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Date: Friday, 9 December 2005, at 7:28 p.m.

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The Need for an International HIV/AIDS Volunteer Services Corps for Africa
Sidi Jammeh, Chinua Akukwe and George Haley, January 27, 2005

One of many child-headed households in Mtubatua, South Africa, used by the local community to accommodate the growing number of orphans left unable to care for themselves. (Photo: Rafs Mayet / AFP-Getty Images)

Africa is facing a formidable foe in HIV/AIDS. According to the latest report by the United Nations agency coordinating the global fight against the pandemic (Unaids), although Africa represents only 10 percent of the global population, it accounts for nearly 64 percent of HIV/AIDS worldwide — 25.4 million infected individuals, and counting. Africa is home to almost 76 percent of women living with HIV/AIDS worldwide. The southern region of Africa, which represents only 2 percent of the global population, is home to nearly 30 percent of the total number of persons living with HIV/AIDS worldwide. Unaids estimates that 2.3 million adults and children in Africa died of AIDS in 2004. Unlike the situation in North America, Europe, South America, and some countries in the Caribbean, where most people who need antiretroviral therapy receive the drugs, nine of every ten infected individuals in Africa that can benefit from these lifesaving drugs cannot access them.

Although remarkable successes have been recorded in the last few years in marshalling resources to fight the epidemic in Africa, a missing link has been the lack of a trained health and development workforce to successfully scale-up a multisectoral response in the continent. We discuss the need for an international volunteer HIV/AIDS service corps that will tackle health and logistics challenges that impede a timely and effective response against HIV/AIDS in Africa. Our proposal does not envisage another global bureaucracy but will match skill sets with identified needs in various parts of Africa, and complement available services in at-risk areas in Africa.

Why an AIDS Volunteer Service Corps?

There are multiple reasons for a volunteer AIDS service corps in Africa. First, HIV/AIDS, although a health condition, has almost single-handedly reversed past development gains in Africa. According to Unaids, life expectancy in Africa today is 49 years instead of 62 years without HIV/AIDS. Nine countries in Africa currently have life expectancy rates of less than 40 years.

Second, 95 percent of Unaids offices in Africa, in a 2004 review, identified lack of health personnel as a major hindrance in the fight against AIDS. Unaids estimates that between 19 percent and 53 percent of all deaths among government health employees in Africa are directly attributable to AIDS. This situation is compounded by some of the lowest physician-to-population ratios in the world. According to the World Bank, there is one physician to every 35,000 persons in Ethiopia, with near similar ratios in many African nations. Healthy workers are laboring to cope with an unprecedented surge in the number of AIDS patients. In some hospitals in Africa, AIDS patients occupy more than 60 percent of all available beds. Furthermore, thousands of health workers have left Africa for more lucrative careers in the West. Although South Africa has the largest number of individuals living with HIV/AIDS, at least 5,000 doctors left South Africa in recent years, according to Unaids.

Third, the non-health workforce in Africa is also reeling from the effects of HIV/AIDS. The International Labor Organization, in a recent report, indicated that HIV/AIDS by 2000 accounted for nearly 12 percent of total labor losses in Zimbabwe and more than 10 percent in Zambia. Agriculture, the mainstay of Africa’s economy (24 percent of the continent’s G.D.P. and 40 percent of its foreign exchange earnings) is under strain from HIV/AIDS. By 2020, AIDS may kill one fifth of all agricultural workers in Africa. AIDS is causing a shortage of teachers in Zambia and Zimbabwe. Businesses in the southern region of Africa sometimes hire two or more persons for the same job because of justified fears of losing a highly trained worker to AIDS.

Fourth, the healthcare infrastructure in Africa is reeling from years of inadequate funding and mismanagement. Community-based clinics need to be revamped, hospitals re-equipped, and training programs jumpstarted. Fifth, funding constraints remain a major obstacle in AIDS remedial efforts in Africa. According to Unaids estimates, the total expenditure on AIDS worldwide in 2004 was about US$6.1 billion. By 2007, at least US$20 billion a year will be needed for an effective fight against the pandemic. Nearly 43 percent of the US$20 billion will be needed in Africa. A recent World Bank guide on widening access to lifesaving HIV/AIDS medicines in developing countries concluded that it would require considerable resources to close the gap between the need to treat millions of people living with HIV/AIDS and the low national healthcare budget of poor countries around the world.

Sixth, prevention programs, despite more than two decades of effort, have not been very effective.Prevention programs encompass information, education, and communication campaigns against selected health conditions, targeted at specific audiences and populations at risk. A recent survey by Unicef indicates that up to 50 percent of young women in some countries with a high rate of HIV transmission are unaware of basic facts about the disease. Another survey of 73 low and middle income countries (most of them in Africa), which account for more than 90 percent of the pandemic, indicates that less than one percent of adults have access to voluntary counseling and testing services and only about one of every ten pregnant women have the opportunity to benefit from intervention programs that can prevent maternal transmission of HIV.

Seventh, we are not aware of any ongoing effort to meet the shortage of health and development workers in Africa through a feasible, immediate deployment of employed and motivated professionals in the West. The widely praised recent initiative by the World Health Organization to provide lifesaving medicines to 3 million people in developing countries by 2005 relies heavily on training or hiring new health workers in Africa.

Finally, the logistic challenge of providing lifesaving medicines to more than 4 million Africans that the Unaids and the World Health Organization deem qualified for urgent care should not be underestimated. These logistic challenges include training the local workforce, providing basic infrastructure such as portable water and basic sanitation, assuring constant electricity supply and telecommunication utilities to enhance coordination of services, developing verifiable management and clinical accountability systems, and improving epidemiological surveillance and reporting techniques.

What Are We Proposing?
We are proposing an International Volunteer HIV/AIDS Service Corps for Africa that will rely on a motivated volunteer in the West who is likely to continue receiving regular salary and other remunerations while on assignment. This volunteer will be linked through an employer or professional association to an agency or organization on the ground in Africa that is providing specific services in a specific target community, country, or region. We believe that if the opportunity exists to link a motivated paid volunteer in the West with an effective organization on the ground, many individuals quietly watching the unfolding tragic saga of AIDS in Africa will come forward and volunteer to serve to the best of their abilities.

The Proposed AIDS Volunteer Workforce

We propose an International Volunteer HIV/AIDS Services Corps that:

Matches the desires of volunteers with the needs of target communities, countries, and regions in Africa.
Targets countries with high rates of HIV transmission and those with low rates with the overall aim of preventing new infections, providing clinical care and support for those already infected, and keeping areas with low rates of infection as low as possible.
Provides multidisciplinary services in chosen target populations, reflecting the multisectoral impact of HIV/AIDS. We envisage teams of volunteer doctors, nurses, public health experts, lawyers, engineers, economists, project managers, telecommunication specialists, logistic experts and other professionals working together with the local work force in Africa to meet the needs of chosen target populations.
Targets, in the first instance, individuals and organizations most likely to volunteer for service in Africa. These targeted volunteers will include African immigrant professionals in the West, Africans in the Diaspora (African Americans in the United States, African citizens of Canada, the Caribbean, Latin America, and Europe), and Africanists (non Africans) that have worked or grown up in Africa. Recruiting efforts will eventually target all other stakeholders.
Eschews bureaucracy by relying on volunteers for regular employment or those who can afford maintenance expenses required for the duration of work in Africa. We envisage in most instances, a three-way understanding between the volunteer, the employer based in the West, and the agency providing a specific service in a specific area of Africa.
Trains local staff and volunteers during period of service to ensure sustainability of programs at the end of the volunteering assignment.
Specifies a defined period of service, most likely one or two years in the first instance.
Technical Areas of Immediate Benefit

Africa is facing tremendous challenges in addressing preventive, treatment and support needs of individuals at risk or living with HIV/AIDS. An international HIV/AIDS volunteer program should assist Africa to meet the following immediate needs:

Providing health, education, and social welfare support to 12 million AIDS orphans in Africa. At this time, there is no organized national or regional effort to address the needs of AIDS orphans in Africa. A multisectoral volunteer team of health workers, educators, social workers, and management experts can assist a specific African country to meet the needs of its AIDS orphans.
Implementing community-based information, education, and communication campaigns against HIV transmission. A volunteer multisectoral group comprised of experts in health education and communication, journalism, consumer marketing, epidemiology, logistics, and monitoring and evaluation will work closely with local counterparts to implement HIV preventive programs.
Providing clinical treatment to individuals qualified to receive antiretroviral drugs. A volunteer team of physicians and nurses with expertise in AIDS care can work with its host country counterparts to extend clinical services to more individuals living with HIV/AIDS.
Designing and implementing micro-credit schemes for women. Poverty and unemployment are major factors in the rising incidence of HIV transmission among African women. Providing steady employment or nurturing the entrepreneurial spirits of women can provide incentives and options against trading sex for basic necessities of life or for feeding small children. A team of rural economists, bankers, program managers, and small-scale entrepreneurs will work with host nation counterparts to empower women, especially young widows or women who lost their husbands to AIDS.
Revamping healthcare infrastructure. A volunteer team of engineers, architects, project managers, energy and telecommunication experts, and health workers can assist health authorities in host countries to revamp existing services.
The above listing is simply illustrative. Each African country has needs that should be matched with skill sets of the volunteers.

Practical Implementation Issues

The proposed three-way arrangement between volunteer, employer, and the agency on the ground in Africa will likely require additional funding for travel expenses and higher insurance premiums. We believe that the World Bank and the African Development Bank, two institutions that finance multiple projects in Africa, including the health sector, could cover travel expenses and insurance premiums for the volunteers. Bilateral agencies with major projects on the ground may also finance such expenses if it would speed up the implementation of their projects. Bilateral agencies from the United States, Canada, Britain, Germany, and Scandinavian countries finance multiple projects in Africa.

In addition, other multilateral agencies such as the World Health Organization, the United Nations Development Program, and the International Labor Organization may also be interested in facilitating the logistics of the volunteer program. Deep-pocketed foundations may also play financial catalytic roles. The key is to link with bilateral, multilateral, and philanthropic organizations already active on the ground in host countries.

To facilitate faster implementation of the volunteer corps, we propose an initial pilot period of two years with enough scale to make a difference in Africa. We anticipate pilot efforts in four potential settings.

Major multilateral agencies: The World Bank and the International Monetary Fund (I.M.F.) have more than 2,000 African professionals who serve in various capacities in various regions of the world. The management of these two institutions, for example, may enter into agreement with Unicef to provide support services (health, education, and social services) to AIDS orphans in Southern Africa. The leadership of the World Bank and I.M.F. will request volunteers from its African staff for a period of one or two years to serve on specific assignments in specific areas of Southern Africa, and pick up the salary and emoluments of each volunteer during the period of service. Depending on need and the number of volunteers, African staff in the two institutions will know in advance when they will be relocating for their volunteer service. We anticipate that other multilateral institutions can replicate the same scenario with their African staff.

Organizations that cater to the needs of African Diaspora professionals in the West: In the United States, you have the National Medical Association (N.M.A.), which represents more than 25,000 African American and other minority physicians. For example, the N.M.A. may reach an agreement with the World Health Organization to provide 300 internist volunteers to help scale up antiretroviral treatment programs in Zambia, a country where there is one physician for every 14,323 persons, according to the World Bank. The N.M.A. will seek volunteers from its membership, perhaps negotiate with the employers of members volunteering for service, and link the volunteers with the World Health Organization for the specific assignment in a specific part of Zambia. The World Health Organization may pick up the transportation costs. Other Diaspora oriented organizations include the National Bar Association (N.B.A.), which represents over 20,000 lawyers, judges, educators, and law students. Unaids indicates that 50 percent of all countries in sub-Saharan Africa are yet to pass national legislation ending discrimination against individuals living with HIV/AIDS. N.B.A. volunteers can work with their local counterparts to develop legislation against HIV/AIDS discrimination either in the work place or at community settings. Another major organization is the National Dental Association representing more than 10,000 dentists and hygienists who can provide oral care, a major concern of AIDS patients battling opportunistic diseases.

Academic institutions: These institutions can send their faculty due for sabbaticals to Africa as volunteers. They can also send students seeking field experience in Africa. Doctoral students and post-doctoral fellows, especially those focusing on African issues, can also participate as volunteers while continuing their research activities. Universities with medical, nursing, engineering, social services, and law schools can form a composite team of experts to tackle multisectoral HIV/AIDS issues in specific areas and specific countries in Africa.

Business organizations with operations in Africa: These business organizations, depending on their areas of expertise may rotate their volunteering staff to complement the community-based social welfare activities of their field operations in Africa. Volunteers may assist in information, communication, and education campaigns against HIV transmission. They may also provide technical assistance to local jurisdictions and civil society on setting up accountability mechanisms and assist in training or retraining local staff on personnel and logistics management issues. These volunteers may also provide technical assistance on community-based micro-credit services for rural women and other forms of activities that could increase the earning potentials of women, and possibly reduce the need to engage in high-risk behaviors to feed themselves and their children. Unaids regards the interruption of male-oriented sexual networking in Africa as critical to overall HIV/AIDS remedial efforts on the continent. The key is to match recipient country needs in the fight against HIV/AIDS with that of available skill sets in the West.

Conclusion
The HIV/AIDS epidemic is unusual in its scope and magnitude. An effective response must also be imaginative, creative, and tailored to meet the needs of target populations. Africa in the next decade will likely lack the requisite local workforce needed to mount a comprehensive, multisectoral response against AIDS. We believe that an international paid volunteer AIDS services corps can enhance the capacity of hard-hit African nations to scale up their response in the short term and assist countries with current low HIV infection levels to keep it that way. Remedial efforts against HIV/AIDS in Africa must marshal the extraordinary compassion felt by all men and women of goodwill into a call for service.

Sidi Jammeh is a senior economist at the World Bank, and the chair-emeritus of the Africa Society, the World Bank, and the International Monetary Fund, Washington, D.C. Chinua Akukwe is a member of the board of directors of the Constituency for Africa, Washington, D.C., and former vice chairman of the National Council for International Health now known as Global Health Council, Washington, D.C. Honorable George Haley is the former United States ambassador to Gambia.

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