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This article has been cited by other articles in PMC. This article examines and assesses the evidence and proposes ways forward.
Among the positive impacts are the increased awareness of and priority given to public health by governments. In many countries infrastructure and laboratories have been strengthened, and in some, primary health care services have been improved. The effect of AIDS on the health work force has been lessened by the provision of antiretroviral treatment to HIV-infected health care workers, by training, and, to an extent, by task-shifting.
Unfortunately, there is limited hard evidence of these health system impacts. At the same time, it should be recognized that global action for health is even more underfunded than is the response to the HIV epidemic.
The real issue is therefore not whether to fund AIDS or health systems, but how to increase funding for both. Instead of endless debate about the comparative advantages of vertical and horizontal approaches, partners should focus on the best ways for investments in response to HIV to also broadly strengthen the primary health care systems.
However, the introduction of antiretroviral ARV treatment, along with other Komatsu ltd and project g essay that the health sector has made, also exposed the effects of decades of neglect of the health sector, economic crises, structural adjustments, declining public expenditures, and decentralized financing, particularly in Sub-Saharan Africa [ 2 ].
We use the WHO definition of a health system as "all organizations, people and actions whose primary intent is to promote, restore or maintain health," and also use WHO's description of six health-system building blocks: In some countries of East Africa, this proportion reached 80 percent [ 11 ].
The effect was that patients with HIV infection crowded out people with other conditions [ 1213 ]. The presence of a large number of AIDS patients with very poor outlooks also contributed to the health professions losing their attractiveness because of increased workloads, exposure to HIV infection, and the work stress that resulted from it [ 12 ].
In addition, the ability of the health service to cope with this increased demand declined, because of HIV-related morbidity and mortality and burnout among health professionals.
For example, five-to-sixfold increases in health worker illness and death rates were reported for Malawi, and the number of deaths of nurses there represented 40 percent of the average annual output of nurses from training [ 14 ].
On the one hand, it is known from industrialized countries and Brazil that patient demand for hospitalization and diagnostic evaluation for opportunistic diseases decreased following the introduction of ART [ 1516 ].
In those settings, this also resulted in savings in health sector expenditures. On the other hand, where health care is less sophisticated and less costly, this is might be offset by the need to provide long-term outpatient care to more and more people requiring lifelong treatment and laboratory tests to monitor ART [ 17 ], and scaled-up some HIV prevention interventions, such as male circumcision and prevention of mother-to-child transmission PMTCT.
To date, despite claims that investing in HIV decreases the ability of the health system to produce other health outcomes, the evidence that this is actually happening is largely anecdotal and equivocal [ 37 ], with as many pointers confirming as arguing against this stance [ 1819 ].
Has health service delivery been expanded? Although the scaling up of HIV services has likely not escaped the bias of health systems in general to better serve urban and more affluent groups, considerable efforts have been made to overcome equity concerns and reach the most vulnerable, marginalized groups, such as injecting drug users IDUssex workers, and men who have sex with men MSM [ 20 - 24 ].
The most spectacular result of WHO's "3 by 5" initiative was to demonstrate that delivering ART through a public health approach is feasible even where health systems are weak overall [ 25 ].
As effective HIV treatment programs are implemented, hospital admissions plummet and hospital beds are freed up, easing the burden on health care staff throughout the system [ 27 - 29 ].
With the success of the public health model of service delivery and the demonstrable adherence of patients on treatment across the world, and especially in Africa, treatment for AIDS is saving and changing lives [ 30 ]. In rural Haiti, the "four pillars" approach to HIV prevention and care introduced by Partners in Health radically increased overall patient visits at the Las-Cahobas primary health clinic between July and Decemberresulting in greatly increased tuberculosis case-finding: Prenatal care visits and immunizations saw similar increases over the same period, going from visits per day to over for both services [ 1819 ].
In Rwanda, basic HIV care has been added into the primary health centers, contributing to increased use of maternal and reproductive health, prenatal, pediatric, and general health care [ 28 ]. Basic health infrastructures have also benefited significantly from the scaling up of responses to HIV.Globalization and Komatsu The advent of computers and information technology over the past 5 years has made it seemingly more accessible for companies to take their vision and products worldwide.
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