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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.

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

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)

Press Release, July 15, 2004


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


Contact: Leigh Pasqual

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]

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]

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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