AIDS at 25

I saw my first pillowcase stenciled with the words "Fight AIDS: Fund Health Workers Now" at the opening ceremonies. Then, Wednesday night, I nearly tripped over the one pictured at right as I exited the conference center. On opening night, the message struck me as obvious and the issue of human resources in the health sector, quite frankly, as dull.

No longer.

The extent of the human resource crisis--and my use of the word crisis here is well founded--was driven home to me that very afternoon. It was the statistic that the world needs 1 million health-care workers to cope with AIDS that swayed me. It was also the nurse who reminded us that it is primarily nurses who care for AIDS patients in rural areas--in Zimbabwe and elsewhere--where there are no doctors (or pain killers or IV fluids). And it was the 79-year-old Zambian doctor who's still rallying on behalf of his sick patients everyday, and who called on the experts not to overlook what his generation may still have to offer. It was the appalling fact that in Botswana between 1999 and 2005, 17 percent of health-care workers died of AIDS.

Leonard Rubenstein, director of Physicians for Human Rights, moderated the session entitled "Human Resources and HIV/AIDS: Advancing Health Workforce Capacity in Delivering Care, Treatment and Support," along with Shoji Nishimoto from UNDP. (Rubenstein noted that the bland title belied the crisis at hand.) People weren't talking about human resource shortages, even two years ago in Bangkok, according to Rubenstein. Yet, it's been on the horizon for decades, and has emerged as one of the major themes of the conference. The countries hardest hit are in Sub-Saharan Africa, the countries also carrying the highest disease burden, as well as Bangladesh, Indonesia, and India.

The four invited speakers outlined the scope of the issue, the factors contributing to it, and what steps are being taken--or should be taken--to address it. I've already touched on the scope, so here's a list of contributing factors, according to speaker Teguest Guerma, associate director, HIV/AIDS department at the WHO:

1) Recruitment - poor investment in training and enrollment of health service providers
2) Distribution - unequal distribution between urban and rural areas and between the public and private sectors
3) Attrition - death from AIDS, resignation (often due to burn out), brain drain (to countries of the North and West), and retirement

What can be done in the short, medium and long term?

Short-term Solutions
Several countries, including Malawi, have created "emergency plans" to deal with personnel shortages. (Malawi's health leaders were at first rebuffed by the Global Fund when they applied for funding to support a human-resources initiative, but they were able to persuade its leaders that the sector was near collapse and required an emergency response.)

Medium/Long-term Solutions
This week, the WHO launched the 10-year Treat, Train and Retain plan. (See here for details.) And the EU is stepping up with a greater financial commitment to developing countries, but more importantly has recognized that it needs to better manage its own vast health-care system to stop the flow of skilled personnel out of Africa and Asia to the EU. The UK already has a code in place about the ethical recruitment of health-care workers and the EU is considering adopting something similar.

A Global Solution:
The final speaker, lawyer and activist Mark Heywood with South Africa's Treatment Action Campaign, spoke in broader terms, laying much of the blame and the need for solutions on the developed world.

"I believe that the HR crisis is not just a global crisis but a globalized crisis. What I mean by that is if you pull the string in one part of the world, it unravels in other parts of the world. Canada steals health-care workers from South Africa, which steals from other African countries, which steal from the private sector, which steals from rural areas. Therefore we need a globalized effort to remedy this, not stop-gap procedures."

In terms of solutions, Heywood called for a redefinition of roles within the health-care sector to offset HR constraints: "The WHO should recommend that the large informal health sector that exists in most of these countries are brought into the formal structure of the health care industry."

He also proposed an international agreement on recruitment of health-care workers that binds countries in conduct.
"Voluntary agreements will not work," he asserted. "Already the British agreement is being circumvented. We have to look at something more binding."

Finally, he labeled the HR crisis a human rights issue: "The highest attainable standard of health needs to be quantified and it needs to be a moral and legal driver."

Despite the panelists differing rhetoric, one thing was clear: They all agreed that if the global community succeeds in addressing the human resource crisis, it will not only serve people living with HIV/AIDS but the entire public health, setting these nations on a stronger development track.