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Why Taking into Account Social Determinants is Essential to Reach a Successful Global Health Policy? An Example from the HIV-Care Sector in Burundi


J. Cailhol*1, T. Nahimana2, L. Munyana2, H. Ntakarutimana2, F. Musanabana3, D. Diack4, M. Dubreuil4, C. Arvieux5, O. Bouchaud1, T. Niyongabo2

Affiliation(s): 1Infectious and Tropical Diseases, Avicenne Hospital, Assistance Publique Hôpitaux de Paris, Bobigny, France, 2HIV-care centre, University Hospital of Bujumbura, 3HIV-care centre, Prince Régent Hospital, Bujumbura, Burundi, 4Project Department, ESTHER, Paris, 5Infectious and Tropical Diseases, University Hospital of Rennes, Rennes, France
Keywords: Social determinants; HIV-care; global health policy; international funding

Health policy usually targets epidemiologically defined population in a specific intervention programme. However, the sectorisation of health problems and the development of health policies, missing ‘surrounding’ socio-economic determinants, may result in inequitable long term results.


In Burundi, the HIV sector is mainly financed by international funding (IF), including the Global Fund (GF). By this way, HIV-infected people can have access to care, antiretrovirals and opportunistic infections medications free of charge. IF can also contribute to major the HIV-healthcare professionals (HCP) salary. Indeed, because of extremely low incomes, public sector HCP move frequently through the country or migrate towards foreign countries, attracted by higher salaries and better working environment. In Burundi, there are now less than 250 physicians left. Through three examples, we will attempt to demonstrate that health policies should consider social determinants.


Example 1: Burundi is one of the poorest countries in the world (more than 70% of the inhabitants earn less than 1 dollar per day): as a result, few people can afford a medical insurance. Apart from HIV-infection, in case of any disease, patients either pay by themselves, almost always helped by their community or remain without any medication. In governmental hospitals, physicians are aware that some common medications such as amoxicillin or cotrimoxazole are available through the GF and use these GF-drugs without regard to HIV status. This behaviour cannot be condemned as physicians cannot leave a patient without medication only because he is not HIV-infected. However, these medications are becoming out-of-stock quickly, and it is impossible to produce accurate estimations of the need in opportunistic infections medications. After all, who will be blamed by the GF for this misuse of a specifically HIV-dedicated funding?
Example 2: HIV-patients must be highly adherent to their medication to be successfully treated. Many patients, who are fully aware of the importance of the treatment for their own health, are forced to interrupt their treatment because they cannot afford daily food. A quick overview of temporary lost of follow-up patients revealed that most of them did not have any money for the monthly transportation costs to their care-centre. On the same way, sustained adherence to HIV prevention cannot be expected if poverty does not allow inhabitants a prospective sight. Indeed, why would they care for their tomorrow’s health if today they don’t have enough food for themselves or their family?
Example 3: Due to better funding in the HIV-sector, deleterious consequences can be expected for the general population and for HIV-patients as well. First, many physicians, even though scarce, are concentrated in the HIV sector, dropping other priority sectors (paediatrics, diabetes mellitus…). Among HIV-sector, well-trained physicians leave the public care sector to join up with international agencies (particularly the WHO and UNAIDS) and also NGOs. Sometimes, pair-educators earn better salaries than nurses or even physicians, leading to a demotivation and conflicts between HCP.

Lessons learned:

Lessons learned in the expanding access to HIV-care in Burundi, i.e. IF repartition and organisation of prevention and HIV-care may be applied to other sectors, leading to a global health policy. Health determinants are linked together and merged into social determinants. Ideally health policies should consider the whole population and its social determinants, instead of focusing on one particular group of diseased people. In concrete terms, for instance, using part of IF dedicated for example to TB, HIV and malaria (GF) to provide HCP viable salaries and medications for other sectors would probably result in a significant improvement of global health.

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