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 . 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 . 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 .
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.