Health worker shortage limits AIDS care in Africa's south

An acute health worker shortage in southern Africa is preventing many people with AIDS from getting lifesaving drugs, and Western donor policies are part of the problem, a new report claims.

Major American and European aid programs do not help pay nurses' salaries because the effort is seen as "unsustainable," says the report, released here yesterday by the medical charity Doctors Without Borders.

Also, the International Monetary Fund, by pushing countries to limit wages, has restricted African governments from raising salaries as a way of easing the "brain drain" of home-grown medical expertise, the report adds.

The report says these factors, along with poor leadership by some African governments, have slowed gains in the numbers of people being put on anti-retroviral treatment. Across sub-Saharan Africa, an estimated 70 percent of those who need the drugs go without treatment.

The health worker crisis "must be confronted as an emergency for the millions of people still waiting for treatment," said Sharonann Lynch of Doctors Without Borders, known by its French abbreviation MSF, at a news conference.

In just the four countries covered by the new report - South Africa, Malawi, Mozambique and Lesotho - more than 1 million people need treatment to survive AIDS, she said.

Western donors once resisted paying for anti-retroviral drugs (ARVs) on sustainability grounds, because patients must take them for life. But that stance was dropped, and since 2003 the number of those receiving the drugs in the region has soared from 100,000 to 1.3 million.

Now MSF wants a similar change to help pay for nurses and other staff needed to administer drugs and care for patients. It also wants the IMF to lift spending limits.

Benedicte Christensen, deputy director of the IMF's African Department, disputed MSF's view of wage ceilings and said some were designed with extra health worker spending in mind. Yet she said the fund is moving away from such caps because they are a "relatively blunt instrument"; Mozambique's cap was abolished a year ago.

The staffing shortage is severe. Lesotho, Malawi and Mozambique have far fewer health workers than the minimum levels set by the World Health Organization. Over half of professional nursing jobs in Lesotho's clinics are vacant, as nurses quit for better-paying jobs elsewhere - sometimes at groups such as MSF - or themselves die of AIDS. The situation is similar in Mozambique, which MSF says explains why new enrollments for AIDS treatment fell 30 percent from 2005 to last year.

A "ray of hope," according to the report, is an initiative in Malawi. That country made a deal with the IMF allowing raises in health workers' salaries, with assistance from the British aid program and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

In comparatively wealthy South Africa, the problem lies with the government, the report says. MSF says nurses should be allowed to prescribe anti-retrovirals, as in Lesotho, given the lack of public-sector doctors.

Dr. Eric Goemaere, the head of MSF in South Africa, described the success of a treatment program in a remote, impoverished area called Lusikisiki. More than 2,000 people with AIDS began treatment from 2003 to last year, meaning that more than two-thirds of those who needed drugs were getting them.

Nurses were integral to the effort, he said. But after MSF handed the program to the government last year, "those same nurses were told they were not allowed to initiate ARVs anymore. As a result, we saw the number of patients recruited in Lusikisiki immediately going down."

South Africa's new AIDS plan predicts that most people will receive treatment from nurses, not doctors. But current practice does not reflect that goal, and Goemaere said national health officials need to send a "clear-cut" message telling demoralized nurses that they will be allowed to play a larger role.

A spokesman for South Africa's health minister did not return phone calls.