An Unintended Consequence of PEPFAR Highlights Need for Health System Strengthening

The President’s Emergency Plan for AIDS Relief (PEPFAR), a $15 billion commitment by former president GW Bush to fight the HIV/AIDs pandemic in resource-limited settings, has been hailed as the greatest bipartisan achievement of the Bush presidency. To date, it is also the largest health initiative by one single country to address one single disease. In sub-Saharan Africa, PEPFAR increased the number of HIV positive individuals receiving antiretroviral treatment from 50,000 in 2004 to at least 1.2 million by 2008 [1]. In addition, these funds improved health facilities, created numerous nongovernmental organizations (NGOs), trained tens of thousands of healthcare workers, and developed reliable drug supply chains across the African Continent.

Despite these exceptional achievements, researchers at Mbarara University of Science and Technology (MUST) in Uganda and Harvard Medical School have uncovered a PEPFAR-influenced unintended but significant consequence to the Ugandan health system. Recently, Bajunirwe et al published the results of a cross sectional survey among MUST medical school alumni who graduated before and after the influx of PEPFAR funding. They found that after PEPFAR, fewer Ugandan medical doctors were electing employment with government run public health facilities. This research offers empirical data on the distribution of the health workforce and the impact of multinational HIV funding.

The cohort analyzed in this study consisted of (n=796) MUST medical school graduates before and after 2005, a year when many large PEPFAR funded HIV programs launched in Uganda. The good news here is that these data showed a significant decrease in total brain drain. The number of Ugandan medical graduates who left the country to practice abroad before PEPFAR (15%) declined to (7.8%) after 2005. However, these post-PEPFAR graduates were 50% more likely to work at a newly funded HIV-related NGO instead of a public facility that provides free services to anyone in need [2]. Pull factors for NGO employment included higher salaries, better working conditions, and benefits. However this “internal brain drain” has exacerbated an enormous health workforce shortage in the public health system of Uganda.

With a rate of 1.8 health workers (including 0.1 physicians) per 1,000 population, Uganda is far below the World Health Organization’s standard of 2.5 workers per 1,000  [3, 4]. Further, those that access health services in public facilities tend to be the among the poorest and most vulnerable groups. With more medical graduates opting for NGO jobs that serve the wealthier proportion of the country and a rapidly growing total population, the health worker shortage in Uganda’s public facilities remains a significant barrier to meeting the needs of the population and improving health outcomes.

A recent call for redefining global health care delivery by Jim Kim et al emphasized the importance of consolidating services and integrating a shared delivery infrastructure to improve systems as a whole and take advantage of economies of scale. Shared infrastructure that consolidates public and private health facilities can improve effectiveness of preventative health measures by integrating essential health screenings such as HIV into a primary care model. Shared infrastructure also makes more efficient use of available human resources, equipment, facilities, and supplies [5].

Kim et al argue that a strengthened health system will not only improve health outcomes but bolster countrywide economic growth. Beyond the obvious notion that healthy people are more productive in the workforce, health systems provide jobs that build a middle class by employing not only skilled health workers but also support, maintenance, and community health staff. Further, health systems drive development through demands for local supplies, equipment, construction, and food service.

At this point in time foreign aid is a necessary component to accelerating the development of strong health systems in resource-limited settings. However, in Uganda, targeting singular diseases and creating private entities to combat them (as PEPFAR has done) is causing undue strain on a fragile health care system. Better health outcomes in places like Uganda will come only after improvements are made to the public health infrastructure through supporting ministries of health that prioritize staff recruitment and retention as well as efficient health service delivery.

1. Emanuel EJ. “PEPFAR and Maximizing the Effects of Global Health Assistance.” JAMA, May 16, 2012. Vol 307, No. 19.

2. Bajunirwe F, Twesigye L, Zhang M, et al. “Influence of the US President’s Emergency Plan for AIDS Relief (PEPfAR) on career choices and emigration of health- profession graduates from a Ugandan medical school: a cross-sectional study.” BMJ Open 2013



5. Kim JY et al. “Redefining global health-care delivery.” The Lancet, 20 May 2013.

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9 Responses to An Unintended Consequence of PEPFAR Highlights Need for Health System Strengthening

  1. linuxmaier says:

    Targeting single diseases rather than outcomes seems like a more achievable way of effecting measurable progress, but it sounds like it’s creating an economy off balance in favor of HIV treatment for the wealthy. Am I understanding the problem correctly?

    Are the public institutions strong enough to handle that kind of capital? Knowing little about such situations aside from a general understanding that lots of cash can cause problems in institutions that aren’t used to handling it, it seems to an outsider that money would be more effectively spent by NGOs that have that kind of experience. I’m pretty much as ignorant as they come on this kind of thing, though.

    • Thanks for the comment. I think there is an implicate bias that foreign NGOs know what to do and can “handle” aid when many (and surely there are exceptions) operate in silos and spend very inefficiently (lots of money to house foreigners in nice places and fly them around on airplanes). Having traveled many miles to get here and staying in a nice apartment, I internalize this irony daily. But I’m arguing that perhaps all those NGO dollars would be better spent consolidating resources and creating and equitable system where at the very least supplies are purchased and staff is paid. The “we can’t trust the government with our foreign aid” attitude is damaging to people who can’t afford very basic services and to the people who are dedicated to treating them.

      • Andrew Maier says:

        And the local people would have the advantage of institutional knowledge which everyone implicitly accepts when decisions are made about themselves (ie, at my work I wouldn’t want someone else to come in and allocate my time, since I know better what’s useful since I’m closer to it. This is true even when the outsider has better judgement than I do because of the huge leg up I get for being acquainted with the situation).

        So your suggestion is that by pooling resources together and funneling them through local authorities, you’re going to gain huge efficiencies in terms of not replicating effort, shared knowledge, local knowledge and local prioritization, not to mention a more direct local economic impact (where you’re not supporting a foreign NGO infrastructure). Is the notion that these efficiencies are big enough to outweigh inexperience in dealing with the problems in the local system? Or are the NGOs basically as inexperienced as the local authorities, and so there’s no real gains going to the NGOs anyway (aside from granting false assurance to foreign donors).

      • I wouldn’t assume inexperience is a factor, rather lack of resources and inefficiency.

      • linuxmaier says:

        Where do local inefficiencies come from?

      • What I have observed is that in general government run facilities are extremely efficient, they have to be and they can do an enormous amount with what they have. However they are over crowded and often lack very basic supplies, medicines, and cash to pay employees regularly. NGOs on the other hand, have lots of resources but serve way fewer people and spend a lot on overhead etc (the point I already made). I am arguing for the best of both scenarios.

      • linuxmaier says:

        That makes a lot of sense to me. Thanks for taking the time to explain it.

  2. Sharon Maier says:

    Laura, this is all very interesting. I enjoyed reading your paper and the discussion you and Andy had. I think your observations are insightful. Good job!

  3. Pingback: Preciva Strives to Make Cancer a Global Health Priority | lauraejacobson

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