Health Worker Shortage

Why is there a crisis?

An overall lack of committed national and international resources is a prime factor in this human resources crisis. The following barriers are also critical:

• Inadequate salaries and poor working conditions
  Of 65 nurses surveyed at MSF clinics in rural Lesotho, 72 percent said they were considering leaving their posts; 77 percent of these said the main factor was the need for more money.

• Rules prevent shifting some tasks to lower level health staff
  Shifting some responsibilities from doctors to nurses or nurses to lay counselors can be a tremendous help in reaching more people who need treatment. But, this strategy is often limited by national policies or those of professional medical or nursing councils.

• A lack of donor funding for recurrent human resource costs, particularly salaries
  Donors more readily support one-time costs, but are less likely to support salary increases; many will also finance life-long ARV treatment, but not support a new health worker post, due to concerns over "sustainability."

• Limits on spending imposed by ministries of finance and international finance institutions can hinder governments' ability to invest in the health workforce
  The number of health positions and the salaries paid to employees are often capped and based on a certain percentage of the country's gross domestic product, in accordance with the International Monetary Fund. This spending cap method does not take into account an urgent need for health workers in the face of a pandemic.

• Another sad factor is the health of health care workers themselves. In Malawi and Lesotho, death from HIV/AIDS is the main cause of the loss of health workers. In Mozambique, an estimated 200 deaths per year of health care workers are attributed to HIV/AIDS.

In Malawi...

Population:	13 million
Life expectancy:	39.7 years
Adult HIV prevalence:	14.1%
No. of people with HIV/AIDS:	940,000
No. of people in need of ART:	170,000
No. of people initiated on ART:	85,000
Treatment deficit:	85,000
Proportion of national budget spent on health:	9.1%

By the end of 2006, the number of patients on antiretroviral (ARV) treatment in Thyolo district where MSF is working alongside government health workers nearly doubled from the previous year. However, even with almost 6,000 people on ARV treatment, some 11,500 people are still need, but the clinics have reached a point of saturation.

The vacancy rate for nurses in rural areas across the country is 60 percent. Severe personnel shortages in Thyolo district health centers cause a constant scramble to help patients, putting a heavy burden on the dwindling number of remaining staff; frequent double shifts are necessary.

The lack of health workers is attributed largely to trained staff leaving for the private sector or going overseas for better paying jobs and better working conditions. The basic current salary for a public sector nurse is about 12,000 kwachas ($US 87) per month, which often necessitates getting a second job.

• Listen to an MSF podcast on HIV/AIDS treatment in Malawi.

In Mozambique...

Population:	20 million
Life expectancy:	41.6 years
Adult HIV prevalence:	16.1%
No. of people with HIV/AIDS:	1.8 million
No. of people in need of ART:	280,000
No. of people initiated on ART:	44,100
Treatment deficit:	235,900
Proportion of national budget spent on health:	10.1%

In Tete town, only one in four health centers has the number of medical technicians allocated and three-quarters of facilities have only nurses and nurse assistants. Due to rules that prohibit nurses from prescribing ARVs, patients are not receiving the treatment they need to live.

In an HIV clinic in Maputo City, each clinical staff member conducts 30 to 40 consultations per day; the center has reached a saturation point that prohibits providing treatment to new patients. In 2006, while the number of people in need of treatment continued to grow, there was a 30 percent drop in the number of those started on ARV treatment from the previous year.

In South Africa...

Population:	46.9 million
Life expectancy:	47 years
Adult HIV prevalence:	18.8%
No. of people with HIV/AIDS:	5.5 million
No. of people in need of ART:	1 million
No. of people initiated on ART:	265,000
Treatment deficit:	735,000
Proportion of national budget spent on health:	10.2%

The number of health workers in South Africa is not a major problem as in other countries profiled in the report; but there is a dramatic divide between the private and public health sectors, the urban and the rural areas, and services to the poor. The private sector, centered in the cities, caters to far less people, but employs two thirds of the country's doctors and half of its nurses.

Meanwhile, an estimated total of one million are in need of ARV treatment throughout the country, with 35,000 currently on a waiting list to receive ARVs.

The graph below illustrates how saturated public sector clinics have become.

The white bars for each month represent the people started on ARVs at three clinics in Khayelitsha township. MSF has worked in Khayelitsha, a poor area on the outskirts of Cape Town in Western Cape province, since 2000. Antenatal HIV prevalence here is approximately 30 percent; nearly double the provincial average.

Clearly, the demand for treatment far outstrips what can be handled by existing staff, with tragic consequences. Between May and December 2006, new monthly ARV initiations dropped drastically, reaching only 60 percent of the new number of people in need.

The gray bars represent the number of people coming to the clinics in need of ARVs. The difference is the number of people who go without treatment.

In Lesotho...

Population:	1.8 million
Life expectancy:	35.2 years
Adult HIV prevalence:	23.2%
No. of people with HIV/AIDS:	270,000
No. of people in need of ART:	57,000
No. of people initiated on ART:	17,700
Treatment deficit:	39,300
Proportion of national budget spent on health:	9.5%

At Scott Hospital Health Service Area in Lesotho, there are four doctors, less than two for every 100,000 people. This tiny country, landlocked in the middle of South Africa, has a major health worker problem. In the 14 rural health care centers that MSF supports, not one reaches the minimum staffing requirement; and throughout the country, only six of 171 health centers are fully staffed.

With numbers like these, a doctor-centered approach to providing health care in Lesotho would be impossible, says Rachel Cohen, head of mission for MSF in that country.

Listen to an MSF podcast on Lesotho.

"Which is why we've made a huge priority in training and empowering nurses to manage at the health center level, the primary care level," says Cohen, "everything from diagnosing HIV, staging patients, diagnosing opportunistic infections, treating opportunistic infections, and, in fact, initiating ARVs."

At a health center in the Scott Health Service Area of Lesotho, an MSF nurse examines a man who is living with HIV/AIDS. 2006 © Wayne Conradie

But, as the number of HIV patients continues to grow, already overburdened nurses face an increasingly large workload. As a consequence, nurses are steadily leaving for other jobs. As of May 2007, 54 percent of professional nursing posts at health centers were vacant.

The government has acknowledged this problem and established an Emergency Human Resources Task Force, but a proposal to raise the pay of health workers has stalled. Meanwhile, the country faces a huge problem with "twin epidemics" HIV and TB, says Cohen; Lesotho has the second highest rates of co-infection in the world.