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Medicines Without Doctors: Why the Global Fund Must Fund Salaries of Health Workers to Expand AIDS Treatment Gorik Ooms*, Wim Van Damme, Marleen Temmerman

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Medicines Without Doctors: Why the Global Fund Must Fund Salaries of Health Workers to Expand AIDS Treatment Gorik Ooms*, Wim Van Damme, Marleen Temmerman Essay Medicines without Doctors: Why the Global Fund Must Fund Salaries of Health Workers to Expand AIDS Treatment Gorik Ooms*, Wim Van Damme, Marleen Temmerman he Global Fund to Fight AIDS, Tuberculosis and Malaria T(“the Global Fund”) was created to fi ght three of the world’s most devastating diseases. Since its creation in 2002, it has struggled with the diffi cult task of focusing on three diseases, and at the same time supporting the fragile public health systems that are supposed to implement this fi ght 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 fi ght AIDS, tuberculosis, and malaria are available, but not the doctors or the nurses to doi:10.1371/journal.pmed.0040128.g001 prescribe those medicines adequately. We believe that this would be a A health worker explains to a patient how to use a miconazole gum patch strategic mistake, as the Global Fund (Photo: Gaël Turine) has an advantage that makes it a hope to launch the public debate with key actor in the fi eld of supporting Funding: The authors received no specifi c funding this article. for this article. health workforces. Most other donors We use the examples of two are forced to aim for sustainability Competing Interests: The authors have declared countries—Mozambique and Malawi— that no competing interests exist. in the conventional sense (implying trying to fi ght against a full-blown AIDS that benefi ciary countries should epidemic with a fragile health system, Citation: Ooms G, Van Damme W, Temmerman M gradually replace international (2007) Medicines without doctors: Why the Global to underline the crucial role of Global Fund must fund salaries of health workers to expand funding with domestic resources); Fund support to the health workforce. AIDS treatment. PLoS Med 4(4): e128. doi:10.1371/ the Global Fund has been promised journal.pmed.0040128 sustained funding by the international The Health Workforce Gap Copyright: © 2007 Ooms et al. This is an open-access community, allowing it to make in Mozambique article distributed under the terms of the Creative Commons Attribution License, which permits sustained commitments to benefi ciary The World Health Organization countries. This is what some of the unrestricted use, distribution, and reproduction in estimates that to achieve the any medium, provided the original author and source countries most affected by AIDS, Millennium Development Goals are credited. tuberculosis, and malaria need to (MDGs), health systems need at Abbreviations: ART, antiretroviral therapy; CCM, increase their health workforce. Their least 2.5 health workers per 1,000 Country Coordination Mechanism; HSS, health health workforce challenges are too people [1]. In Mozambique, there systems strengthening; IMF, International Monetary big to consider a gradual replacement Fund; MDG, Millennium Development Goal; TRP, are 514 doctors, 3,954 nurses, and Technical Review Panel of international funding with domestic 2,229 midwives: per 1,000 people Gorik Ooms is Executive Director of the Belgian resources. there are 0.36 full-time equivalents We also believe that the debate about section of Médecins Sans Frontières, Brussels, of health workers (2004 fi gures) [2]. Belgium. Wim Van Damme is with the Institute this intention should be public, and we Mozambique’s health workforce would for Tropical Medicine, Antwerp, Belgium. Marleen Temmerman is with the International Centre for have to be multiplied by seven to Reproductive Health, Ghent University Hospital, achieve the MDGs. Ghent, Belgium. The Essay section contains opinion pieces on topics To roll out antiretroviral of broad interest to a general medical audience. * To whom correspondence should be addressed. therapy (ART) across the country, E-mail: [email protected] PLoS Medicine | www.plosmedicine.org 0605 April 2007 | Volume 4 | Issue 4 | e128 Mozambique estimates that it would of an explicit decision by donors “to in 2002, Round 3 in 2003 and so forth. need eight health workers per 1,000 consider measures that might otherwise Round 7 was launched in March 2007.) patients receiving ART [3]. This be dismissed as unsustainable” because These proposals are reviewed by is in line with the estimations of of the scale of the crisis [6]. It is not the Technical Review Panel (TRP), Hirschhorn et al.: the numbers of clear how serious a health workforce a panel of independent experts. The health workers required to provide crisis needs to be for donors to consider TRP recommends certain proposals for ART to 1,000 patients include one to “unsustainable” measures. funding to the Board. two physicians, two to seven nurses, Second, Malawi was able to come The Global Fund’s Board includes one to three pharmacy staff, and to a special agreement with the representatives of donor and recipient a wide range of counsellors and International Monetary Fund (IMF). governments, non-governmental treatment supporters [3]. These Malawi agreed to a ceiling on the organisations, the private sector, and fi ndings apply to ART programmes “government wage bill” with the IMF affected communities. It approves in their start-up phase, which require in September 2003. In July 2005, the proposals upon recommendation from an intensive follow-up, but even if a IMF accepted that the ceiling “will the TRP. It also approves the guidelines mature ART programme could be be adjusted upward ([or] downward) and the proposal forms for each of the effective with only four health workers by the full amount of donor-funded Rounds of the Global Fund. per 1,000 patients, the number of supplementary wages and salaries for The Secretariat is the executive additional health workers required the health sector that is greater ([or] branch of the Global Fund. In remains a huge challenge, knowing less) than the program baseline” [7]. principle, it does not interfere with that 199,000 people in Mozambique All countries listed in Table 1 have the approval process. In practice, it needed ART by the end of 2005 [4]. agreed with the IMF to control their does elaborate the guidelines and the Is Mozambique’s health workforce wage bill—either as a performance proposal forms, and thus it has an gap exceptional? There are 12 criterion or benchmark, or as a infl uence on the eligibility of proposals. countries in Africa with an HIV promise in a “Letter of Intent”—except For an intervention to be eligible, prevalence of more than 5% and less for Zimbabwe and Côte d’Ivoire, it needs to be proposed by a CCM, than two nurses per 1,000 people (see which do not have ongoing IMF- recommended by the TRP, approved Table 1). If we rank these countries supported programmes. Malawi is by the Board, and it must fi t within according to density of nurses, the only country benefi ting from an the guidelines and proposal forms Mozambique comes last. In terms of automatic adjustment of this ceiling. proposed by the Secretariat. expanding access to ART, no country The IMF justifi es these ceilings As an illustration of the complexity faces a bigger health workforce crisis because of “concerns about potential of this governance structure, we could than Mozambique. macroeconomic problems that could mention the initial uncertainty about result from entering into long-term the eligibility of AIDS treatment The Health Workforce Gap expenditure commitments without interventions. During the fi rst Board in Malawi long-term donor commitments to meeting, the Health Minister of In Malawi, there are 266 doctors and fi nance them” [8]. France said that “there should be 7,264 nurses (no fi gures on midwives In addition, Malawi obtained no false dilemma over treatment or are available): per 1,000 people there funding from the Global Fund under prevention”, but did not receive a are 0.61 full-time equivalents of health its Fifth Call for Proposals. The clear answer from the Board [9]. Then workers (2004 fi gures) [5]. The health Board of the Global Fund decided to CCMs proposed ART interventions, the workforce would need to be multiplied consider health systems strengthening TRP recommended some of them, and by four to achieve the MDGs. (HSS) interventions for funding as the Board approved them. In 2004, Peter Piot, head of the a specifi c category under its Fifth By doing so, the Global Fund has Joint United Nations Programme on Call for Proposals, and it was as an developed—perhaps implicitly—a HIV/AIDS, and Suma Chakrabarti, HSS intervention that the Malawi novel approach to sustainability. permanent secretary of the United response was approved. But under the Sustainability in the conventional Kingdom Department for International Sixth Call for Proposals, specifi c HSS sense implies that benefi ciary Development, during a joint visit to interventions were no longer eligible. countries gradually replace foreign Malawi concluded that it would be assistance with domestic resources. impossible to roll out ART without Global Fund Support to the Health This is not realistic for low-income undermining the health system, unless Workforce countries providing ART. Nonetheless, the level of health workers could be The Global Fund has a unique the Global Fund does support increased dramatically. They instructed governance structure. At the core ART interventions in low-income their agencies to support an initiative of this structure are the Country countries: thus it shifted concerns to address the health workforce crisis. Coordination Mechanisms (CCMs): about sustainability from national to The result was “a shift from piecemeal national platforms of stakeholders, international level (if the Global Fund donor support for a number of formulating proposals in answer to can sustain these interventions, they uncoordinated initiatives to a more the calls for proposals launched by the are sustainable, albeit in a different comprehensive approach” [6].
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