Scaling-up antiretroviral treatment in Southern African countries with human resource shortage: How will health systems adapt?

https://doi.org/10.1016/j.socscimed.2008.01.043Get rights and content

Abstract

Scaling-up antiretroviral treatment (ART) to socially meaningful levels in low-income countries with a high AIDS burden is constrained by (1) the continuously growing caseload of people to be maintained on long-term ART; (2) evident problems of shortage and skewed distribution in the health workforce; and (3) the heavy workload inherent to presently used ART delivery models. If we want to imagine how health systems can react to such challenges, we need to understand better what needs to be done regarding the different types of functions ART requires, and how these can be distributed through the care supply system, knowing that different functions rely on different rationales (professional, bureaucratic, social) for which the human input need not necessarily be found in formal healthcare supply systems. Given the present realities of an increasingly pluralistic healthcare supply and highly eclectic demand, we advance three main generic requirements for ART interventions to be successful: trustworthiness, affordability and exclusiveness – and their constituting elements. We then apply this analytic model to the baseline situation (no fundamental changes) and different scenarios. In Scenario A there are no fundamental changes, but ART gets priority status and increased resources. In Scenario B the ART scale-up strengthens the overall health system: we detail a B1 technocratic variant scenario, with profoundly re-engineered ART service production, including significant task shifting, away from classical delivery models and aimed at maximum standardisation and control of all operations; while in the B2 community-based variant scenario the typology of ART functions is maximally exploited to distribute the tasks over a human potential pool that is as wide as possible, including patients and possible communities. The latter two scenarios would entail a high degree of de-medicalisation of ART.

Introduction

High AIDS-related mortality among young adults is ravaging societies in Southern Africa. Over the past few years antiretrovirals (ARVs) have become more affordable, and new global health initiatives are bringing in considerable financial resources for scaling-up antiretroviral treatment (ART), thereby introducing new actors and new institutional arrangements. Today, it is the implementing capacity of the health systems of those Southern African countries whose societies are ravaged by AIDS which appears to be the main limiting factor. This capacity depends mainly on the health workforce who has to ‘do the job’ (Kober & Van Damme, 2004). How will the health workforce handle this new task of lifelong catering for large numbers of people on ART? Our aim was to imagine, based on our understanding of past and present African health systems and of the more specific characteristics of ART, what is likely to happen in a number of scenarios as defined by a mix of assumptions.

We will first try to find out what large scale expansion of presently existing ART models would mean for countries in that region, given the health workforce constraints, and given the strategies that are presently considered to tackle the health workforce problem. We will then analyse the nature of the specific functions involved in lifelong ART in order to find out what kind of organisational set-up is needed and adapted to each of these functions. Furthermore, we will present what we see as major characteristics of healthcare supply and demand systems today, and what are the conditions for large scale programmes to be successful in a pluralistic healthcare supply landscape. Finally, we will apply these analytic frames to a range of plausible scenarios with respect to ART and try to foresee what is likely to happen. We will assume throughout this exercise that the availability of financial resources for ART will not be a problem.

Section snippets

The challenge of ART in high burden countries

The end report on “3 by 5”, the programme that aimed at having 3 million people on ART by the end of 2005, estimates that by December 2005, not 3 million, but between 1.2 and 1.3 million people received ART in low- and middle-income countries (World Health Organization & UNAIDS, 2006). The weakness of health systems and their absorptive capacity have been identified as major bottlenecks for further rapid scale-up of ART, especially in the countries with the highest HIV burden (McCoy et al., 2005

An analytic frame for assessing the healthcare supply landscape

Today, the healthcare situation in low- and middle-income countries (LMICs) and certainly in much of sub-Saharan Africa and Asia, has evolved into one that cannot adequately be described within the usual and dominant narrative of highly controlled healthcare systems. This narrative goes back a long time, reflecting to a large extent the historical equilibriums reached in industrialised societies in the first half of the 20th century, where the respective rights, functions and duties of the

Scenarios: what is likely going to happen? Impact on health systems

We distinguish several possible scenarios. In the baseline scenario, no fundamental changes occur in either the field of HRH or in the ART delivery models, or in the wider health system. In scenario A, no such fundamental changes occur either, but ART monopolises a growing share of resources including HRH, thus shifting resources away from the non-ART part of the health system. In scenario B, enough additional resources can be mobilised and they are used to strengthen the entire health system.

Which scenario? Where?

It seems unlikely that decisive action to turn the tide in AIDS can occur without fundamental changes in the health systems of the countries of Southern Africa. Whether no effective large scale ART programmes will be created (baseline scenario); or ART programmes will monopolise resources and weaken the wider health system (scenario A); or current health systems will be enormously strengthened, requiring a far larger share of society's resources (scenario B); or radically new ART delivery

References (47)

  • P. Travis et al.

    Overcoming health-systems constraints to achieve the Millennium Development Goals

    Lancet

    (2004)
  • W. Van Damme et al.

    Health system strengthening and scaling up antiretroviral therapy: the need for context-specific delivery models: comment on Schneider et al

    Reproductive Health Matters

    (2006)
  • J.M. Aitken et al.

    HIV/AIDS, equity and health sector personnel in Southern Africa

    (2003)
  • R. Apondi et al.

    Home-based antiretroviral care is associated with positive social outcomes in a prospective cohort in Uganda

    Journal of Acquired Immune Deficiency Syndromes

    (2007)
  • D. Blaauw et al.

    Organisational relationships and the ‘software’ of health sector reform. Background paper

    Disease Control Priorities Project (DCPP) capacity strengthening and management reform

    (2003)
  • A. Buve et al.

    Mortality among female nurses in the face of the AIDS epidemic: a pilot study in Zambia

    AIDS

    (1994)
  • D. Cohen

    Human capital and the HIV epidemic in sub-Saharan Africa

    (2002)
  • M. Dieleman et al.

    ‘We are also dying like any other people, we are also people’: perceptions of the impact of HIV/AIDS on health workers in two districts in Zambia

    Health Policy and Planning

    (2007)
  • D. Dovlo

    Using mid-level cadres as substitutes for internationally mobile health professionals in Africa. A desk review

    Human Resources for Health

    (2004)
  • E. Freidson

    Professionalism. The third logic

    (2001)
  • L.R. Hirschhorn et al.

    Estimating health workforce needs for antiretroviral therapy in resource-limited settings

    Human Resources for Health

    (2006)
  • J. Huddart et al.

    The health sector human resources crisis in Africa: An issues paper

    (2003)
  • Joint Learning Initiative

    Human resources for health. Overcoming the crisis

    (2004)
  • Cited by (136)

    View all citing articles on Scopus
    View full text