Health and development

Cultural sensitivity is critical for the success of development strategies according to a new report produced by the United Nations Population Fund (UNFPA). Credit UNFPA

Cultural sensitivity is critical for the success of development strategies according to a new report produced by the United Nations Population Fund (UNFPA). Reaching Common Ground: Culture, Gender and Human Rights, launched 12 November 2008, reports that culture is a central component of successful development of countries, and must be integrated into development policy and programming.

The State of World Population 2008 report affirms that development strategies that are sensitive to cultural values can reduce harmful practices against women and promote human rights, including gender equality and women’s empowerment.

Despite many declarations and affirmations in support of women’s rights, the report argues, gender inequality is widespread and deep-rooted in many cultures. Coercive power relations underlie practices such as child marriage - a leading cause of obstetric fistula and maternal death—and female genital mutilation or cutting. These and other harmful practices continue in many countries despite laws against them.

Gender inequality and HIV

The effects of gender inequality leave women and girls more at risk of exposure to HIV. Less access to education and economic opportunities results in women being more dependent on men in their relationships, and many who have no means of support must resort to bartering or selling sex to support themselves and their children. Where women can’t own property and lack legal protections, their dependence within their families is even greater. Economic and social dependence on men often limits women's power to refuse sex or to negotiate the use of condoms.

The report, which coincides with this year’s 60th anniversary of the Universal Declaration of Human Rights, is based on the concept that the international human rights framework has universal validity. Human rights express values common to all cultures and protect groups as well as individuals. The report endorses culturally sensitive approaches to the promotion of human rights, in general, and women’s rights, in particular.

Culturally sensitive approaches call for familiarity with how cultures work, and how to work with them. The report suggests that partnerships - especially with community-based institutions and leaders - can create effective strategies to promote human rights and end their abuses, such as female genital mutilation or cutting, wife inheritance or rape within marriage.

“Communities have to look at their cultural values and practices and determine whether they impede or promote the realization of human rights. Then, they can build on the positive and change the negative,” said Thoraya Ahmed Obaid, Executive Director of UNFPA

Therefore, The State of World Population report cautions that cultural sensitivity and engagement do not mean acceptance of harmful traditional practices, or a free pass for human rights abuses. Values and practices that infringe human rights can be found in all cultures. Understanding cultural realities can reveal the most effective ways to challenge these harmful cultural practices and strengthen beneficial ones.

The report concludes that analysing people’s choices in their local conditions and cultural contexts is a precondition for better development policies.

The Clinton Global Initiative (CGI) is a
non-partisan catalyst for action that brings
together a community of global leaders
from various backgrounds to devise and
implement innovative solutions to some
of the world’s most pressing challenges.

The annual meeting of the Clinton Global Initiative (CGI) concludes today in New York. The three-day event brought together a diverse group of world leaders from government, business, international agencies and civil society to examine global challenges and transform that awareness into action.

UNAIDS Executive Director Dr Peter Piot and former President of the Portuguese Republic, Jorge Sampaio participated in a working group breakfast on global health which addressed AIDS, tuberculosis, and malaria.

Increased effort and investment in the AIDS response in recent years have yielded examples of successful approaches that can be replicated or scaled up globally. The participants identified and explored opportunities to improve the way we respond to these diseases with existing tools and knowledge and highlighted current challenges.

Since its inception in 2005, CGI has convened a community that includes more than 80 current and former heads of state, hundreds of business, international and non-profit leaders, major philanthropists, and Nobel Peace Laureates. Their aim is to devise and implement innovative solutions to some of the world’s most pressing challenges.

The 2008 Annual Meeting focussed on challenges and opportunities in the following four focus areas: education, energy and climate change, global health and poverty alleviation.

The Global Campaign for the Health MDGs: First year report 2008.

A group of global leaders met in New York on 26 September 2007 to launch the Global Campaign for the Health Millennium Development Goals (MDGs). The Campaign aims to give renewed impetus to Goals 4, 5 and 6 which focus on the urgent need to improve maternal, newborn and child health and to combat HIV/AIDS, malaria and other diseases.

To mark the first year of the Campaign, a progress report was released on 25 September. It provides an update of major activities during the last year, and highlights concrete actions that are required to accelerate the necessary progress if we are to reach the health related MDGs by 2015.

Read the contribution by Dr Peter Piot, Executive Director, UNAIDS:

Scaling up towards Universal Access: AIDS, Malaria, Tuberculosis and Immunization

AIDS is inextricably linked to the other MDGs: education, gender equality and poverty eradication are all vital for fighting it. And in many countries reducing HIV infections and deaths from AIDS is essential for making progress on other MDGs.

By the end of 2007, the global number of new HIV infections and AIDS-related deaths had begun to decline – largely the result of action on political commitments. At the G8 summits in 2005 and 2008, and at the UN High-Level Meeting on HIV/AIDS in 2006, leaders agreed to scale up to universal access to HIV prevention, treatment, care and support by 2010.

There are now 105 countries with national targets for universal access, and 147 countries submitted progress reports this year. In 2007, investment in HIV programmes reached US$10 billion, up from US$8.3 billion in 2005. Extraordinary efforts resulted in three million people in low- and middle-income countries receiving anti-retroviral treatment in 2007 – a million more than in 2006.

Several heavily affected countries are making progress on HIV prevention. There are falls in the number of people having more than one partner in the last year, increases in condom use among promiscuous young people, and, in sub-Saharan Africa, signs that people are beginning to have sex at a later age.

Access has improved to antiretroviral drugs that prevent mother-to-child transmission (PMTCT) of HIV. In low- and middle-income countries, a third of women who need the drugs can get them – up from 14% in 2005. Some countries, including Argentina, Botswana, Georgia and the Russian Federation, have achieved close to universal access, with PMTCT services at more than 75% coverage. In Botswana, just 4% of children born to HIV-positive mothers are infected.

Other prevention efforts are also improving. Of 39 countries reporting on it, coverage of HIV-prevention services for sex workers is 60%. For people who inject drugs coverage is nearly 50% in 15 countries, and for men who have sex with other men it is 40% in 27 countries.

In many countries AIDS programmes are supporting fragile health systems, improving service delivery, staff, information systems, governance and the procurement and management of drugs. We recommend using a third of HIV/AIDS resources to strengthen health systems.

There is more to do. In low- and middle-income countries, two-thirds of people requiring antiretroviral drugs cannot get them. For every two people starting HIV treatment, five become infected. AIDS remains the biggest killer of African adults (25-49) and is among the top ten killers worldwide. Like climate change, AIDS will require a long-term response. We need to build on progress and strengthen links with other health programmes, notably tuberculosis, sexual and reproductive health, and maternal and child health.

This will require more money: over 50% more by 2010 to maintain the current pace of growth in prevention and treatment. The price is worth paying.

Peter Piot
Executive Director
UNAIDS

(from left) Dr. Peter Piot, Executive Director
of UNAIDS; Julian Lob-Levyt, Executive
Secretary of the Global Alliance for Vaccines
and Immunization (GAVI); Dr. Tedros
Adhanom, Minister of Health, Ethiopia;
Andrew Jack, Financial Times Pharmaceuticals
Correspondent; Michel Kazatchkine,
Executive Director of the Global Fund;
Ann Veneman, Executive Director of
UNICEF participate in MDG HLM side
event on MDG 6 equity challenge.
23 September, UNHQ, New York.
Credit: UNAIDS/Brad Hamilton

In 2000, global leaders embraced a series of Millennium Development Goals (MDGs) that resolved to make the world safer, healthier, and more equitable.

We are half-way to the 2015 target date and progress is mixed and uneven. To assess the gaps and understand what more needs to be done to ensure nations are on course to achieve the commitments they have made, a High-level Event on the MDGs takes place on 25 September 2008 hosted by the United Nations Secretary-General and the President of the General Assembly.

MDG 6 and universal access to HIV prevention, treatment, care and support by 2010

MDG 6 aims that by 2015 the world will have halted and begun to reverse the global HIV epidemic.

UN Member States have also committed, in a Political Declaration at the General Assembly in 2006, to taking extraordinary action to move towards universal access to HIV prevention, treatment, care and support by 2010. At this juncture it is useful to assess the HIV response.

Dr. Peter Piot, Executive Director of UNAIDS
speaks at MDG HLM side event on MDG
6 equity challenge. 23 September, UNHQ,
New York. (right) Julian Lob-Levyt, Executive
Secretary of the Global Alliance for Vaccines
and Immunization (GAVI)
Credit: UNAIDS/Brad Hamilton

Although Goal 6 specifically addresses the HIV epidemic, an effective HIV response will also support achievement of other Millennium Development Goals. Success in the achievement of the MDGs will also make an impact on HIV epidemics around the world. Addressing the obstacles to universal access to HIV prevention, treatment, care and support services will contribute to the achievement of the broader MDGs. These include addressing stigma and discrimination, human rights and gender inequality as well as ensuring sustainable financing, affordable commodities, strengthened health systems and human resources, and accountability.

MDG 1: Eradicate extreme poverty and hunger.

There is a complex relationship between AIDS, poverty and human development, a so-called ‘vicious circle’ within which the impacts of AIDS increase poverty and social deprivation, while socio-economic inequalities increase vulnerability to HIV infection.

With the eradication of extreme poverty and hunger, people may reconsider lifestyle options which put them at higher risk of HIV such as working far away from home or in commercial sex.

Especially in high-prevalence settings, HIV deepens household poverty and slows economic growth. Alleviating the epidemic’s burden helps countries to grow their economies, reduce income inequalities, and prevent acute hunger. In Western Kenya, antiretroviral treatment has led to a large and significant increase in the labour supply. Within six months of starting treatment there is a 20% increase in the likelihood of participating in the labour force, and a 35% increase in weekly hours worked. This brings economic and other benefits to the family including for children’s nutritional status.

MDG 2: Achieve universal primary education.

The HIV response promotes universal education initiatives. Ensuring children’s access to school is an important aspect of HIV prevention, as higher levels of education are associated with safer sexual behaviours and delayed sexual debut and reduce girls’ vulnerability to HIV.

School attendance is a central focus of initiatives to address the needs of children orphaned or made vulnerable by HIV. Better access to treatment helps to minimize the epidemic’s impact on fragile educational systems; it also reduces the likelihood that young people will be withdrawn from school in response to HIV in the household.

MDG 3: Promote gender equality and empower women.

The effects of gender inequality leave women and girls more at risk of exposure to HIV so progress in this Goal is of fundamental importance to the HIV response.

Less access to education and economic opportunity results in women being more dependent on men in their relationships, and some who have no means of support must resort to bartering or selling sex to support themselves and their children. Where women cannot own property and lack legal protections, their dependence within their families is even greater.

The HIV response itself is also helping to drive efforts to reduce inequalities between the sexes. Countries are now monitored on the degree to which gender equity is a component of national HIV responses. Thus, the epidemic has increased the urgency of initiatives to forge new gender norms, and extensive worldwide efforts are under way to develop new HIV prevention methods that women may initiate. HIV has prompted parents, communities, and governments alike to approach the sexual and reproductive health needs of women, girls, and sexual minorities with renewed commitment.

MDG 4: Reduce child mortality.

Deaths due to AIDS among children is declining since 2003 as there is a drop in new infections and more children being put on treatment. However in most-affected countries such as Botswana and Zimbabwe, more than one third of all deaths in children under 5 are due to AIDS.

A key component of a comprehensive HIV response is the scaling up of prevention strategies that can nearly eliminate the risk of mother-to-child HIV transmission.

MDG 5: Improve maternal health.

Women now account for about half of all people living with HIV, and for more than 60% of infections in Africa. Greater access to antiretroviral medicines is improving the health and well-being of women, and pre-natal programmes for preventing mother-to-child transmission help mothers remain in good health to care for their children.

Integration of HIV initiatives with programmes addressing sexual and reproductive health is helping to ensure that women have access to the information and services they need to make informed reproductive decisions.

MDG 6: Combat HIV/AIDS, malaria, and other diseases.

Progress in TB control will greatly benefit the AIDS response as TB, which is mostly curable and preventable, is one of the most important causes of illness and death among people living with HIV.

A strong HIV response yields health benefits that extend well beyond HIV itself. The push to expand access to HIV treatment in resource-limited settings is helping to strengthen fragile health infrastructures and is driving improvements in human capacity in low- and middle-income countries.

MDG 8: Develop a global partnership for development.

Perhaps more than any other issue in our time, HIV has highlighted global and economic inequities, and has galvanized action on international development. HIV has helped place people at the centre of development.

Progress on inclusive, country-owned development strategies will deliver greater success for improved aid effectiveness, strengthened health systems and the AIDS response.

The AIDS response has championed more inclusive partnerships as being key and has pioneered the principle of country ownership through the 'three ones'.

High-level Event on the MDGs: Side events

UNAIDS Secretariat, its cosponsors and partners will host the following side events in relation to MDG 6:

The MDG 6 equity challenge
Organized by the Mission of Ethiopia, UNAIDS, Global Fund to Fight AIDS, TB and Malaria, and the Global Alliance for Vaccines and Immunization (GAVI). The meeting will focus on achieving MDG 6 by increasing access to basic health services, especially the delivery of new health technologies to geographically and socially marginalized communities.

UN system coherence to achieve MDG 6
Organized by the Missions of Ireland and Tanzania, UNAIDS, and UN Development Operations Coordination Office. The meeting will highlight coordination mechanisms to promote and enhance system wide support of national priorities to achieve MDG 6.

The AIDS response: Relationship to development in Africa

As high-level participants and international experts gather to discuss Africa’s development needs and challenges at UN headquarters in New York on 22 September, we take a look at how HIV and the AIDS response is impacting development on the continent.

In countries in Africa most heavily affected by HIV, the epidemic has reduced life expectancy by more than 20 years, slowed economic growth and deepened household poverty. However effective, sustainable AIDS responses offer an opportunity to overturn the critical development challenges to overcoming poverty, improving education, extending life expectancy and reducing child mortality.

Development needs leveraged through AIDS leadership

When committed national leadership on AIDS is combined with long-term coordinated financing, dividends beyond the epidemic are being seen in Africa. Scaling up HIV services means addressing years of under-investment in health human resources in resulting in strengthened health systems which lead to improved maternal and child health. As individuals benefit from antiretroviral treatment, they live longer and their labour productivity rises, lifting households from poverty and improving food security for their families.

“How we fare in fighting AIDS will impact all our efforts to cut poverty and improve nutrition, reduce child mortality and improve maternal health, curb the spread of malaria and tuberculosis.” - United Nations Secretary-General Ban Ki-Moon speaking at the General Assembly High Level Meeting on HIV/AIDS, New York, June 2008

In addition, an AIDS response that addresses deep seated drivers or causes of vulnerability to HIV infection—stigma, discrimination, gender inequality and human rights—will impact wider development.

Successes and progress

Affected countries in Africa are showing strengthening leadership in addressing challenges by increasing the use of their own resources. The per capita domestic public HIV expenditure (from governments’ own sources) in sub-Saharan Africa was six times greater than other parts of the world after adjusting by income level (2008 Report on the global AIDS epidemic).

The substantial increases in AIDS funding and the investment in prevention and treatment of recent years are producing encouraging results in a number of countries in Africa.

In Rwanda and Zimbabwe changes in sexual behaviour—waiting longer before becoming sexually active, having fewer multiple partners, increased condom usage among people with multiple partners—have been followed by declines in the number of new HIV infections. Condom use is increasing among young people with multiple partners in Benin, Burkina Faso, Cameroon, Chad, Ghana, Kenya, Malawi, Namibia, Uganda, Tanzania and Zambia.

HIV epidemics in Malawi, South Africa and Zambia appear to have stabilized and most of the comparatively smaller HIV epidemics in West Africa are stable or are declining, as is the case for Burkina Faso, Cote d’Ivoire, Mali and Nigeria. HIV prevalence in HIV epidemics in East Africa have either stabilized or are receding.

Gains in access to antiretroviral treatment

More people have access to HIV treatment than ever before. Of the 3 million people who received HIV treatment in 2007, more than 2 million of them are in sub-Saharan Africa. In the period 2003 to 2007, Namibia scaled up treatment from 1% to 88%, Rwanda from 3% to 71%. As a result we’ve seen number of AIDS-related deaths decline over the past two years from 2.2 million to 2 million in 2007.

This is paying incalculable dividends for African countries. HIV treatment means that HIV-positive people are living longer, in better health and with a higher quality of life. They can continue to be productive within their workplace and community and there is less risk of their household falling into poverty and food insecurity.

Good progress has also been made in the prevention of mother-to-child transmission of HIV with increases in coverage of services in countries including Botswana, Namibia, Swaziland and South Africa.

This progress suggests a return on the investments made on different fronts, particularly in HIV prevention and treatment, and shows that with continued commitment, countries can overcome the development challenge that the epidemic poses.

Demographic impact of HIV

However, in spite of successes the epidemic continues to outstrip the response. The 2008 report on the global AIDS epidemic released by UNAIDS shows that AIDS continues to be the leading cause of death on the continent of Africa. In southern Africa, the average life expectancy at birth is estimated to have declined to levels last seen in the 1950s—below 50 years for the sub-region as a whole.

The numbers are stark: 67% of all people living with HIV and almost 90% of children living with HIV are in sub-Saharan Africa. In Botswana and Zimbabwe more than one third of all deaths in children under 5 are due to AIDS.

Progress, but gaps remain

As pointed out in the UN Secretary-General’s Report to the June 2008 High-level meeting on AIDS, countries need to sustain the progress that they have already made and continued leadership is required for the implementation of fully funded and sustainable national strategies and programmes on HIV.

HIV: A public health and a development issue

HIV is both a public health and a development issue which requires a sustained, inclusive and multi-sectoral response.

The Commission on HIV/AIDS in Africa (CHGA) issued a report earlier this year which included a call for leadership at all levels to be mobilized and coordinated for a concrete HIV response and broader development plan. The report also calls for addressing gender inequalities in national strategies as 60% of people living with HIV in sub-Saharan Africa are women.

High-level meeting on Africa’s development needs

At the high-level meeting on Africa’s development needs taking place in New York on 22 September, heads of State or Government, ministers as well as civil society organizations, intergovernmental organizations, UN agencies, funds and programmes, as well as the Bretton Woods institutions will gather to discuss “Africa’s development needs: State of implementation of various commitments, challenges and the way forward.” The meeting will conclude with the adoption of a Political Declaration. UNAIDS Secretariat, its cosponsors and partners will host a series of side events.

Photo credit: Nigel Stead/LSE

As part of the London School of Economics and Political Science’s (LSE) speakers series on AIDS (LSEAIDS), UNAIDS Executive Director Dr Peter Piot delivered a public lecture titled “The future of AIDS: Exceptionalism Revisited” on May 15.

In his lecture, he reviewed the global response to AIDS to date and considered what is needed in the longer term. He also examined the epidemic within the context of pressing wider health and development issues.

LSEAIDS brings together leading social scientists and experts at the LSE to explore some of the long-term effects of AIDS that risk being overlooked. The group defines the AIDS epidemic as a 'long-wave' event whose full social and economic effects will be with us for decades.

This was Dr Piot’s second LSEAIDS lecture; he first addressed this forum in February 2005.

The event was chaired by Professor Tony Barnett, LSEAIDS and hosted by the LSE, LSE Health and the UK Government’s Department for International Development (DfID).

The new International Health Partnership
public web site shares information on
strengthening health systems and services

The International Health Partnership (IHP+) has launched a public web site to facilitate the dissemination of information and tools related to strengthening health systems and services.

The IHP+ is a partnership which includes 13 partner countries, United Nations agencies including UNAIDS, bilateral donors, civil society and private sector partners.

Launched in September 2007, the initiative aims to increase donor, country and international coordination on health and development issues in order to make progress on achieving the health-related Millennium Development Goals—reducing child mortality, improving maternal health, and halting and reversing the spread of HIV.

Participants signed a compact agreeing to work together within countries’ national plans to improve coordination in order to address problems related to health worker staffing, infrastructure, health commodities, logistics, tracking progress, and effective financing.

Each of the 13 participating countries has provided a Country stocktaking report that documents the current state of health systems strengthening and describes progress made to date along with the continued challenges.

The web site will serve as a forum for participating countries to present the results of stock-taking exercises and, in some cases, draft road maps to development of the compact. As these documents become available, they will be added to the web site.

The IHP+ work plan, progress reports as well as meeting minutes and other official documents can all be accessed on this new web site.

It is hoped that this site will become a useful tool to meet one of the objectives of IHP+: “Ensure mutual accountability and monitoring of performance.”

“Sharing knowledge through this partnership can help lead to better coordinated and more transparent responses to strengthening national health care systems,” said UNAIDS Executive Office Director, Tim Martineau.

“UNAIDS is happy to be a partner in this initiative which emphasizes actions which are country-led and country-focused and which will help deliver on our shared goal of achieving universal access treatment targets.”

IHP+ aims to scale-up coverage and use of health services in order to deliver improved health outcomes against the health-related Millennium Development Goals and universal access commitments.

Partners will work together to ensure that health plans are well-designed, well-supported and well-implemented and to make their work more effective and better aligned with developing countries’ established priorities.

Participants will focus on issues such as
poverty reduction, state capacity to
promote and guide development, rising
oil prices and the global credit crisis.

The first session of the Joint Annual Meetings of the African Union Conference of Ministers of Economy and Finance and the United Nations Economic Commission for Africa Conference of Ministers of Finance, Planning and Economic Development is taking place in Addis Ababa, Ethiopia from 31 March to 2 April 2008.

The conference will also mark the start of a yearlong commemoration of the Economic Commission for Africa’s 50th anniversary. As part of the celebrations, participants, including selected African Heads of State and Government and other eminent persons, will be invited to reflect on the theme of the Conference, ‘Meeting Africa’s New Challenges in the 21st Century’.

The conference will begin with an overview of recent economic and social developments in Africa which will include the state of the global economy, overall growth performance in Africa, trends in social development in Africa and the continents economic prospects for 2008.

UNAIDS Executive Director Dr
Piot will highlight ways in
which the AIDS response can
be stepped up in Africa.

Participants will go on to focus on issues such as poverty reduction, state capacity to promote and guide development, particularly in relation to providing adequate infrastructure and social services, rising oil prices and the global credit crisis.

Four high-level thematic debates will be held on; HIV: keeping the promise; Empowering the poor; Growth, employment and poverty; and Climate change and development.

UNAIDS Executive Director, Dr Peter Piot will lead the debate on HIV and highlight that in spite of efforts to address the epidemic in Africa, AIDS remains a significant challenge which is hampering efforts to achieve the Millennium Development Goals. Dr Piot will highlight ways in which the AIDS response can be stepped up in Africa and will outline some specific recommendations for sustainable financing.

Photo credit: G. Bekele

The Global Health Workforce Alliance (GHWA) held the first ever Global Forum on Human Resources for Health in Kampala, Uganda from March 2-7, 2008. The GHWA, hosted and administered by the World Health Organization (WHO), has been created to identify and implement solutions to the health workforce crisis.

UNAIDS Executive Director  Dr Peter Piot gave the following plenary speech on "Partnerships and linking for action".

Download speech as PDF

Plenary speech by Dr Peter Piot, UNAIDS Executive Director

Kampala, Uganda 5 March, 2008.

UNAIDS Executive Director Dr Peter Piot addressing plenary at the Global Forum on Human resources for Health, in Munyonyo, Kampala, 5 March 2008
Credit: UNAIDS/C. Opolot

Thank you Sigrun – and thank you for inviting me here today.

I came to Kampala for three reasons. Firstly, this Forum is one of the most important meetings in public health to take place this year. We are starting to build a coalition to address one of the greatest obstacles to health.

Secondly, I am here to pledge the firm support of UNAIDS to this initiative.

Thirdly, it is time to de-polarize this debate. Whether we invest in the AIDS response or in strengthening health systems. It is not a question of one or the other. Even when it comes to AIDS, it is not simply a question of strengthening health services but also community mobilization. We must not forget about people or health outcomes

The issue of human resources for health is complex. But we all know it’s not a new one. I lived it myself in the mid-70s in rural Zaire. But nor is it limited to Africa. Last week I was in India where this is an enormous maldistribution of human resources for health.

The shortage results from decades of under-investment by governments, donors and international agencies. It has been intensified by globalization, but globalization may also bring some of the solutions. Responsibility for the current situation is shared – between donors, national governments, NGOs, research organization and international organizations among others. We therefore have a shared duty to address it. That’s why this afternoon’s panel, with its focus on partnership, is so vital.

The debate we are having now is long overdue. And a major reason for its happening at all is AIDS!

One of the peculiar characteristics of AIDS is that it exposes injustices. AIDS - more than any other issue - has thrown a spotlight on the urgent need to strengthen human resources for health, for three reasons.  Firstly, AIDS represents a significant burden on health systems. In some countries, half of all hospital beds are occupied with patients with AIDS-related illnesses. Secondly, to expand ART, and to make ART sustainable, we need strong health systems. Thirdly, being a health worker does not protect you from becoming infected. Botswana, for example lost approximately 17% of its healthcare workforce to AIDS between 1999 and 2005.

There have been good examples of how AIDS investment has helped overcome the human resources for health crisis. I remember well going to Malawi in 2004 with Sir Suma Chakrabarti, then Permanent Secretary of the UK’s DFID. AIDS had brought the health workforce literally to its knees. There was no way it could cope. It was an emergency that required exceptional measures. DFID and other donors financing the sector agreed to fund a groundbreaking initiative, the Emergency Human Resources Programme, to top up salaries for nurses and other health care workers as an incentive not to leave the country. This was totally novel: donors usually resist paying salaries, but in this case we managed to break the taboo.  I’m glad to say that the Global Fund to Fight AIDS, Tuberculosis and Malaria is now supporting this programme.

This is just one example of another characteristic of AIDS: it forces us to do things differently. WHO’s “Treat, train, retain” initiative for health-workers with HIV is another new and pragmatic approach. I don’t know of any other programme that starts by addressing the health of the workers involved. It provides wins all round – to the health workers themselves, to the people who need their services, and to the health sector as a whole. So, when we are talking about strengthening health systems, let’s first make sure that people stay alive! But good partnerships require more than processes. There are too many partnerships that are not enough about results and outcomes.

AIDS funding and programming enhanced essential infrastructure for health facilities. Where HIV services have been integrated into existing service delivery sites, AIDS money helped renovate health facilities, upgraded clinics and laboratories and provided training opportunities for health care workers.

AIDS has also helped promote “task shifting”, an old concept/idea in public health – moving responsibility for certain tasks to other health-workers and community members to free up doctors and nurses to take care of other patients and to deliver other essential health services. Here in Uganda, there is an increasing trend for people living with HIV to take on tasks such as counseling for testing, adherence support, treatment literacy and to produce good quality outcomes.  In Kenya, several organizations have been implementing prevention, treatment literacy and home based care programmes, which are led by people living with HIV at the community level.  Women Fighting AIDS in Kenya, supported by UNICEF in Kisumu and Port Reitz General Hospitals, trained PLWHAs who were then used as PMTCT champions to provide counseling to ante-natal mothers and their partners.

We also see, particularly here in Africa that faith-based organizations play a major in the fight against AIDS providing vital HIV care and treatment services. For example, Christian hospitals and health centers are providing about 40% of HIV care and treatment services in Lesotho and almost a third in Zambia. In other countries, the formal and informal private sector is also very important.

AIDS has brought in new resources, to benefit not only HIV programmes but health systems more widely. Take for example the Haitian “accompagnateurs” – community workers who have been brought into the health workforce through the AIDS programmme. Or in Rwanda, HIV treatment and care was integrated with regular health services, resulting in better coverage for maternal and child health according to a study by Family Health International (FHI) presented at last year’s PEPFAR Implementers Meeting in Kigali.  Les Mutuelles de Santé is another example of financing scheme to mobilize resources for health services.

So I have serious issues with the current wave of statements like “There’s too much money going to AIDS” or “Donors should prioritize health system strengthening”. They completely ignore the growing body of evidence that AIDS expenditure strengthens the health sector and contributes to broader development programmes, besides the fact that AIDS programmes are having measurable results, saving millions of lives. Indeed, AIDS has been an advocate for health systems strengthening.

They also seem to assume that dealing with HIV is mostly about treatment. It isn’t! For every one person we put on antiretroviral therapy, another four or five become infected with HIV. If we don’t radically enhance HIV prevention, demands for treatment will just keep on growing, placing an even greater burden on health systems in the future.

And prevention – except for PMTCT – is far more than a health issue. Prevention is a community based action. Effective HIV prevention derives from a range of multi-sectoral interventions (governments, nongovernmental organizations, faith-based organizations, the education sector, media, the private sector and trade unions and people living with HIV).

A lot of the recent surge of funding started as a direct consequence of the AIDS epidemic. AIDS advocacy did not only succeed in mobilizing money, but it also highlighted the profound disparities in health services that separated the developing countries from the developed world. It is however true that  there are examples where AIDS related activities and AIDS funding are taking away health workers from other tasks. AIDS funding created new and more interesting job opportunities for doctors and nurses with NGOs and foreign aid agencies and thus can be a drain on the public sector. We have seen it happening in Malawi and in Zambia where focus of disease programmes shifted to HIV. However, and certainly in the heavily affected countries, the AIDS burdens for health services is also a reality. We need to find common solutions and ways of working together.

This brings me to my next point. AIDS has taught us about the critical value of partnerships. Tackling AIDS is one of the toughest challenges the world faces today. Like dealing with climate change, it’s tremendously complex - way beyond the capacity of any single sector or institution. It’s one of those issues that jolts us out of our comfort zone, and forces us to create new alliances with a variety of constituencies – across sectors and at state and non-state level.

UNAIDS itself is a joint programme. We are working with a wide range of constituencies – government, scientists, business, labour, and the media. One of the most important partnerships of all has been our relationship with civil society. It was the activists who kick-started the AIDS movement. Without them, we wouldn’t have achieved anything like the progress we’ve made.  It’s thanks to these partnerships that we have been able to mobilize political momentum around AIDS, to leverage funding to $10 billion per year.

In the twelve years since UNAIDS was created, we’ve learnt a lot about partnerships. We’ve seen the advantages of being able to convene diverse actors from public, private, and non profit sectors – all with different strengths. They have the potential to achieve spectacular results – way beyond anything they could hope to achieve on their own.

But coordination and accountability are still important. That’s why UNAIDS established the Three Ones principles, as a framework for partnerships on AIDS.  Just to remind you, these are: one agreed national action framework, one national coordinating authority and one agreed monitoring and evaluation system.

The lessons we’ve learnt through implementing the Three Ones are salutary – and very relevant to the aims of this Alliance. The Agenda for Action is right to highlight the need for “national responses to be guided by a national leadership that convenes all actors around one agreed national effort”, and to point to the importance of accountability. The challenge is to engage serious commitment at all levels – in-country, in donor capitals and international organization headquarters. This requires time and effort. But it will be time and effort well spent.

I began today by saying that addressing the shortage of human resources for health was a joint responsibility. It is something that no institution can tackle alone. It is complex, cross-sectoral and long-term. And, like AIDS, it is not a quick-fix problem and there is no one solution that fits all. This may be a major reason why so little has been done before. Another reason may be the fact that the current crisis of human resources for health is also a highly political issue and therefore any possible solutions need to have full political support. But coming together in this alliance is in itself a tremendous step forward. There is a lot at stake; therefore our response must address the emergencies of today and to draw up longer-term plans for the future.

The Agenda for Action offers a comprehensive menu of activities, but I want to suggest some very concrete actions where we can all work and benefit together.

The first is that we must build partnerships far beyond the public sector. Partnerships are crucial for the success of any solution. We must also look at the critical role of non-state actors in the provision of services and their role in the training of human resources. In many countries, 40 to 60% of health services are delivered by the private sector. We have to establish more private/public partnerships with greater engagement of the private sector, beyond workplace programmes. Equally, in many countries, particularly here in Africa, many clinics and health centers are run by faith-based organization. We need to bring them all into the policy dialogue of heath services provision.

The second is to engage the full participation of civil society. As I mentioned earlier, civil society has been at the heart of the AIDS response from the very beginning. And its presence there has been vital. Not only does civil society activism mobilize action, but community members are an invaluable source of knowledge about what works and about how to reach people. We must listen and learn from them, and at the same time invest in building their capacity to deliver alongside that of public sector.

The third is for health ministries to make improving human resource management a priority. This is implicit in the Agenda for Action. But I think we need to spell it out more clearly. Today’s crisis has come about for two reasons. Lack of investment and lack of management. There’s a lot to do, but one of the first steps should be to establish incentives for performance and raise health-worker morale.

Fourth, we need to work together to question and challenge our concepts of fiscal space, predict medium term expenditure frameworks and the suitability of salary supplementation. We have to involve ministries of finance in the discussions of solutions. We should also work together with the World Bank and IMF on these constraints.

There is also the need to address the issue of public sector pay and work conditions. To address issues such as poor infrastructure, lack of equipment and drugs, long hours and heavy workloads and lack of career development in addition to poor remuneration. This needs to be combined with putting human resources for health on the agenda of civil service reform and donor willingness support and invest in supplementing health workers’ salaries and training. Donors and countries should consider the lessons learnt from the Malawi experience.

These issues are at the heart of any assessment of countries’ ability to scale up the response and the achievements of the MDGs. They are relevant for all of the health MDGs and need close examination and a common assessment of the risks and opportunities.

Press conference at the close of Global Forum on Human resources for Health, Kampala 5 March, 2008. (From left): Chair of the board Global Health Workforce Alliance, Dr Lincoln Chen; UNAIDS Executive Director, Dr Peter Piot and Representative of Women Living with HIV in Uganda, Beatrice Were.
Credit: UNAIDS/C. Opolot

We can be very ambitious, but need clear targets, goals and a partnership, where put the institutional interest aside. Fight for common good and common goal. We need to re-set the rules and to put into practice what has been discussed globally at country level. Every research programme must include overhead (/indirect costs for strengthening capacity. This is starting to be done among largest investors in heath (GAVI; GF; PEPFAR etc).

We also need to find a practical way to compensate low and middle-income countries that are losing their skilled staff in whose education they have invested.

The final – and most relevant for this afternoon’s session - is to be serious about applying the Three Ones principles, for all parties to come together and align around a single strategic plan for strengthening human resources for health that focuses clearly not just on process but on results.  One National AIDS Coordination authority and one agreed country-level monitoring and evaluation system. Such a framework has been invaluable for a well coordinated AIDS response. We are not there yet, but we have made progress.

If we make progress on action plan, it will be because have worked together. It is through diversity we will success. Pragmatic approach is needed, one step at a time, and strong leadership which will hold us together. I believe we have that leadership.

That may sound ambitious. But if we can come back in a year’s time and say we’ve made progress in these four areas, the world’s health workforce will look a lot more robust than it does today – and its population will be fitter as a result.

We have to act now and “to work together to ensure access to a motivated, skilled, and supported health worker by every person in every village everywhere.” Dr. LEE Jong-wook

Thank you.

The Global Health Workforce Alliance (GHWA) is convening the first ever Global Forum on Human Resources for Health in Kampala, Uganda from March 2-7, 2008.

The GHWA, hosted and administered by the World Health Organization (WHO), has been created to identify and implement solutions to the health workforce crisis. What is this crisis and how does it impact on the AIDS response?

Healthcare systems depend on trained staff

One of the major obstacles identified to scaling up access to HIV prevention, treatment, care and support in a country is a weak national healthcare system.

The question of human resources for health is a critical factor in any effective response to AIDS. A shortage of trained health care workers, particularly in low and middle-income countries, presents a real challenge to the ability of a country to respond to the HIV prevention, treatment and care needs of their populations.

In parts of sub-Saharan Africa shortages are so acute that they limit the potential to scale up programmes aimed at achieving health-related Millennium Goals including the roll-out of treatment for AIDS. - World Health Assembly, 2005

WHO estimates that more than 4 million additional doctors, nurses, midwives, managers and public health workers are urgently needed to avert serious crises in health-care delivery in 57 countries around the world—26 of these in sub-Saharan Africa. WHO estimates that at least 1.3 billion people around the world lack access to even the most basic health care.

Insufficient human resources has been identified as a primary obstacle to the delivery of antiretroviral treatment and other HIV-related services in many countries in Eastern Europe, Africa and Asia. Many healthcare systems have poor availability and quality of pre- and post-test counselling, health education, home care, diagnosis and treatment of opportunistic infections.

Governments pledge to increase capacity

At the 2006 High Level Meeting on AIDS, UN Member States reaffirmed their commitment to fully implement the 2001 Declaration of Commitment on HIV/AIDS and further strengthened international commitment on AIDS by:

“Pledging to increase capacity of human resources for health, and committing additional resources to low- and middle-income countries for the development and implementation of alternative and simplified service delivery models and the expansion of community-level provision of comprehensive AIDS, health and other social services.” However translating government commitment to increasing capacity into more health workers on the ground is a challenge of some complexity.

Balancing macroeconomic stability and staff retention

While AIDS funding has increased in recent years, simply pouring this into the healthcare system of a country to strengthen capacity is not the solution.

Most economists agree that a high rate of growth of a money supply causes a high rate of inflation - a rise in the general level of prices of goods and services in a given economy over a period of time.

Governments believe that fiscal and monetary policies – to keep inflation low - are needed to control and manage their economy to prevent potentially damaging sharp shocks and fluctuation in growth.

Low-income countries with high HIV-prevalence have to juggle the need to invest in their healthcare systems with a responsibility to maintain macroeconomic stability – nationally and regionally.

These economic policies include keeping salaries low and so constrain the hiring of the doctors, nurses, community health-care workers. Low salaries lead to low worker morale and low productivity and make it extremely difficult for some countries to retain their staff.

Open labour markets mean skilled professionals are migrating in record numbers to high-income countries, draining human capacity where it is most needed.

Global Forum on Human Resources for Health

Consensus is growing that this is a global crisis which calls for coordinated action.

The Global Health Workforce Alliance (GHWA) has been established to explore and implement solutions to this health workforce crisis. It is hosted and administered by the World Health Organization (WHO).

As a first step in the process, the GHWA are holding the first Global Forum on Human Resources for Health in Kampala this week. This meeting brings together government leaders, health and development professionals, civil society and academics from around the world who hope to consolidate a global movement on this.

Participants will explore solutions to improving education, training, and health sector management as well as looking at recent trends in migration.