Médecins sans Frontières says it is reaching the upper limit of the numbers it can treat in southern Africa due to a desperate shortage of medical staff that is beyond its control. Donors and governments need to address salaries, budgets, training and restrictive finance rules that are blocking the expansion of the health care workforce in every country in the region, MSF says today in a new report, Help Wanted.
"The international community says it wants to achieve universal access, and in Khayelitsha we were coming close, but at a certain point things started to collapse. We are absolutely saturated, and even with all of MSF's means, we have come back to waiting lists, and it feels again like we are losing the battle,” said Dr Eric Goemaere, MSF head of mission in South Africa.
Since 2000, MSF has been supporting provincial and city clinics in Khayelitsha (population 500,000), a poor township on the outskirts of Cape Town in Western Cape province, South Africa. Since 2001, 7,262 adults and children have been initiated on treatment and 5,848 (81%) remain in care.
However, the clinics are saturated. Between May and December 2006, monthly ART initiation at the Khayelitsha clinics dropped from more than 270 - approximately 60% of estimated new need per month - to just over 100, reports MSF. Without further staff, waiting lists will grow. Almost 400 patients who qualify for treatment are currently waiting, said Marta Darder of MSF South Africa.
But solutions to the staffing problem do not seem imminent. According to Western Cape authorities, 466 clinical nurse practitioners (the most skilled category of nurse) are needed for basic health services by 2010, but only 71 (15%) are currently employed.
In Mozambique the rate at which people can be started on treatment is also slowing; a fall of 30% in new patients on treatment from 2005 to 2006 is reported at an MSF project in Maputo province, the region with the lion’s share of Mozambique’s 608 doctors. In Mavalane district in Mozambique, patients are forced to wait for up to two months to start treatment because of the lack of doctors and nurses, and many have died during the wait.
Mozambique’s objective for 2007 is to provide a total of 95,000 people with ART, says the MSF report, but the lack of human resources is recognised as the major hurdle to realising the government's plans. The Ministry of Health has calculated that the following additional staff would be necessary to scale up ART: 130 medical doctors, 125 “tecnicos de medicina” or mid-level workers, 380 nurses, 200 nurse-aides, as well as 90 pharmacy and 29 lab personnel.
In Lesotho, which has 89 doctors for a population of 1.8 million, MSF has devolved as much HIV care as possible to nurses, but throughout the country 54% of nurse posts currently stand vacant, leaving nurse assistants with only two years of training to carry much of the clinical burden. Eighty per cent of doctors in Lesotho are from other African countries, and most are working in the country only until they get registered in South Africa, where they can earn much higher salaries.
Devolution of care to nurses is not practical in all settings: some countries have tough rules about who can do what, and changing these rules is proving a slow process.
"In Thyolo district we are treating 7,000 people with HIV/AIDS. We need to increase this number to 10,000 by the end of the year, but our programme is hitting a wall because there are simply not enough nurses, doctors and medical assistants," said Veronica Chikafa, a nurse/matron working with MSF in Malawi. In Thyolo district a medical assistant can see up to 200 patients per day, far too many to ensure quality care.
However Malawi is at least beginning to tackle the crisis. A six-year Emergency Human Resources Plan was launched by the Malawian government in 2004 with the support of the UK Department for International Development and the Global Fund to Fight AIDS, TB and Malaria.
The plan includes salary increases for healthcare workers, recruitment of retired workers, incentives for staff to work in rural areas and improved training. Significantly, the government was able to win agreement from the International Monetary Fund to increase salaries. The IMF has attempted to curtail expansion of the public sector in Africa by prohibiting salary increases and freezing recruitment as a condition of financial aid. For the time being, every other African country remains tied by these rules, which typically limit the public sector wage bill to around 7.5% of gross domestic product, regardless of need.
MSF highlights a number of urgent measures in its report that need to be taken in order to address the crisis.
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 healthcare 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 and increase the health workforce.
The full report can be downloaded in pdf form from MSF South Africa's website