PAPER: Health systems and access to antiretroviral drugs for HIV in Southern Africa: service delivery and human resources challenges.
Health systems and access to antiretroviral drugs for
HIV in Southern Africa: service delivery and human resources challenges.
Abstract
Without strengthened health systems,
significant access to antiretroviral (ARV) therapy in many developing countries
is unlikely to be achieved. This paper reflects on systemic challenges to
scaling up ARV access in countries with both massive epidemics and weak health
systems. It draws on the authors' experience in southern Africa and the World
Health Organization's framework on health system performance. Whilst
acknowledging the still significant gap in financing, the paper focuses on the
challenges of reorienting service delivery towards chronic disease care and the
human resource crisis in health systems. Inadequate supply, poor distribution,
low remuneration and accelerated migration of skilled health workers are
increasingly regarded as key systems constraints to scaling up of HIV
treatment. Problems, however, go beyond the issue of numbers to include
productivity and cultures of service delivery. As more countries receive funds
for antiretroviral access programmes, strong national stewardship of these programmes
becomes increasingly necessary. The paper proposes a set of short- and
long-term stewardship tasks, which include resisting the verticalisation of HIV
treatment, the evaluation of community health workers and their potential role
in HIV treatment access, international action on the brain drain, and greater
investment in national human resource functions of planning, production,
remuneration and management.
Schneider, H., Blaauw, D., Gilson,
L., Chabikuli, N., & Goudge, J. (2006). Health systems and access to
antiretroviral drugs for HIV in Southern Africa: service delivery and human
resources challenges. Reproductive health matters, 14(27),
12-23.
Aim of this paper
Pp 13
This paper
reflects on the task of scaling up HIV treatment in the face of generalised HIV
epidemics (i.e. massive need) and fragile health systems
HIV delivery is focus on “hardware”
rather than “software”
Pp 16
These models of
HIV care share more with chronic disease care than TB control. Contem- porary
approaches to chronic disease care are explicit in highlighting the need for
ensuring adequate resources for the technologies of inter- vention (e.g.
protocols and systems) as well as building ‘‘informed, motivated and adequately
staffed teams’’, operating in partnership with ‘‘informed and empowered
patients’’.22 While both are
necessary components of a whole, the focus in disease programmes globally has
tended to be on technologies rather than on the relation- ships between people,
on the ‘‘hardware’’ rather than ‘‘software’’ of service delivery.23
Culture of service delivery may
related to quality of health workers. Health workers may be part of victim
within a health systems: poor wages, overwhelming rules, neglected by their
dictors, earn low living wages
The challenge of
creating resources
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High levels of HIV
infection amongst health personnel may be one contributor to attrition of
personnel in some countries.38 By the late 1990s,
deaths constituted more than 40% of all nurses lost to the public sector in
Malawi and Zambia,29 while in South
Africa in 2002, 16.3% of health workers were infected with HIV.39
Health workers in
many countries, particularly lower level cadres, are paid salaries well below
subsistence levels. Non-payment of salaries is not uncommon.40 Moreover, with currency de- valuations and
salary freezes imposed through structural adjustment programmes, many health
workers have experienced dramatic reversals in their incomes over time.25 A poorly remunerated workforce is unlikely to
be a productive one.
Aggregate ratios
of health personnel at national level hide large disparities within countries;
the brain drain is as much an internal problem as an international one. The
liberalisation of the private for-profit sector in many countries and the pro-
liferation of non-governmental organisations have made possible a flight out of
the public sector and rural areas within countries.35 The consequences of such flows are not only
shortages but also a high turnover of staff and loss of institutional memory.
Pp 19
Cultures of service
delivery
A less tangible
but no less significant dimension of the human resource crisis is the
demoralisation and demotivation of those remaining within the system.28 Demotivated health workers are less inclined
to orient their actions towards the achievement of organisational goals and may
be less willing to balance self-interested behaviour with altruism and
solidarity towards users of ser- vices.41 In many health systems, underpaid health workers have
increasingly looked to health sys- tems as a means to ensure their own survival
rather than as an avenue for expression of professional and societal norms of
caring and altruism.40,42,43
In the context of
HIV treatment, these entrenched norms of service delivery limit the ability to
create individualised, patient-centred therapeu- tic partnerships premised on
rights and equality between providers and patients. In addition, poorly planned
and overly hasty introduction of new drugs into such environments may promote perverse
incentives and informal economies of drug use that undermine access and
accelerate the development of drug resistance.
Effective
stewardship (the job
of supervising or taking care of something, such as an organization or property) for
better health systems
Pp 20
Shaping values
forms an essential part of the oversight of health systems referred to by WHO
as ‘‘stewardship’’, the process of setting the rules of the game, determining
not only the content of health policy but also the mechanisms by which policy
is implemented.46 Although a
national function, effective stewardship is as much a global concern insofar as
international responses to the health crisis in sub-Saharan Africa have often
served to fragment, rather than strengthen, the sovereign capacity of country
health systems.9,10
Pp 20
In a context of
multiple pressures – interna- tional and national expectations, proliferation
of donor assistance, the danger of drug resistance and need for capacity
development and innova- tion at all levels of the health system – appro- priate
national stewardship of HIV treatment programmes is not only an essential but
also a highly strategic task. It involves a willingness to view the resources
mobilised for HIV as an opportunity to re-build national health systems, whilst
simultaneously creating the capacity to respond to the immediate need for
access to treatment. The challenge can be summarised as a set of short-term and
long-term goals focused on the development of systems (embodied in the notion
of chronic disease care) for HIV treatment specifically and health systems more
generically (Table 3).
Pp 20
Systems for
chronic disease care would include setting national standards (e.g. on drug
regi- mens), enabling sharing of local experiences and lessons learned, opening
up debates on the patient–provider relationship, and as the scale- up process
proceeds, monitoring equity of access. Effective stewardship also requires
resisting the tendency towards verticalisation (often in order to meet targets)
of programme initiatives and ensuring that treatment access occurs as much as
possible in an integrated fashion through the existing public health system.
This requires iden- tifying opportunities for building on existing strengths
(such as sector-wide approaches) and finding ways to draw in the multiplicity
of actors on the margins of the formal health system. Inte- gration can be
viewed at a number of levels: at the point of service delivery, in the
management of programmes at district or local level, and in the financing,
procurement of resources and moni- toring of programmes at national level.
Pp 20
There is growing
consensus that a long-term perspective on ARV scale-up has to address the
critical shortage of human resources.28 This would include at a minimum:
promoting
international action on the brain drain;
at country level
(re)investment in traditional human resource functions such as planning,
production, remuneration and management of health care providers;
addressing
macro-economic constraints on employment and remuneration of health care
providers;
evaluation of the
performance of existing nationally developed cadres such as mid-level and
community health workers and their poten- tial role in HIV treatment scale-up.
Pp 21
Conclusions
Without
strengthened or even transformed na- tional health systems it is hard to see
how access to ARVs can be sustainably achieved in coun- tries with weak health
systems. To be effective, ARVs also require integration into a continuum of HIV
care, best modelled on understandings developed in the field of chronic disease
care. The scale of this challenge in countries with generalised HIV epidemics
cannot be under- estimated. However, insofar as the ARV scale- up process
cannot avoid drawing attention to health system weaknesses, it provides an opportunity,
firstly, to reassert a coherent approach to national health systems and
secondly, to ensure that funds mobilised for treatment access are oriented
towards long-term goals, rather than just short-term access targets.
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