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]. Board of the Global Fund. (The Board manner). The response in Malawi might remain of the Global Fund regularly launches The international community unique for several reasons. First, the calls for proposals, known as Rounds: endorsed this novel approach. In Malawi response was possible because Round 1 and Round 2 were launched June 2006, the United Nations

PLoS Medicine | www.plosmedicine.org 0606 April 2007 | Volume 4 | Issue 4 | e128 Table 1. Health Workforce Gaps and Wage Bill Agreements in 13 African Countries Countries with Adult HIV Nurses (Density per Physicians Adult HIV Wage Bill Conditionality in IMF-Supported Prevalence >5% and <2 Nurses 1,000 Population), (Density per 1,000 Prevalence Programmes per 1,000 Population 2004 Population), 2004 (%), 2005

Zambia 1.74 0.12 17.0 Yes Cameroon 1.60 0.19 5.4 No, but government promised to keep wage bill below 5.9% of GDP (December 2, 2003) Kenya 1.14 0.14 6.1 Yes Congo, Republic of 0.96 0.20 5.3 Yes Zimbabwe 0.72 0.16 20.1 No ongoing IMF-supported programmes Lesotho 0.62 0.05 23.2 No, but government promised to reduce wage bill (February 12, 2001) Uganda 0.61 0.08 6.7 Yes Côte d’Ivoire 0.60 0.12 7.1 No ongoing IMF-supported programmes Malawi 0.59 0.02 14.1 Yes, but with automatic adjustment Tanzania 0.37 0.02 6.5 No, but government promised to keep wage bill below 4.7% of GDP (July 14, 2005) Central African Republic 0.30 0.08 10.7 Yes Mozambique 0.21 0.03 16.1 No longer applicable since 2006, but replaced by promise to keep wage bill below 7.5% (April 3, 2006)

GDP, gross domestic product. doi:10.1371/journal.pmed.0040128.t001

General Assembly committed itself “to Dräger et al. note that this concern programmes for the Global Fund supporting and strengthening existing about sustainability “cannot be found and long-term development of health fi nancial mechanisms, including for any other activities fi nanced by infrastructure for the World Bank the Global Fund to Fight AIDS, the Global Fund” and suspect that it is [15]. In November 2006, the TRP and Tuberculosis and Malaria, as well as closely linked to IMF and World Bank the Secretariat, in their report to the relevant United Nations organizations, macroeconomic policies [11]. Board, recommended that “the Board through the provision of funds in a The advocates of supporting salaries convene a suitable forum, which can sustained manner” (emphasis added) of health workers from the Global discuss and attempt to resolve the [10]. It might sound like a nuance, but Fund obtained a short-lived victory question of the appropriate scope the difference between “sustainability in 2005, when Round 5 of the Global and defi nition of acceptable HSS relying on domestic resources in the Fund included a specifi c category for activities prior to Round 7. Ideally, this long run” and “sustainability relying HSS interventions. discussion will lead to a clarifi cation on the provision of external funds in a But Round 5 also caused some actors and narrowing of the scope of HSS sustained manner” is fundamental. to evaluate their role in the global activities which the Global Fund sees as This novel approach is what health landscape. The World Bank its mandate to fund” [16]. countries like Mozambique need to insisted on a “Comparative Advantage This evolution is problematic strengthen their workforce. They Study” of Global Fund and World because the World Bank does not share need to hire more health workers, but Bank AIDS programmes. Alexander the Global Fund’s novel approach to they are unable to sustain the costs of Shakow, who conducted the study, sustainability, certainly not for health hiring additional health workers with recommended that the Global Fund workers’ salaries. The World Bank domestic resources. focus on disease-specifi c interventions, believes that “it is not prudent for If the controversy about ART was leaving HSS interventions to the countries to commit to permanent easy to solve, the controversy about World Bank [12]. In January 2006, expenditures for such items as salaries strengthening health workforces was the Global AIDS Alliance and Health for nurses and doctors on the basis tougher. Some Global Fund supporters GAP—supported by more than 30 of uncertain fi nancing fl ows from understood from the beginning that experts and 300 non-governmental development assistance funds” [17]. its success in expanding coverage organisations—urged the Global Some bilateral donors might be of ART depended on its willingness Fund to keep HSS interventions as willing to consider “unsustainable” to pay for the salaries of additional a specifi c category [13,14]. In April interventions to address health health workers. However, the Global 2006, the Board decided to narrow workforce crises, as they did in Malawi. Fund has never been keen to expand the scope of eligible interventions, But Malawi remains the exception that its novel approach to sustainability to adopting a proposal form that no confi rms the general rule. Bilateral the funding of the health workforce. longer included HSS interventions as donors will fi nd it diffi cult to make Since Round 2, the Global Fund has a specifi c category. In August 2006, their commitments reliable enough applied strict criteria for the funding of Richard Feachem, the executive for the IMF to adjust the ceiling on the salaries of health workers. With regards director of the Global Fund, endorsed government wage bill. Most bilateral to salaries, applicants must explain a new “division of labour” between donors can only commit for as long as “how these salaries will be sustained the World Bank and the Global Fund: their government remains in place— after the proposal period is over” [11]. rapid scale-up of disease-specifi c only a few years.

PLoS Medicine | www.plosmedicine.org 0607 April 2007 | Volume 4 | Issue 4 | e128 Conclusion in accordance with their needs [19]. memorandum of understanding. Available: http:⁄⁄www.imf.org/external/np/loi/2006/ Both the cases of Mozambique It would allow individual donors to mwi/012006.pdf. Accessed 13 March 2007. and Malawi illustrate the crucial overcome their inability to make 8. Fedelino A, Schwartz G, Verhoeven M (2006) commitments beyond the term of Aid scaling up: Do wage bill ceilings stand in importance of addressing the health the way? International Monetary Fund Working workforce crisis. It is easier to remedy their governments, because their Paper WP/06/106. Available: http:⁄⁄www.imf. the shortage of medicines with contributions would be compulsory. org/external/pubs/ft/wp/2006/wp06106.pdf. (This is not a heresy. Many bilateral Accessed 13 March 2007. external funding than it is to remedy 9. The Global Fund (2002) Minutes of the shortage of health workers with donors consider their contributions to the fi rst meeting of the Board. Geneva, the World Bank as compulsory [20]. 28–29 January 2002. Available: http:⁄⁄www. external funding. Medicines can be theglobalfund.org/en/fi les/publicdoc/ bought; health workers need to be This can be achieved for contributions First%20Board%20Meeting.pdf. Accessed 13 trained fi rst. This underlines the to the Global Fund.) Furthermore, the March 2007. pooling of resources by many donors 10. United Nations General Assembly (2006) importance of starting emergency Political declaration on HIV/AIDS. Available: human resources programmes now, would increase continuity: if one donor http:⁄⁄data.unaids.org/pub/Report/2006/ reduces its contribution, another donor 20060615_HLM_PoliticalDeclaration_ before the growing case load— ARES60262_en.pdf. Accessed 13 March 2007. resulting from the fact that most could compensate. 11. Dräger S, Gedik G, Dal Poz M. (2006) Health people on ART will stay alive longer, And that is exactly what countries workforce issues and the Global Fund to fi ght like Mozambique need to increase their AIDS, Tuberculosis and Malaria: An analytical while the number of people in need review. Hum Resourc Health 4: 23. Available: of ART will grow—undermines either health workforce: sustained assistance. http:⁄⁄www.human-resources-health.com/ the quality of ART programmes, or the content/pdf/1478-4491-4-23.pdf. Accessed 13 Acknowledgments March 2007. performance of health systems [18]. 12. Shakow A (2006) Global Fund–World Bank Without support from the The authors would like to acknowledge HIV/AIDS programs: Comparative advantage the valuable contributions of Sarah Venis Global Fund, it will be diffi cult study. Available: http:⁄⁄siteresources. (Médecins Sans Frontières, London, United worldbank.org/INTHIVAIDS/ for Mozambique to develop its Kingdom) and Tony Reid (Médecins Sans Resources/375798-1103037153392/ own emergency human resources GFWBReportFinalVersion.pdf. Accessed 13 Frontières, Brussels, Belgium). March 2007. programme. Bilateral donors are References 13. Global AIDS Alliance (2006) Health care unable to support human resources workforce platform. Available: http:⁄⁄www. 1. Wemos (2006) IMF macroeconomic policies globalaidsalliance.org/Health_Care_ programmes that rely on sustained and health sector budgets. Available: Workforce_Platform_January_2006.cfm. external assistance over decades. The http:⁄⁄www.wemos.nl/Documents/ Accessed 13 March 2007. World Bank is unwilling to use foreign wemos_synthesis_report_fi nal.pdf. Accessed 14. Health GAP (2006) Urgent call for 13 March 2007. U.S. initiative on health workforce in assistance for salaries of health workers. 2. 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