Drugs without doctors

International aid group Médecins sans Frontières (MSF) says that a lack of healthcare staff is endangering the lives of millions of people living with HIV/Aids, for whom the drugs are available, but the doctors to prescribe them are not.

In a report titled Help Wanted, which was released this week and focuses on MSF’s experience in Southern Africa, the NGO says that failure to allow nurses to administer antiretroviral (ARV) therapy combined with poor salaries and working conditions for healthcare workers have led to a ‘brain drain”. Aids-related illness and mortality are also to blame: in Lesotho, Mozambique and Malawi death is the main cause of loss of healthcare workers.

As the HIV epidemic matures into an Aids epidemic, demand for ARV therapy is outstripping supply in many regions; the South African national department of health reports that 35 000 people are currently on waiting lists for the treatment.

MSF says that a critical factor is the failure to allow specially trained nurses to initiate patients on to ARV therapy, and to supervise the ongoing treatment. It recommends that doctors oversee these activities, but not be the sole administrators, so that they can be free to concentrate on more difficult cases.

The introduction of this strategy at MSF-run clinics has allowed it to increase greatly the number of patients on ARVs. MSF points out that while the new National Strategic Plan for HIV/Aids has predicted that most routine ARV treatment will be administered by nurses by 2011, the department of health has not made allowances for this in its Human Resources for Health Plan.

In order to shift this task from doctors to nurses, governments and healthcare councils must first agree. MSF says that while nothing in South Africa prevents nurses from administering ARV treatment, confusion about the issue means that in some places they are not allowed to. This causes bottlenecks, as patients are forced to wait for ever more scarce doctors.

MSF says that in the rural Eastern Cape town of Lusikisiki, while utilisation of clinic services almost doubled over two years, there was no concurrent increase in the number of professional nurses. In this area the number of doctors is 14 times below the average national level and almost four out of five people live below the poverty line.

In South Africa about two thirds of doctors and 50% of nurses are employed in the private sector, which services roughly seven million people out of a total population of about 47-million.

MSF says that even the clinics it supports are struggling. In 2000, the NGO began supporting HIV clinics in Khayelitsha, which demonstrated to a largely sceptical world that mass provision of ARV therapy among impoverished communities could be successful. Since 2001, 7 262 adults and children have begun ARV therapy, with just more than 80% remaining on therapy for at least a year. But, even as demand increases, enrolment for ARV therapy is falling at the three clinics that MSF supports because staff are working at maximum capacity.

To improve capacity the NGO, together with the Western Cape government, is decentralising treatment further to nurses at primary health care clinics.

MSF says that while national and international organisations have largely acknowledged the crisis, the response has been ‘piecemeal or insufficient”. The report attacks international donors who make commitments to provide lifelong supplies of ARVs and build new clinics, but will not help fund salaries because this is ‘unsustainable”.

‘Donors are quick to support initiatives involving lay health workers, but often refuse to fund measures to recruit and retain health professionals.”

MSF also points out that almost one in five nurses and midwives trained in sub-Saharan Africa are now working in developed countries.

The main reasons why healthcare workers leave are low salaries and inadequate or unpleasant working conditions. MSF points out that even when doctors and nurses don’t leave, low salaries mean that many look to augment their income — for instance Mozambican doctors regularly leave work to conduct their own private practices at lunch time.

MSF admits that the hiring of healthcare workers by international NGOs — including itself — can add to staffing shortages. Conversely, while NGOs can hire their own staff to overcome institutional barriers — such as imposed limits on salary spending — when the NGO pulls out, the public sector may not have the capacity to absorb the additional staff because of caps on staff or salary levels.