Health system resources
The capacity of health providers to deliver services is determined by the resources they can deploy. These can be divided into tangible resources such as buildings, equipment, staff and supplies, and intangible ones - the management systems that control their deployment. These are all often severely defective in high-burden countries, and will need substantial investments. It can be argued that deficiencies in human resources most severely constrain the capacity for effective service delivery.
The human resource crisis
It is widely recognized that there now exists a health workforce crisis throughout the developing world (11-13). It is characterized by a shortage and maldistribution of trained health workers caused by elevated attrition rates from, among other things, voluntary changes of occupation and emigration from poor to richer countries, a shortfall in the production of trained health workers (in part attributable to a shortage of candidates qualified by general education attainment to enter pre-service training), and a tendency to focus training efforts on the higher-level, internationally recognized cadres.
This has been a crisis in the making for several decades, and certainly existed well before the advent of HIV/AIDS, but it has been exacerbated by the epidemic (14). There has been a dramatic increase in deaths within the health workforce, attributable to AIDS (see, for example, Figure 4.1). In Malawi, 44 deaths occurring in 1997-1998 among nurses represented 40% of the annual output from training; in Zambia, 185 deaths in 1999 represented 38% of the annual output from government training schools (16). Absence because of ill-health has also dramatically increased. One study of laboratory workers in Malawi found that nearly half of total working time was lost to sickness and related causes. A secondary effect is increased absenteeism as health workers need time to care for sick relatives and to attend funerals.
Systemic solutions to the workforce crisis
Human resource specialists now agree that the crisis will only yield to systemic solutions such as substantial improvement in the basic package of pay and benefits, an expansion in the volume of pre-service training, decentralization of some aspects of personnel management, a programme of management training focused on supportive supervision, and adequate protection of the workforce against the risk of occupational exposure to HIV infection (17-19).
Systemic solutions need to link improved rewards to improved productivity. One way to do this is to make payment conditional on the meeting of performance criteria. A good example is Médecins Sans Frontières' incentive payment scheme in Thyolo District, Malawi. The incentives are given to all health workers, not just those directly involved in activities supported by Médecins Sans Frontières; payment of the incentives is discretionary and dependent on performance criteria; and the scheme is administered by local managers, thus empowering their supervision of the workforce (see Box 4.2). This isolated example illustrates reform principles of system-wide relevance.
Given the prevailing shortages, massive expansion of human resources is needed to permit scale-up of antiretroviral therapy without excessive damage to existing programmes. This implies a large number of actions including: emergency recruitment, in some cases from abroad; relaxing fiscal constraints related to public sector hiring; introducing new cadres; increasing community input; initiating treatment-focused in-service training on a large scale; and expanding pre-service training. Although the benefits of expanded pre-service training will inevitably accrue outside the short timescale of 3 by 5, delay in tackling this crucial bottleneck will impose insuperable obstacles on efforts to maintain the momentum of expanded access.
The experience of the pilot sites delivering antiretroviral therapy provides only limited guidance for the optimum staffing of future services, since they have generally been intensive in their use of human resources. New patterns of service delivery and staffing, such as those recommended by WHO (20), need to be implemented; they should entail less frequent patient contact with the provider system, rely less on skilled labour inputs, and optimize the use of inputs other than those from the formal delivery system. These new patterns imply maximum delegation of tasks within the formal health care team, and maximum involvement of community resources. On the basis of standardized treatment guidelines, competency-based training (ensuring better alignment between training and practice), adequate supervision mechanisms, and improved management systems would contribute to productivity gains. Chapter 3 described how volunteers drawn from people living with HIV/AIDS, who may already be receiving antiretroviral therapy, constitute a resource that can be deployed to good effect.
Different issues arise in the settings of middle-income countries and countries in transition, where resources are less severely constrained, the numbers of trained health workers are generally higher, and the basic capacities of health facilities are more secure. The emphasis therefore lies on ensuring, through appropriate collective financing mechanisms, universal entitlements to care that include the most vulnerable and stigmatized populations. Subsidiary concerns include reducing the cost of treatment regimes, establishing reliable diagnostic and drug distribution networks, and improving surveillance (21). Box 4.3 describes a remarkable success story.