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Africa: Medicines without Doctors
May 23, 2007 (070523)
(Reposted from sources cited below)
"The World Health Organization estimates that to achieve the
Millennium Development Goals (MDGs), health systems need at least
2.5 health workers per 1,000 people. In Mozambique, ... per 1,000
people there are 0.36 full-time equivalents of health workers (2004
figures).Mozambique's health workforce would have to be multiplied
by seven to achieve the MDGs."
While Mozambique faces perhaps the worst healthforce crisis, there
are 12 other countries in Africa with an HIV prevalence of more
than 5% and less than two nurses per 1,000 people. Adding enough
healthcare workers is simply not sustainable only from domestic
resources, notes a recent article is the journal Public Library of
Science Medicine. Yet the Global Fund to Fight AIDS, TB, and
Malaria seems set to abandon the objective of strengthening health
systems to the World Bank, which requires countries to prove
their plans will eventually be sustainable from domestic funding.
The result, the journal authors argue, would be "medicines without
doctors." They illustrate their case with specific studies of the
situation in Mozambique and Malawi.
Another AfricaFocus Bulletin sent out today includes petitions to
the G8 group of rich countries meeting in June in Germany, on AIDS,
health, education, and other issues, for signature by individuals
For earlier AfricaFocus Bulletins on health-related issues, visit
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
Medicines without Doctors: Why the Global Fund Must Fund Salaries
of Health Workers to Expand AIDS Treatment
by Gorik Ooms, Wim Van Damme, and Marleen Temmerman
[Gorik Ooms is Executive Director of the Belgian section of
M‚decins Sans FrontiŠres, Brussels, Belgium. Wim Van Damme is with
the Institute for Tropical Medicine, Antwerp, Belgium. Marleen
Temmerman is with the International Centre for Reproductive Health,
Ghent University Hospital, Ghent, Belgium.]
Public Library of Science Medicine 4/4 (2007)
Address correspondence to firstname.lastname@example.org
[text only. For full paper with tables and footnotes, visit
The Global Fund to Fight AIDS, Tuberculosis and Malaria ("the
Global Fund") was created to fight three of the world's most
devastating diseases. Since its creation in 2002, it has struggled
with the difficult task of focusing on three diseases, and at the
same time supporting the fragile public health systems that are
supposed to implement this fight on the ground.
Recent internal comments from the Global Fund suggest an intention
to focus more on the three diseases, and to leave the strengthening
of health systems and support for the health workforce to others.
This could create a "Medicines without Doctors" situation in which
the medicines to fight AIDS, tuberculosis, and malaria are
available, but not the doctors or the nurses to prescribe those
We believe that this would be a strategic mistake, as the Global
Fund has an advantage that makes it a key actor in the field of
supporting health workforces. Most other donors are forced to aim
for sustainability in the conventional sense (implying that
beneficiary countries should gradually replace international
funding with domestic resources); the Global Fund has been promised
sustained funding by the international community, allowing it to
make sustained commitments to beneficiary countries. This is what
some of the countries most affected by AIDS, tuberculosis, and
malaria need to increase their health workforce. Their health
workforce challenges are too big to consider a gradual replacement
of international funding with domestic resources.
We also believe that the debate about this intention should be
public, and we hope to launch the public debate with this article.
We use the examples of two countries - Mozambique and Malawi -
trying to fight against a full-blown AIDS epidemic with a fragile
health system, to underline the crucial role of Global Fund support
to the health workforce.
The Health Workforce Gap in Mozambique
The World Health Organization estimates that to achieve the
Millennium Development Goals (MDGs), health systems need at least
2.5 health workers per 1,000 people. In Mozambique, there are 514
doctors, 3,954 nurses, and 2,229 midwives: per 1,000 people there
are 0.36 full-time equivalents of health workers (2004 figures).
Mozambique's health workforce would have to be multiplied by seven
to achieve the MDGs.
To roll out antiretroviral therapy (ART) across the country,
Mozambique estimates that it would need eight health workers per
1,000 patients receiving ART. This is in line with the estimations
of Hirschhorn et al.: the numbers of health workers required to
provide ART to 1,000 patients include one to two physicians, two to
seven nurses, one to three pharmacy staff, and a wide range of
counsellors and treatment supporters These findings apply to ART
programmes in their start-up phase, which require an intensive
follow-up, but even if a mature ART programme could be effective
with only four health workers per 1,000 patients, the number of
additional health workers required remains a huge challenge,
knowing that 199,000 people in Mozambique needed ART by the end of
Is Mozambique's health workforce gap exceptional? There are 12
countries in Africa with an HIV prevalence of more than 5% and less
than two nurses per 1,000 people. If we rank these countries
according to density of nurses, Mozambique comes last. In terms of
expanding access to ART, no country faces a bigger health workforce
crisis than Mozambique.
[Table 1 shows health workforce gaps in 13 African countries,
ranked according to density of nurses: Zambia, Cameroon. Kenya,
Republic of Congo, Zimbabwe, Lesotho, Uganda, Côte d'Ivoire,
Malawi, Tanzania, Central African Republic, Mozambique]
The Health Workforce Gap in Malawi
In Malawi, there are 266 doctors and 7,264 nurses (no figures on
midwives are available): per 1,000 people there are 0.61 full-time
equivalents of health workers (2004 figures).The health workforce
would need to be multiplied by four to achieve the MDGs.
In 2004, Peter Piot, head of the Joint United Nations Programme on
HIV/AIDS, and Suma Chakrabarti, permanent secretary of the United
Kingdom Department for International Development, during a joint
visit to Malawi concluded that it would be impossible to roll out
ART without undermining the health system, unless the level of
health workers could be increased dramatically. They instructed
their agencies to support an initiative to address the health
workforce crisis. The result was "a shift from piecemeal donor
support for a number of uncoordinated initiatives to a more
The response in Malawi might remain unique for several reasons.
First, the Malawi response was possible because of an explicit
decision by donors "to consider measures that might otherwise be
dismissed as unsustainable" because of the scale of the crisis. It
is not clear how serious a health workforce crisis needs to be for
donors to consider "unsustainable" measures.
Second, Malawi was able to come to a special agreement with the
International Monetary Fund (IMF). Malawi agreed to a ceiling on
the "government wage bill" with the IMF in September 2003. In July
2005, the IMF accepted that the ceiling "will be adjusted upward
([or] downward) by the full amount of donor-funded supplementary
wages and salaries for the health sector that is greater ([or]
less) than the program baseline". All countries listed in Table 1
have agreed with the IMF to control their wage bill -- either as a
performance criterion or benchmark, or as a promise in a "Letter of
Intent" -- for Zimbabwe and C“te d'Ivoire, which do not have
ongoing IMF-supported programmes. Malawi is the only country
benefiting from an automatic adjustment of this ceiling. The IMF
justifies these ceilings because of "concerns about potential
macroeconomic problems that could result from entering into
long-term expenditure commitments without long-term donor
commitments to finance them".
In addition, Malawi obtained funding from the Global Fund under its
Fifth Call for Proposals. The Board of the Global Fund decided to
consider health systems strengthening (HSS) interventions for
funding as a specific category under its Fifth Call for Proposals,
and it was as an HSS intervention that the Malawi response was
approved. But under the Sixth Call for Proposals, specific HSS
interventions were no longer eligible.
Global Fund Support to the Health Workforce
The Global Fund has a unique governance structure. At the core of
this structure are the Country Coordination Mechanisms (CCMs):
national platforms of stakeholders, formulating proposals in answer
to the calls for proposals launched by the Board of the Global
Fund. (The Board of the Global Fund regularly launches calls for
proposals, known as Rounds: Round 1 and Round 2 were launched in
2002, Round 3 in 2003 and so forth. Round 7 was launched in March
These proposals are reviewed by the Technical Review Panel (TRP),
a panel of independent experts. The TRP recommends certain
proposals for funding to the Board.
The Global Fund's Board includes representatives of donor and
recipient governments, non-governmental organisations, the private
sector, and affected communities. It approves proposals upon
recommendation from the TRP. It also approves the guidelines and
the proposal forms for each of the Rounds of the Global Fund.
The Secretariat is the executive branch of the Global Fund. In
principle, it does not interfere with the approval process. In
practice, it does elaborate the guidelines and the proposal forms,
and thus it has an influence on the eligibility of proposals.
For an intervention to be eligible, it needs to be proposed by a
CCM, recommended by the TRP, approved by the Board, and it must fit
within the guidelines and proposal forms proposed by the
As an illustration of the complexity of this governance structure,
we could mention the initial uncertainty about the eligibility of
AIDS treatment interventions. During the first Board meeting, the
Health Minister of France said that "there should be no false
dilemma over treatment or prevention", but did not receive a clear
answer from the Board. Then CCMs proposed ART interventions, the
TRP recommended some of them, and the Board approved them.
By doing so, the Global Fund has developed -- perhaps implicitly --
;a novel approach to sustainability. Sustainability in the
conventional sense implies that beneficiary countries gradually
replace foreign assistance with domestic resources. This is not
realistic for low-income countries providing ART. Nonetheless, the
Global Fund does support ART interventions in low-income countries:
thus it shifted concerns about sustainability from national to
international level (if the Global Fund can sustain these
interventions, they are sustainable, albeit in a different manner).
The international community endorsed this novel approach. In June
2006, the United Nations General Assembly committed itself "to
supporting and strengthening existing financial mechanisms,
including the Global Fund to Fight AIDS, Tuberculosis and Malaria,
as well as relevant United Nations organizations, through the
**provision of funds in a sustained manner**" (emphasis added). It
might sound like a nuance, but the difference between
"sustainability relying on domestic resources in the long run" and
"sustainability relying on the provision of external funds in a
sustained manner" is fundamental.
This novel approach is what countries like Mozambique need to
strengthen their workforce. They need to hire more health workers,
but they are unable to sustain the costs of hiring additional
health workers with domestic resources.
If the controversy about ART was easy to solve, the controversy
about strengthening health workforces was tougher. Some Global Fund
supporters understood from the beginning that its success in
expanding coverage of ART depended on its willingness to pay for
the salaries of additional health workers. However, the Global Fund
has never been keen to expand its novel approach to sustainability
to the funding of the health workforce. Since Round 2, the Global
Fund has applied strict criteria for the funding of salaries of
health workers. With regards to salaries, applicants must explain
"how these salaries will be sustained after the proposal period is
over". Drager et al. note that this concern about sustainability
"cannot be found for any other activities financed by the Global
Fund" and suspect that it is closely linked to IMF and World Bank
The advocates of supporting salaries of health workers from the
Global Fund obtained a short-lived victory in 2005, when Round 5 of
the Global Fund included a specific category for HSS interventions.
But Round 5 also caused some actors to evaluate their role in the
global health landscape. The World Bank insisted on a "Comparative
Advantage Study" of Global Fund and World Bank AIDS programmes.
Alexander Shakow, who conducted the study, recommended that the
Global Fund focus on disease-specific interventions, leaving HSS
interventions to the World Bank. In January 2006, the Global AIDS
Alliance and Health GAP -- supported by more than 30 experts and
300 non-governmental organisations -- urged the Global Fund to keep
HSS interventions as a specific category. In April 2006, the Board
decided to narrow the scope of eligible interventions, adopting a
proposal form that no longer included HSS interventions as a
specific category. In August 2006, Richard Feachem, the executive
director of the Global Fund, endorsed a new "division of labour"
between the World Bank and the Global Fund: rapid scale-up of
disease-specific programmes for the Global Fund and long-term
development of health infrastructure for the World Bank. In
November 2006, the TRP and the Secretariat, in their report to the
Board, recommended that "the Board convene a suitable forum, which
can discuss and attempt to resolve the question of the appropriate
scope and definition of acceptable HSS activities prior to Round 7.
Ideally, this discussion will lead to a clarification and narrowing
of the scope of HSS activities which the Global Fund sees as its
mandate to fund".
This evolution is problematic because the World Bank does not share
the Global Fund's novel approach to sustainability, certainly not
for health workers' salaries. The World Bank believes that "it is
not prudent for countries to commit to permanent expenditures for
such items as salaries for nurses and doctors on the basis of
uncertain financing flows from development assistance funds".
Some bilateral donors might be willing to consider "unsustainable"
interventions to address health workforce crises, as they did in
Malawi. But Malawi remains the exception that confirms the general
rule. Bilateral donors will find it difficult to make their
commitments reliable enough for the IMF to adjust the ceiling on
the government wage bill. Most bilateral donors can only commit for
as long as their government remains in place -- only a few years.
Both the cases of Mozambique and Malawi illustrate the crucial
importance of addressing the health workforce crisis. It is easier
to remedy the shortage of medicines with external funding than it
is to remedy the shortage of health workers with external funding.
Medicines can be bought; health workers need to be trained first.
This underlines the importance of starting emergency human
resources programmes now, before the growing case
load—resulting from the fact that most people on ART will
stay alive longer, while the number of people in need of ART will
grow—undermines either the quality of ART programmes, or the
performance of health systems.
Without support from the Global Fund, it will be difficult for
Mozambique to develop its own emergency human resources programme.
Bilateral donors are unable to support human resources programmes
that rely on sustained external assistance over decades. The World
Bank is unwilling to use foreign assistance for salaries of health
workers. The IMF is unwilling to stretch ceilings on wage bills,
because commitments from bilateral donors are unreliable. Without
flexibility about these ceilings, bilateral donors cannot support
salaries of doctors and nurses, even if they want to. It is a
The Global Fund is probably the only actor able to break through
this vicious circle. It is the only donor mechanism that benefits
from an explicit endorsement from the international community to
practice a novel approach to sustainability.
But donors must give the Global Fund the resources to do so. As one
of us argued in a previous article, it is feasible to turn the
Global Fund into a world health insurance, funded by rich countries
in accordance with their wealth, and creating rights for poor
countries to obtain assistance in accordance with their needs . It
would allow individual donors to overcome their inability to make
commitments beyond the term of their governments, because their
contributions would be compulsory. (This is not a heresy. Many
bilateral donors consider their contributions to the World Bank as
compulsory. This can be achieved for contributions to the Global
Fund.) Furthermore, the pooling of resources by many donors would
increase continuity: if one donor reduces its contribution, another
donor could compensate.
And that is exactly what countries like Mozambique need to increase
their health workforce: sustained assistance.
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