Health Worker Shortage
2006 © Julie Remy
In May 2007, Doctors Without Borders/Médecins Sans Frontières (MSF) released a study on the impact of the lack of health workers on providing HIV/AIDS treatment in southern Africa, the heart of the HIV/AIDS pandemic. The information was gathered from MSF HIV/AIDS-treatment programs in Lesotho, Malawi, Mozambique, and South Africa.
The findings are clear. An increasing number of patients dependent on a decreasing amount of health workers leaves many without care and without hope. At one clinic in Mavalane district, Mozambique, patients must wait up to two months to begin antiretroviral (ARV) treatment; some die waiting. In Thyolo district, Malawi, a medical assistant can see up to 200 patients a day, far too many to ensure adequate attention.
Meanwhile, the ranks of nurses, medical assistants, and others in the public sector are dwindling as overwhelmed, burned-out workers leave for better working and living conditions. In 2006, one major hospital in Lesotho lost 25 nurses to other jobs.
Substantial strides in improving health care have been made in southern Africa - where it was once considered impossible to provide lifesaving HIV/AIDS treatment. International pressure helped bring down prices of some ARV medicines and jump-start HIV/AIDS programs, resulting in a growing number of people receiving treatment from 100,000 to 1.3 million between 2003 and 2006.
But more than 70 percent of those who need treatment in this region have not yet received it, and without fundamental change, the outlook for expanding access to treatment and improving the quality of care is bleak.
"There are so many patients here to see. The number is about 75 to 100 patients per day. Sometimes people wait for hours to be attended to. Yesterday, I was alone on duty without even any medical assistant to help me. Sometimes I have to do both day and night shifts in the same day! We need at least five more nurses here."
– Loveness Makeyi, 35, Nurse/Midwife, Khonjeni Clinic, Malawi
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:
For this study, MSF focused on four southern African countries where it has HIV/AIDS treatment programs – Lesotho, Malawi, Mozambique, and South Africa – and predominantly on rural areas in these countries where the health worker shortage is most striking.
The study also specifically addresses the lack of nurses, but it should be noted that a lack of all health staff, from doctors to lab technicians to pharmacists, is s strong limiting factor in the ability to provide and maintain access to quality HIV/AIDS treatment.
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 ($US 87) per month, which often necessitates getting a second job.
"I make 3,000,000 m éticais ($US 115) a month. With this, I can buy one bag of rice, one bottle of oil, and pay the energy at home. I'm borrowing money from my neighbors because I cannot afford to send my children to school."
– Maria, 44, Pediatric Nurse, Tete Health Center No.2, Mozambique
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.
"I am still trying to work with passion, but the conditions are demoralizing. The workload increases by the day. On top of that, since 2003, there are two vacant posts for professional nurses in this clinic. If it was not because I am motivated, nearly a militant supporting the ARV roll out, I would have left long ago."
– Mpumelelo Mantangana, 48, Professional Nurse, Ubuntu TB/HIV Clinic, Khayelitsha, South Africa
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.
"Last year, my brother took me on a horse to the clinic because I was too sick to walk. Now I am on ARVs and I take my tablets every day.
Since September 2006, I have been a lay counselor. My role here is to give counseling to all HIV-positive people and teach patients about the importance of adherence. My other crucial role is that of being a drug dispenser, especially for ARVs. I think my job is very important and it reduces the heavy workload on the nurses."
–Joseph Ramokoatsi, 35, Lay Counselor, St. Rodrique Health Centre, Lesotho
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."
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.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)