Student Advocacy
Students Taking Action on Global AIDS
Strengthening Africa's Health Systems
One of the most significant barriers to achieving universal access to HIV-AIDS treatment and prevention is the lack of health infrastructure in sub-Saharan Africa. In order to achieve universal access to comprehensive HIV prevention, treatment, care and support services; drastically cut maternal and child mortality; and achieve the other health-related Millennium Development Goals by 2010, strong health systems are essential.
Although the United States has made important progress in combating global HIV/AIDS through the President's Emergency Plan for AIDS Relief (PEPFAR), the expansion and sustainability of US-supported HIV services requires a multi-faceted plan to address the health worker crisis facing many AIDS-burdened countries.
In its 2007 review of PEPFAR, the Institute of Medicine found that "the growing consensus is that existing capacity for HIV/AIDS services is nearing exhaustion, and donors need to focus more on helping to expand capacity. During its visits to the focus countries, the Committee saw many programs of all varieties, but particularly those providing antiretroviral treatment were overflowing their capacity, had long waiting lists, and had insufficient numbers of staff, most of whom were overwhelmed. The shortage of health care workers of all kinds was particularly acute."
In sum, the problem involves a severe shortage of people, places, and things.
A Shortage of People
The Health Work Force
In sub-Saharan Africa, a mere 3% of the world's health workers combat 24% of the global disease burden. The World Health Organization (WHO) estimates that this region faces an acute shortage of more than 800,000 doctors, nurses, and midwives, and a shortfall of nearly 1.5 million health workers overall. Resolving this crisis would require African governments to more than double the size of their health workforce. To put this in perspective, many African countries only have 1 doctor per 100,000 people. This would mean that a city the size of Boston with over 600,000 residents would only have 6 doctors. The shortage is not only of clinicians, but also of the managers who can ensure that the health system runs as efficiently as limited resources allow – that drugs arrive at health facilities; that workers receive paychecks and supervision; that equipment is maintained in working order. One study found that to achieve the UN's Millennium Development Goals, Tanzania required more than 15 times the managerial and administrative human resource capacity it was projected to have in the health sector by 2015, and Chad would need nearly 90 times its projected managerial and administrative staff.
A Shortage of Places
Hospitals and Clinics
"The evidence from many developing countries with massive deprivation where maternal mortality is high suggests that the sheer absence of staff and facilities is the most substantial barrier to progress" – Lancet, October 2006
The first challenge many people face in receiving health care, especially in rural areas, is simply reaching a functioning health facility. Eighty percent of Tanzanians live in rural areas – the average walk to a health facility is 10 kilometers. For the sick, the pregnant, the disabled – people who most urgently need to reach health centers – that is a difficult and often prohibitive journey, especially when time spent traveling to and from the clinic is not time securing food for your family. When people reach health centers, too often these are not equipped to provide essential health services. For example, as of 2006, only 16% of dispensaries, which make up the majority of health facilities in Kenya, were equipped to provide full TB diagnostic and treatment services. Kenya ranks 10th among the world's 22 countries with the highest TB burden. Many health facilities in Africa still lack such basic infrastructure as clean water and a reliable supply of electricity. Even where functioning health facilities exist, user fees often block access to essential health services. When Uganda removed such fees, health facility attendance shot up 50-100% virtually overnight.
A Shortage of Things
Access to Medicines and Supplies
There are 40 million people living with HIV & AIDS and 6.5 million of those are in immediate need of treatment. Unfortunately only 2 million of those people are receiving treatment, leaving a gap of 4.5 million people.
For some people, AIDS no longer carries a death sentence. Thanks to advances in research, people receiving antiretroviral treatment are living long and productive lives. The drugs exist, but miniscule health budgets compounded with logistical problems mean that many people cannot access even the most basic medicines. According to the latest available data from the World Health Organization, the majority of people in most African countries do not have sustainable access to affordable essential drugs or the basic tools needed to deliver adequate medical care. For example, South Africa's Equity Gage survey found that of five key items, such as condoms, oral re-hydration solution, childhood immunizations, all commonly distributed or used at primary health care facilities, none was available all of the time. The problem is not just that health facilities lack drugs, equipment, and supplies. The equipment they do have often doesn't work. According to the WHO, "Over 50% of medical equipment in developing countries is not functioning, not used correctly, and invariably not maintained."
Fortunately, problems that keep people from receiving the standard of health care which is an internationally recognized legal right– including the shortages of people, places, and things --can be solved.
Addressing the Crisis
The African Health Capacity Investment Act
The first piece of U.S. legislation that would address this crisis directly is the African Health Capacity Investment Act of 2007, which authorizes $650 million over the next three years for training and retaining health workers in Africa, and provides incentives for them to serve in rural areas. The funds may also be used to build basic infrastructure so that health facilities have running water and supplies of essential drugs. The problem dwarfs this single piece of legislation, however.
The President's Emergency Plan for AIDS Relief (PEPFAR)
The President's Emergency Plan for AIDS Relief (PEPFAR), which accounts for the bulk of US global health spending, should also dedicate a portion of investments to health systems required for countries to reach their health goals and commitments. The billions of dollars that the United States is allocating toward PEPFAR must be backed by substantial investments in health systems strengthening so that the health workers, medicines, supplies, equipment, and well-functioning facilities will be in place over the long term to deliver AIDS medication to millions of people for the rest of their lives, and to deliver other needed prevention, care, and support services in an integrated fashion.
PEPFAR is up for reauthorization – which means that Congress will have to pass new legislation to extend its funding beyond September 2008.This creates an opportunity to strengthen the original legislation. PHR and its allies are working hard to get this next round of PEPFAR to dedicate billions of dollars over the next five years to health systems strengthening, including to support countries in developing and implementing comprehensive strategies to bolster their health workforces.
The Global Fund
Just as the needs exceed the reach of any single piece of legislation, the crisis exceeds the reach of a single nation. PHR is therefore engaged in international advocacy to yield significant funds for health systems. One of these opportunities is the Global Fund to Fight AIDS, Tuberculosis and Malaria, which currently invests about $2 billion per year in about 130 countries to fight these three diseases. More than half of the funds go to Africa. The Global Fund permits countries to apply for funds to support health system strengthening activities that are needed to enable them to improve the outcomes of their struggles against these three diseases, which together kill about 6 million people per year. Over the past several years, the Fund has been engaged in internal debates as to how much it should be funding health systems, and PHR has constantly been pushing for an expanded role. PHR has developed a guide to help countries unlock the health systems funding available through the Global Fund.
Local Partners and the G8
New investments will have to come from both wealthy nations and developing countries themselves. PHR supports activist groups comprised of health professionals in Africa, such as the (continent-wide) African Public Health Rights Alliance, the Action Group for Health, Human Rights and HIV/AIDS in Uganda, and the Kenya Health Rights Advocacy Network. Each group is advocating for its own government to increase investments in health. PHR has, and will continue to, call upon the G8 countries, the world's wealthiest nations, to commit to ensuring that African countries have the resources they need to fully implement their strategies to build health systems.
The health systems crisis in Africa is immense, and the response must be equally large. Such a response is possible. The solutions exist.
Country after country in Africa is implementing programs and trying innovative approaches that are enabling more health workers to serve in underserved areas; training and retaining more health workers; working to ensure better access to well-equipped health facilities; and filling labs with functioning equipment and pharmacies with needed medicines. To replicate these solutions and to enable everyone to have access to essential health services requires the political will among leaders in the United States and around the world. We need your help to achieve this.
For more information or to get involved in the campaign, contact Pete Witzler at 617-301-4243 or pwtizler@phrusa.org
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