South Africa: Staff Shortages Cause Key ARV Programme to Falter

Medecins Sans Frontieres' (MSF) flagship antiretroviral programme in Khayelitsha is taking strain and has been forced to put patients on waiting lists as nurses and doctors struggle to cope with the growing demand.

In a report titled "Help Wanted", the humanitarian organization warns that efforts to further increase access to HIV treatment and maintain and improve quality of care are coming up against a wall due to the severe shortage of health workers.

"This is contributing to unnecessary illness and death," the authors said.

MSF began providing antiretroviral therapy in 2000 and has reached 80 000 people in more than 30 countries.

The impact of the human resource crisis is witnessed by MSF across southern Africa, the epicentre of the AIDS pandemic.

"Health workers are overwhelmed, overworked and exhausted," the report said.

Dr Eric Goemaere, head of the MSF mission in South Africa, said the clinics are inundated: "The international community says it wants to achieve universal access, and in Khayelitsha we were coming close, but at a certain point things started to collapse. We are absolutely saturated, and even with all of MSF's means, we have come back to waiting lists, and it feels again like we are losing the battle.

"For those guys sitting in offices far away from the epidemic our message is that you will be held responsible if you are not reactive or flexible enough to find solutions to the staff shortages."

MSF has been supporting provincial and city clinics in Khayelitsha since 2000, and the programme is often held up as a best-practice project worldwide.

Since 2001, 7 262 adults and children have been initiated on treatment and 5 848 (81%) remain in care.

But last December, for the 107 patients started on ARV treatment at three clinics in Khayelitsha another 396 others were put on a waiting list.

Mpumelelo Mantangana, a professional nurse at the Ubuntu TB/HIV Clinic in Khayelitsha summed up the feeling of many health workers: "When we started giving ARVs, we felt an injection of morale because we could now do something to keep our patients alive. But now, where there are so many people infected, we can't cope with the demand."

Mantangana said she was still trying to work with "passion", but that conditions were demoralizing: "The workload increases by the day. On top of that, since 2003, there are two vacant posts for professional nurses in this clinic. If it was not because I am motivated, nearly a militant, supporting the ARV roll out, I would have left long ago."

MSF has also worked in the Eastern Cape's Lusikisiki sub-district, one of the poorest and most densely populated rural areas in South Africa, where there is one hospital, 12 clinics and 80% of residents live below the poverty line.

The number of doctors in the sub-district is 14 times lower than the national level while, in 2005, almost four in ten nursing posts in the province were vacant.

MSF implemented an ARV programme at primary care level and was able to rapidly scale up treatment through task-shifting to nurses, community mobilization and the use of lay workers and community volunteers.

Utilisation of clinic services almost doubled in two years, but the number of professional nurses remained constant.

By October last year, 2 200 people were receiving ARVs with over 80% of patients remaining in care after 12 months. This programme is now run by the provincial health department.

Government's new National Strategic Plan (NSP) sets as a goal the treatment of 80% of all HIV positive people by 2011. Yet 35 000 people are already officially on waiting lists for treatment.

The plan also predicts that most people in need of treatment will receive it from nurses in primary care clinics rather than doctors in hospitals.

However, MSF cautioned that the NSP could be hampered by the human resources shortages which it said were not addressed in the health department's "Human Resources for Health Plan".

The MSF report also looked at Lesotho, Malawi and Mozambique where the situation is even more dire than in South Africa.

While South Africa has on average 74 doctors per 100 000 inhabitants, Lesotho has five, and Malawi and Mozambique only two.

The number of nurses per 100 000 in South Africa is around 393, but 62 in Lesotho, 56 in Malawi and a mere 20 in Mozambique.

n Thyolo district in Malawi, a single medical assistant can see up to 200 patients per day. In Mavalane district in Mozambique, patients are forced to wait up to two months to start ARV treatment because of lack of doctors and nurses, and many have died during the wait.

In Scott Hospital Health Service Area in Lesotho, over half of professional nursing posts at health centres are vacant while the HIV-associated workload is increasing sharply.

"Access to drugs is a necessary condition, but will not be enough to save millions of lives at risk unless priority is also given to ensure the necessary personnel to provide treatment," the MSF report concludes.