Global Fund risks `Medicines without Doctors` if it doesn’t finance health sector scale-up

A team of international health experts this week warned the Global Fund to fight AIDS, TB, and malaria: fund the salaries of health workers or else risk a situation in which medicines for these three diseases are made available in poor countries but there are no health professionals to deliver them.

"Recent comments from the inside of the Global Fund," say Gorik Ooms (Medecins Sans Frontieres, Belgium) and colleagues, writing in PLoS Medicine, "suggest an intention to focus more on the three diseases, and to leave the strengthening of health systems and the support to the health workforce to others."

"This might create "Medicines Without Doctors" situations: situations in which the medicines to fight AIDS, Tuberculosis and Malaria are available, but not the doctors or the nurses to prescribe those medicines adequately."

It would be a strategic mistake, say the authors, for the Global Fund to create such a situation. The Global Fund is already supporting HIV treatment and prevention programmes, and is projected to provide treatment to 1.8 million people over five years.

Strategic advantage: Global Fund, not World Bank, best placed to strengthen health systems

"The Global Fund has an advantage that makes it a key actor in the field of supporting health workforces," they say.

"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, whereas 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."

Ooms and colleagues 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.

Mozambique, for example, estimates that in order to roll out HIV drug therapy across the country, it would need eight health workers per 1000 patients receiving treatment: one to two doctors, two to seven nurses, one to three pharmacy staff and a wide range of counsellors and pharmacy staff.

And yet currently, per 1,000 people there are only 0.36 full-time equivalents of health workers. Mozambique had just 514 qualified doctors in 2004, according to World Health Organization figures.

In Malawi, there are 0.61 health workers per 1000 people, but the country is beginning to expand its health sector with donor support explicitly intended to scale up antiretroviral treatment without undermining the health sector. The United Kingdom’s Department for International Development has made a substantial long-term commitment together with other donors to support improvements, chiefly in primary care.

Malawi is also the only country to win an important concession from the International Monetary Fund: an agreement that it will not be penalised for spending more on health sector wages than a cap agreed in 2003. Ceilings on government wage bills are features of IMF lending agreements with several African countries, and they restrict health care recruitment.

Malawi also benefited from health sector strengthening funds from the Global Fund’s fifth grant round.

As long as the Fund can continue to raise money, national treatment programmes that could not be funded with domestic resources or piecemeal donor support become sustainable. Moreover, the international community committed itself at the 2006 UN General Assembly to “sustainability relying on the provision of external funds in a sustained manner”, and this approach needs to be extended to strengthening the health sector, they argue.

But, funding of health sector strengthening was abandoned by the Global Fund in 2006, when the Global Fund’s board agreed that the World Bank should be responsible for long-term infrastructure development. The World Bank does not see its role as expansion of the health sector workforce without long-term promises of bilateral aid, and national government (bilateral) donor commitments are necessarily short-term, since governments, tax revenues and political priorities may change overnight.

Gorik Ooms and colleagues urge the Global Fund to reconsider its opposition to funding of health sector strengthening: “The Global Fund is the only donor mechanism that benefits from an explicit endorsement from the international community to practice a unique approach to sustainability.”