Dr. Mit Philips of Médecins Sans Frontières (MSF) answers questions about how the lack of health care workers threatens further roll-out of HIV/AIDS treatment to those in urgent need of it in sub-Saharan Africa.
MSF says the lack of health care workers is the main obstacle to expanding access to aids treatment in many African countries. What is the scope of the crisis?
In sub-Saharan Africa the gap between patient’s needs and health worker’s capacity is acute. In countries like Mozambique and Malawi, there are just above 20 nurses for 100,000 people when the World Health Organisation recommends 100 as a minimum. The situation in rural areas is even worse with about half that ratio. One should realise that staff already previously struggling to cope, have had to face an increasing number of patients due to the spread of HIV/AIDS.
This has two major consequences. First, waiting rooms get more and more crowded and waiting queues longer. Second, the ever-increasing pressure on essential staff means they are very likely to give up and leave their job for “greener pastures” abroad or in the private sector.
What are the consequences for HIV/AIDS patients?
There are more and more patients and less and less health staff, which leads to pretty obvious consequences. First of all, quality of care is put at risk with very limited consultation time staff can allocate to patients. Also, delays between diagnosis and treatment initiation can lead to the death of patients in desperate need of treatment – half the patients in advanced stages of the disease are likely to die within a year. Finally, spending full days in waiting rooms for follow-up consultations may push patients on treatment to stop coming to the clinic and the risk is real that they will stop adhering properly to their treatment.
It is very frustrating for us to see that relatively cheap drugs are now available on the shelves of health structures—although problems still remain on that front—but that there is no one to hand them to patients. One needs to keep in mind that in southern Africa alone, about a million people in need of treatment are not getting it.
What is the message you would like to convey to donors and governments?
They really need to approach the issue with urgent and effective action: we need changes on the short term at patient level. This disease kills so many people each year and the lack of health staff falls far short of what the population needs. Current plans to overcome the deficit—including pre-service training—are usually expected to provide effects on the long run, but we cannot afford to wait. Patients are dying today. We cannot wait for another nursing course to finish, we need to retain and attract more staff now!
Why are so many nurses and doctors missing?
First of all, it must be said that in many countries with high HIV burden, the first cause of attrition among health staff is illness and deaths, mostly linked to HIV/AIDS. This reduces the workforce and increases the pressure on remaining staff.
Another important factor is the exodus of staff to “greener pastures.” Although a lot of emphasis has been put on the attractiveness of jobs in Europe or the United States, an important part is played by factors that push health staff away from their clinics, such as low salaries and harsh working conditions. In Malawi, a nurse can keep more than 400 people alive for barely $3 per day in a health structure with no water or electricity. In practise it may mean that she has to perform more than 150 consultations every day. How long can we expect her to cope with that?
If health staff are so important and they are saving lives, why don’t governments do more to attract and retain them?
Some countries are still stuck because health workforce plans are determined based on what domestic resources are available. How much staff can be recruited in the public sector and how high their basic salary can be is restricted at country level. At what level this ceiling sits depends mostly on agreements between the Ministry of Finance and the International Monetary Fund (IMF). In short, the poorer the country the least they will be able to spend on wage bills, including health staff.
It seems to us quite incoherent—and frankly speaking really shocking—to note that there seems to be no political will to ease these restrictions. Since many years now the issue is on the agenda in international fora, without fundamental change. In view of all these people waiting for treatment, it is incomprehensible to us that the size and the salaries of the workforce remain dependent on macro-economic considerations rather than medical imperatives.
But some donors are willing to give more funds for salaries?
Most donors still do not want this kind of long-term responsibility. In the classic aid paradigm, this falls on governments. Donor countries say they do not want to be involved in recurrent costs as it would not be sustainable, implying that country’s should use their own domestic resources. Ironically, most pay for drugs which, in the case of HIV, will have to be taken by patients for the rest of their lives.
Some donors have now understood that health staff is completely essential to reach objectives linked to health care and AIDS care in particular. They have allocated funds to human resources for health, but they prefer to spend it on pre-service training, buying equipment, and improved infrastructure for training and health care; this avoids the open-ended commitment implied by salaries.
Sweden, the UK, and some other donor countries claim budget support and health sector support can be used for boosting the public health workforce, however without a solution to the expenditure restrictions this will not be effective. The money allocated through these channels will face the same constraints as the rest of the public sector and this aid money can thus not be used effectively.
This is the current contradiction: donor countries have pledged to increase funding to tackle the health workforce deficit, but these resources are not taken into account when setting the level of what can be spent. Donor money can thus not be spent on retaining health workers in the public sector above a certain amount, or it will replace government money to another sector.
What can MSF do on the field to cope with the shortage?
Our field teams try to cope with the human resources gap through reorganising care; this includes task shifting. This means delegation of certain tasks to health staff with less qualification or without medical training. The purpose of task shifting is to increase the patient treatment capacity of clinic teams, without having to cut back on quality of care. In countries hard hit by HIV/AIDS, task shifting often means that the responsibility to initiate AIDS treatment is delegated to nurses, which gives doctors more time to concentrate on complicated cases. MSF has introduced such a nurse based model in several places with good results, for instance in Lesotho and Rwanda.
Task shifting from nurses to assistant nurses or from health staff to laypersons is also done. Lay workers, often people living with HIV, are used for counselling and support of HIV patients. This leads to decreased workload for the nurses. However it remains crucial that these lay workers get adequate training, supervision and support; we will still need qualified health workers, no doubt. Obviously, these workers should get paid accordingly; otherwise we’ll face similar problems with attrition and turn over.
Task shifting does indeed relieve the pressure on doctors and nurses. But it must never be an excuse for not dealing with the fundamental problem—that is the need of more health staff overall. We need to challenge the lack of resources leading to poor care for patients in low-income countries. Otherwise the health services in sub-Saharan Africa will be doomed to remain ineffective in providing a response that matches the scope of the HIV epidemic crisis, and other critical health problems.
Do you see a light at the end of the tunnel to boost the health workforce?
The main opportunity for the moment is the decision by the Global Fund for AIDS. Tuberculosis, and Malaria (GFATM) to allow funding for health systems strengthening, which includes measures to train, support, and retain health workers. It is important that governments facing serious human resources for health problems do seize this funding opportunity to break out of the current stalemate. GFATM has confirmed it is willing to finance ambitious plans to tackle the health workforce deficit, let’s take them on their word.
We also see increasingly that health workers themselves and patient groups stand up to demand improved support and retention of health staff. These are important groups to put pressure on policy makers.