Patients without providers: emergency response needed

Despite a global effort to expand access to HIV/AIDS care and treatment over 8,000 people with HIV/AIDS are still dying every day.

In the projects mentioned in this report, MSF has increased access to ART despite human resource constraints by hiring additional staff, supplementing pay, shifting certain clinical tasks to nurses, and creating new capacity by training lay workers. Health workers are also offered technical and management support as well as professional development opportunities. However, even in MSF programmes where significant external resources are brought in, our ability to scale up, maintain quality, and address specific medical challenges is being stretched to the limit. What can be done at a local level by MSF or other programme implementers is limited in scope and effectiveness. Fundamental changes in national and international policy and donor practices are urgently needed.

  • Emergency retention measures must be developed at the national level to break the cycle of high attrition so that patients can receive the care they need. Improving salaries, working conditions, and incentives - particularly to retain and attract workers in rural and underserved areas - are critical first steps. For most countries this will require international donor support. Access to treatment for health care workers must also be urgently addressed.
  • Scope of practice and other work rules set by professional councils and national governments need to be more flexible so that available staff can take on crucial tasks: in particular, trained nurses need to be able to prescribe ARVs and lay workers need to be allowed to carry out testing and counselling.
  • Multilateral and bilateral donor rules must be changed and funds must be mobilised to allow support for recurrent human resource costs, in particular salaries.
  • National spending limits must be lifted by ministries of finance and international finance institutions, such as the IMF, to ensure governments can increase salaries, increase the health workforce.

While there is wide acknowledgement of the depth and scope of the human resources crisis, initiatives taken so far have largely focused on piecemeal or insufficient measures. A notable exception is Malawi's national Emergency Human Resources Plan. Donors broke common practice by funding recurrent expenses associated with increasing salaries for most categories of health care workers and creating new posts. This was possible because the government of Malawi negotiated with the IMF for flexible spending limits for health staff.

It is inconsistent and incomprehensible for donors to provide funds for life-long ART and the building of new clinics, but refuse support for health care worker salaries on grounds that the latter is unsustainable. Funding commodities, particularly ARVs, was an essential step for donors to take, and with a great deal of international pressure this has had a catalytic effect, stimulating governments to set ambitious goals for ART scale-up and expanded treatment access. But people living with HIV/AIDS do not only need drugs and clinics; they need trained, motivated health care workers to diagnose, monitor, and treat them.

Five years ago, providing ART to people in sub-Saharan Africa was a contentious issue, with many believing it was too complicated and costly. The refusal to accept that people with HIV/AIDS in the developing world would die because the drugs were too expensive forced a sea change in attitude and policy. The human resource crisis calls for a similar refusal to accept the status quo. The lack of health staff is a deadly impediment to expanding and sustaining antiretroviral treatment and must be confronted as an emergency for the millions of people with HIV/AIDS still waiting for treatment.

"The nurses at our clinics are overwhelmed by the number of patients. As a result, there is a risk that quality of care can be compromised. Consultation time is too short, and sick patients with complicated infections, especially TB, may not be diagnosed or treated properly. When nurses suffer, patients suffer." - Dr Peter Saranchuk, Medical Co-ordinator, MSF Lesotho