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Contributions from
the Column
InWEnt Forum
HIV/AIDS – Health workers under pressure
Waste water – an untapped resource
12/2005 |
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[ HIV/AIDS ]
Doctors and nurses under pressure
Working conditions must urgently improve in Africa’s national health systems. According to Claudia Kornahrens, nothing else will prevent health professionals from moving abroad. Migration is undermining services. D+C/E+Z talked to the head of the Health Division at InWEnt about African health care problems.
[ Interview with Claudia Kornahrens ]
What is the HIV/AIDS crisis like for health sector workers in Africa?
Doctors and nurses are under pressure from three sides. First of all, there are the known problems of humanpower shortage and inadequate infrastructure, because HIV/AIDS poses new challenges and increases workloads. Second, doctors and nurses are affected by the epidemic like any other group in society. It is estimated that, in some countries, as many as 20 % of health sector workers could die of AIDS in the years ahead. AIDS-related deaths and incapacity thin out workforces even more. Finally, there is the special psychological pressure to which health workers are exposed. They see large numbers of people suffer and die and are unable to help because drugs, such as antiretrovirals, are not available. The situation is not the same in all parts of sub-Saharan Africa, however. Some regions are worse hit than others.
Just how big are the bigger workloads?
In some hospitals, patient numbers have increased by as much as 50 % due to HIV/AIDS, especially as a result of secondary diseases such as tuberculosis. But the burden of the growing number of patients does not only weigh heavy on doctors and nurses. It adds to the workload of everyone in the health sector – from laboratory staff to administrative personnel, to top management.
To what extent do health services provide up-to-date treatment?
Even without the introduction of antiretroviral treatment (ART), sustainably funding the fight against HIV/AIDS is a serious challenge. Starting ART and other new therapies reducing HIV transmission rates from mother to child, for example, sends out an important signal which fuels hope in the struggle to control the epidemic. But the treatment schemes are complex, they need to be supervised, side-effects have to be monitored. So even more personnel with even more qualifications are needed. To deploy ART, some countries will need to increase already inadequate health sector staff levels by as much as 20 %.
How many people living with HIV/AIDS receive an up-to-date standard of care?
At present, the World Health Organisation reckons that around 500,000 people in sub-Saharan Africa are receiving antiretroviral drugs. The number in need of treatment is put at 4.7 million and the total number of HIV infected in the region at 25 million.
Given that the situation is that desperate, is capacity building enough?
No, it is not. It is just as important, of course, to improve infrastructures, including laboratory facilities and drug supplies, and to maintain the existing human resources. In Tanzania alone, experts reckon the number of health professionals will soon fall 17,500 short of what is required – even without the introduction of ART. Moreover, nurses and auxiliary personnel will often have to perform tasks normally assigned to doctors. What is more, the pattern of resource and humanpower distribution between urban and rural areas is very uneven.
How great is the risk of health workers migrating to richer countries?
Very great. Health worker migration is already a serious problem. To cite one much-quoted statistic: there are more Malawian doctors in the United Kingdom today than in Malawi. Apart from low incomes at home, the factors that push health workers to migrate include salary stagnation and lack of promotion prospects. Even with a good education, the opportunities for career advancement are unclear. On top of that, workloads are heavy and infrastructures poor. Many health sector workers can feed themselves and their families only by topping up their pay with a secondary income from the private sector.
Is migration widening the gap between highly trained and less qualified workers?
Definitely, because predominantly those with the best qualifications leave to work abroad. On a personal level, it is entirely understandable. But the consequences are far-reaching. Teaching and training also draw on the pool of professionals with above-average qualifications, so migration makes for deficits in that area, too. Migration of domestically trained specialists does massive damage to an economy.
What possibilities do you see for stemming the outflow of highly qualified personnel?
Health worker motivation and migration are being discussed on many levels. The situation of health professionals will be a focus of the 2006 World Health Report of the World Health Organisation WHO. An international working group called the Joint Learning Initiative has just presented the results of a multi-year study for the Global Health Trust. Its recommendations aim at creating strategic human resource management systems for the health sector in consultation with national finance ministries. Health care will continue to fall short of requirements as long as the human factor fails to receive sufficient attention.
What can be done, in tangible terms?
First we need to exhaust all the options for motivating health workers: income security would be an important first step. Public employers need to make working conditions more attractive and develop incentives. It is also important to upgrade work in rural areas, as these are often undersupplied. Like everyone else, health workers prefer to work in urban environments, where quality of life is higher and where they are likely to find better schools for their children.
Are you saying that health services are ailing more for want of career patterns than for lack of human resources?
There is a need for both. The Joint Learning Initiative report I mentioned before states that Africa needs a million more doctors, nurses and midwives. What we discover in InWEnt training courses, however, is that qualified people cannot rely on transparent career systems.
Performance is supposed to be the key everywhere. But it is not always the key to promotion, is it?
The question is: do formal performance evaluation systems exist and are they used efficiently? In the public sector, decisions on staff transfers, promotion and training are typically taken at a high hierarchical level and are often not transparent.
Where is the money supposed to come from to fund adequate health worker pay, extra recruitment and better infrastructure?
In the medium term, most African countries will not be able to develop the resource capacity needed to ensure proper health care on their own. They will depend on development partners’ contributions to bridge the gaps. Thanks to the Global Fund, various foundations and bilateral and other donors, HIV/AIDS funding has increased worldwide in recent years and is already boosting personnel recruitment. What is needed are national development strategies setting out political priorities and action to harmonise the different activities in each country.
What training options exist for health professionals?
There are national programmes for training health workers in all the relevant areas of prevention, testing, counselling, nursing and treatment. The question is whether that training is adequate and sustained. International actors such as foundations, bilateral development partners and NGOs are particularly active. The WHO has developed training packages and standards for treatment and use of antiretroviral drugs. In conjunction with Tanzanian partners and others, InWEnt and the German Technical Cooperation (GTZ) have developed a series of capacity building programmes for AIDS prevention and antiretroviral therapy.
Where does InWEnt set priorities?
Capacity building is one of the most important tasks of all in the fight against HIV/AIDS. And I am not just talking about training individuals to act as multipliers in their working environment. Our capacity building programmes are also pitched at organisational level, addressing state-run health training institutes, for example, and hospitals. InWEnt also engages in hospital management and offers one-year advanced training courses in Germany. Policy dialogues and other events are also important as a platform for discussing issues such as governance and AIDS or HIV/AIDS and human rights. After all, HIV/AIDS is not just a health sector problem; in many African countries, every sector is affected. That is why InWEnt offers training for diverse target groups in education, business and media.
Questions by Hans Dembowski
and Norbert Glaser.
Claudia Kornahrens
is head of the Health Division at InWEnt
and responsible for HIV/AIDS programmes
for Africa.
claudia.kornahrens@inwent.org
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