摘要：The challenges facing efforts in Africa to increase access to antiretroviral HIV treatment underscore the urgent need to strengthen national health systems across the continent. However, donor aid to developing countries continues to be disproportionately channeled to international nongovernmental organizations (NGOs) rather than to ministries of health. The rapid proliferation of NGOs has provoked “brain drain” from the public sector by luring workers away with higher salaries, fragmentation of services, and increased management burdens for local authorities in many countries. Projects by NGOs sometimes can undermine the strengthening of public primary health care systems. We argue for a return to a public focus for donor aid, and for NGOs to adopt a code of conduct that establishes standards and best practices for NGO relationships with public sector health systems. An estimated 20 million people worldwide could still benefit from antiretroviral therapy (ART) for HIV/AIDS, 1 yet the World Health Organization's “three by five” goal of placing 3 million HIV-infected people on treatment by 2005 has still not been met. Widespread deficiencies in public sector health infrastructure and workforce are at the root of failures to achieve treatment goals. 2 , 3 According to one analysis, many new HIV treatment projects “are being implemented without adequate investment in strengthening the weak, and in some cases collapsing, health systems in sub-Saharan Africa.” 4 (p18) Treatment expansion fueled by new large-scale funding from the President's Emergency Program for AIDS Relief; the Global Fund to Fight AIDS, TB, and Malaria; and the World Bank has been slowed by insufficient health infrastructure. 5 There is an emerging consensus among donors and local governments recognizing the urgency of strengthening the public sector through workforce expansion, infrastructure investment, and management capacity building. 6 – 8 With sufficient support, national public sector systems can coordinate large-scale programs and bring integrated, quality services, such as HIV/AIDS treatment and care, to the greatest number of people most equitably. However, much of the new HIV/AIDS funding is still channeled to international nongovernmental organizations (NGOs), whereas funding for public sector health systems remains constrained. Observers in developing countries with high HIV burdens have become convinced that the practices of NGOs may be causing permanent harm to public systems of care by fragmenting services, promoting internal “brain drain” from the public sector, and creating an excessive management burden for local health managers, who must monitor multiple projects. 9 Paul Farmer, who pioneered the provision of ART in resource-poor settings in Haiti with the NGO Partners in Health, highlighted this problem in his 2006 American Public Health Association address: The NGOs, which fight for the right to health care by serving the African poor directly, often do so at the expense of the public sector, creating a local brain drain by luring nurses, doctors, and other professionals from the public hospitals … to NGO-land where salaries are better and the tools of our trade more plentiful. 10 (p6) Recently, notable exceptions including Partners in Health and Médecins Sans Frontières in the Khayelitsha township clinic in South Africa have recognized these challenges and worked to strengthen public services. Through our own experience in Mozambique with Health Alliance International, which supports increased ART through public sector strengthening, we have witnessed the pitfalls associated with the international NGO model. We believe that an international NGO code of conduct could help strengthen health systems by promoting a more constructive role for NGOs at this vital moment in the AIDS crisis.
