The Global Fund, GAVI and the Gates Foundation say that pockets of success in several African nations have shown that their approaches are sound and that in time overall health across the continent will improve.
Bill and Melinda Gates referred questions to Dr. Tadataka Yamada, president of the Gates Foundation's global health program. Yamada, a leading gastroenterologist and former research director at the drug company GlaxoSmithKline, said African nations themselves must do more to improve public health. They should spend less on weapons and more on doctors before they demand increased assistance, he said.
"We're a catalyzer. What we can't do is fill the gaps in government budgets," Yamada said. "It's not sustainable."
During Mankuebe Nyoba's short life, no doctor was available in the maternity ward at "Queen II." That was normal. Fifteen babies were born overnight. Those babies, 110 mothers and other infants were cared for by three nurse-midwives. That was normal.
One woman, Limpho Jobo, 24, lay on a bed screaming as the harried midwives cared for others. Suddenly, Jobo slid off the bed onto the bare floor. At that moment, her baby was born. Jobo's eyes rolled back.
Somehow, she and the baby survived.
After so frantic a night, no one at the hospital told Matsepang Nyoba or her husband why their baby had died. Suspicions were etched on Peo Nyoba's face. "When we first arrived . . . . [Matsepang] was already in labor, but it took a long time before we were served . . . ," he said. "It is not quite clear what really happened afterward. The way I see it, [the death] could have been avoided."
Sub-Saharan African nations face desperate shortages of doctors and nurses. Some clinicians, including nurses and doctors, have died of AIDS -- in some cases caused when they were accidentally stuck with used needles. More than a dozen nurses interviewed throughout Lesotho said they would leave as soon as possible for safer, better-paying jobs in South Africa or Europe.
The narrow approach of the Global Fund and other aid groups compounds the problem, according to global health experts and African officials.
Ramatlapeng, the health minister, said her nation faced a conundrum. Donors won't help finance higher salaries for basic health workers. Yet the same groups refuse requests for other types of aid, citing concern that funds would not be spent effectively because of a dearth of staff.
The Global Fund pays for salary increases for clinicians who provide antiretroviral drug therapy, known as ART, for HIV/AIDS patients. Doctors and nurses move into AIDS care to receive these raises, creating a brain drain.
"All over the country, people are furious about incentives for ART staff," said Rachel M. Cohen, mission chief in Lesotho for Doctors Without Borders, which operates health facilities in partnership with the government.
Because of the brain drain, responsibilities for education, triage and low-level nursing pass down to lay people, particularly in rural areas that rarely if ever see a clinician. In much of Africa, task-shifting is the key response to staff shortages.
"But there are limits," Cohen said. "Some things shouldn't be done by lay people."
The situation is as bad or worse elsewhere in Africa.
In Rwanda, nurses often earn $50 to $100 a month if paid from a clinic's standard budget. They work beside Global Fund-supported nurses who earn $175 to $200 a month.
Florence Mukakabano, head nurse at the Central Hospital of Kigali, the capital of Rwanda, said she loses many of her staff nurses to United Nations agencies, NGOs and the hospital's own Global Fund-supported AIDS program.