One of my current areas of research, looks at the relationship between funding for HIV/AIDS programs and the delivery of non-targeted health services in sub-Saharan Africa. I find that the disbursements of funding is associated with lower coverage of other health services, including immunizations, and that this effect does not appear to be driven just by the epidemic itself and appears strongest in countries with the lowest density of health workers. I have always argued that these findings suggest that HIV/AIDS funding may be “crowding in” human resources into HIV activities leaving fewer health workers or less capacity for other health activities. Documenting these effects at the country-level, however, has always been challenging and most policy makers are very quick to dismiss “anecdotal reports” of such occurrences.
A recent qualitative study of these mechanims in Zambia by Johanna Hanefeld and Maurice Musheke, certainly support this view. In this study, the authors conducted a series of interviews with key informants at multiple levels of the health sector in Zambia in 2007. They investigate how the strategies employed by the global health initiatives, including PEPFAR and the Global Fund, are addressing the shortage of health workers in Zambia. Referring to these strategies, the authors suggest that:
“… interventions aims to alleviate the human resource shortage in relation to ART, examining their impact at district and provincial level in detail suggests possible negative, unintended consequences.”
They provide some disturbing quotes:
“One senior Ministry of Health official observed, “HIV, TB and malaria have taken almost 90% of our time, not to mention that they have also taken most of our budgetary money to the extent that we have actually neglected what we call noncommunicable diseases”
In Zambia, a great deal of the PEPFAR funds are being channeled in “off-budget” channels, specifically though non-governmental organizations. The authors find that:
“Of the health workers involved in the two public sector sites that started ART in Zambia in 2002 (University Teaching Hospital, Lusaka, and Ndola Central Hospital), including the doctors leading these programmes, the majority have now left the public sector to work for GHI-funded organizations that support the roll-out of ART.”
I think the findings of this study are very important. The authors have done a great job documenting what appears to be happening in Zambia, and likely in other countries as well. Of course, this is not necessarily a bad thing, depending on how one views the gains from one health intervention over the other, but it does raise some important questions. Specifically, to what extent are we willing to accept the negative effects of these initiatives on the rest of the health sector.