The migration of nurses: trends and policies

This paper examines the policy context of the rise in the international mobility and migration of nurses. It describes the profile of the migration of nurses and the policy context governing the international recruitment of nurses to five countries: Australia, Ireland, Norway, the United Kingdom, and the United States. We also examine the policy challenges for workforce planning and the design of health systems infrastructure. Data are derived from registries of professional nurses, censuses, interviews with key informants, case studies in source and destination countries, focus groups, and empirical modelling to examine the patterns and implications of the movement of nurses across borders. The flow of nurses to these destination countries has risen, in some cases quite substantially. Recruitment from lower-middle income countries and low-income countries, as defined by The World Bank, dominate trends in nurse migration to the United Kingdom, Ireland, and the United States, while Norway and Australia, primarily register nurses from other high-income countries. Inadequate data systems in many countries prevent effective monitoring of these workforce flows. Policy options to manage nurse migration include: improving working conditions in both source and destination countries, instituting multilateral agreements to manage the flow more effectively, and developing compensation arrangements between source and destination countries. Recommendations for enhancements to workforce data systems are provided.     

International Nurse Recruitment in India

Objective. This paper describes the practice of international recruitment of Indian nurses in the model of a "business process outsourcing" of comprehensive training-cum-recruitment-cum-placement for popular destinations like the United Kingdom and United States through an agency system that has acquired growing intensity in India.
Findings. Despite the extremely low nurse to population ratio in India, hospital managers in India are not concerned about the growing exodus of nurses to other countries. In fact, they are actively joining forces with profitable commercial ventures that operate as both training and recruiting agencies. Most of this activity is concentrated in Delhi, Bangalore, and Kochi.
Conclusions. Gaps in data on nursing education, employment, and migration, as well as nonstandardization of definitions of "registered nurse," impair the analysis of international migration of nurses from India, making it difficult to assess the impact of migration on vacancy rates. One thing is clear, however, the chain of commercial interests that facilitate nurse migration is increasingly well organized and profitable, making the future growth of this business a certainty.     

Nurse Migration: A Canadian Case Study

Objective. To synthesize information about nurse migration in and out of Canada and analyze its role as a policy lever to address the Canadian nursing shortage.
Principal Findings. Canada is both a source and a destination country for international nurse migration with an estimated net loss of nurses. The United States is the major beneficiary of Canadian nurse emigration resulting from the reduction of full-time jobs for nurses in Canada due to health system reforms. Canada faces a significant projected shortage of nurses that is too large to be ameliorated by ethical international nurse recruitment and immigration.
Conclusions. The current and projected shortage of nurses in Canada is a product of health care cost containment policies that failed to take into account long-term consequences for nurse workforce adequacy. An aging nurse workforce, exacerbated by layoffs of younger nurses with less seniority, and increasing demand for nurses contribute to a projection of nurse shortage that is too great to be solved ethically through international nurse recruitment. National policies to increase domestic nurse production and retention are recommended in addition to international collaboration among developed countries to move toward greater national nurse workforce self sufficiency.     

Non-physician providers of obstetric care in Mexico: Perspectives of physicians, obstetric nurses and professional midwives

Background

Economically developed countries have recruited large numbers of overseas health workers to fill domestic shortages. Recognition of the negative impact this can have on health care in developing countries led the United Kingdom Department of Health to issue a Code of Practice for National Health Service (NHS) employers in 1999 providing ethical guidance on international recruitment. Case reports suggest this guidance had limited influence in the context of other NHS policy priorities.

Methods

The temporal association between trends in new professional registrations from doctors qualifying overseas and relevant United Kingdom government policy is reported. Government policy documents were identified by a literature review; further information was obtained, when appropriate, through requests made under the Freedom of Information Act. Data on new professional registration of doctors were obtained from the General Medical Council (GMC).

Results

New United Kingdom professional registrations by doctors trained in Africa and south Asia more than doubled from 3105 in 2001 to 7343 in 2003, as NHS Trusts sought to achieve recruitment targets specified in the 2000 NHS Plan; this occurred despite ethical guidance to avoid active recruitment of doctors from resource-poor countries. Registration of such doctors declined subsequently, but in response to other government policy initiatives. A fall in registration of South African-trained doctors from 3206 in 2003 to 4 in 2004 followed a Memorandum of Understanding with South Africa signed in 2003. Registrations from India and Pakistan fell from a peak of 4626 in 2004 to 1169 in 2007 following changes in United Kingdom immigration law in 2005 and 2006. Since 2007, registration of new doctors trained outside the European Economic Area has remained relatively stable, but in 2010 the United Kingdom still registered 722 new doctors trained in Africa and 1207 trained in India and Pakistan.

Conclusions

Ethical guidance was ineffective in preventing mass registration by doctors trained in resource-poor countries between 2001 and 2004 because of competing NHS policy priorities. Changes in United Kingdom immigration laws and bilateral agreements have subsequently reduced new registrations, but about 4000 new doctors a year continue to register who trained in Africa, Asia and less economically developed European countries.     

Nurses on the Move: A Global Overview

Objective. To look at nurse migration flows in the light of national nursing workforce imbalances, examine factors that encourage or inhibit nurse mobility, and explore the potential benefits of circular migration.
Principal Findings. The number of international migrants has doubled since 1970 and nurses are increasingly part of the migratory stream. Critical nursing shortages in industrialized countries are generating a demand that is fueling energetic international recruitment campaigns. Structural adjustments in the developing countries have created severe workforce imbalances and shortfalls often coexist with large numbers of unemployed health professionals. A nurse's motivation to migrate is multifactorial, not limited to financial incentives, and barriers exist that discourage or slow the migration process. The migration flows vary in direction and magnitude over time, responding to socioeconomic factors present in source and destination countries. The dearth of data on which to develop international health human resource policy remains. There is growing recognition, however, that migration will continue and that temporary migration will be a focus of attention in the years to come.
Conclusions. Today's search for labor is a highly organized global hunt for talent that includes nurses. International migration is a symptom of the larger systemic problems that make nurses leave their jobs. Nurse mobility becomes a major issue only in a context of migrant exploitation or nursing shortage. Injecting migrant nurses into dysfunctional health systems—ones that are not capable of attracting and retaining staff domestically—will not solve the nursing shortage.     

Managed Migration: The Caribbean Approach to Addressing Nursing Services Capacity

Objective. To (1) provide a contextual analysis of the Caribbean region with respect to forces shaping the current and emerging nursing workforce picture in the region; (2) discuss country-specific case(s) within the Caribbean; and (3) describe the Managed Migration Program as a potential framework for addressing regional and global nurse migration issues.
Principal Findings. The Caribbean is in the midst of a crisis of shortages of nurses with an average vacancy rate of 42 percent. Low pay, poor career prospects, and lack of education opportunities are among the reasons nurses resign. Many of these nurses look outside the region for job opportunities in the United Kingdom, Canada, the United States, and other countries. Compounding the situation is the lack of resources to train nurses to fill the vacancies. The Managed Migration Program of the Caribbean is a multilateral, cross-sector, multi-interventional, long-term strategy for developing and maintaining an adequate supply of nurses for the region.
Conclusions. The Managed Migration Program of the Caribbean has made progress in establishing regional support for addressing the nursing shortage crisis and developing a number of interesting initiatives such as training for export and temporary migration. Recommendations to move the Managed Migration Program of the Caribbean forward focus on advocacy, integration of the program into regional policy decisions, and integration of the program with regional health programming.     

The Potent Lever of Toil: Nursing Development and Exportation in the Postcolonial Philippines

Although the colonial relationship between the Philippines and the United States precipitated nurse education and migration patterns that exist today, little is known about the factors that sustained them. During the first half of the twentieth century, for example, the Philippines trained its nurse workforce primarily for domestic use. After the country''s independence in 1946, however, that practice reversed. Nurse education in the Philippines was driven largely by US market demand in tandem with local messages linking work and nationalism and explicit policies to send nurses abroad. As these ideologies and practices became firmly entrenched, nurse production not only exceeded the country''s numerical requirements but focused largely on preparing practitioners for the health care needs of developed nations rather than the public health needs of the indigenous population. This historical trend has important present-day ramifications for the Philippines, whose continued exodus of nurses threatens its public health.IN RECENT YEARS, THE migratory pull of nurses from poorer to richer nations has been a vexing problem, particularly as it relates to variations in state–labor relations and health workforce policies that in some instances threaten the public''s health in those nations that send nurses abroad.¹ There have been numerous attempts to address migration of nurses and other health workers and to create guiding principles and voluntary international standards for the ethical recruitment of health workers.² Contemporary policies and codes of practice aimed at remedying global disparities in nursing care and the management of nurse migration streams, however, have been largely unsuccessful. Part of their failure is their inattention to the impact of social structures and historical precedents on present-day trends.As it did throughout the twentieth century, the Philippines currently leads the world in exporting nurses to meet demand in the United States and other developed nations.³ It has been argued, moreover, that the country''s persistent production of nurses for the global market is a state strategy to develop an export industry for economic development.⁴ Thus, unlike many other countries that lose nurses primarily through aggressive external recruitment, the Philippines has developed explicit internal policies and practices that encourage the production of nurses for export and operate in tandem with state-influenced policies in receiving countries (i.e., immigration services, nursing licensing authorities) to ease the process of emigration.I examine the formation of state policies and practices in the Philippines that guided nurse professionalization, practice, and immigration over the past century. I argue that the Philippines’ state policy priorities were rooted in the imperialist relationship between the United States and the Philippines and that these dominant ideologies were accepted and reinforced over time. Work equated with nationalism, and working abroad and remitting salaries home demonstrated loyalty to the state while enhancing its economic security. These state-influenced messages eventually guided the export-oriented industrialization of nursing in the Philippines that prioritizes economic development over the public''s health.     

Nurse migration and health workforce planning: Ireland as illustrative of international challenges

Ireland began actively recruiting nurses internationally in 2000. Between 2000 and 2010, 35% of new recruits into the health system were non-EU migrant nurses. Ireland is more heavily reliant upon international nurse recruitment than the UK, New Zealand or Australia. This paper draws on in-depth interviews (N=21) conducted in 2007 with non-EU migrant nurses working in Ireland, a quantitative survey of non-EU migrant nurses (N=337) conducted in 2009 and in-depth interviews conducted with key stakeholders (N=12) in late 2009/early 2010. Available primary and secondary data indicate a fresh challenge for health workforce planning in Ireland as immigration slows and nurses (both non-EU and Irish trained) consider emigration. Successful international nurse recruitment campaigns obviated the need for health workforce planning in the short-term, however the assumption that international nurse recruitment had 'solved' the nursing shortage was short-lived and the current presumption that nurse migration (both emigration and immigration) will always 'work' for Ireland over-plays the reliability of migration as a health workforce planning tool. This article analyses Ireland's experience of international nurse recruitment 2000-2010, providing a case study which is illustrative of health workforce planning challenges faced internationally.     

Trends in international nurse migration

Predicted shortages and recruitment targets for nurses in developed countries threaten to deplete nurse supply and undermine global health initiatives in developing countries. A twofold approach is required, involving greater diligence by developing countries in creating a largely sustainable domestic nurse workforce and their greater investment through international aid in building nursing education capacity in the less developed countries that supply them with nurses.     

International rescue? The dynamics and policy implications of the international recruitment of nurses to the UK

This paper focuses on one global aspect of the current health sector workforce policy agenda - the international recruitment and migration of health workers. It does so primarily by using a case study of the recruitment of nurses to the UK, as a means of exploring the policy challenges and associated research questions. The paper highlights the limitations in comparing national data on the nursing workforce, illustrating the extent to which currently collated national data can present a misleading picture of staff:population ratios in different countries. It then reports on the significant growth in the numbers of nurses entering the UK from other countries, using registration data. In 2001/02, more than 16 000 nurses entered the UK nursing register from non-UK sources. In this year, for the first time, the number exceeded the number of home-trained nurses. An analysis of postcode data highlights that these non-UK nurses have a younger age profile than home-based registered nurses and are more likely to report a postcode in London and south-east England. The paper also examines the push and pull factors that contribute to the international mobility of health workers. The paper concludes by examining the policy implications of this growing reliance on international recruitment, including the effect of the ethical guidelines on international recruitment introduced by the Department of Health in England.     

Migration of Nurses from Sub-Saharan Africa: A Review of Issues and Challenges

Objective. To assess the impact of out-migration of nurses on the health systems in sub-Saharan Africa (SSA).
Setting. The countries of SSA.
Design and Methods. Review of secondary sources: existing publications and country documents on the health workforce; documents prepared for the Joint Learning Initiative Global Human Resources for Health report, the World Health Organization (AFRO) synthesis on migration, and the International Council of Nurses series on the global nursing situation. Analysis of associated data.
Principal Findings. The state of nursing practice in SSA appears to have been impacted negatively by migration. Available (though inadequate) quantitative data on stocks and flows, qualitative information on migration issues and trends, and on the main strategies being employed in both source and recipient countries indicate that the problem is likely to grow over the next 5–10 years.
Conclusions. Multiple actions are needed at various policy levels in both source and receiving countries to moderate negative effects of nurse emigration in developing countries in Africa; however, critically, source countries must establish more effective policies and strategies.     

The impact of out-migration on the nursing workforce in Kenya

Objective. To examine the impact of out‐migration on Kenya's nursing workforce. Study Setting. This study analyzed deidentified nursing data from the Kenya Health Workforce Informatics System, collected by the Nursing Council of Kenya and the Department of Nursing in the Ministry of Medical Services. Study Design. We analyzed trends in Kenya's nursing workforce from 1999 to 2007, including supply, deployment, and intent to out‐migrate, measured by requests for verification of credentials from destination countries. Principle Findings. From 1999 to 2007, 6 percent of Kenya's nursing workforce of 41,367 nurses applied to out‐migrate. Eighty‐five percent of applicants were registered or B.Sc.N. prepared nurses, 49 percent applied within 10 years of their initial registration as a nurse, and 82 percent of first‐time applications were for the United States or United Kingdom. For every 4.5 nurses that Kenya adds to its nursing workforce through training, 1 nurse from the workforce applies to out‐migrate, potentially reducing by 22 percent Kenya's ability to increase its nursing workforce through training. Conclusions. Nurse out‐migration depletes Kenya's nursing workforce of its most highly educated nurses, reduces the percentage of younger nurses in an aging nursing stock, decreases Kenya's ability to increase its nursing workforce through training, and represents a substantial economic loss to the country.     

"I won't be staying here for long": a qualitative study on the retention of migrant nurses in Ireland

Background  

Although international nurse recruitment campaigns have succeeded in attracting large numbers of migrant nurses to countries such as Ireland, where domestic supply has not kept pace with demand, the long-term success of such initiatives from a workforce planning perspective will depend on the extent to which these nurses can be retained in destination countries.     

The ethics of recruiting foreign nurses

Because they face a growing nursing shortage, many U.S. health care institutions have turned to recruiting foreign nurses. For foreign nurses, the practice is often an opportunity to make a better life for themselves and their families. And it helps solve a serious problem for the U.S. organizations involved. But the recruitment of foreign nurses raises a number of ethical questions. The first article here examines the practice as seen from three viewpoints, the global, that of the particular recruiting health care organization, and that of the recruited foreign nurse. The author concludes that the practice can be both a "blessing" and a "curse." The second article discusses the practice as seen from a Third World nation from which the United States, along with other Western countries, is recruiting nurses. The author, who formerly supported the practice, now opposes it.     

Assessment of variation in the alberta context tool: the contribution of unit level contextual factors and specialty in Canadian pediatric acute care settings

Background

A growing number of countries are introducing some form of nurse prescribing. However, international reviews concerning nurse prescribing are scarce and lack a systematic and theoretical approach. The aim of this review was twofold: firstly, to gain insight into the scientific and professional literature describing the extent to and the ways in which nurse prescribing has been realised or is being introduced in Western European and Anglo-Saxon countries; secondly, to identify possible mechanisms underlying the introduction and organisation of nurse prescribing on the basis of Abbott's theory on the division of professional labor.

Methods

A comprehensive search of six literature databases and seven websites was performed without any limitation as to date of publication, language or country. Additionally, experts in the field of nurse prescribing were consulted. A three stage inclusion process, consisting of initial sifting, more detailed selection and checking full-text publications, was performed independently by pairs of reviewers. Data were synthesized using narrative and tabular methods.

Results

One hundred and twenty-four publications met the inclusion criteria. So far, seven Western European and Anglo-Saxon countries have implemented nurse prescribing of medicines, viz., Australia, Canada, Ireland, New Zealand, Sweden, the UK and the USA. The Netherlands and Spain are in the process of introducing nurse prescribing. A diversity of external and internal forces has led to the introduction of nurse prescribing internationally. The legal, educational and organizational conditions under which nurses prescribe medicines vary considerably between countries; from situations where nurses prescribe independently to situations in which prescribing by nurses is only allowed under strict conditions and supervision of physicians.

Conclusions

Differences between countries are reflected in the jurisdictional settlements between the nursing and medical professions concerning prescribing. In some countries, nurses share (full) jurisdiction with the medical profession, whereas in other countries nurses prescribe in a subordinate position. In most countries the jurisdiction over prescribing remains predominantly with the medical profession. There seems to be a mechanism linking the jurisdictional settlements between professions with the forces that led to the introduction of nurse prescribing. Forces focussing on efficiency appear to lead to more extensive prescribing rights.     

Nurse Migration from a Source Country Perspective: Philippine Country Case Study

Objectives. To describe nurse migration patterns in the Philippines and their benefits and costs.
Principal Findings. The Philippines is a job-scarce environment and, even for those with jobs in the health care sector, poor working conditions often motivate nurses to seek employment overseas. The country has also become dependent on labor migration to ease the tight domestic labor market. National opinion has generally focused on the improved quality of life for individual migrants and their families, and on the benefits of remittances to the nation. However, a shortage of highly skilled nurses and the massive retraining of physicians to become nurses elsewhere has created severe problems for the Filipino health system, including the closure of many hospitals. As a result, policy makers are debating the need for new policies to manage migration such that benefits are also returned to the educational institutions and hospitals that are producing the emigrant nurses.
Conclusions and Recommendations. There is new interest in the Philippines in identifying ways to mitigate the costs to the health system of nurse emigration. Many of the policy options being debated involve collaboration with those countries recruiting Filipino nurses. Bilateral agreements are essential for managing migration in such a way that both sending and receiving countries derive benefit from the exchange.     

Developing a Nursing Database System in Kenya

Objective. To describe the development, initial findings, and implications of a national nursing workforce database system in Kenya.
Principal Findings. Creating a national electronic nursing workforce database provides more reliable information on nurse demographics, migration patterns, and workforce capacity. Data analyses are most useful for human resources for health (HRH) planning when workforce capacity data can be linked to worksite staffing requirements. As a result of establishing this database, the Kenya Ministry of Health has improved capability to assess its nursing workforce and document important workforce trends, such as out-migration. Current data identify the United States as the leading recipient country of Kenyan nurses. The overwhelming majority of Kenyan nurses who elect to out-migrate are among Kenya's most qualified.
Conclusions. The Kenya nursing database is a first step toward facilitating evidence-based decision making in HRH. This database is unique to developing countries in sub-Saharan Africa. Establishing an electronic workforce database requires long-term investment and sustained support by national and global stakeholders.     

Exploring longitudinal shifts in international nurse migration to the United States between 2003 and 2013 through a random effects panel data analysis

Background

No study has examined the longitudinal trends in National Council Licensure Exam for Registered Nurse (NCLEX-RN) applicants and pass rates among internationally-educated nurses (IENs) seeking to work in the United States, nor has any analysis explored the impact of specific events on these trends, including changes to the NCLEX-RN exam, the role of the economic crisis, or the passing of the WHO Code on the International Recruitment of Health Personnel. This study seeks to understand the impact of the three aforementioned factors that may be influencing current and future IEN recruitment patterns in the United States.

Methods

In this random effects panel data analysis, we analyzed 11 years (2003–2013) of annual IEN applicant numbers and pass rates for registered nurse credentialing. Data were obtained from publicly available reports on exam pass rates. With the global economic crisis and NCLEX-RN changes in 2008 coupled with the WHO Code passage in 2010, we sought to compare if (1) the number of applicants changed significantly after those 2 years and (2) if pass rates changed following exam modifications implemented in 2008 and 2011.

Results

A total of 177 countries were eligible for inclusion in this analysis, representing findings from 200,453 IEN applicants to the United States between 2003 and 2013. The majority of applicants were from the Philippines (58 %) and India (11 %), with these two countries combined representing 69 % of the total. Candidates from Sub-Saharan African countries totalled 7133 (3 % of all applications) over the study period, with half of these coming from Nigeria alone. No significant changes were found in the number of candidates following the 2008 economic crisis or the 2010 WHO Code, although pass rates decreased significantly following the 2008 exam modifications and the WHO Code implementation.

Conclusion

This study suggests that, while the WHO Code has had an influence on overall IEN migration dynamics to the United States by decreasing candidate numbers, in most cases, the WHO Code was not the single cause of these fluctuations. Indeed, the impact of the NCLEX-RN exam changes appears to exert a larger influence.

     

Trends in and effects of smoking in the world

Smoking is undoubtedly a major cause of illness and premature death. It is responsible for as much as 90% of all cases of lung cancer, 75% of chronic bronchitis and emphysema and 25% of cases of ischaemic heart disease in men under 65 years, as well as for a number of other types of cancer, pregnancy complications and more frequent respiratory ailments in children from smoking families. In South-East Asia, tobacco chewing is estimated to cause about 90% of the deaths due to oral cancer. Worldwide, cigarette consumption per adult has increased only very slightly, by 7.1%, between 1970 and 1985. It fell in many industrial countries, e.g. by 9% in the United States of America and Canada, 6% in Australia and New Zealand, and by as much as 25% in the United Kingdom. On the contrary, in many developing countries adult per capita cigarette consumption has increased markedly, e.g. by 42% in Africa, 24% in Latin America and 22% in Asia. In many industrialized countries, the percentage of smokers has started to fall in recent years. For instance, in the United Kingdom, the percentage of male smokers fell from 65% to 45% and that of female smokers from 45% to 34%. In the United States, male prevalence decreased from 54% to 29% and female prevalence from 36% to 24%. In Norway, male smoking prevalence decreased from 53% to 42%, in Australia from 72% to 33% and in Canada from 44% to 35%. On the contrary, in developing countries prevalence of smoking is frequently higher than in the affluent countries. In Tunisia, for instance, 60% of the men smoke. Smoking-related diseases account for 7% of all deaths in Chile and Ecuador and 24% in Venezuela, 30% in Cuba, 10% in France, 17% in Canada, 15-20% in the United Kingdom, and up to 35% among white South-Africans. It has been calculated that 600,000 new cases of lung cancer occur worldwide every year, most of them due to smoking. Projections show that by the year 2000 the yearly number of new lung-cancer cases worldwide may be as high as 2 million. 500,000 deaths are attributable to smoking in Europe, at least 630,000 in India, 10,000 in South Africa, 23,000 in Australia, 30,000 in Canada, 19,000 in Venezuela and about 400,000 in the United States in 1980. The hypermorbidity of smokers causes an extra need for medical care.(ABSTRACT TRUNCATED AT 400 WORDS)     

Human resource development and antiretroviral treatment in Free State province, South Africa

Background

In common with other developing countries, South Africa's public health system is characterised by human resource shortfalls. These are likely to be exacerbated by the escalating demand for HIV care and a large-scale antiretroviral therapy (ART) programme. Focusing on professional nurses, the main front-line providers of primary health care in South Africa, we studied patterns of planning, recruitment, training and task allocation associated with an expanding ART programme in the districts of one province, the Free State.

Methods

Data collection included an audit of professional nurse posts created and filled following the introduction of the ART programme, repeated surveys of facilities providing ART over two years to assess the deployment of staff, and secondary data analysis of government personnel databases to track broader patterns of recruitment and training.

Results

Although a substantial number of new professional nurse posts were established for the ART programme in the Free State, nearly 80% of these posts were filled by nurses transferring from other programmes within the same facility or from facilities within the same district, rather than by new recruits. From the beginning, ART nurse posts tended to be graded at a senior level, and later, in an effort to recruit professional nurses for the ART programme, the majority (54.6%) of nurses entering the programme were promoted to a senior level. The vacancy rate of nurse ART posts was significantly lower than that of other posts in the primary health care (PHC) system (15.7% vs 37.1%). Nursing posts in urban ART facilities were more easily filled than those in rural areas, exacerbating existing imbalances. The shift of nurses into the ART programme was partially compensated for by the appointment of additional support staff, task shifting to community health workers, and a large investment in training of PHC workers. However, the use of less-trained, mid-level enrolled nurses and nursing assistants in the ART programme remained low.

Conclusion

The introduction of the ART programme has revealed both strengths and weaknesses of human resource development in one province of South Africa. Without concerted efforts to increase the supply of key health professionals, accompanied by changes in the deployment of health workers, the core goals of the ART programme – i.e. providing universal access to ART and strengthening the health system – will not be achieved.