HIV programmes in poor countries lack health workers

The shortage of health workers is at crisis point and is the key obstacle to expanding AIDS prevention and treatment programmes in most low and middle income countries, a new report from the World Health Organization says.

The report, released at the 16th international conference on AIDS in Toronto on 13-18 August, is based upon consultations with AIDS experts and government officials from around the world. It calls for a coordinated global approach.

In a closing address to the conference, Anders Nordström, the acting director general of WHO, told delegates, “No improvement in financing or medical products can make a lasting difference in people's lives until the crisis in the health workforce is solved.”

More than four million health workers are needed to fill gaps in 57 countries, mostly in Africa, says the report, entitled Treat, Train, Retain. Sub-Saharan Africa has 11% of the world's population and 64% of all people living with HIV but only 3% of the world's health workers, it says.

Demoralising working conditions, low pay, better opportunities in the private sector and abroad, and sickness as a result of HIV/AIDS in workers themselves are cited in the report as reasons why the health system is fragile. These reasons have had a knock-on effect, as health work is now viewed as an undesirable career choice in many African countries, it says.

Recruitment to richer countries remains a serious problem, said activist Mark Heywood of the University of Witwatersrand. He told a special conference session devoted to the topic, “This really is a globalised crisis. If you pull the string in one part of the world it unravels in another part of the world. So, Canada steals healthcare workers from South Africa, and South Africa steals healthcare workers from other African countries.”

Lower income countries have had to develop creative ways to maximise their health human resources to treat AIDS, delegates heard. Malawi, for example, has one of the most severe lack of health workers in the world—only 266 doctors for a population of 12 million—and an adult HIV prevalence of 14%. By simplifying treatment regimens and introducing task shifting (where nurses are trained to prescribe antiretrovirals and community members to help with testing), Malawi is on track to reach 50% treatment coverage by 2015.

“But there is a limit to how creative low income countries can be,” said Lieve Fransen, the vice chairwoman of the Global Fund to Fight AIDS, Tuberculosis, and Malaria and representing the European Commission's Directorate General of Development. She urged more responsibility on the part of rich countries to help manage migration with policies that both protect individuals' rights to pursue better prospects elsewhere and stem the brain drain that has handicapped health systems in poorer countries.

She reported that 37% of South African doctors and 34% of Zimbabwean nurses had migrated to other countries, and 75% of Ghana's doctors leave their country within a few years of finishing medical school. But she said that migration can be positive “as long as circular mobility occurs, where health workers move between North and South and rural and urban areas.”

Dr Fransen outlined the European Union's response to WHO's plan, which includes securing access to prevention and treatment for health workers; supporting task shifting and training of community workers; and helping countries set new priorities for strengthening human resources in health. She also said that the EU was currently considering adopting the United Kingdom's code of conduct for international recruitment of health workers (BMJ 2004;328:1218.)

Critics worry that the WHO report has no clear action plan and no new funds committed in spite of its $7.2bn (£3.8bn; €5.6bn) price tag.

Mohga Kamal-Yanni, a health policy adviser for Oxfam, said that WHO is good at setting standards and guidelines but has not proved effective at lobbying governments and reforming policy to ensure resources are strategically invested in health systems and workers.

“Topping up numbers is not enough,” she said. “What we need is to take care of health workers in their own communities—better wages and training, the ability to work in settings where there is basic equipment and a continual supply of medicines, and for women especially, assistance with child care and transportation costs.”

Another problem that is often not discussed, Dr Kamal-Yanni added, is the poaching of health workers by non-governmental organisations from the public sector. Anecdotal evidence indicates the US president's emergency plan for AIDS relief has hired away nurses with better wages in some African regions. Former US president Bill Clinton pledged, in his speech to conference delegates, that his foundation would not hire doctors and nurses from the public sector.

See this week's story about male circumcision and HIV.