The chanting of the AIDS activists could be heard throughout the last global AIDS meeting held in 2006 in Toronto, Canada. “Where are the doctors?! Where are the nurses?!” Now that the cost of antiretroviral medicines has declined dramatically, one of the main barriers to care for people living with HIV/AIDS is the shortage of healthcare workers to provide the treatment.
The Bank in Action
But the World Bank already had a team working on the issue. In 2005, the Bank’s African Health Workforce Program received $1.6 million from the Bill & Melinda Gates Foundation and the government of Norway to address the shortage, low productivity, and maldistribution of health workers throughout Africa. The program has conducted analysis on how to train large numbers of appropriate workers and how to retain and motivate existing workers in areas of greatest need. One of the main accomplishments of the Africa Health Workforce team is the building of an evidence base to determine what type of incentives motivate health workers to stay in country.
HIV test performed at a health clinic in Ouagadougou, Burkina Faso (Photo by Arne Hoel, World Bank)
There have been lots of surprises along the way.
Conventional wisdom says that increased wages are the most important factor in retaining and motivating health care workers, particularly in eastern and southern African countries hard hit by the HIV/AIDS epidemic. In these countries many health workers have died of HIV/AIDS and many, exhausted by the increased workload brought about by the increased health needs of people living with HIV/AIDS, have migrated to other countries. Those who stayed face poor working conditions, insufficient training and isolation.
Yet the Africa Health Workforce team found that it was often improved equipment, safe housing, and access to training that motivated workers to stay. Improved housing, properly equipped clinics, and education for their children often ranked higher than wages. The finding was particularly important in many African countries where raising health workers’ wages is expensive and often leads to demands for wage increases from civil servants in other sectors.
A doctor examines an AIDS patient at a health clinic in Ouagadougou, Burkina Faso (Photo by Arne Hoel, World Bank)
When the AIDS Campaign Team for Africa (ACTafrica), led by Elizabeth Lule, and Kate Tulenko of the Africa Health Workforce team led by Agnes Soucat, met with representatives from global unions in 2007 they received a big surprise. Asked what would be the single most important step to improving health worker retention and job satisfaction, union representatives said it wasn’t wages or promotions—it was protection from occupational exposure to HIV/AIDS. Most of the unions’ members did not have the training, equipment, or systems to effectively protect themselves from accidental needle sticks and other potential work-related exposure to HIV. This was especially true in hospital settings where over half the patients are HIV positive. If they were stuck by a needle, there often was no way for them to receive either emergency preventive treatment or long term anti-retroviral treatment should they contract HIV.
In response to the union’s request, Tulenko, together with Bekir Onrusal of the World Bank Safeguards Group, drafted guidelines for integrating safe disposal of “sharps” into the Bank’s healthcare safeguards, safeguards that informed the African Health Workforce Program. The Bank’s waste plans were already addressing the disposal of sharps but tended to do so in a way that did not protect healthcare workers. A few simple measures, such as providing gloves and puncture-proof sharps containers, can drastically reduce the number of occupational HIV infections and keep healthcare workers healthy as they perform lifesaving duties.
Collaborating to Protect Health Workers
Supply of the anti-retroviral drug Nevirapine at a health clinic in Ouagadougou, Burkina Faso (Photo by Arne Hoel, World Bank)
The team also worked with the World Health Organization (WHO) on its “Treat, Train, Retain” guidelines to help countries increase the number of healthcare workers providing HIV/AIDS care. The guidelines addressed “Task Shifting,” a team-based approach to HIV/AIDS prevention, treatment, and care that replaces the outdated physician-nurse model.
“It’s the ultimate in improving efficiency,” said Tulenko. “Instead of just two types of health care workers, you have an entire team, with effective division of labor. Each team member specializes in a component of HIV/AIDS care. Such approaches have been successful in a variety of developed and developing country settings including the United Kingdom, the United States, Malawi, and Uganda,” she said.
Often used are “physician extenders” such as physician assistants, mid-level cadres such as medical officers, nurse practitioners or nurse midwives, and front line workers such as sanitarians and community health workers. Such teams can provide higher quality care at a lower per patient cost to a large number of patients. The Bank team also recommended country-specific costing and financing plans both for short term investment costs such as initial training of new workers and long term recurrent costs such as the wages of newly hired workers. The team shared with WHO the health worker costing tool it had developed. This spreadsheet has been used by WHO’s Global Health Workforce Alliance as the basis for its costing tool.
In Mexico City this week, the results of the Africa Health Workforce Program’s work on HIV/AIDS will be presented as part of the launch of The Changing HIV/AIDS Landscape, a compendium of selected papers prepared in conjunction with The World Bank’s Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007-2011. The launch takes place at the XVII International AIDS Conference.