attract approximately 9.6% of the countries physicians each year (3).

A CALL FOR INCREASED INCENTIVE

While the reasons for such health worker migration, and resultant heath care system deterioration vary, a major factor is insufficient remuneration. A number of wealthy nations have been accused of adding to the HIV & AIDS plight, by actively recruiting health care workers out of Africa. This has led to a recent call by a number of leading experts in the field for such “pilfering” to be criminalised. During the AIDS conference last month, UNAIDS Executive Director, Peter Piot, emphasised the need for an increase in efforts to encourage African health workers to remain in countries that need them most.

Médecins Sans Frontière (MSF) also used the conference to voice their concerns, warning delegates of the deadly impact that the lack of health care workers is having in the fight against the epidemic in Africa. MSF have openly criticised donor institutions such as the World Bank and The International Monetary Fund (IMF) for putting in place legislation that prevents donor funds from being used for salary increases in the public sector. According to Dr. Moses Massaquoi, MSF medical coordinator in Malawi, it is “intolerable” for donors to say that a raise in wages would be unsustainable, when each nurse in the country is responsible for the life of approximately 400 patients, and US$ 7,500 worth of drugs, with a salary that works out to only US$ 3 per day. In addition to the MSF, experts of the World Health Organisation (WHO) are also of the view that foreign funding should be used to increase doctors’ remuneration and to boost medical personnel recruitment and training.

AFRICAN PASTURES BECOME GREENER, BUT STILL MUCH TO BE DONE

The Group of Eight (G8) industrialised nations have been in discussions recently, and a preliminary plan by the G8 emphasises the need for international cooperation, while simultaneously urging for improved ways to provide assistance to affected countries in this regard. The plan has stressed the need for a multi-layered approach to decrease health worker shortages. The cost of the initiative, in which 1.5 million additional health workers will be trained, is estimated at about US$ 7 billion annually. In addition, the recent reauthorisation of the US Presidents’ Emergency Plan for AIDS Relief (PEPFAR) has made attempts to address the health worker shortage issue, with an important difference from the original legislation to develop long-term health workforce plans. PEPFAR now aim to fund 140,000 new health workers in target countries.

Further increases in funding will be essential, but it is just as critical that these funds are used effectively. Currently, a number of African countries have shown that there is much that can be done in attempts to stem the deterioration of their health sectors. In Zambia, for example, the influx of international funds into the healthcare system has shown various positive results, including the increased availability of antiretroviral (ARV) treatment and the administration of ARVs in the prevention of mother-to-child transmission (PMTCT) of HIV. Training is also an important facet to address the problems that these countries are facing, and Zambian officials have conceded that while they have made much progress, the health sector continues to be negatively affected by a lack of training. Countries such as Swaziland have made attempts to address this issue by utilising the services of foreign doctors. In addition, numerous African studies have suggested that training nurses to treat HIV positive patients can lighten the tremendous workload of doctors, and therefore improve health care delivery, and it will be crucial in the future that strategies such as these are utilised to their full potential.

PAVING THE WAY FOR FUTURE GENERATIONS

So it would seem that some positive strides are being taken in attempts to address the issue of deteriorating health sectors in developing countries, but far more will be required in the coming years. Speakers at the conference have reiterated the fact that calls to decrease funding for HIV & AIDS are inappropriate, as HIV remains a global emergency that requires continuous funding and effort. According to Peter Piot, "It will require a long-term response well beyond the few years ahead of us". It is imperative that the advances made in the “few years ahead of us” pave the way for future generations, and the strengthening of health care systems must be seen as a top priority.