Health Systems and Access to Antiretroviral Drugs for HIV in Southern Africa: Service Delivery and Human Resources Challenges
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A 2006 Reproductive Health Matters.
All rights reserved.
Reproductive Health Matters 2006;14(27):12–23
0968-8080/06 $ – see front matter
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FEATURES
Health Systems and Access to Antiretroviral Drugs for
HIV in Southern Africa: Service Delivery and
Human Resources Challenges
Helen Schneider,a Duane Blaauw,b Lucy Gilson,c Nzapfurundi Chabikuli,d Jane Goudgee
a Associate Professor, Centre for Health Policy, University of Witwatersrand, Johannesburg,
South Africa. E-mail: Helen.Schneider@nhls.ac.za
b Senior Researcher, Centre for Health Policy, University of Witwatersrand
c Associate Professor, Centre for Health Policy, University of Witwatersrand, and Reader,
Health Policy Unit, London School of Hygiene and Tropical Medicine, London, UK
d Senior Researcher, Centre for Health Policy, University of Witwatersrand
e Senior Researcher, Centre for Health Policy, University of Witwatersrand
Abstract: Without strengthened health systems, significant access to antiretroviral (ARV) therapy
in many developing countries is unlikely to be achieved. This paper reflects on systemic challenges
to scaling up ARV access in countries with both massive epidemics and weak health systems. It
draws on the authors’ experience in southern Africa and the World Health Organization’s framework
on health system performance. Whilst acknowledging the still significant gap in financing, the paper
focuses on the challenges of reorienting service delivery towards chronic disease care and the
human resource crisis in health systems. Inadequate supply, poor distribution, low remuneration and
accelerated migration of skilled health workers are increasingly regarded as key systems constraints
to scaling up of HIV treatment. Problems, however, go beyond the issue of numbers to include
productivity and cultures of service delivery. As more countries receive funds for antiretroviral access
programmes, strong national stewardship of these programmes becomes increasingly necessary. The
paper proposes a set of short- and long-term stewardship tasks, which include resisting the
verticalisation of HIV treatment, the evaluation of community health workers and their potential
role in HIV treatment access, international action on the brain drain, and greater investment in
national human resource functions of planning, production, remuneration and management.
A 2006 Reproductive Health Matters. All rights reserved.
Keywords: HIV antiretroviral drugs, scale up of treatment and services, health systems,
southern Africa
T
O deny access to life-saving antiretroviral Is it possible to make ARVs available to the
(ARV) therapy, whether on the basis of price large numbers of people who need them and
or inadequate infrastructure, has become what constraints need to be overcome? How
globally untenable. Numerous pilot sites and will the equity principle be maintained in the
projects, some internationally celebrated, have inevitably incremental process of scale-up? Is
demonstrated that it is possible to use ARVs it feasible to manage the investment in ARVs
effectively in low-resource settings.1,2 so that they do not divert scarce resources
As more and more countries receive exter- away from other essential activities and instead
nal resources to embark on HIV treatment benefit the health system for delivery of all
programmes, they face a number of questions. health programmes?
12H Schneider et al / Reproductive Health Matters 2006;14(27):12–23
These questions are not confined to ARV scale- lenges, especially when confronted with the multi-
up. A renewed global concern to address the plicity of initiatives and sheer pace of the scale-up
overwhelming disease burdens of the South has in many countries. We conclude by summarising
repeatedly hit against ‘‘the precarious state of what we see as the stewardship tasks, outlined in
health systems in many developing countries’’.3 a matrix of both short- and long-term and micro
Health systems failures are seen as being at the root and macro health systems strengthening tasks.
of the disappointing outcomes of tuberculosis (TB)
control strategies (DOTS),4 Integrated Manage-
ment of Childhood Illness (IMCI)5 and the inte- Overview of health system challenges
gration of reproductive health services.6 Several The state of public health systems, particularly in
authors7–9 have warned of increasing fragmenta- sub-Saharan Africa where ARVs are needed most,
tion and health systems chaos in the wake of the is a troubled one. Decades of economic crises,
global proliferation of public–private partnerships structural adjustments and declining public expen-
attempting to tackle HIV in one way or another. diture have severely undermined the capacity to
The tendency to bypass health systems by creating provide the most basic of health safety nets in
vertical structures that drain resources from a many places. Constraints to introducing new health
‘‘crumbling core’’10 may address short-term needs interventions in such environments are numerous
but cannot form the basis for universal access. HIV and have been comprehensively described by
treatment, as with reproductive health services or Hanson et al.12 They include demand-side barriers
TB care, and in contrast to polio immunisation or (e.g. affordability, stigma) to accessing services,
social marketing of bed nets and condoms, cannot inadequate service delivery infrastructure, weak
be provided in a separate vertical programme drug regulatory and supply systems and the dif-
without re-creating a whole new parallel health ficulty of managing multiple donor inputs. Table 1
system infrastructure. If ARVs are to reach the summarises the health system constraints specific
huge numbers who need them, and in an organised to ARV scale-up, in line with the framework pro-
and regulated manner, the existing health care posed by WHO in 2000.13 This framework divides
infrastructure will have to be called upon. The health systems into three objectives (goodness,
private-for-profit, non-governmental and work- fairness and responsiveness) and a set of functions
place sectors may have a role to play, but cannot (delivering services, creating resources, financing
substitute for the core function of the public health and stewardship) required to achieve these objec-
sector, both as provider of services and as manager tives. Although regarded by some as a narrow
of roll-out.11 representation of a health system or of scaling-
This paper reflects on the task of scaling up HIV up12, it does serve as a useful heuristic for con-
treatment in the face of generalised HIV epidemics sidering a classic service delivery intervention such
(i.e. massive need) and fragile health systems. It is as HIV treatment.
based on published accounts and the experiences Adequate financing is obviously a key ARV
of the authors in the southern African region, a mix scale-up challenge. Although global funding for
of low and middle-income country health systems. HIV/AIDS has increased significantly over the last
Drawing on the World Health Organization (WHO) years, the resources mobilised for treatment still
framework for health systems, the paper begins fall far short of need,14 let alone for rebuilding
with a summary of challenges to achieving uni- health systems.8 Much of the new funds also
versal access. It then discusses, in more depth, bypass and are in danger of overshadowing estab-
the need for chronic disease care systems to be lished national mechanisms for managing external
integrated into a continuum of HIV care, and the health sector assistance, such as the sector-wide
human resource base and cultures of care this approaches (SWAps).15 However, even if adequate
presupposes. While in most places universal access funds were made available through integrated
will remain a distant goal, almost all health systems systems, years of under-investment in the resource
have elements of good performance that can form base of health systems – in particular people and
the basis for starting a scale-up process that sim- infrastructure – have established difficulties that
ultaneously also strengthens the health system cannot be reversed in the short term. These macro
itself. Managing these opportunities presents dimensions of health systems have their coun-
immediate and significant ‘‘stewardship’’ chal- terparts in a set of micro-level service delivery
13H Schneider et al / Reproductive Health Matters 2006;14(27):12–23
challenges associated with establishing chronic drugs, especially in the early period of treatment,
disease care systems. The sections that follow elab- occur relatively frequently, some of which are
orate on these challenges. sufficiently dangerous to require modifications to
treatment. Significant mortality (up to 10%) was
found in the early months of treatment in one
Service delivery challenge: antiretroviral South African setting.17
therapy as chronic disease care Initial experiences in several developing coun-
Antiretroviral therapy, as presently available, is tries have shown that these challenges are not
highly effective but complex to manage. It insurmountable.1,18 Botswana, a middle-income
necessitates life-long treatment with at least three country of 1.7 million people with a devastat-
antiretroviral drugs (triple therapy or highly active ing HIV epidemic has instituted a programme of
antiretroviral therapy, HAART). Breakthrough universal access to ARVs. By April 2004, more
drug resistance, followed by rising viral loads than 17,000 people had been enrolled onto the
and clinical failure is relatively common, even programme and adherence rates measured by
with high levels of adherence.16 This entails outcomes such as viral loads were high.19
ongoing clinical and laboratory monitoring and Médecins sans Frontières (MSF) has comprehen-
access to second-line regimens. Side-effects of sive, district-based HIV/AIDS projects, which
14H Schneider et al / Reproductive Health Matters 2006;14(27):12–23
include antiretroviral therapy, in 25 countries.20
Many more treatment programmes are being
initiated through governments with bilateral and
multilateral donor funding.
As a rule, these initial pilot projects have set
and demonstrated high performance with regards
to follow-up, adherence and survival. This per-
formance, however, rests on a significant re-
source base, involving a relatively complex human
resource and systems mix producing a wide
range of activities. Treatment programmes include
medical staff, mid-level health workers (nurses
or clinical assistants), laboratory personnel, lay
counsellors, community health workers or treat-
ment supporters and programme managers (see
Box 1). While experience has shown that it is
possible to systematise HIV care (including ARVs)
into algorithms for application by mid-level
workers, especially if combined with strong public
health/district support systems,1,2 provision still
involves mobilising different combinations of
skills and at different times. Moreover, it is more
doctor-intensive than other primary health care
activities such as immunisation and antenatal care.
In these pilot projects, ARVs are also integrated
into a wider set of public health, clinical and out-
PEP BONET / PANOS PICTURES
MSF volunteer HIV counsellors for PMTCT, Zambia, 2005
15H Schneider et al / Reproductive Health Matters 2006;14(27):12–23 reach activities in a ‘‘continuum’’ of care, support aspect of replicating successful ARV programmes, and sometimes prevention, which is free at the implies a new kind of relationship or contract point of use. Widening HIV testing and enrolling (the negotiated nature of rights, responsibilities people into follow-up systems of care are central and obligations) between providers and patients. to the success of ARVs. Large-scale, voluntary This contract is based on very high levels of HIV testing by well individuals, in turn, will only understanding (‘‘treatment literacy’’) on the part of occur if providers are perceived as trustworthy and users and the provision of treatment support empathetic. In some programmes, much of the systems in return for which patients assume new success of ARVs has been attributed to community- responsibilities – making decisions regarding care, based activities involving patient advocacy groups, adhering to treatment but also participating in NGOs or lay counsellors. Such players act as impor- community and prevention activities. tant intermediaries, stimulating demand, reduc- These models of HIV care share more with ing social barriers to entry into care and providing chronic disease care than TB control. Contem- social support to people once they are diagnosed porary approaches to chronic disease care are and embark on treatment. The precise nature and explicit in highlighting the need for ensuring combination of such social support and the extent adequate resources for the technologies of inter- to which lay or community-based providers are vention (e.g. protocols and systems) as well as volunteer or remunerated varies from place to place. building ‘‘informed, motivated and adequately Although treatment for HIV can be managed staffed teams’’, operating in partnership with principally within the primary health care sys- ‘‘informed and empowered patients’’.22 While tem, doing it effectively is not simple. Ensuring both are necessary components of a whole, the life-long treatment, accessible and well-function- focus in disease programmes globally has tended ing health facilities, management of referral rela- to be on technologies rather than on the relation- tionships, partnerships with non-state actors, ships between people, on the ‘‘hardware’’ rather monitoring and evaluation, and removing the than ‘‘software’’ of service delivery.23 many barriers to entry and remaining in care, all There are limits to which the complexity of imply a high level of systems and managerial interpersonal and social dimensions of chronic capacity. This makes ARVs more complex than disease care can be minimised by standardised many other health care interventions. design and protocols. Removing cultural and The closest analogy to ARVs in the health sys- physical barriers to care and creating organisa- tem is TB care. HIV care shares many of the well- tional cultures in which providers are responsive known features of TB control with the added to patient needs are locally negotiated processes problem, in common with non-communicable which hinge on a degree of local decision- chronic diseases (such as diabetes), of not being making and ability to problem-solve. Paradoxi- curable and requiring treatment over years rather cally, therefore, building chronic care capacity than months. Experiences with TB control, nota- for HIV/AIDS requires both the dissemination of bly the DOTS (‘‘Directly Observed Therapy, Short standardised practices on the one hand, and Course’’) Strategy, provide a significant base developing local capacity for decision-making upon which to draw in programme design and on the other, and about enabling innovation while implementation. However, HIV treatment pro- ensuring conformity to guidelines. It requires the grammes, as described earlier, have departed in combination of hierarchical, top-down processes important respects from the DOTS approach, spe- with mechanisms to facilitate a fluid and bottom- cifically in their philosophies of and approaches up process of learning shaped by local actors. to partnerships with patients. Strategies have Building local capacity in turn requires a renewed focused on removing utilisation barriers (such focus on the functioning of core health systems as bringing drugs to patients), patient informa- structures, namely primary health care and the tion and provision of social support.1,2 In these district health system. contexts, adherence is often framed in patient- The Médecins sans Frontières project in Malawi centred and rights-based discourses around providing comprehensive HIV care, described in patient empowerment and participation, removal Box 1,21 invested in strengthening the district of socio-economic barriers and of agency and hospital by recruiting additional staff externally dignity. This shift, probably the most complex and by upgrading the local hospital laboratory. 16
H Schneider et al / Reproductive Health Matters 2006;14(27):12–23
Through negotiations, the project introduced a nificant obstacles. The inadequate supply (and in
performance-related incentive for all district staff fact a growing crisis in the supply) of skilled and
to deal with local tensions around differential motivated health care workers is now regarded
salaries between government and NGO staff. The as the key systems constraint to scaling up of
project also recruited national staff from outside HIV treatment.24–27
the district and made sure that all health care staff The problem of human resource development
had access to ARVs. Drug supplies were procured is multi-faceted – it includes supply, migration,
and distributed largely through existing mecha- distribution, skills mix, remuneration and pro-
nisms. Local initiatives such as this provide impor- ductivity dimensions.28 Despite the conventional
tant examples on strengthening health systems view of African public health sectors as bloated,29
through HIV/AIDS, especially if supported by the health worker-to-population ratios of deve-
national processes which encourage sharing of loping country health systems remain vastly infe-
lessons and which direct new resources to replicate rior to those of industrialised nations (Figure 1).
such experiences elsewhere. However, they speak When measured against need, the shortfalls in
little to achieving these effects on a system-wide developing countries are considerable. Kurowski
national level. The project employed 41 Malawi et al30 estimated the human resource require-
nationals, a situation which would not be feasible ments necessary to meet essential health care
in every district without some concerted national needs, including HIV treatment, in Tanzania and
action to increase the supply of human resources. Chad. Their case studies indicated a 2.7 and
In this country, recruitment by non-governmental 5.4-fold gap, respectively, in the necessary size
HIV/AIDS projects appears to be a major reason of the health sector workforce (Table 2). There
for loss of staff from public sector institutions. was also an imbalance between unskilled and
skilled staff.
The South African government calculated
The challenge of creating resources that 13,805 new health professionals (doctors,
Although most health systems contain success- nurses, pharmacists, dieticians and counsellors)
ful examples of service delivery for TB, chronic would be needed by 2008 to meet the targets of
diseases and in recent times ARVs, expanding the Operational Plan for Comprehensive HIV
access beyond these islands of success faces sig- and AIDS Care, Management and Treatment.31
17H Schneider et al / Reproductive Health Matters 2006;14(27):12–23
other countries, is only able to fill 78% of doctor
posts and 81% of nursing posts.3
Aggregate ratios of health personnel at national
level hide large disparities within countries; the
brain drain is as much an internal problem as an
international one. The liberalisation of the private
for-profit sector in many countries and the pro-
liferation of non-governmental organisations have
made possible a flight out of the public sector and
rural areas within countries.35 The consequences of
such flows are not only shortages but also a high
turnover of staff and loss of institutional memory.
Yet in 2003, there were 52,574 unfilled profes- Initiatives over time to protect the human
sional posts in the South African public health resource base of health systems are poorly docu-
sector, representing a 31.1% vacancy rate.32 mented – there is very little literature to be found
Seen over time, the supply of health profes- on now several decades of experience with mid-
sionals in most African countries has not always level cadres (e.g. auxiliaries and assistants) in
been as limited as it is now. After an initial period many countries.36 HIV/AIDS responses have
of growth in supply, most countries have expe- themselves given rise to a large infrastructure of
rienced a consistent decline in the availability of community and home-based carers, often based in
human resources. The current situation is the prod- non-governmental organisations. Relying mostly
uct of multiple pressures over several decades – on a volunteer or semi-remunerated base, this con-
reduced social sector expenditure, dramatic and stitutes a significant de facto workforce presence in
sometimes overnight drops in real incomes of the health sector. For example, there were an esti-
health professionals, a consequent decline in their mated 30,000 community-based carers in South
‘‘social value’’ and status,33 less investment in Africa in 2002 which government plans to for-
training and production of new cadres, a failure malise into an infrastructure of community health
to retain those that are trained, and HIV infection. workers who are managed by NGOs but supported
While the African continent has for decades and regulated by the state.37 The extent to which
experienced a brain drain of skilled human re- the existing and emerging skills base of health
sources, the evidence points to a greatly accel- systems can be mobilised for HIV care is inade-
erated recent process of international migration, quately understood.
generated by a human resource crisis (albeit rela- High levels of HIV infection amongst health
tive) in the health systems of the industrialised personnel may be one contributor to attrition of
North.33 Despite the paucity of data and lack of personnel in some countries.38 By the late 1990s,
standardised measures documenting migration deaths constituted more than 40% of all nurses
trends, indications are of a staggering flow of lost to the public sector in Malawi and Zambia,29
health personnel out of developing countries. For while in South Africa in 2002, 16.3% of health
example, nearly 500 doctors and more than 1,000 workers were infected with HIV.39
nurses from South Africa register annually with Health workers in many countries, particularly
the United Kingdom General Medical Council.34 lower level cadres, are paid salaries well below
Kenya has lost 4,000 nurses to the UK and US; subsistence levels. Non-payment of salaries is
in Zimbabwe, only 360 of 1,200 doctors trained not uncommon.40 Moreover, with currency de-
during the 1990s were still practising in their valuations and salary freezes imposed through
country in 2000,25 and so on. While the traditional structural adjustment programmes, many health
flow out of countries has been of doctors, the workers have experienced dramatic reversals in
recruitment of nurses has now overtaken that of their incomes over time.25 A poorly remunerated
doctors.34 Vacancy rates in some countries, despite workforce is unlikely to be a productive one.
inadequate staff establishments, are extremely high, McPake et al40 observed in Uganda that ‘‘utilisation
of the order of 30–40% of public sector posts for levels are less than expected. . . and the workload is
professional staff.25,29 Even Botswana, a middle- managed by a handful of the expected staff
income country able to attract professionals from complement who are available for a fraction of
18H Schneider et al / Reproductive Health Matters 2006;14(27):12–23
the working week’’. Following an assessment of the should thus not be seen purely as a phenomenon
availability and time use of staff in their two of rent-seeking in the face of poverty. Such
country case studies, Kurowski et al30 concluded behaviours are well-described in health systems
that major gains in human resource supply could be where health workers earn living wages. In South
made by focusing in the first instance on improv- Africa, for example, public sector health workers
ing the productivity of staff. They estimated that are frequently described as harsh, unsympathetic
improved productivity would increase the supply of and readily breaching patient confidentiality.45
personnel by 26% in Tanzania and 35% in Chad. In the context of HIV treatment, these entrenched
norms of service delivery limit the ability to
create individualised, patient-centred therapeu-
Cultures of service delivery tic partnerships premised on rights and equality
A less tangible but no less significant dimension of between providers and patients. In addition,
the human resource crisis is the demoralisation poorly planned and overly hasty introduction of
and demotivation of those remaining within the new drugs into such environments may promote
system.28 Demotivated health workers are less perverse incentives and informal economies of
inclined to orient their actions towards the drug use that undermine access and accelerate the
achievement of organisational goals and may be development of drug resistance.
less willing to balance self-interested behaviour
with altruism and solidarity towards users of ser-
vices.41 In many health systems, underpaid health The challenge of stewardship
workers have increasingly looked to health sys- In the face of overwhelming difficulty, conven-
tems as a means to ensure their own survival rather tional portrayals of public services in developing
than as an avenue for expression of professional countries, by both policymakers and the public, are
and societal norms of caring and altruism.40,42,43 typically negative and often expressed in fatalistic
Mackintosh and Tibandebage describe how in terms. However, Mackintosh and Tibandebage
one hospital they investigated in Tanzania: ‘‘nurses caution against an excessively pessimistic view of
were caught between many of the worst pressures health systems and suggest that organisational
on the system: low and declining wages, poor cultures are, in reality, highly variable and open to
chances of advancement, poor and often dangerous influence. Thus, in the same Tanzanian context
working conditions, and an experience of aban- described above: ‘‘a number of facilities, seemingly
donment by the doctors formally responsible for against the odds, were providing accessible care
patient care. This sense of being abused has in the in decent conditions, stretching resources effec-
worst cases turned full circle into a culture of abuse tively for the benefit of users, treating patients
of patients’’ (p.8).42 Predatory behaviour towards with respect’’ (p.10).42 Summary statements on
the state/public health system on the one hand and the problems confronting health systems fail to
towards patients on the other hand is sufficiently acknowledge what may be important elements of
rampant as to constitute a set of norms or values resilience and functionality within systems. These
that powerfully shape the everyday practice of provide clues as to the possibilities for building on
health care providers in many health systems.43 The existing strengths. Factors such as the quality of
manifestations include the near universal practice facility and district leadership may be key to such
of informal, illegal fees in poor countries, use of variation and are deserving of further attention.
public facilities for private gain, absenteeism, re- Fairness in allocation of career and training oppor-
selling of state-provided drugs and denying emer- tunities, for example, are often powerful signals of
gency care unless payments are made. local management cultures and significantly influ-
While improvements in the supply and remu- ence motivation.24 Through their discourse and
neration of health care workers is a necessary practice, leaders and managers set the frames for
precondition for the reversal of these norms, they what is acceptable and unacceptable in health
will not be sufficient on their own: ‘‘The problems system practice. Leadership that recognises, cham-
of demoralization and negative attitudes are more pions and rewards facilities, districts or health
complex than money and call for a multi-dimen- system foci that express appropriate norms and
sional rehabilitation program involving measures values may form the starting point for influencing
of both the carrot and stick.’’44 Abuse of patients norms and values more generally.42
19H Schneider et al / Reproductive Health Matters 2006;14(27):12–23
Shaping values forms an essential part of the up process proceeds, monitoring equity of access.
oversight of health systems referred to by WHO as Effective stewardship also requires resisting the
‘‘stewardship’’, the process of setting the rules of tendency towards verticalisation (often in order
the game, determining not only the content of to meet targets) of programme initiatives and
health policy but also the mechanisms by which ensuring that treatment access occurs as much as
policy is implemented.46 Although a national possible in an integrated fashion through the
function, effective stewardship is as much a global existing public health system. This requires iden-
concern insofar as international responses to the tifying opportunities for building on existing
health crisis in sub-Saharan Africa have often strengths (such as sector-wide approaches) and
served to fragment, rather than strengthen, the finding ways to draw in the multiplicity of actors
sovereign capacity of country health systems.9,10 on the margins of the formal health system. Inte-
In a context of multiple pressures – interna- gration can be viewed at a number of levels: at
tional and national expectations, proliferation of the point of service delivery, in the management
donor assistance, the danger of drug resistance of programmes at district or local level, and in the
and need for capacity development and innova- financing, procurement of resources and moni-
tion at all levels of the health system – appro- toring of programmes at national level.
priate national stewardship of HIV treatment There is growing consensus that a long-term
programmes is not only an essential but also a perspective on ARV scale-up has to address the
highly strategic task. It involves a willingness to critical shortage of human resources.28 This would
view the resources mobilised for HIV as an include at a minimum:
opportunity to re-build national health systems,
whilst simultaneously creating the capacity to promoting international action on the brain
respond to the immediate need for access to drain;
treatment. The challenge can be summarised as a at country level (re)investment in traditional
set of short-term and long-term goals focused on human resource functions such as planning,
the development of systems (embodied in the production, remuneration and management of
notion of chronic disease care) for HIV treatment health care providers;
specifically and health systems more generically addressing macro-economic constraints on
(Table 3). employment and remuneration of health care
Systems for chronic disease care would include providers;
setting national standards (e.g. on drug regi- evaluation of the performance of existing
mens), enabling sharing of local experiences nationally developed cadres such as mid-level
and lessons learned, opening up debates on the and community health workers and their poten-
patient–provider relationship, and as the scale- tial role in HIV treatment scale-up.
20H Schneider et al / Reproductive Health Matters 2006;14(27):12–23
Conclusions tunity, firstly, to reassert a coherent approach to
Without strengthened or even transformed na- national health systems and secondly, to ensure
tional health systems it is hard to see how access that funds mobilised for treatment access are
to ARVs can be sustainably achieved in coun- oriented towards long-term goals, rather than
tries with weak health systems. To be effective, just short-term access targets.
ARVs also require integration into a continuum
of HIV care, best modelled on understandings Acknowledgements
developed in the field of chronic disease care. This paper has its origins in a longer monograph
The scale of this challenge in countries with prepared for the Global Health Policy Research
generalised HIV epidemics cannot be under- Network (PRN), funded by the Bill and Melinda
estimated. However, insofar as the ARV scale- Gates Foundation and housed in the Center for
up process cannot avoid drawing attention to Global Development, Washington, DC. The mono-
health system weaknesses, it provides an oppor- graph is available at bhttp://www.wits.ac.za/chpN.
References
1. Farmer P, Leandre F, Mukherjee 7. Wemos Foundation. Good Rationing antiretroviral therapy
J, et al. Community-based intentions with side-effects: for HIV/AIDS in Africa: choices
treatment of advanced HIV Information on Global Public- and consequences (Policy Forum).
disease: introducing DOT– Private Initiatives in Health. Public Library of Science
HAART (directly observed Amsterdam7 Wemos Foundation, Medicine 2005;2(11):e303. At:
therapy with highly active 2004. bhttp://medicine.plosjournals.
antiretroviral therapy). Bulletin 8. McCoy D, Chopra M, Loewenson orgN.
of World Health Organization R, et al. Expanding access to 15. Cassels A. A Guide to Sector-
2001;79(12):1145–51. antiretroviral therapy in sub- Wide Approaches for Health
2. Kasper T, Coetzee D, Louis F, et al. Saharan Africa: avoiding the Development: Concepts, Issues
Demystifying antiretroviral pitfalls and dangers; capitalizing and Working Arrangements.
therapy in resource-poor settings. on opportunities. American Geneva7 World Health
Essential Drugs Monitor 2003; Journal of Public Health 2005; Organization, 1997.
32:20–1. 95(1):18–22. 16. Singh N, Berman SM, Swindells
3. Joint Learning Initiative. 9. Saunders DM, Chopra M. S, et al. Adherence of human
Human Resources for Health Confronting Africa’s health crisis: immunodeficiency virus-infected
and Development: A Joint more of the same will not be patients to antiretroviral therapy.
Learning Initiative. New York7 enough [Education and Debate]. Clinical Infectious Diseases 1999;
Rockefeller Foundation, 2003. BMJ 2005;331:755–8. 29(4):824–30.
4. Nunn P, Harries A, Godfrey- 10. Loewenson R, McCoy D. Access 17. Coetzee D, Hildebrand K, Boulle
Fausset P, et al. The research to antiretroviral treatment in A, et al. Outcomes after two
agenda for improving health Africa [Editorial]. BMJ 2004; years of providing antiretroviral
policy, systems performance 328:241–42. treatment in Khayelitsha,
and service delivery for 11. World Health Organization. South Africa. AIDS 2004;18:
tuberculosis control: a WHO Health and the Millennium 887–95.
perspective. Bulletin of World Development Goals. Geneva7 18. Coetzee D, Boulle A, Hildebrand
Health Organization 2002;80: WHO, 2005. K, et al. Promoting adherence to
471–76. 12. Hanson K, Ranson KM, Oliveira- antiretroviral therapy: the
5. Bryce J, el Arifeen S, Pariyo G, Cruz V, et al. Expanding access experience from a primary care
et al. Multi-country evaluation to priority health interventions: setting in Khayelitsha, South
of IMCI Study Group. Reducing a framework for understanding Africa. AIDS 2004;18(Suppl.3):
child mortality: can public constraints to scaling up. S27–31.
health deliver? Lancet 2003; Journal of International 19. MASA Antiretroviral Therapy.
362:159–64. Development 2003;15:1–14. Access for All: The Masa
6. Lush L, Cleland J, Walt G, et al. 13. World Health Organization. The Programme – providing all
Integrating reproductive health: World Health Report 2000. Health Batswana with access to care
myth and ideology. Bulletin of Systems: Improving Performance. and treatment. Vol.9, June/July
World Health Organization Geneva7 WHO, 2000. 2004.
1999;77:771–77. 14. Rosen S, Sanne I, Collier A, et al. 20. Médecins sans Frontières.
21H Schneider et al / Reproductive Health Matters 2006;14(27):12–23
Antiretroviral Therapy in et al. Human resources for health: Review 2005. Durban7 Health
Primary Health Care: requirements and availability in Systems Trust, 2005.
Experience of the Chiradzulu the context of scaling-up priority 38. Tawfik L, Kinoti S. The Impact
Programme in Malawi Case interventions in low-income of HIV/AIDS on the Health
Study. Briefing Document. countries. Case studies from Sector in Sub-Saharan Africa:
Malawi7 MSF, 2004. Tanzania and Chad. Report to the the Issue of Human Resources.
21. Kemp J, Aitken JM, Le Grand S, Department for International Washington DC7 SARA, AED,
et al. Equity in health sector Development. London7 LSHTM, USAID, 2002.
responses to HIV/AIDS in IDRC, STI, 2004. 39. Shisana O, Hall E, Maluleke KR,
Malawi. Discussion Paper 5. 31. South African Department of et al. The Impact of HIV/AIDS
Harare7 Equinet, 2003. Health. Operational Plan for on the Health Sector: National
22. Bodenheimer T, Wagner EH, Comprehensive HIV and AIDS Survey of Health Personnel,
Grumbach K. Improving Care, Management and Ambulatory and Hospitalised
primary care for patients with Treatment for South Africa. Patients and Health Facilities,
chronic illness: the chronic care Pretoria7 Department of Health, 2002. Pretoria7 Human Sciences
model, part 2. Journal of the November 2003. Research Council, Medical
American Medical Association 32. Padarath A, Ntuli A, Burthiaume University of South Africa,
2002;288:1909–14. L. Human resources. In: Ijumab Medical Research Council,
23. Blaauw D, Gilson L, Penn- PI, Day C, Ntuli A, editors. 2002.
Kekana L, et al. Organisational South African Health Review 40. McPake B, Asiimwe D, Mwesigye
relationships and the ‘‘software’’ 2003-04. Durban7 Health F, et al. Informal economic
of health sector reform. Systems Trust, 2004. activities of public health
Background paper. Disease 33. Marchal B, Kegels G. Health workers in Uganda: implications
Control Priorities Project. At: workforce imbalance in terms for quality and accessibility.
bwww.fic.nih.gov/dcpp/N. of globalization: brain drain Social Science and Medicine
24. Hongoro C, McPake B. Human or professional mobility. 1999;49:849–65.
resources in health: putting the International Journal of Health 41. Franco LM, Bennett S, Kanfer R.
right agenda back to front Planning and Management Health sector reform and
[Editorial]. Tropical Medicine 2003;18(Suppl.1):S89–S101. public sector health worker
and International Health 2003; 34. Stilwell B, Diallo K, Zurn P, et al. motivation: a conceptual
8:965–6. Developing evidence-based framework. Social Science and
25. Liese B, Blanchet N, Dussault G. ethical policies on the migration Medicine 2002;54:1255–1266.
The Human Resource Crisis in of health workers: conceptual 42. Mackintosh M, Tibandebage P.
Health Services in Sub-Saharan and practical challenges. Sustainable redistribution with
Africa. Background paper. Human Resources for Health health care markets? Rethinking
Washington DC7 World Bank, 2003;1(1):8. At: bhttp://www. regulatory intervention in the
2003. human-resources-health.com/N. Tanzanian context. Discussion
26. Kober K, van Damme W. Scaling 35. Padarath A, Chamberlain C, Papers in Economics No.23.
up access to antiretroviral McCoy D, et al. Health personnel Milton Keynes7 Open University,
treatment in southern Africa: in southern Africa: confronting 2000.
who will do the job? Lancet maldistribution and brain drain. 43. Van Lerberghe W, Conceiçao C,
2004;364(9428):103–07. Equinet Discussion Paper No.3. Van Damme W, Ferrinho P.
27. Chen L. Hanvoravongchai HIV/ Zimbabwe: Equinet, Health When staff is underpaid:
AIDS and human resources Systems Trust, MEDACT, dealing with the individual
[Editorial]. Bulletin of World (undated). coping strategies of health
Health Organization 2005;83(4): 36. Dovlo D. Using mid-level cadres personnel. Bulletin of World
243–44. as substitutes for internationally Health Organization 2002;80(7):
28. Chen L, Evans T, Anand S, et al. mobile health professionals in 581–84.
Human resources for health: Africa. A desk review. Human 44. Segall M. District health systems
overcoming the crisis. Lancet Resources for Health 2004;2:7. in a neoliberal world: a review
2004;364:1984–90. At: bhttp://www.human- of five key policy areas.
29. USAID. The Health Sector resources-health.com/N. International Journal of Health
Human Resource Crisis in 37. Friedman I. CHWs and Planning and Management
Africa: An Issues Paper. Community Care-givers: 2003;18(Suppl.1):S5–26.
Washington DC7 USAID, AED, Towards a Unified Model of 45. Gilson L, Palmer N, Schneider H.
SARA, 2003. Practice. In: Ijumba P, Barron P, Trust and health worker
30. Kurowski C, Wyss K, Abdulla S, editors. South African Health performance: exploring a
22H Schneider et al / Reproductive Health Matters 2006;14(27):12–23
conceptual framework using 46. Travis P, Egger D, Davies P, et al. Health Systems Performance
South African evidence. Social Towards Better Stewardship: Assessment Debates, Methods
Science and Medicine 2005;61: Concepts and Critical Issues. In: and Empiricism. Geneva7 WHO,
1418–29. Murray CJL, Evans DB, editors. 2003.
Résumé Resumen
Seul un renforcement des systèmes de santé En muchos paı́ses en desarrollo, es improbable
permettra à nombre de pays en développement que se logre mayor acceso a la terapia
de garantir un large accès à la thérapie antirretroviral (ARV) sin antes fortalecer los
antirétrovirale. Cet article réfléchit aux obstacles sistemas de salud. En este artı́culo, basado en la
systémiques contrariant l’accès aux ARV dans experiencia de los autores en África meridional y
des pays où l’épidémie est massive et les en el marco de la Organización Mundial de la
systèmes de santé faibles. Il est fondé sur Salud sobre el desempeño de los sistemas
l’expérience des auteurs en Afrique australe et sanitarios, se reflexiona sobre los retos sistémicos
sur le cadre de l’OMS pour l’évaluation de la relacionados con la ampliación del acceso a
performance des systèmes de santé. Tout en los ARV en los paı́ses con grandes epidemias y
constatant la persistance des manques financiers, sistemas de salud deficientes. Aunque se reconoce
l’article se concentre sur la réorientation des la brecha aún considerable en financiamiento, se
services vers le traitement des maladies chroniques destacan los retos en reorientar la prestación de
et la crise des ressources humaines dans les servicios hacia el tratamiento de enfermedades
systèmes de santé. Des facteurs comme la pénurie crónicas y la crisis de recursos humanos en los
de personnel, la distribution inégale, la faible sistemas de salud. El suministro inadecuado, la
rémunération et la migration accélérée des agents deficiente distribución, la baja remuneración y la
de santé qualifiés sont de plus en plus considérés acelerada migración de los trabajadores sanitarios
comme des obstacles systémiques clés à calificados, son considerados cada vez más como
l’élargissement du traitement du VIH. Néanmoins, limitaciones clave de los sistemas en la ampliación
les problèmes dépassent la question de l’offre pour del tratamiento del VIH. Otos problemas son la
inclure la productivité et les cultures de la productividad y las culturas de prestación de
prestation des services. À mesure que davantage servicios. A medida que más paı́ses reciben fondos
de pays reçoivent des fonds pour les programmes para los programas de acceso a los ARV, también
d’accès aux antirétroviraux, un fort encadrement aumenta la necesidad de contar con una sólida
national de ces programmes devient de plus en administración nacional de esos programas. En
plus nécessaire. L’article propose un ensemble de este artı́culo se propone una serie de tareas
tâches de supervision à court et long terme, administrativas de corto y largo plazo: resistencia
notamment s’opposer à la verticalisation du a la verticalización del tratamiento del VIH,
traitement du VIH, évaluer les agents de santé evaluación de los trabajadores de la salud
communautaires et leur rôle potentiel dans comunitarios y su posible función en ampliar el
l’accès au traitement du VIH, mener une action acceso al tratamiento del VIH, acción internacional
internationale sur l’exode des cadres et investir respecto al éxodo de profesionales y una mayor
davantage dans les fonctions nationales des inversión en las funciones de planificación,
ressources humaines en matière de planification, producción, remuneración y administración de
production, rémunération et gestion. los recursos humanos nacionales.
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