Schneider Helen, Blaauw Duane, Gilson Lucy, Chabikuli Nzapfurundi, Goudge Jane
Centre for Health Policy, University of Witwatersrand, Johannesburg, South Africa.
Reprod Health Matters. 2006 May;14(27):12-23. doi: 10.1016/S0968-8080(06)27232-X.
Without strengthened health systems, significant access to antiretroviral (ARV) therapy in many developing countries is unlikely to be achieved. This paper reflects on systemic challenges to scaling up ARV access in countries with both massive epidemics and weak health systems. It draws on the authors' experience in southern Africa and the World Health Organization's framework on health system performance. Whilst acknowledging the still significant gap in financing, the paper focuses on the challenges of reorienting service delivery towards chronic disease care and the human resource crisis in health systems. Inadequate supply, poor distribution, low remuneration and accelerated migration of skilled health workers are increasingly regarded as key systems constraints to scaling up of HIV treatment. Problems, however, go beyond the issue of numbers to include productivity and cultures of service delivery. As more countries receive funds for antiretroviral access programmes, strong national stewardship of these programmes becomes increasingly necessary. The paper proposes a set of short- and long-term stewardship tasks, which include resisting the verticalisation of HIV treatment, the evaluation of community health workers and their potential role in HIV treatment access, international action on the brain drain, and greater investment in national human resource functions of planning, production, remuneration and management.
如果没有强大的卫生系统，许多发展中国家就不太可能实现抗逆转录病毒（ARV）疗法的广泛可及性。本文思考了在艾滋病疫情严重且卫生系统薄弱的国家扩大抗逆转录病毒疗法可及性所面临的系统性挑战。它借鉴了作者在南部非洲的经验以及世界卫生组织关于卫生系统绩效的框架。在承认资金方面仍存在巨大差距的同时，本文重点关注将服务提供重新定位为慢性病护理所面临的挑战以及卫生系统中的人力资源危机。供应不足、分配不善、薪酬过低以及技术熟练的卫生工作者加速外流，日益被视为扩大艾滋病毒治疗规模的关键系统制约因素。然而，问题不仅在于数量，还包括生产力和服务提供的文化。随着越来越多的国家获得抗逆转录病毒治疗项目资金，各国对这些项目进行强有力的管理变得愈发必要。本文提出了一系列短期和长期管理任务，其中包括抵制艾滋病毒治疗的垂直化、评估社区卫生工作者及其在扩大艾滋病毒治疗可及性方面的潜在作用、针对人才外流采取国际行动，以及加大对国家人力资源规划、培养、薪酬和管理职能的投资。
