terça-feira, 17 de abril de 2007

Remédios sem médicos e enfermeiros: um dilema africano

Plos Medicine publica um estudo sobre a disponibilidade de medicamentos para aids, malária e tuberculose em países com um número reduzido de médicos e enfermeiros. Os autores fazem paródia com com o movimento Medicine sans frontiers, lançando o Medicines without Doctors, que chamei de Remédios sem médicos e enfermeiros. Ou seja, mesmo com o apoio de fundos beneméritos (Melinda e Bill Gates, p.ex) e a cooperação da Big Pharma (sem ironia), o problema continua, porque há necessidade de uma estrutura mínima. Vou continuar ainda essa semana, discutindo artigo de Laurie Garrett na Foreign Affairs sobre o tema, mas já discuti a situação de Gana (exportação de médicos) e da Nigéria (resistência à vacinação) como exemplos da difícil situação da África.O texto é Ooms G, Van Damme W, Temmerman M (2007) Medicines without Doctors: Why the Global Fund Must Fund Salaries of Health Workers to Expand AIDS Treatment. PLoS Med 4(4): e128 doi:10.1371/journal.pmed.0040128 e, a conclusão segue abaixo.
Both the cases of Mozambique and Malawi illustrate the crucial importance of addressing the health workforce crisis. It is easier to remedy the shortage of medicines with external funding than it is to remedy the shortage of health workers with external funding. Medicines can be bought; health workers need to be trained first. This underlines the importance of starting emergency human resources programmes now, before the growing case load—resulting from the fact that most people on ART will stay alive longer, while the number of people in need of ART will grow—undermines either the quality of ART programmes, or the performance of health systems
. Without support from the Global Fund, it will be difficult for Mozambique to develop its own emergency human resources programme. Bilateral donors are unable to support human resources programmes that rely on sustained external assistance over decades. The World Bank is unwilling to use foreign assistance for salaries of health workers. The IMF is unwilling to stretch ceilings on wage bills, because commitments from bilateral donors are unreliable. Without flexibility about these ceilings, bilateral donors cannot support salaries of doctors and nurses, even if they want to. It is a vicious circle. The Global Fund is probably the only actor able to break through this vicious circle. It is the only donor mechanism that benefits from an explicit endorsement from the international community to practice a novel approach to sustainability.But donors must give the Global Fund the resources to do so. As one of us argued in a previous article, it is feasible to turn the Global Fund into a world health insurance, funded by rich countries in accordance with their wealth, and creating rights for poor countries to obtain assistance in accordance with their needs. It would allow individual donors to overcome their inability to make commitments beyond the term of their governments, because their contributions would be compulsory. (This is not a heresy. Many bilateral donors consider their contributions to the World Bank as compulsory
. This can be achieved for contributions to the Global Fund.) Furthermore, the pooling of resources by many donors would increase continuity: if one donor reduces its contribution, another donor could compensate.And that is exactly what countries like Mozambique need to increase their health workforce: sustained assistance.

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