In the last eight years, international funding for HIV/AIDS treatment has increased dramatically, changing the landscape of national health systems and eliciting both praise and criticism. Today, two large funding mechanisms provide roughly half of all international funding for HIV/AIDS: the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR).

Earlier this month, Ruairi Brugha and colleagues published “Health workforce responses to global health initiatives funding: a comparison of Malawi and Zambia,” a critical look at the influence of the Global Fund and PEPFAR in Malawi and Zambia. Although both countries receive funding from both sources,  Malawi  receives most of its international HIV/AIDS support from the Global Fund, whereas  Zambia receives significant Global Fund and PEPFAR support. Although the article looks at slightly different time periods and uses different sampling methods in each country, it offers a useful overview of the influence of international funds on national health systems. Furthermore, it provides points of comparison between a country with two major HIV/AIDS-focused international funders and a country with just one.

By looking at health care facilities’ records, the study’s authors were able to show a substantial increase in the number of patients receiving antiretroviral (ARV) services in Malawi and Zambia during the period of increased international funding. The facilities providing more HIV care also continued to provide routine health services for non-HIV concerns. This scale-up in HIV/AIDS services was mainly funded by the Global Fund in Malawi and both the Global Fund and PEPFAR in Zambia. In Malawi, this funding also lead to a 10% increase in the total number of clinical staff—doctors, nurses, clinical officers, and medical assistants—the vast majority of whom were posted in facilities offering ARV treatment. However, clinic managers in Malawi reported that increases in the number of staff did not keep pace with the increased workload that resulted from the introduction of more HIV/AIDS services. Nevertheless, the staff remained positive about offering more services and found that staff training had improved the quality of HIV-related and non-HIV care.

At the same time, the article offers a cautionary note about the unintended consequences for national health systems due to a large influx of foreign funds. Poor coordination between government- and donor-led health programs may encourage competition between programs, as each seeks to hire the most skilled health workers. For example, during the course of the study period (2004-2007) in Zambia, total numbers of clinic staff remained stable; however, some study participants criticized the PEPFAR-funded nongovernmental organizations for enticing health workers away from the public sector with higher salaries. As HIV/AIDS services were scaled up in Zambia without an accompanying expansion of health workers, the workload increased dramatically. This problem was particularly acute in rural areas, where heavy workloads, coupled with a shortage of housing, made it difficult to attract and keep staff in rural clinics.

Overall, Brugha et al.’s work suggests that the scale-up in HIV/AIDS funding from donor countries has led to substantially more people receiving antiretroviral therapy services, and by extension, one infers, better health outcomes and more lives saved. This finding points to the necessity of continuing and expanding global health funding mechanisms in an effort to end the HIV pandemic. Interestingly, in comparing Malawi and Zambia, the authors conclude that having a one primary funding mechanism for foreign HIV/AIDS support may better facilitate the coordination of a national health workforce strategy and increase a country’s capacity to respond to the epidemic. The authors also advocate for donor countries to continue to fund the expansion of health worker capacity, particularly by supporting preservice training institutions.