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?
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.