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Treat, Train, Retain

By José M. Zuniga

May 2006

Jose M. Zuniga
As far as World Health Organization (WHO) consultations go, the "Consultation on AIDS and Human Resources for Health" I participated in May 11-12, 2006, on behalf of the International Association of Physicians in AIDS Care (IAPAC) was exceptional. Greeting us in the WHO's Executive Board Room was the WHO's Director-General, Lee Jong-wook, accompanied by Tim Evans and Anarfi Asamoa-Baah, his Associate Director-Generals for the Evidence and Information for Policy (EIP) and HIV, Tuberculosis, and Malaria (HTM) clusters, respectively. Their individual remarks and collective message were spare and to the point -- "We face a crisis in human resources. The solution is not straightforward, and there is no consensus on how to proceed. We need your help."

For veterans of such technical consultations that typically focus narrowly on a topic du jour, whether convened by the WHO or other equally bureaucratic institutions, such statements are de rigueur, and are often followed by the introduction of a consensus document written well in advance of the "consultation" and to which all parties convened to offer technical assistance are expected to sign on in a show of solidarity. This particular consultation, however, was different because it covered a broad spectrum of challenges confronting the health workforce in developed and developing countries alike, was low on rhetoric (especially from the WHO), and engaged almost every individual in attendance.

As fate would have it, this consultation would be the second to last public event over which the WHO's Director-General presided. His hectic schedule required the 61-year-old tuberculosis specialist to wear multiple hats in the global battles against avian flu, HIV/AIDS, malaria, obesity, tobacco, and tuberculosis, to name just a half dozen of the health woes facing humankind. He died May 22, 2006, from a stroke following emergency surgery to remove a blood clot in his brain [Editor's Note: See "In Memoriam," in this issue.]. His untimely passing -- sad as it is for his family, his colleagues, and the global health community -- would be devastating to the HIV/AIDS movement were it not for his clear and unwavering leadership around and commitment to ensuring that the benefit of antiretroviral therapy (ART) now taken for granted in the developed world reaches many more men, women, and children living with HIV/AIDS in the developing world.

A man of few words, Lee preferred action. Upon his election in 2003, colleagues at the WHO described him to me as the antithesis of contrived momentum. In his years heading the WHO's "Stop TB" program, for example, he brought new direction and marshaled resources in response to a growing epidemic of multiple drug resistant-tuberculosis. Whichever side of the argument one takes with respect to that program's successes or failures, there is much to be said about steadfast, results-oriented leadership.

It was thus no surprise to those who knew and respected him that upon his election Lee staked his political clout on an initiative meant to offer access to ART to 3 million people living with HIV/AIDS in the developing world by 2005. The challenges were immense, the conditions not perfect, the resources not quite enough, the political will not quite hardened, yet the world faced a public health crisis in HIV/AIDS that required a public health solution -- even if it represented a time-delimited goal that might not be met. In promoting the "3 by 5" initiative, he seemed to challenge the world with a simple question: Is it better to do nothing in the face of a modern-day plague, or to aim high and possibly miss the target but still save and enhance the lives of more than the few who today (then 2003) are alive and living more productive lives as a result of ART?

Those who regularly read my Report from the President in the IAPAC Monthly know that IAPAC was supportive of the "3 by 5" initiative. Our support was steadfast throughout its two-year run because it was in line with the ethical framework under which the association labors, based largely on former UN Secretary-General Dag Hammarskjöld's doctrine that "to let oneself be bound by a duty from the moment you first see it approaching is part of the integrity that alone justifies responsibility." In line with the initiative's objectives, IAPAC scaled up its educational offerings in African, Eastern European, and Latin American countries, as well as China, through our Global AIDS Learning & Evaluation Network (GALEN). We also produced and distributed sets of GRIP Guides that graphically illustrate first- and second-line antiretroviral regimens recommended in the WHO's "Scaling Up Antiretroviral Therapy in Resource-Limited Settings: Guidelines for a Public Health Approach."1

We were also at times highly critical of the "3 by 5" initiative. Our criticism (sometimes pointed) was meant to influence course corrections around such critical issues as the value of fully engaging strategic partners in various aspects of the initiative's work, the need to rapidly scale up capacity-building efforts advanced by multiple interested parties, and the imperative to begin to redress years of health workforce neglect that threatened the initiative's progress. In retrospect, ours was the desire to influence the initiative's execution, rather than quibbling with its objectives -- a distinction sometimes lost in translation.

Midway through the initiative, and certainly by December 2005, it was clear that the "3 by 5" initiative would miss its target. In the end, and purely from an empirical perspective, the initiative succeeded in ensuring that 1.3 million people were on ART by December 2005 (or 20% of the 6.5 million deemed clinically eligible for ART) -- a significant increase from the 400,000 (a level of ART coverage just over 6%) who benefited from treatment at the initiative's launch (210,000 of whom lived in the Latin American region, most in Brazil). In two years, the number of HIV-positive patients on ART in low- and middle-income countries tripled, and access to ART in sub-Saharan Africa increased by more than 800% (Table 1). Still, to many critics and skeptics, the inability to reach the target of 3 million signaled failure -- even if it represented a global, collective failing. To Lee and his WHO colleagues, in league with other United Nations agencies and like-minded allies, missing the target represented a further opportunity -- one he and others seized upon to declare a global mission to achieve universal access to ART by 2010.

Table 1. Estimated ART Coverage by Geographical Region (Low- and Middle-Income Countries)
Table 1. Estimated ART Coverage by Geographical Region (Low- and Middle-Income Countries)

In his low-key but persuasive style, Lee and his colleagues reinvigorated the 100-plus individuals who participated in this month's WHO consultation by calling upon us to confront one of the most pressing challenges to each and every public health initiative we might devise to prolong and enhance human life free from disease. The challenge is to bolster a global health workforce -- an estimated 59.2 million dedicated men and women worldwide (including its invisible backbone, tens of thousands of health management and support workers) -- who are mobilized to address specific health concerns, among them:

Yet the very foundation of health systems globally has been undermined by draconian monetary policies and neglected by national governments spending less each year on their health system infrastructures. These factors have led to the human resources crisis alluded to by Lee and his colleagues, a crisis that has contributed to an urgent situation, just one dimension of which is the severe shortage of motivated, skilled, and supported health workers. According to data published in the "World Health Report 2006," the greatest shortage occurs in Southeast Asia, with burgeoning crises in Bangladesh, India, and Indonesia. Not surprisingly, the greatest relative need exists in sub-Saharan Africa, where an increase of almost 140% in resources dedicated to health care would be necessary to alleviate severe shortages (Table 2).

Table 2. Estimated Shortages of Physicians, Nurses and Midwives
Table 2. Estimated Shortages of Physicians, Nurses and Midwives

Why the scarcity of human resources? There are myriad reasons, not the least of which include attrition due to inadequate remuneration, stress, and poor working conditions; migration (or "brain drain") from developing to developed countries; deaths from HIV and other endemic diseases; an exodus from the health professions; and a paucity of new graduates from or enrollees to health-related academic institutions. Drilling down into statistics around just two of the factors contributing to scarcity -- brain drain and illness and death from HIV/AIDS -- one immediately realizes the enormity of the challenge and its domino-like effects.

If one looks at the issue of brain drain, while respecting the human right to migration, it would appear the primary culprits are developed world health systems dealing with their own health workforce shortages. Data compiled by affluent member-countries of the Organization for Economic Cooperation and Development (OECD) indicate that physicians and nurses trained abroad comprise a significant percentage of the total health workforce in most of them, but especially in English-speaking countries (e.g., 33% of physicians working in the United Kingdom were trained abroad). According to WHO estimates, physicians and nurses trained in sub-Saharan Africa and working in OECD member countries represent 23% and 5%, respectively, of the current physician and nurse workforce in those countries.

In geographical areas experiencing high HIV prevalence rates, attrition rates due to HIV-related morbidity and mortality have led to the alarming prediction that if HIV-positive health workers are left untreated, the proportion of those dying as a result of their HIV disease may reach 40% by 2010. Statistics compiled by its Ministry of Health reveal that in Zambia, AIDS-related deaths among female nurses in two public sector hospitals increased from two per 1,000 in 1980 to 26.7 per 1,000 in 2001. Another set of statistics demonstrates that Botswana lost 17% of its health workforce to AIDS between 1999 and 2005.

With respect to scaling up access to ART in developing countries, it was from within this long-neglected health workforce that the first pioneers started programs, which were initially small in scope and reach, but which offered access to ART to their HIV-positive patients, albeit mostly to society's elite. Still neglected, the same health workforce rose to the challenge raised by the "3 by 5" initiative and can rightly claim credit for whatever success this initiative has achieved. Now that a global call for universal access to ART is on the lips of activists, donors, politicians, and patients, it is time to recognize that a health workforce decimated by years of neglect cannot fully rise to the challenge without a much-needed investment by all stakeholders responsible for promoting sound public health policy and strengthening health care delivery systems. Without such a recognition, and subsequent action, the imbalance between our expectations and the means that exist to realize them will grow -- as will the historic and devastating deterioration of a health workforce we must all rely upon to meet our health needs and allow us to live healthy and productive lives.

José M. Zuniga is President/CEO of the International Association of Physicians in AIDS Care, and Editor-in-Chief of the IAPAC Monthly.


  1. World Health Organization. Scaling Up Antiretroviral Therapy in Resource-Limited Settings: Treatment Guidelines for a Public Health Approach. 2003 Revision. Geneva. 2004.

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