With the cost of antiretroviral drugs falling, the burning question in the
scaling-up debate is no longer how to finance access to drugs or indeed the
scaling up of antiretroviral treatment (ART) schemes, but rather how to ensure
the implementation of the programmes. Health system performance is increasingly
acknowledged as a condition for success of programmes such as the '35
Initiative' and the notion that the human resources will be one of the decisive
determinants is gaining  ground (Tawfiq & Kinoti 2003 Narabsimhan et
al. 2004). However, in most south-eastern African countries, the health
workforce is teetering. Chronic deficiencies in training capacity, distribution
and skill mix, and retention in the medical and caring professions have left the
health services with narrow margins to cope with new challenges (Aitken &
Kemp 2003 Huddart et al. 2003). Furthermore, under current conditions in many
developing countries, performance and accountability of health providers are
difficult to ensure. In other words, countries in south-eastern Africa are not
only facing huge problems of implementation capacity to scale up ART schemes,
but also to ensure the adequate performance of the health system as a whole.
While the human resources crisis is being acknowledged (Narabsimhan et al.
2004 WHO 2004), little has been said about how to deal with it. This paper
first briefly summarizes the specific impact of the human immunodeficiency
virus/acquired immunodeficiency syndrome (HIV/AIDS) pandemic on the health
services in order to show how it is related to the larger perspective of health
workforce imbalances. It then argues that in the high-burden countries of
southern and eastern Africa, the direct and indirect impact on the health
services, combined with the societal impact of the HIV/AIDS pandemic requires
true paradigm shifts in the domains of  human resource management and
policy making, education and international aid.
The impact of HIV/AIDS on the demand and need for health care
The HIV/AIDS-related burden of disease increases the demand for medical care
dramatically and in doing so, the pandemic indirectly affects the health
workforce in terms of increasing emotional, physical and mental stress.
Tuberculosis (TB), pneumonia and other opportunistic infections, and
malnutrition are all on the rise in AIDS-stricken countries. Public hospitals
carry the heaviest burden, as witnessed by data on HIV-related admissions and
length of stay in South Africa. While both the number of total admissions in
medical wards and the bed capacity remained stable between 1995 and 2000, the
HIV/AIDS-related admissions in all categories of hospitals increased by a factor
of 7 (Shisana et al. 2003). As a result, currently, 46% of patients admitted to
South African hospitals are HIV positive. AIDS patients were also shown to stay
longer (mean length of 13.7 days) than non-AIDS patients (mean length of stay
8.2 days) for all categories of hospitals combined. Trends regarding bed
occupancy rates are difficult to ascertain. The Shisana report did not find a
significant change in bed occupancy rates despite the increase in admissions of
both HIV/AIDS and TB patients.
Evidently, this increased burden on the hospitals exerts an impact on morale
and job satisfaction of health workers. HIV/AIDS patients are often brought to
the hospital at an advanced stage of illness. The resulting high inpatient death
rates combined with the limited possibilities of effective care contribute to
professional frustration, higher absenteeism and burnout and to low staff
morale. In many settings in AIDS-stricken countries, working conditions for
health workers are difficult, salaries low and supplies inadequate. In these
unfavourable environments, providing quality care is not self-evident and
responsiveness of staff towards AIDS patients may suffer (Unger et al. 2002
Shisana et al. 2003). Unger et al.(2002) report that South African health
workers 'experience stress, fear, frustration and depression due to their
contact with patients living with AIDS and the limitations of their work
environments'. It should be noted that the roll-out of ART on a large scale will
improve the effectiveness of care and may be expected to reduce the levels of
The direct effects of the HIV/AIDS pandemic on the health workforce
HIV/AIDS directly affects the attrition rates, level of motivation and
professional practice, and absenteeism rates of health workers. Strikingly,
accurate data on HIV prevalence among health workers are relatively scarce, but
health workers are at least as likely to be affected by HIV as any other group
of the population (Buvet al. 1994). In public and private health facilities in
Free State, Mpumalanga, KwaZulu Natal and North West (South Africa), 15.7% of
health workers are estimated to be HIV positive. In the age group 1835 years,
20% were found to be HIV positive (Shisana et al. 2003). A death certificate
analysis in this study also showed that HIV/AIDS-related illnesses, including
TB, accounted for 13% of health workers' deaths between 1997 and 2001. In
Botswana, HIV prevalence is expected to rise from the current 1732% to 2841% by
Two to three per cent of health workers had AIDS in 2001 and projections show
this figure to rise to 69% by 2011, if current trends continue (Abt Associates
South Africa Inc. 2000). HIV/AIDS also affects the health workers' attitude and
practice. The occupational risk may be correlated with the HIV seroprevalence
rates among patients, but it has been shown to vary in function with occupation,
place of work and adherence to procedures for prevention (Consten et al. 1995
Tawfiq & Kinoti 2003). Lack of adequate supplies of protective means
(gloves, gowns, goggles and disinfectants) is another important determinant. In
developed countries, the average risk of occupational HIV transmission after a
percutaneous exposure is estimated to be 0.3% and below 0.1% after mucous
membrane exposure (Anonymous 2001). Comprehensive data from developing countries
are lacking, but de Graaf et al. (1998) estimated a mean occupational risk of
0.11% per person per year taking into account the same 0.3% chance of
transmission by accident and 1.9% percutaneous exposures per person per year
among 99 Dutch medical professionals who had been working in AIDS-endemic areas.
Even if there is some uncertainty about the actual risk, the perceived risk is
high (Aitken & Kemp 2003) and this can affect the quality of care of
HIV-positive patients. Indeed, negative staff attitudes combined with inadequate
knowledge of procedures cause reluctance to care for HIV-positive patients
(Masini & Mwampeta 1993), as well as making the medical professions less
Health workers need to take care of relatives living with AIDS. Together with
funeral attendance, this leads to increased absenteeism (Aitken & Kemp
2003). In Hlabisa district hospital (KwaZulu Natal, South Africa), the average
number of days off work increased from an already high 41.8 days in 1998 to 57.5
days in 2001 largely because of this phenomenon (Unger et al. 2002).
From a health service manager's point of view, the above problems of
attrition, demotivation and absenteeism are compounded by the loss of
institutional memory. Often AIDS takes out experienced staff and with them
informal and tacit knowledge that may be difficult to restore. It also reduces
the on-site training capacity (Cohen 2002), which is not only required to fills
gaps left by AIDS, but also to prepare health workers for new tasks in the
diagnosis and treatment of HIV/AIDS.
AIDS further aggravates the human resource crisis in south-eastern Africa
With some sense of exaggeration, one could say that the pandemic is just the
latest plague falling upon the health workers. The classic health workforce
issues of maintaining adequate levels of training and inflow in the professions,
ensuring adequate distribution and skill mix and retaining health professionals
are in fact continuing to undermine health services in many countries (Huddart
et al. 2003 Narabsimhan et al. 2004).
AIDS affects each of these elements. Not only geographical distribution, but
also the existing skill mix imbalances are likely to worsen. Health workers who
have HIV-positive relatives to care for or who themselves are infected are
unlikely to accept work in remote areas where possibilities of adequate care are
limited or non-existent. On the contrary, the educated and experienced are not
safe from AIDS, which takes out a core layer in the professional health
workforce. A workforce that is already demotivated because of inadequate
remuneration and working conditions may get the fatal blow from the daily
confrontation with hospital wards full of terminal patients. Both the actual and
the perceived risk of occupational contamination contribute to the conditions
that push staff to consider leaving for abroad.
The HIV/AIDS pandemic is thus emerging as a pervasive factor in the general
human resource crisis in south-eastern Africa and entwined with the internal and
external brain drain (Marchal & Kegels 2003). The South African Medical
Association estimates that in South Africa during the last 4 years, 4000 doctors
left the public sector for private practice or for other countries, equalling
roughly the number of doctors trained in that period (Kapp 2004), while 78% of
its rural doctors are of non-South African origin (Martineau et al. 2002). At
the same time, the 23 400 South African health workers working in Canada, the
US, the UK and Australia correspond to 9.8% of all health professionals
registered in South Africa (OECD 2004). However, just to compensate the losses
to HIV over the next decade, South Africa will need to train 2540% more doctors
and nurses (Haacker 2002). Needless to say, the current situation has direct
consequences for scaling-up HIV/AIDS programmes. In Botswana, the acute shortage
of health professionals impaired the medical check-ups at the intake phase of an
ART programme and thus reduced the enrollment of candidates and the treatment
rates (Cohen 2002). A comprehensive approach to enhance the health workforce
requires paradigm shifts
As discussed above, the health workforce in eastern and southern Africa finds
itself in the double trap of the HIV/AIDS pandemic, being affected both directly
and indirectly. However not only the scaling up of ART or even the health sector
as a whole is threatened. Indeed, entire societies are now in a process of what
de Waal (in press) calls 'social involution of a scale probably unprecedented in
human history'. Not only health care but also food security, education and
economic development are under increasing pressure. In this perspective,
strategies that proved to be effective and correct in past conditions may no
longer be adequate now, and may even hamper an effective response. In our
opinion, the current conditions governing south-eastern Africa call for true
paradigm shifts, not only in the domain of human resource policies, but also in
Protecting the current health workforce from HIV
The first short-term priority is to reduce the impact of the pandemic on the
health workers. Universal introduction of safer nursing and surgical techniques,
safe waste disposal, adequate barrier techniques and post-exposure prophylaxis
can contribute to prevent health workers from being infected in the work place.
Care and support to HIV-positive health workers with HAART, prophylactic
isoniazide and cotrimoxazole schemes and counselling are a second set of
required measures. These have been described elsewhere (IOE 2002 Aitken &
Kemp 2003 Huddart et al. 2003).
In many places, they are being introduced, but often in a fragmented manner.
Health workers are still often left exposed because of the lack of knowledge or
supplies and fear of stigmatization (Shisana et al. 2003). Complicated as these
measures are, they might well be the easiest part.
Reviewing the organization of health care provision to modify the medical
Scaling-up ART in countries facing large deficits in the health workforce
will require a review of the current production and the configuration of health
services. Regarding the latter, whichever model is chosen (to integrate AIDS
care in existing general health services or in TB directly observed therapy
programmes (Abdool Karim et al. 2004) or to run mobile clinics), it is likely
that the cornerstone will be delegation of tasks to lesser-qualified health
workers and lay persons, supervised by the increasingly scarce professionals.
This goes against the current trend to improve the quality of medical and
nursing education through raising the course entry requirements, the duration of
training and the level of qualification. Indeed, this is likely to lead to lower
outputs and higher costs of training (Huddart et al. 2003) and it will not
resolve current imbalances and deficits in the short and medium term. An
appropriate balance between training outputs of different cadres needs therefore
to be struck, whereby professionals will have to be assigned a role of
supportive supervision of large cadres of semi-professional health workers and
caretakers. Koenig et al. (2004) showed that lay health workers can play an
effective role if integrated in a comprehensive approach to home-based care. At
the same time, the internationally less marketable cadres may answer the brain
drain issue in these countries. But not only the future skill mix has to be
taken into account, also the required numbers of staff. The current production
capacity of health care workers needs urgent attention (Aitken & Kemp 2003).
Health workforce policies
The long-term priority is to institute effective human resource policies to
train and retain the required health workers. Unfortunately, the track record of
international agencies and countries alike is not impressive. On the one hand,
Poverty Reduction Strategy Papers (PRSP) offer quite some opportunities to this
end, but a review of the PRSPHeavily Indebted Poor Countries (HIPC) initiative
in six African countries shows that neither AIDS nor the human resource crisis
figure high on the agenda and an in-depth analysis of the HR crisis is mostly
absent (HSRC 2003). On the other hand, public sector expenditure and recruitment
ceilings imposed by structural adjustment programmes and similar donor-imposed
conditions stifle recruitment and simply need to be lifted. Indeed, in these
times of AIDS, it can no longer be justified to freeze the health workforce both
in number and skill mix.
Obviously, increased recruitment and improving the attraction of working in
healthcare needs money. Only middle-income countries like South Africa, Botswana
and Thailand may be able to finance significant improvements both of the number
and wages of health workers on the strength of their own resources. Besides
PRSPHIPC, the global initiatives through which increasing financial flows are
injected into AIDS programmes in the south are obvious potential funders. Only,
they need to allow allocation of their funds to recurrent expenditure in order
to finance expanding and stabilizing the health workforce. By themselves they
may, however, be insufficient and other sources of funding will need to be
Rethinking international aid policies
Some of the other principles of international aid should be reconsidered,
too. Approaches to technical assistance that used to be politically correct and
'developmentally' sound in past conditions are no longer suitable and reduce the
effectiveness of international co-operation seriously. In high-prevalence
countries, the principle of sustainability of interventions can no longer be
maintained. Sending out health professionals in both clinical and managerial
roles to high-prevalence countries now responds to huge needs and cannot be
excluded on the pretext that this would amount to unsustainable and undesirable
substitution. If nothing changes, the funding flow will continue to exceed the
absorption capacity in most countries.
Tackling the brain drain
Finally, health workforce issues do not respect national boundaries. Brain
drain is a prime example of the complexity of the causes of the human resource
crisis and it indicates that health sector decisions in industrialized countries
profoundly affect human resource balances in the south (Marchal & Kegels
2003). The active pull exerted by the industrialized countries on medical
professionals from the south is contributing to debilitating the health services
in these countries.
Unless the issues of low attraction, inadequate training output and low
retention of health workers are effectively tackled in the south but perhaps
even more importantly, in the industrialized countries the African health
workers will continue to seek greener pastures elsewhere. Across eastern and
southern Africa, the regions hardest hit by HIV/AIDS, the pandemic's onslaught
on the health workforce undermines the performance of the health system and
institutes a vicious circle that puts the capacity of the health services under
ever-greater pressure. Human resource issues being entangled and interrelated,
all actors should realize that the HR challenge is multidimensional and that it
requires concerted action. Indeed, it is now time to stop reciting the mantra
of  the importance of human resources for the scaling up of interventions.
Instead, realistic, open-minded analyses and assessments need to be undertaken.
Unless the current paradigms are revisited, the fundamental changes to
effectively strengthen the health workforce are unlikely to be initiated.
Published in: Tropical Medicine & International Health
Volume 10 Issue 4 Page 300 - April 2005
Sourced through EQUINET NEWS
Published by Blackwell-synergy as an open-source article:
Acknowledgements Go to: The Institute of Tropical Medicine, Antwerp
has a contract with IMMPACT, the Initiative for Maternal Mortality Programme
Assessment that covers the salary of Bruno Marchal (0.7 FTE) and Vincent De
Brouwere (0,50 FTE). This paper was, however, not written for IMMPACT and
expresses solely the opinions of the authors and in no way those of IMMPACT or
its funding bodies. We would like to thank the referees for their useful
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