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CAPE TOWN, Jul 21 2009 (IPS) - If developing countries want to succeed in improving their health systems, they urgently need to decentralise them and shift tasks from doctors to nurses and community health workers, said experts at the Fifth International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention in Cape Town.
Professor Alan Whiteside, director of the Health Economics and HIV/AIDS Research Division (HEARD) of the University of KwaZulu-Natal, agreed: “We probably have as much money as we’re gonna get, so we have to spend more wisely.”
He believes holding international organisations as well as national governments accountable for their spending on health is “absolutely critical” to monitor in what areas money was spent and ensure effective implementation. Whiteside stressed the fact that “HIV money needs to be used to build health systems”, not just on treatment.
“There are serious deficiencies in our health systems and without addressing the weaknesses, we cannot upscale,” warned IAS senior policy advisor Jacqueline Bataringaya. “Yet, we need an additional one million doctors, nurses and midwives in Africa.”
She suggested that because of limited funding due to the global financial crisis, developing countries needed to identify policy priorities to move forward. “We need to see what we can do with the money we’ve got,” said Bataringaya.
Scaling up the numbers of healthcare workers is key to improve health systems, Whiteside said. Shortage of skills and human resources has been lamented in Africa for many years, especially since qualified health personnel has been leaving in large numbers to work in developed countries for better pay. But little has been done to improve the situation.
According to the World Health Organisation (WHO), 37 percent of doctors trained in South Africa are working in the developed world. South African trained nurses made up almost a tenth of the workforce in Australia, Canada, Finland, France, Germany, Portugal, the United Kingdom and the United States.
Whiteside suggested setting up a tax for governments or companies in developed countries who employ health workers from developing countries to balance out the skills loss occurring in those countries.
Opposing Whiteside’s opinion, Michel Kazatchkine, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, defended the way in which financial aid has been spent, claiming that substantial budgets have been made available to increase numbers of health workers, especially in developing countries.
“A quarter of all Global Fund resources go to support the health workforce, for example towards training, task-shifting and so on. We have invested $4 billion in the last six years,” he said.
Kazatchkine admitted, however, that the gap between the standard of HIV treatment and care between developing and developed countries was still widening: “That is of huge concern. We are facing impossible dilemmas with not high enough standards of care and not enough room for patient enrolment.”
He was optimistic that more money for HIV can be found. Kazatchkine advocated finding new sources of finance, such as the Global Fund’s recently launched Debt2Health project, which erases part of a developing country’s debt, provided that half of this money is re-invested into that country’s health system.
“This is an innovative way of changing debt into proactive money,” claimed Kazatchkine. In May, Australia was the first country to write off about $60 million in Indonesian commercial debt as part of the scheme. Instead of repaying its debt to Australia, Indonesia will invest half of the total in its national health system, with particular focus on boosting tuberculosis programmes.
Another way to make health systems achieve more with limited financial resources is task-shifting, health experts agreed, which means that nurses and lay health workers take on tasks traditionally performed by doctors, such as counselling, treatment management and HIV care. This frees up doctors’ “expensive” time to focus on more serious medical issues, while making sure that larger numbers of patients are attended to each day.
“Task-shifting and community involvement are critical to fill the gap in skills and personnel,” explained Whiteside, pointing to the example of Malawi, where well-trained community care workers have been successfully taking on nursing responsibilities in homes and clinics to ease the workload of nurses and doctors.
“They are crucial because they reach out directly to homes and communities,” added Wafaa El-Sadr, director of the International Centre for AIDS Care and Treatment Programmes (ICAP). “The challenge here is how to institutionalise and remunerate these new workers and how to make them an integral part of the health system.”
This has been successfully done in Lesotho, where Scott Hospital started a nurse-initiated and managed ARV and HIV care programme for adults and children of the health district. Scott Hospital, which is located in Lesotho’s western lowlands, has 14 associated clinics, which service more than 900 villages.
While one doctor used to service the entire health district – Lesotho suffers severe health worker shortage with an average of five doctors and 63 nurses per 100,000 patients – now almost a hundred nurses and lay health workers attend to patients.
“It was a mammoth task. We have high HIV infection due to 23.2 percent HIV prevalence combined with very limited human resources. We had to be very innovative and decentralise HIV care,” explained Scott Hospital medical superintendent Dr Lipontso Makakole.
The Scott Hospital team developed nurse-friendly HIV care guidelines and implemented task-shifting: while nurses received clinical management skills to take over tasks from doctors, lay counsellors were trained to do counselling, adherence training and antiretroviral (ARV) treatment preparation to free up nurses. They also trained a new cadre of specialised HIV/TB counsellors.
“As a result, we initiated 37 percent more patients onto ARVs in 2008,” said Makakole. “80 percent of adults and 89 percent of children remained in HIV care. Those are very favourable outcomes that show that nurse-led HIV care works.”
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