Antiretroviral Treatment Antiretroviral Treatment (ART) (ART)

& Human resources& Human resources

Wim Van DammeWim Van Damme

Department of Public HealthDepartment of Public Health

ITM,ITM, 17 October 17 October 2006 2006

Programme todayProgramme today

1.1. Scale-up ART in developing Scale-up ART in developing countriescountries

2.2. Human resources as bottleneckHuman resources as bottleneck

AIDS AIDS = =

most prominent most prominent disease on political disease on political

scenescene

AIDS AIDS = =

most prominent disease on most prominent disease on political scenepolitical scene

Why?Why?

HIV prevalence in adults in sub-Saharan Africa, 1990−2005

Deaths in South-AfricaDeaths in South-Africa(a model for of future AIDS and non-AIDS Deaths)(a model for of future AIDS and non-AIDS Deaths)

0

200000

400000

600000

800000

1000000

1200000

1995 2000 2005 2010 2015

year

num

ber o

f dea

ths

Other deaths AIDS Deaths

Deaths at ages 15-34Deaths at ages 15-34South Africa: 1980-2025South Africa: 1980-2025

(Estimated and projected )(Estimated and projected )

0

400

800

1,200

1,600

2,000

Dea

ths

(th

ou

san

ds)

Without AIDS

With AIDS

1980-1985 1985-1990 1990-1995 1995-2000 2000-2005 2005-2010 2010-2015 2015-2020 2020-2025

Disease

Dead

Changes in life expectancyChanges in life expectancyin selected African countries in selected African countries

with high and low HIV prevalence: 1950-2005with high and low HIV prevalence: 1950-2005

with high HIV prevalence:ZimbabweSouth AfricaBotswana

with low HIV prevalence:MadagascarSenegalMali

30

35

40

45

50

55

60

65

Lif

e e

xp

ecta

ncy

(y

ears

)

1950– 1955

1955- 1960

1960-1965

1965-1970

1970-1975

1975-1980

1980-1985

1985-1990

1990-1995

1995-2000

2000-2005

AIDS orphans in South Africa

Orphans

AIDS = political issue…AIDS = political issue…

Because AIDS in Southern-Africa = dramaticBecause AIDS in Southern-Africa = dramatic– Demographic impactDemographic impact– Economic impactEconomic impact– Social impactSocial impact

Reduction in life expectancy Reduction in life expectancy “social involution” “social involution”

““AIDS = Unprecedented health crisis” (!! ??)AIDS = Unprecedented health crisis” (!! ??)

““AIDS = development crisis”AIDS = development crisis”

““AIDS = potential security threat”(??)AIDS = potential security threat”(??)

AIDS get a lot of AIDS get a lot of attention worldwide.attention worldwide.

What are the What are the consequences?consequences?

International reactionsInternational reactions

International International politicalpolitical reactionsreactions– to raise awareness & to raise awareness & – financial commitmentsfinancial commitments

International International policypolicy reactions reactionsaiming at operational results: aiming at operational results:

prevention, treatment & care, prevention, treatment & care, impact mitigationimpact mitigation

Political reactions … leading toPolitical reactions … leading to increased donor funding & increased donor funding & international Aids policies.international Aids policies.

Donor fundingDonor funding– World Bank: MAPWorld Bank: MAP– Creation Global FundCreation Global Fund– Private foundations: Gates & ClintonPrivate foundations: Gates & Clinton– Bush Plan (=PEPFAR)Bush Plan (=PEPFAR)

International Aids policiesInternational Aids policies– UNAIDSUNAIDS– WHO: ‘3-by-5’WHO: ‘3-by-5’

Number of people on antiretroviral therapy Number of people on antiretroviral therapy in low- and middle-income countries, 2002–2005in low- and middle-income countries, 2002–2005

North Africa and the Middle East

Europe and Central Asia

East, South and South-East Asia

Latin America and the Caribbean

Sub-Saharan Africa

Source: WHO/UNAIDS (2005). Progress on global access to HIV antiretroviral therapy: An update on “3 by 5.”

0

200

400

600

800

1000

1200

1400

End 2002

Mid-2003

End 2003

Mid-2004

End 2004

Mid-2005

End 2005

People receiving therapy (thousands)

7.1

People in sub-Saharan Africa on antiretroviral treatment People in sub-Saharan Africa on antiretroviral treatment as percentage of those in need, 2002–2005as percentage of those in need, 2002–2005

20022003

2004

2005

7.2Source: WHO/UNAIDS (2005). Progress on global access to HIV antiretroviral therapy: An update on “3 by 5.”

Tanzania21,500

(7%)

Zimbabwe24,500

(8%)

Mozambique20,000

(9%)

Malawi33,000 (20%)

South Africa206,500

(21%)

Zambia48,500 (27%)

Rwanda19,000 (39%)

Uganda75,000 (51%)

Thailand81,500 (60%)

Brazil174,000

(83%)

Botswana72,000 (85%)

Estimated people on ART (Dec 05)

Human Resources for Health Human Resources for Health (HRH) in times of AIDS(HRH) in times of AIDS

AIDS:AIDS:which consequences for which consequences for

health staff?health staff?

Who will do the job?Who will do the job?

3 steps in HRH3 steps in HRH

1.1. HRH shortages & imbalancesHRH shortages & imbalances

2.2. Impact of AIDS on HRHImpact of AIDS on HRH

3.3. HRH needs for ARTHRH needs for ART

CountriesCountries Nurses per 100 000 Nurses per 100 000 populationpopulation

Physicians per 100 000 Physicians per 100 000 populationpopulation

South AfricaSouth Africa 388388 6969SwazilandSwaziland 320320 1717BotswanaBotswana 241241 2828

ZimbabweZimbabwe 5454 1515ZambiaZambia 113113 77

MalawiMalawi 2525 11MozambiqueMozambique 2020 22BelgiumBelgium 10741074 418418

UKUK 496496 166166

USAUSA 772772 549549

Source: WHO, 2004 (last update 26 Oct 2004)

HRH shortagesHRH shortages

Training institutions

Public sector

Private-not-for-profit sector:NGOs - missions

Private-for-profit sector

Attritiondue to illness, death, retirement,

work in other sectors ...

Abroadpublic & private health facilities

Rural facilities

Management & Admin

MoH

Urban facilities

Flows in health labour market(using a country-perspective)

International organisations

OverallHRH shortages

Internal brain drain

Externalbrain drain

Maldistribution

Impact of AIDS on HRHImpact of AIDS on HRH

Increased disease burden Increased disease burden (OIs, incl. TB, Malaria?)(OIs, incl. TB, Malaria?)

Increased demand for careIncreased demand for careMore consultations More consultations More hospitalisationsMore hospitalisationsLonger hospital staysLonger hospital stays

““crowding-out effects”crowding-out effects”

AIDS AIDS Increased health Increased health

worker attrition & worker attrition & absenteeismabsenteeism

Health workers our Health workers our dying from AIDSdying from AIDS

Increased Increased absenteeism due to absenteeism due to

own illnessown illness

illness of family illness of family membersmembers

funeralsfunerals

Consequences for the Consequences for the remaining carersremaining carers

Increased workloadIncreased workload

Compelled to work longer Compelled to work longer hours, see more patients, hours, see more patients, assume more tasksassume more tasks

““Burn-out”Burn-out”

Workplace security Workplace security (perceived?) risk of HIV (perceived?) risk of HIV infectioninfection

Training institutions

Public sector

Private-not-for-profit sector:NGOs - missions

Private-for-profit sector

Attritiondue to illness, death, retirement,

work in other sectors ...

Abroadpublic & private health facilities

Rural facilities

Management & Admin

MoH

Urban facilities

Flows in health labour market(using a country-perspective)

International organisations

OverallHRH shortages

Internal brain drain

Externalbrain drain

Maldistribution

Acceleration of Acceleration of HRH flows ??HRH flows ??

HRH crisisHRH crisisin sub-Saharan Africain sub-Saharan Africa

Absolute shortages & mal-Absolute shortages & mal-distributiondistribution

Worsened by AIDSWorsened by AIDS

workload workload ↑↑↑↑↑↑

(?) Accelerated flows &(?) Accelerated flows &

Brain drainBrain drain

ART = labour intensiveART = labour intensive

South-Africa: team of 11 staff for 500 South-Africa: team of 11 staff for 500 patients on ART: 1 doctor, 2 nurses, 5 patients on ART: 1 doctor, 2 nurses, 5 counsellors, …counsellors, …

WHO review: 5 to 7 staff for 1000 patientsWHO review: 5 to 7 staff for 1000 patients

Usually doctor-based modelsUsually doctor-based models

PLWHAs per PLWHAs per medical doctormedical doctor

PLWHAs per PLWHAs per nursenurse

CambodiaCambodia 7575 2020

ThailandThailand 3030 66

BrazilBrazil 22 77

Health workers & PLWHAsHealth workers & PLWHAs(2004 data: UNAIDS & WHO)(2004 data: UNAIDS & WHO)

PLWHAs per PLWHAs per medical doctormedical doctor

PLWHAs per PLWHAs per nursenurse

BotswanaBotswana 676676 8181

UgandaUganda 397397 3737

South AfricaSouth Africa 171171 3030

CambodiaCambodia 7575 2020

ThailandThailand 3030 66

BrazilBrazil 22 77

PLWHAs per PLWHAs per medical doctormedical doctor

PLWHAs per PLWHAs per nursenurse

MalawiMalawi 7,4357,435 286286

MozambiqueMozambique 3,4463,446 328328

ZimbabweZimbabwe 2,3372,337 260260

TanzaniaTanzania 2,1642,164 117117

RwandaRwanda 1,4901,490 142142

ZambiaZambia 1,2161,216 7575

SwazilandSwaziland 1,1351,135 6464

BotswanaBotswana 676676 8181

UgandaUganda 397397 3737

South AfricaSouth Africa 171171 3030

CambodiaCambodia 7575 2020

ThailandThailand 3030 66

BrazilBrazil 22 77

““Emergency HRH plans”Emergency HRH plans”TTR = treat – train - retainTTR = treat – train - retain

Treat health workersTreat health workers

Investment in HRH / health Investment in HRH / health systemssystemsNeed for more HRH throughNeed for more HRH through

Training?Training?

Retention?Retention?

Importation?Importation?

Innovative solutions for Innovative solutions for ART deliveryART delivery

– ““Task shifting”…Task shifting”…… … from MDs to clinical officers to nurses to from MDs to clinical officers to nurses to … ‘lay providers’? Or community health … ‘lay providers’? Or community health workers? Simplification of treatment workers? Simplification of treatment protocols?protocols?

Group treatment?? – peer treatment?? Group treatment?? – peer treatment?? (expert patients?)(expert patients?)

Implications: legal – financial – mentality Implications: legal – financial – mentality - …- …

““Need for a paradigm shift”??Need for a paradigm shift”??

In conclusionIn conclusionAIDS in high-prevalence countries =AIDS in high-prevalence countries =– dramatic for societydramatic for society– dramatic for health systemdramatic for health system

To tackle AIDS needs important investment ($/€) To tackle AIDS needs important investment ($/€) – but: feasible– but: feasibleMoney = becoming available (Global Fund – Money = becoming available (Global Fund – PEPFAR)PEPFAR)But: capacity constraints: Who will do the job?But: capacity constraints: Who will do the job? investment needed in health system, investment needed in health system, including human resources + adaptation of including human resources + adaptation of treatment modelstreatment models