In sub-Saharan Africa, the dire shortage of professional healthcare workers is one of the greatest obstacles to rolling out life-saving medical treatment for diseases such as HIV/Aids, TB and malaria. While donor support to address these diseases has increased, providing funding for salaries and other “recurrent” costs to address the human resource crisis, it has remained largely taboo.
In our daily work in Lesotho, Médecins sans Frontières (MSF) witnesses the consequences of such funding gaps: scores of nurses are leaving for “greener pastures” and patients are left in understaffed, overcrowded clinics.
One donor that seemed to be an exception to the rule was the Global Fund to Fight Aids, TB and Malaria. In 2005 a specific “window” was created to support health systems, including human resource costs. This was a welcome development. But, in Geneva, a committee of the Global Fund board is considering removing this, a move that may prove to be a tragic mistake.
Lesotho is a case in point.
Lesotho has the third-highest HIV prevalence in the world with almost a quarter of adults infected, a staggering 270 000 people. Lesotho’s ministry of health and social welfare reports that 17 000 of these are now receiving antiretroviral drugs (ARVs). Yet the country’s catastrophic human resource situation threatens to make improvements and continuity of HIV care and treatment impossible.
At present, 15% to 20% of all nursing posts are vacant. South Africa, which is also facing a human resources crisis, still has proportionally eight times more nurses than Lesotho.
In January last year, MSF launched a programme in Lesotho in Scott Hospital Health Service Area, a rural health district. In the past year, nearly 4 000 people have been enrolled in HIV care and more than 1 000 had started on ARVs. The World Health Organisation recommends that nurses should have a workload of no more than 20 patients per day. But nurses in this health district are conducting up to 45 consultations each day, before they even start to see HIV cases.
As a result, nurses are leaving. In Scott Hospital HSA today, about a quarter of nursing posts are vacant. MSF is trying to overcome these shortages by providing mobile MSF medical teams to bring “in-service” support to nurses, filling in gaps where necessary, training community health workers to take on new tasks to reduce nurses’ workload and introducing measures to improve staff retention. But ultimately, a major initiative will need to be developed at the national level to recruit, train and retain skilled nurses and other professional healthcare workers. According to the nurses we work with, a critical first step to retain nurses and attract new ones is salary increases.
Donors, including the Global Fund, often argue that they cannot pay for fixed human resource costs because it is not “sustainable”. Yet, after years of pressure from activists and NGOs, they are paying for ARVs, which need to be taken for life, with no such requirement for “sustainability”. The same emergency approach needs to be taken to address the human resource crisis.
The question for the Global Fund should not be whether to fund salaries, but how to more rapidly disburse funds to strengthen the health workforce so that patients are not left without the urgent medical care they need.
Rachel Cohen is head of mission, Lesotho Médecins sans Frontières