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