Efforts to increase access to life-saving treatment, including antiretroviral therapy (ART), for people living with HIV/AIDS in resource-limited settings has been the growing focus of international efforts. One of the greatest challenges to scaling up will be the limited supply of adequately trained human resources for health, including doctors, nurses, pharmacists and other skilled providers. As national treatment programmes are planned, better estimates of human resource needs and improved approaches to assessing the impact of different staffing models are critically needed. However there have been few systematic assessments of staffing patterns in existing programmes or of the estimates being used in planning larger programmes.
Human Resources
Estimating health workforce needs for antiretroviral therapy in resource-limited settings
Evaluated strategies to increase attraction and retention of health workers in remote and rural areas
Carmen Dolea, Laura Stormont & Jean-Marc Braichet: Bulletin of the World Health Organization 88:350–356, May 2010
The lack of health workers in remote and rural areas is a worldwide concern. Many countries have proposed and implemented interventions to address this issue, but very little is known about the effectiveness of such interventions and their sustainability in the long run. This paper provides an analysis of the effectiveness of interventions to attract and retain health workers in remote and rural areas from an impact evaluation perspective. It reports on a literature review of studies that have conducted evaluations of such interventions. It presents a synthesis of the indicators and methods used to measure the effects of rural retention interventions against several policy dimensions such as: attractiveness of rural or remote areas, deployment/recruitment, retention, and health workforce and health systems performance. It also discusses the quality of the current evidence on evaluation studies and emphasises the need for more thorough evaluations to support policy-makers in developing, implementing and evaluating effective interventions to increase availability of health workers in underserved areas and ultimately contribute to reaching the United Nations' Millennium Development Goals.
Evaluating a streamlined clinical tool and educational outreach intervention for health care workers in Malawi: the PALM PLUS case study
Sodhi S, Banda H, Kathyola D, Burciul B, Thompson S, Joshua M et al: BMC International Health and Human Rights 11(Suppl 2):S11, 8 November 2011
PALM PLUS (Practical Approach to Lung Health and HIV/AIDS in Malawi) is an intervention designed to simplify and integrate existing Malawian national guidelines into a single, simple, user-friendly guideline for mid-level health care workers. Training utilises a peer-to-peer educational outreach approach. Research is being undertaken to evaluate this intervention to generate evidence that will guide future decision-making for consideration of roll out in Malawi. In the first phase of qualitative inquiry respondents from intervention sites demonstrated in-depth knowledge of PALM PLUS compared to those from control sites. Participants in intervention sites felt that the PALM PLUS tool empowered them to provide better health services to patients. Interim staff retention data shows that there were, on average, three to four staff departing from the control and intervention sites per month. Additional qualitative, quantitative and economic analyses are planned. This initiative is an example of South-South knowledge translation between South Africa and Malawi, mediated by a Canadian academic-NGO hybrid. Success in developing and rolling out PALM PLUS in Malawi suggests that it is possible to adapt and implement this intervention for use in other resource-limited settings.
Evaluation of community-based education and service courses for undergraduate radiography students at Makerere University, Uganda
Mubuuke AG, Kiguli-Malwadde E, Byanyima R and Businge F: Rural and Remote Health 8 (976), 8 December 2008
Ugandan radiography, medical, nursing, dentistry and pharmacy students are sent to community health facilities where they are expected to participate in community services and other primary healthcare activities for training (COBES). This study was designed to obtain the opinions of radiography teachers and students of the significance and relevance of this community-based training to radiography training. Both students and teachers (91.4%) affirmed the community training to be significant and relevant to radiography training. In total, 71.4% of the students had participated in X-ray services and 39.2% in ultrasound services during COBES; and 68.6% of the students reported the need to be better prepared for the COBES training. They confirmed community-based training to be relevant to Ugandan radiography training.
Examining health-care volunteerism in a food- and financially insecure world
Maes K: Bulletin of the World Health Organization 88(11), November 2010
Insecure access to food is increasingly recognized as a major contributor to cycles of poverty and HIV and AIDS in sub-Saharan Africa, according to this article. In this context, volunteers espouse desires for economic ‘progress’ amid a mix of pro-social and self-interested motivations to be volunteer AIDS caregivers. For these volunteers, food insecurity was particularly demotivating. Food crisis on top of chronic food insecurity pushed them to reconsider what they deemed as appropriate compensation for their efforts. Ironically, volunteers in such contexts may often be poorer than their clients. Ideally, effective and resilient community health workers should derive mental satisfaction and fair remuneration from their labour. The question for policy-makers is how to generate the spiritual benefits of altruistic, compassionate care as well as a level of remuneration that allows for secure livelihoods among volunteers who are often socioeconomically marginalized. WHO’s recent recommendation challenges various public and private entities to adapt to a system in which funding and other measures are used to create fairly-paid and secure health-care jobs in low-income countries facing pervasive food insecurity and high burdens of chronic and infectious disease. In sub-Saharan Africa, hiring, training and paying community health workers may be a win-win situation: people receive secure jobs that provide food security for their families and communities, and their participation strengthens health-care systems and people in need of care. The article emphasises that health programmers need to listen to what volunteers themselves – and the people whom they serve – say about the benefits and costs of volunteering.
Examining Prevalence of HIV in Workforces in Southern Africa
The authors surveyed workforces in southern Africa to determine HIV prevalence among formally employed, largely male populations. Voluntary, anonymous, unlinked seroprevalence surveys of 34 workforces with 44 000 employees were carried out in South Africa, Botswana, and Zambia in 2000-2001. Average HIV prevalence for the entire sample was 16.6%. Country-wide prevalence was 14.5% in South Africa, 17.9% in Zambia, and 24.6% in Botswana.
Existing capacity to manage pharmaceuticals and related commodities in east Africa: An assessment with specific reference to antiretroviral therapy
Waako PJ, Odoi-Adome R, Obua C, Owino E, Tumwikirize W, Ogwal-Okeng J, Anokbonggo WW, Matowe L and Aupont O: Human Resources for Health, 9 March 2009
Heads and implementing workers of fifty HIV and AIDS programs and institutions accredited to offer antiretroviral services in Uganda, Kenya, Tanzania and Rwanda were key informants in face-to- face interviews guided by structured questionnaires. Inadequate human resource capacity including, inability to select, quantify and distribute ARVs and related commodities, and irrational prescribing and dispensing were some of the problems identified. A competence gap existed in all the four countries with a variety of healthcare professionals involved in the supply and distribution of ARVs. There is inadequate capacity for managing medicines and related commodities in East Africa. There is an urgent need for training in aspects of pharmaceutical management to different categories of health workers. Skills building activities that do not take healthcare workers from their places of work are preferred.
Expanding access to ART in South Africa: The role of nurse-initiated treatment
Colvin CJ, Fairall L, Lewin S, Georgeu D, Zwarenstein M, Bachmann M et al: South African Medical Journal 100(4): 210–212, April 2010
Although task-shifting is widely promoted as the solution to expanding anti-retroviral therapy (ART) access, this article notes that the evidence for non-physician-provided ART in Africa is limited, with few studies comparing the performance of non-physicians with doctors. However, field reports from programmes that have used non-physicians to deliver ART, including from rural settings in South Africa, are more plentiful and report similarly positive (although less reliable) results in terms of both ART outcomes and improved access. The authors argue that positive results from trials in South Africa regarding nurse initiation and management of patients on ART may mean that this may become a key strategy for expanding ART access. Along with basic training and support and an appropriately phased implementation, the authors recommend drafting guidelines that are designed for and specific to nurses and that clarify referral options, so that nurses will feel adequately prepared and supported for their ART tasks.
Expanding access to priority health interventions: The human resources challenge
Kurowski C, Wyss K, Abdulla S, Yémadji ND: Health Economics and Finance Programme, London School of Hygiene and Tropical Medicine
Endorsing the Millennium Development Goals (MDG), the international community committed itself to significant improvements in the health of the poor and set ambitious targets. Achieving the MDG will depend on improving access to priority health interventions, which requires significant supply and demand side constraints to be overcome. The study investigated the human resource implications of expanding the coverage of priority health interventions in Tanzania and Chad. The authors conclude that the health workforce in Tanzania and Chad, and probably in many other SSA countries, is grossly insufficient for the expansion of priority interventions envisaged in current international dialogue. An immediate response at the national and international level is required to ensure progress towards the MDG.
Experience of initiating collaboration of traditional healers in managing HIV and AIDS in Tanzania
Kayombo EJ, Uiso FC, Mbwambo ZH, Mahunnah RL, Moshi MJ, Mgonda YH: Journal of Ethnobiology and Ethnomedicine 3:6, 26 January 2007
Collaboration between traditional healers and biomedical practitioners is now being accepted by many African countries south of the Sahara because of the increasing problem of HIV/AIDS. The key problem, however, is how to initiate collaboration between two health systems which differ in theory of disease causation and management. This paper presents findings on experience learned by initiation of collaboration between traditional healers and the Institute of Traditional Medicine in Arusha and Dar-es-Salaam Municipalities, Tanzania where 132 and 60 traditional healers respectively were interviewed. Of these 110 traditional healers claimed to be treating HIV/AIDS. The objective of the study was to initiate sustainable collaboration with traditional healers in managing HIV/AIDS. Consultative meetings with leaders of traditional healers' associations and government officials were held, followed by surveys at respective traditional healers' "vilinge" (traditional clinics). The findings were analysed using both qualitative and quantitative methods.