-- By pouring most contributions into the fight against high-profile killers such as AIDS, Gates grantees have increased the demand for specially trained, higher-paid clinicians, diverting staff from basic care. The resulting staff shortages have abandoned many children of AIDS survivors to more common killers: birth sepsis, diarrhea and asphyxia.
-- The focus on a few diseases has shortchanged basic needs such as nutrition and transportation, undermining the effectiveness of the foundation's grants. Many AIDS patients have so little food that they vomit their free AIDS pills. For lack of bus fare, others cannot get to clinics that offer lifesaving treatment.
-- Gates-funded vaccination programs have instructed caregivers to ignore - even discourage patients from discussing - ailments that the vaccinations cannot prevent. This is especially harmful in outposts where a visit to a clinic for a shot is the only contact some villagers have with health care providers for years.
Joe McCannon, vice president of the Institute for Healthcare Improvement, a U.S. nongovernmental aid organization with operations in Africa, said, "You have to ask: 'Net, are we having a positive effect?' It's a haunting question."
Having started in 2002, "the Global Fund is very young," said its director, Dr. Michel Kazatchkine, a French physician who formerly led France's National Agency for AIDS Research. To see decades of neglect reversed, "Wait for two or three more years," he said.
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.
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 U.N. agencies, nongovernmental organizations and the hospital's own Global Fund-supported AIDS program.
In some cases, salary increases targeted to certain types of care "may have had a distorting effect," Kazatchkine acknowledged. But the AIDS crisis justifies such dislocations, he said. "We are a global fund for AIDS, TB and malaria. We are not a global fund that funds local health."
He emphasized a key principle of the Global Fund: If the group took over from weak or inept governments, the result would be worse, because African countries would never develop their own expertise.