BEING HUMAN MEANS A SIMPLE LIFE WITH GOOD FAITH AND ACTION
Percentage
of health workers
with
AIDS per year, Botswana
P
r
o
j
e
c
t
e
d
Adapted
from “The Impact of HIV/AIDS on the Health Sector in Botswana”, 2000, Abt
Assoc.
Demographic profiles
of health personnel are required to develop more refined analyses of health
sector impacts, since
risk is influenced by age, gender and geographical location. An assessment
conducted in Botswana
suggests that the age profile of health workers may differ significantly from
that of the general
population aged 20–64 (5). Younger health workers are migrating from the
service
more than older ones
and they are also dying more
from HIV/AIDS,
contributing to higher attrition
from this age group.
Loss
rates by cadre
To gain insight into
the scale of need for training new staff to carry out HIV/AIDS service tasks,
information was
gathered on the number of staff leaving the health services, by cadre, in a
Zambia
HIV/AIDS workforce
study. As shown in Table 1, losses were greatest for midwives, the cadre in
highest demand and
shortest supply. In the Lusaka hospitals and clinics, loss of midwives and
nurses
was particularly
great, with Lusaka Trust Hospital experiencing a 60% loss rate of midwives. The
principal reason for
staff losses is salary, with a large number leaving Zambia for jobs in the
United
Kingdom and the United
States of America. Other common reasons were transfers and death.
Although the Zambian
government recently increased nurse and midwife salaries, widespread
complaints continue,
so the recent salary
increase may not
influence staff loss rates (6).
Table
1. HIV/AIDS staff loss rates by cadre, Zambia
Cadre
Number
currently
at
work
Number
who left
in
last 12 months
Loss
rate
Doctors
23 7 30%
Midwives
50 18 36%
Nurses
42 14 33%
Clinical
officers 10 2 20%
Lab
technicians 19 4 21%
Other
30 9 30%
Volunteers
31 8 26%
Total:
All staff 205 62 30%
Source
:
Huddart J, Furth R, Lyons J. 2004.
The
Zambia HIV/AIDS workforce study: preparing for scale-up
.
Quality Assurance Project,
University
Research Co.,LLC.
Why
are health workers absent?
Within the formal
health sector, data from an assessment of health workers in Kenya and Malawi
has
shown that the major
reason for absences from work is related to illness. In Kenya, 34% of
absenteeism was due to
personal illness and 6% to attending to a sick person (7)This was followed by
29% unknown, 17%
“personal reasons,” and 14% attending funerals. In Malawi, personal illness was
similar at 38%,
followed by caring for relatives (27%) (8). Kenyan health workers cited the
need for
support to deal with
the increased number of deaths, grief due to losing family and friends from
AIDS, and general
fatigue due to work demands. They also highlighted the importance of access to
counselling and psychosocial support to deal with the increased number of
deaths (9).
Unfilled
posts in the health sector
Due to local economic
constraints and structural adjustment programmes imposed by the international
donor agencies and
governance issues, many posts in developing country health systems remain
unfilled for many
years. Yet, the numbers of service providers in the face of the staggering
demands
imposed by the
HIV/AIDS epidemic is too small to respond to the needs. In Malawi, for example,
over 64% of all nurse
posts are vacant (10). A World Bank report states that Malawi faces a grave
health personnel
shortage (11).
Human capital can be
conserved, however, by giving
antiretroviral
treatment (ART) priority to nurses,
teachers, engineers,
judges, police officers and other skilled workers whose contributions are
important to economic
development or social stability (12). An issue that complicates this solution
is
that ART cannot be
separated from the need for basic primary health care services, a human right
for
all. Though difficult,
a policy response must be developed and implemented in the context of a
comprehensive approach
to enhance weak health systems.
The
gender dimension
Another important
issue in discussing the HRH crisis in the context of HIV/AIDS is the gender
dimension. One of the MDGs is to promote gender equality and empower women. In
fact, more
women than men are
affected by the epidemic directly, and indirectly as caregivers. The attrition
rate
of front-line workers
in the health sector is exacerbated by HIV/AIDS because more women than men
serve at the
operational level, women are leaving clinical nursing services, and more women
than men
are dying of AIDS due to
increased disease risk.
Front-line health
workers in sub-Saharan Africa are
largely female at the
operational level, while top
management and policy
levels have been mainly male. In Ghana in the late 1990s, 59% of all public
health staff was
female, but this reduced to 33.5%
at the Ministry of
Health headquarters. Only 17%
of doctors were female
as compared to 87.4% of registered nurses and 90.2% of enrolled nurses (13).
In Malawi in 2003, 75%
of service providers leaving clinical service provision were women (14). A
disproportionate risk
of HIV infection has been
linked to male/female
power differentials (15) to
wage differentials, to
nurses’ subordination to physicians (16) and to the undervaluing of caring
labour in the formal
economy (17). Policies must respond to gender-related impacts.
Health
system effects of HIV/AIDS
HIVAIDS has changed
the landscape of disease in the
developing world,
especially in Africa, due to
the resurgence of
common conditions and therefore increased demand for preventive and curative
services to respond to
the epidemiological and clinic
al impacts of the
pandemic. These effects include
increased burden of
disease, increased service needs associated with
caring for these
illnesses and for
HIV/AIDS itself, and
the inadequate and diminishing capacity to respond to these needs, central to
which is the limited
human resource capacity.
The
increased disease
burden
due to increased cases
of illnesses
such TB, malnutrition,
diarrhoea, meningitis, pneumocystis carinii pneumonia (PCP) in
the form of
opportunistic infections associated
with HIV infection
means that prevention and care
and treatment
programmes must be modified to
respond to the new
scenarios. Public health specialists, clinicians, pathologists, counselors and
various
others cannot use the
traditional skills to deal with
the changing
epidemiology and clinical dimensions
of the epidemic. In
Malawi, over the last two decades TB case notification rates have increased
five-fold, and the reported cases per 100 000 population have risen from 95 in
1987 to 275 in 2001
(18). In
Swaziland, for
example, the rate of TB, per 100 000 population increased by almost four times
from
around 210 in 1990 to
820 in 2004. (It is widely accepted that HIV/AIDS drives the incidence of TB.)
As suggested by Figure
4, “Reported TB patients, Swaziland, 1991–2004”, the increase in TB rates
has had a marked
effect on hospitals and staff responsibilities, despite increasing emphasis on
ambulatory and
home-based care for TB. Although the
average length of stay
for TB has fallen due to
a policy change, the
length of stay for TB remains
around 14 days, the
highest of all major diagnoses
(19).
Figure
4. Reported TB patients in Swaziland, 1991–2004
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
1991
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
As shown in Figure 5,
data reported by Cheluget etal.
(20) indicate that admissions in sampled
facilities in Kenya
increased overall from 4379 in 1996 to 6450 in 1999 to 7545 in 2002. About 48%
of these were
AIDS-related.
Figure
5. Caseload in Kenyan
facilities,
1996, 1999 and 2002
In addition to their
existing duties, health workers are called upon to assist with recently
introduced
HIV/AIDS services such
as voluntary counselling an
d testing (VCT) and
training family members for
home-based care. Their
assessment results showed
an overload for the
service providers for VCT and
prevention of
mother-to-child-transmission (PMTCT) programmes. Ideally, a counsellor was expected
to have an average of
160 clients per month. These data showed that they catered for about two to
three times this
number.
“We no longer know
what to do, as we are expected to be here and there. The Government
needs to guide us,
especially those of us who are doubling as counselors.” Focus group
participant
(21). The complexity of services
needed for prevention,
diagnostics, care and treatment of HIV/AIDS
disease with ARVs and
the associated opportunistic infections means that systems will have to change
Admissions
by Diagnosis, Kenya-1996, 1999 &
2002
(n=18,191)
1%
51%
48%
HIV/AIDS and
related illnesses
Other illnesses
Unknown
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