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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS (2005)

Chapter: Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries

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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

Appendix C
Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries

Gilbert Kombe, Xingzhu Liu, Nancy Pielemeier, Catherine Decker

Abt Associates

BACKGROUND

There is broad recognition that human capacity is a critical constraint in scaling up HIV/AIDS services in low-resource countries. Difficulties in producing and retaining a sufficient number of health workers is not a new problem, but the sheer magnitude of the HIV/AIDS epidemic and its impact on human resources (HR)1 through an array of supply and demand-side factors has made the problem worse (Smith, 2004). For example, in sub-Saharan Africa, both budgetary stringency and fiscal economic crises have reduced the governments’ ability to attract and train health workers, as well as to retain them and maintain their morale. Studies indicate that the numbers of trained health workers in many low resource areas remain insufficient and currently many such settings are experiencing serious scarcities of almost all cadres due to economic and fiscal difficulties (USAID, 2003). According to the World Health Organization (WHO), about 100,000 health workers globally need to be trained in order to reach the target to deliver antiretroviral therapy (ART) to 3 million people. These health workers include those involved in managing and delivering antiretroviral treatment services, those working on testing and counseling, and community treatment supporters assisting people living with HIV/AIDS who are receiving medication (WHO, 2003).

1  

The term “human resource” is interchangeably used with “health care workers,” “health workers,” and “providers.”

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

There are many reasons why the United States Government (USG) should invest in understanding the magnitude and complexity of HR issues in the 15 focus countries. First, these countries account for more than 50 percent of all global infections and nearly 75 percent of all HIV infections in Sub-Saharan Africa. It is estimated that without a significantly expanded response to the epidemic, more people will become infected in the next few years. Second, there is compelling evidence from published and unpublished reports that the 15 countries studied have a critical shortage of human resource stock. The current ratio of key health workers to population in each country is not encouraging. According to the latest available information, 7 of the 15 countries have a ratio less than one doctor to 5,000 and 6 of them have a ratio below one nurse to 2,000 inhabitants as shown in Table C-1. These ratios are well below the WHO recommended minimum standard of one doctor per 5,000 inhabitants and one nurse per 500 population. Third, understanding the number of available health care workers, their skill mix, training needs, and the distribution of such personnel is essential in planning a USG response to fill in HR gaps through allocation of appropriate resources. This information can also be of critical value to countries themselves in developing appropriate strategies to address the HR problems to improve their overall health systems. As the President Emergency Plan for AIDS Relief (PEPFAR) countries begin to scale up HIV/AIDS activities, increased attention should focus on identifying and addressing these HR constraints.

The objective of this paper is to provide broad estimates on the quantity and mix of human resources needed to deliver full HIV/AIDS services in PEPFAR countries. The paper is organized in the following manner. First, the paper presents the methodological approach used in the analysis. Second, it presents specific findings on the current and projected future HR stocks, projects the HR needs to provide full HIV/AIDS services2 under PEPFAR targets, and identifies the gaps. Finally, it recommends strategies to fill these HR gaps, discusses policy implications and the way forward.

METHODOLOGICAL APPROACH

A comprehensive desktop review of published and unpublished documents was conducted to obtain information on human resources in the 15

2  

The term “full HIV/AIDS services” used here refers to antiretroviral therapy (ART), voluntary counseling and testing (VCT), prevention of mother-to-child transmission (PMTCT) and treatment of opportunistic infections (OIs). It excludes activities such as care of orphans and vulnerable children, information education and communication, condom distribution, management information systems, etc.

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

TABLE C-1 Basic HIV/AIDS Indices and Human Resource Status in the 15 PEPFAR Focus Countries

Country

Population (year)

 

Population with HIV (15–49)b

HIV Prevalence (15–49) %b

Botswana

1,646,640

(1999)a

270,000

37.3

Cote d’Ivoire

14,685,000

(1996)d

530,000

7.0

Ethiopia

68,613,470

(2003)a

1,400,000

4.4

Kenya

27,390,000

(1995)d

1,100,000

6.7

Mozambique

17,691,000

(2000)a

1,200,000

12.2

Namibia

1,750,000

(1997)d

200,000

21.3

Nigeria

126,910,000

(2000)a

3,300,000

5.4

Rwanda

8,163,000

(2002)a

230,000

5.1

South Africa

44,812,420

(2001)a

5,100,000

21.5

Tanzania

35,181,300

(2002)a

1,500,000

8.8

Uganda

24,600,000

(2002)a

450,000

4.1

Zambia

10,402,960

(2003)a

830,000

24.6

Haiti

7,797,000

(1998)d

260,000

5.6

Guyana

759,000

(2000)a

11,000

2.5

Vietnam

79,492,930

(2001)a

200,000

0.4

aWorld Development Indicators Database, World Bank (http://devdata.worldbank.org/dataquery/).

b2004 Report on the Global AIDS Epidemic, UNAIDS.

PEPFAR focus countries. The latest available data were collected from various databases and documents from sources such as UNAIDS, WHO, World Bank, etc. Information was also supplemented by country assessments conducted by the Partners for Health Reformplus Project and other collaborating agencies. The WHO online Global Atlas of the Health Workforce was the primary source of data on the current HR stock for each country by year and by profession.3

In making HR projections, a number of key assumptions were applied. We discuss five assumptions that have the most impact on human resource

3  

This database has the latest available data on health personnel including doctors and nurses for all PEPFAR countries. Some statistics were found on pharmacists and midwives but not for all 15 countries. Personnel such as lab technicians and counselors were not included. Based on a previous conversation with the database manager, for some countries, both public and private sector data are included, although it is unclear how consistently private sector HR data are included across countries.

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

Total Number of Doctors (year)c

Doctor per Population Ratio

Total Number of Nurses (year)c

Nurse per Population Ratio

488

(1999)

3,374

4090

(1999)

403

1,322

(1996)

11,108

6,785

(1996)

2,164

1,162

(2003)

59,048

14,123

(2003)

4,858

3,616

(1995)

7,575

24,679

(1995)

1,110

435

(2000)

40,669

5,078

(2000)

3,484

516

(1997)

3,392

4,978

(1997)

352

30,885

(2000)

4,109

154,000

(2003)

824

155

(2002)

52,665

1,745

(2002)

4,678

30,740

(2001)

1,458

172,338

(2001)

260

822

(2002)

42,800

13,292

(2002)

2,647

1,175

(2002)

20,936

2,200

(2002)

11,182

756

(2003)

13,761

10,558

(2003)

985

1,949

(1998)

4,001

834

(1998)

9,349

366

(2000)

2,074

1,738

(2000)

437

42,327

(2001)

1,878

59,201

(2001)

1,343

cAll statistics come from WHO online Global Atlas of the Health Workforce (www.who.int/GlobalAtlas/home.asp) except data on Ethiopia (“The Human and Financial Resource Requirements for Scaling Up HIV/AIDS Services in Ethiopia.” Kombe et al. February 2005. PHRplus), (“Health Manpower Situation in Nigeria: Nigeria, 1995-2000.” Health Manpower Registration Councils/Boards) and Zambia.

d“Human Resources for Health: Overcoming the Crisis.” Joint Learning Initiative, 2004.

needs for providing full HIV/AIDS services. First, with regard to ART, individual country targets for ART were estimated by determining country weights based on the number of infected adults in the individual country divided by the total number of infected adults in all 15 countries. This number was then multiplied by 2 million to obtain the individual country target for ART. Second, we assumed that all patients not receiving ART would need OI care. Therefore, OI targets were estimated by subtracting the ART target from the estimated number of patients eligible for ART.

Third, it is assumed that VCT and PMTCT will be gateways to HAART in a manner characterized by certain key ratios. It is assumed here that the diagnosis rate of HIV-positive individuals is twice the country-specific prevalence rate (to account for self-selection). Also, it is assumed that 20 percent of those identified as HIV positive individuals will be clinically eligible as suggested under the PEPFAR Initiative. Fourth, we estimated the HR need by multiplying the number of encounters per patient by the time needed per encounter by the size of target population. The total time is then converted into person-year by considering the number of working days per

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

year (180), and the number of effective working hours (6),4 and the average share of provider’s time used for HIV services (50 percent).5 We then multiply the number of person-years by (a) the number of people in need of HIV/AIDS services and (b) the PEPFAR target population.

The fifth assumption deals with estimating projected HR growth over the next 5 years. The annual growth rate of the HR stock of each country over the next 5 years is assumed to be equivalent to the annual growth rate of the past 5 years. The aggregate growth rate is the weighted average of the growth rates of individual countries—estimated at 4.5 percent.

MAIN FINDINGS

Five main findings can be drawn from this paper. First, as shown in Table C-2, the total human resource stock available in 2004 is estimated at 566,580. This number does not include community health workers, counselors, and social workers due to lack of data. Nurses and midwives6 make up the majority (74 percent) followed by doctors (21 percent), and pharmacists (5 percent). Applying the 2004 baseline data and assuming that existing conditions are not going to change, the projected growth in the total number of health workers will increase from 566,580 in 2004 to 592,076 in 2008 at an annual rate of approximately 4.5 percent. This increase is primarily driven by Nigeria, South Africa, and Vietnam, all countries with large populations and high personnel totals. Meanwhile, countries like Tanzania and Uganda will see a decrease in the total HR stock. The remaining 10 PEPFAR countries will have a minimal growth in the next 4 years.

Second, to provide full HIV/AIDS services to all eligible patients, the total human resource need is about 78,360 in 2004, rising to 95,246 in 2008. To reach PEPFAR targets, the total human resource need is about 11,232 in 2004, but by 2008, this figure will increase to 56,146 due to the planned scale-up of PEPFAR funded programs (see Table C-3 for country specific data). It must be noted that PEPFAR needs are a subset of the total number of health workers to provide full HIV/AID services.

Third, the question of how many health workers have been trained in the 15 PEPFAR countries has been a subject of debate by many health planners. It is estimated that on average 10 percent of the health workers

4  

Based on workforce study in Zambia, on average a doctor spends approximately 18.5 minutes per visit (average of 22 minutes for the initial visit and 15 minutes for follow-up visits) with a patient on ART (Huddart et al. 2004).

5  

Therefore, full time equivalent (FTE) requirements are half those presented below.

6  

Nurses and midwives are categorized together in this study.

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

TABLE C-2 Current and Projected Human Resource Stock in the 15 PEPFAR Focus Countries

Gross Human Resource Stock by Type

Available in:

2004

2005

2006

2007

2008

Doctors

117,523

123,230

129,265

135,649

142,403

Nurses

419,906

424,247

429,246

434,864

441,071

Pharmacists

29,151

29,930

30,755

31,604

32,484

Total

566,580

577,407

589,266

602,117

615,958

Estimated number of health workers trained in HIV care

56, 658

57,245

57,865

58,518

59,208

including doctors, nurses and pharmacists have already been trained in full HIV/AIDS service provision in each of the countries. Based on this assumption, the number of available staff trained to provide HIV/AIDS services is 10 percent of the figures shown in Table C-2, increasing from 56,658 to 59,208 between 2004 and 2008 respectively. There has also been a lot of debate on how many health workers are needed to reach the PEPFAR goals of 2 million people on ART, preventing 7 million infections, and providing care to 10 million orphans and vulnerable children. Under the PEPFAR initiative, in 2005, the total number of trained health workers needed to reach PEPFAR targets is approximately 4,431.7 This number will almost double in 2006 to roughly 8,676.

Fourth, we explore the issue of “human resource gap” by comparing the trained health workers with estimated HR needs over the next 4 years. The HR gap is an indication of the severity of human resources shortages. To put this into context, the magnitude of HR Gap is illustrated for doctors, nurses and pharmacists. As shown in Figure C-1, in 2004 the number of trained doctors falls well short of those needed to treat all patients eligible for HIV services.

The gap is widest for pharmacists, followed by doctors, with nurses showing a gap of only 10 percent (having 41,991 trained out of 46,635 needed). In all three cases the gap widens as time goes by, resulting in insufficient numbers of trained doctors and pharmacists for the provision of PEPFAR services in 2008. This human resource gap exists for both

7  

Note that the HR gap to reach the PEPFAR targets is a subset of the gap to reach all of those in need.

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

TABLE C-3 Estimated Total of Key Health Workers Needed to Deliver Health Services in the 15 PEPFAR Focus Countries

 

 

2004

Country

Staff Type

Available

PEPFAR Needed

Botswana

Doctors

488

66

Nurses

4,090

66

Pharmacists

160

35

Cote d’Ivoire

Doctors

1,322

89

Nurses

6,785

200

Pharmacists

378

46

Ethiopia

Doctors

1,971

232

Nurses

4,160

703

Pharmacists

95

118

Kenya

Doctors

3,616

215

Nurses

24,679

419

Pharmacists

1,370

112

Mozambique

Doctors

435

210

Nurses

5,078

433

Pharmacists

419

108

Namibia

Doctors

516

34

Nurses

4,978

44

Pharmacists

149

17

Nigeria

Doctors

30,885

580

Nurses

108,230

1,537

Pharmacists

8,642

300

Rwanda

Doctors

155

41

Nurses

1,745

91

Pharmacists

11

21

South

Africa Doctors

30,740

872

Nurses

172,338

1,371

Pharmacists

10,742

453

Tanzania

Doctors

822

269

Nurses

13,292

540

Pharmacists

365

140

Uganda

Doctors

1,175

103

Nurses

2,200

154

Pharmacists

125

55

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

2006

2008

Available

PEPFAR Needed

Available

PEPFAR Needed

551

197

622

329

4,451

197

4,844

329

173

106

188

177

1,444

268

1,577

447

7,409

601

8,091

1,002

413

138

451

230

2,167

695

2,383

1,159

4,176

2,109

4,192

3,516

106

354

119

589

3,949

646

4,312

1,076

26,950

1,256

29,430

2,094

1,496

337

1,634

562

529

629

643

1,048

5,162

1,298

5,247

2,163

434

323

449

538

563

102

615

169

5,436

132

5,936

219

163

52

178

87

35,911

1,739

41,755

2,898

108,230

4,610

108,230

7,684

8,642

599

8,642

1,498

169

123

185

204

1,906

274

2,081

457

12

63

13

105

33,556

2,616

36,630

4,361

172,338

4,112

172,338

6,853

11,189

1,358

11,655

2,264

727

808

643

1,347

9,696

1,619

7,073

2,698

323

419

285

698

1,283

310

1,401

517

1,514

461

1,043

768

131

165

143

275

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

 

 

2004

Country

Staff Type

Available

PEPFAR Needed

Zambia

Doctors

756

152

Nurses

10,558

242

Pharmacists

75

79

Haiti

Doctors

1,949

44

Nurses

834

109

Pharmacists

557

23

Guyana

Doctors

366

2

Nurses

1,738

6

Pharmacists

86

1

Vietnam

Doctors

42,327

31

Nurses

59,201

853

Pharmacists

5,977

16

reaching all those in need and reaching the PEPFAR targets. The current trained HR stock is not enough to provide full HIV/AIDS services to all those in need.

To further illustrate this HR gap, we analyzed the gap for doctors across the 15 countries. As shown in Box C-1, the 15 countries were divided into six categories according to the adult HIV prevalence rate (for those aged 15–49) and doctor gap (total need for doctors divided by total stock of doctors) multiplied by 100 to give percentage). The HR gap was divided into three groups: severe, moderate and low. Prevalence was divided into high (greater than 6 percent) and low (less than 6 percent).

An initial review of the HR gap for doctors points towards an association between the gap of a country and its HIV prevalence rate. First, none of the countries with high HR gaps have low HIV prevalence rates. Second, all of the low prevalence countries are either low or medium HR gap countries.

In general, the estimated HR gap in many countries will increase along with the scaling-up of PEPFAR programs year by year. Countries such as Cote D’Ivoire, Vietnam, and Guyana have only a modest doctor gap, while Tanzania, Mozambique, Botswana, and Zambia have large gaps. It is vital to point out that in the latter countries, the provision of HIV/AIDS services will absorb more than 100 percent of the available stock because the total doctor need is larger than the available stock. Namibia, Ethiopia, Rwanda, Uganda and Kenya have medium gaps and are expected to absorb over 50

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

2006

2008

Available

PEPFAR Needed

Available

PEPFAR Needed

783

455

810

758

10,558

726

10,558

1,210

75

236

75

393

2,128

133

2,224

222

911

327

952

545

608

69

636

115

400

6

436

10

1,898

17

2,073

29

94

3

103

5

45,105

92

48,066

153

59,201

2,560

59,201

4,266

6,096

47

6,217

79

percent of the doctor stock for the provision of HIV/AIDS services. In Cote d’Ivoire and South Africa where the gap is low and the prevalence rate is high the provision of HIV/AIDS services will utilize less than 50 percent of the HR stock because they have a large HR stock. Finally, countries with a low HR gap and a low prevalence rate, such as Guyana, Haiti, Nigeria, and Vietnam will also absorb less than 50 percent of HR stock for the provision of HIV/AIDS services.

Finally, the projected gaps in trained HIV/AIDS personnel, in particular for doctors, lead to the fifth finding. Countries need to mobilize a large number of master trainers to train health workers on HIV/AIDS care. The need for master trainers is estimated in 2 parts. First, we consider the need to train enough trainees to provide full HIV/AIDS services to all eligible patients. In 2005, the 15 countries will need approximately 3,067 master trainers.8 These trainers will include 1,141 doctors, 1,209 nurses, and 717 pharmacists, as shown in Table C-4. Second, we focus on the master trainers needed under the PEPFAR Initiative. Our analysis indicates that in 2005, the total need for master trainers for PEPFAR is 354,9 which increases to 1629 (580 doctors, 631 nurses, and 418 pharmacists) by 2008.

8  

We assumed that 1 master trainer trains between 10–15 trainees, an average of 12.5. This assumption was made based on previous studies in Zambia, Nigeria, and Ethiopia (Kombe, 2003; 2004).

9  

Please note this is a subset of the need for master trainers to reach all those in need.

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

FIGURE C-1 Human resource gap for doctors, nurses (including midwives), and pharmacists.

SENSITIVITY ANALYSIS

A sensitivity analysis was performed to determine the extent to which the human resources vary along with the variation in the assumed percentage of health worker’s time used for HIV/AIDS services. The analysis was performed by changing the percentage share between a minimum of 25 percent and a maximum of 75 percent, with 50 percent as the average.10 For example, if the percentage share of providers’ time used for HIV/AIDS services decreases from 50 percent to 25 percent, the estimated HR gap (PEPFAR HR need minus HIV/AIDS trained HR) increases from 20,361 to 63,725, more than triple as shown in Table C-5.

LIMITATIONS OF THE STUDY

This review and analysis has several limitations. First, the availability and reliability of the HR data was not consistent across the 15 PEPFAR

10  

Note that this does not change the FTE requirements, but rather the number of health workers who need to be trained.

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

BOX C-1
Categorization of Countries According to the Level of Prevalence and Doctors’ Gapa

 

HIV Prevalence

Doctor Gap (total need for doctors/total stock of doctors)a 100%

High Adult HIV/AIDS Prevalence (more than 6%)

Low Adult HIV/AIDS Prevalence (less than 6%)

Severe

(>100%)

Tanzania

Mozambique

Botswana

Zambia

 

Moderate

(50-100%)

Namibia

Kenya

Ethiopia

Rwanda

Uganda

Low

(<50%)

Cote d’Ivoire

South Africa

Guyana

Haiti

Nigeria

Vietnam

aAssumption that 50 percent of HR time is used for HIV/AIDS services

countries. It is not known whether all the data collected from the WHO online Global Atlas of the Health Workforce includes the private sector providers. Health personnel such as laboratory technicians and counselors are excluded from this analysis due to the lack of data.

Second, in some countries like Guyana and Rwanda, only 1 point of data was available, reducing the power of projection. Similarly, data on the numbers of deaths, retirements, emigrants, immigrants, staff turnovers, new graduates, etc. needed to estimate the decrease or increase of stock were not available, leading to the assumption that the change in the next 4 years will follow the pattern of the past 5 years (which may not be accurate).

Third, this lack of available data and time constraint restricted the opportunity for a detailed country level analysis. Therefore, it is extremely important to point out that all analyses are considered to be approximations and can only be used broadly for the development of an overall human resource capacity building strategy, rather than for country level planning. Fourth, key assumptions (e.g., time share between HIV/AIDS with non-HIV/AIDS services) have a significant impact on HR gap estimates. Finally, it must also be noted that the analysis is restricted to na-

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

TABLE C-4 Estimated Need for Master Trainers in the 15 PEPFAR Focus Countries

 

2004

2005

2006

2007

2008

Need for Master Trainers to Provide full HIV/AIDS Services to all Eligible Patients

Doctors

1,058

1,141

1,227

1,318

1,413

Nurses

1,082

1,209

1,342

1,482

1,631

Pharmacists

674

717

762

809

859

Total

2,814

3,067

3,331

3,609

3,903

Need for Master Trainers to Reach PEPFAR Targets

Doctors

41

136

249

395

580

Nurses

25

126

269

441

631

Pharmacists

35

92

177

297

418

Total

101

354

695

1,133

1,629

TABLE C-5 Sensitivity Analysis of Human Resource Gap in the 15 PEPFAR Focus Countries in 2009

 

25% of Health Worker’s Time Used for HIV Services

50% of Health Worker’s Time Used for HIV Services

75% of Health Worker’s Time Used for HIV Services

Number of Trained Health Workers Needed to Provide PEPFAR Services

Doctors

21,591

7,244

3,578

Nurses

29,376

7,893

4,033

Pharmacists

12,758

5,224

2,713

Total

63,725

20,361

10,324

Number of Trained Health Workers Needed to Provide Full HIV/AIDS Services to all in Need

Doctors

42,726

17,662

9,325

Nurses

71,452

20,385

9,477

Pharmacists

23,798

10,740

6,400

Total

137,976

48,787

25,202

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

tional level because of data limitations on distribution of health workers between rural and urban settings.

DISCUSSION

Policy Implications of the Findings

Numerous studies have identified the major policy and program priorities needed to address the human resource gap in low resource countries, particularly those highly impacted by HIV/AIDS (JLI, 2004). The solutions focus on strategies to improve recruitment, retraining, retention and redeployment of health personnel. This analysis focuses primarily on the first 2 solutions: recruitment, or increasing the total stock of human resources, and retraining of existing personnel to deliver priority HIV/AIDS services. This is not meant to imply that retention and redeployment, or the reengineering of tasks among various categories of health personnel, are not critical to address the AIDS epidemic, as well as to address the overall crisis in human resources for health (HRH). However, the scope of this study and the limitations of available data limit our ability to draw firm conclusions on these strategic options beyond endorsing others’ calls to identify strategies to improve health worker salaries and incentives to increase retention, and to identify alternative personnel mixes to provide HIV/AIDS services.

The data limitations faced in this study do raise an issue of first order priority, noted also by similar studies (JLI, 2004; Martineau, 2004), that there is an urgent need for investment in databases and monitoring systems for human resources for health. The data available are insufficient, as illustrated by the lack of information on key categories of personnel, such as laboratory technicians and counselors, and therefore likely undercounting the total stock. It is highly likely that the countries that appear from this analysis to have the lowest human resource gap are precisely the countries that are losing the highest numbers of health personnel to international migration.

Notwithstanding the limitations of the data on which this analysis is based, there are a number of emerging implications for human resource policy development, which are likely to persist even when more precise human resource data become available. This analysis pinpoints the variation in the human resource gap across PEPFAR countries, based on HIV prevalence level, as well as on the relative scarcity of HRH. The program priorities vary slightly according to classification of countries within these dimensions; however, all PEPFAR countries need to focus on training of existing personnel, and most, if not all, PEPFAR countries need to focus on retaining and expanding the total HRH stock.

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

Conclusion

It is apparent that the HRH gap is a major constraint for both providing full coverage for HIV/AIDS services and reaching PEPFAR targets. The fact that many countries have a smaller stock of doctors and pharmacists than nurses calls for targeted strategies to address the shortage. Efforts should also be made to continue training large numbers of nurses and midwives to keep pace with migration and to fill the huge demand for nurses. If HRH capacity strategies are not implemented at the early stages of the PEPFAR program, the constraint will be more severe and plans to scale up will prove more difficult. Countries and development partners should define the role of donor assistance in training of trainers, and determine under what circumstances donors should be involved in direct training of staff and direct delivery of care in the short, medium, and long term, in order to meet both short-term PEPFAR goals, as well as longer term goals to provide sustained services to the affected population.

Second, each country should develop a national human resource for health plan. As recommended by the JLI, these plans should guide enhanced investments in human resources through appropriate education, deployment, and retention.

Third, development partners should work together under the guidance of the host government and within the country’s national human resource plan to support both basic training of additional recruits, as well as in-service training of existing personnel, to meet the growing requirements for HRH for HIV/AIDS services.

The Way Forward

It is clear from the analysis that the way forward should focus on building innovative and sustainable strategies to address HRH in the 15 countries. Governments and donors should design and implement strategies for training the existing human resources for HIV/AIDS services. They should invest in conducting country specific HRH assessments and develop HRH plans according to specific country need. Furthermore, they should improve databases and monitoring systems for human resource for health.

REFERENCES

Health Manpower Registration Councils/Boards. 2001. Health Manpower Situation in Nigeria: 1995–2000.

Huddart J, Lyons JV, Furth R. 2004. The Zambia HIV/AIDS Workforce Study: Preparing for Scale-Up. [Online]. Available: http://www.qaproject.org/pubs/PDFs/ORMZambiaWorkforcel.pdf [accessed February 8, 2005].

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×

JLI (Joint Learning Initiative). 2004. Human Resources for Health: Overcoming the Crisis. [Online]. http://www.globalhealthtrust.org/report/Human_Resources_for_Health.pdf [accessed February 9, 2005].


Kombe G, Smith O. 2003. The Costs of Anti-Retroviral Treatment in Zambia. [Online]. Available: http://www.phrplus.org/Pubs/Tech029_fin.pdf [accessed February 8, 2005].

Kombe G, Galaty D, Gadhia R, Decker C. 2005. The Human and Financial Resource Requirements for Scaling Up HIV/AIDS Services in Ethiopia. [Online]. Available: http://www.phrplus.org/Pubs/Tech059_fin.pdf [accessed February 18, 2005].

Kombe G, Galaty D, Nwagbara C. 2004. Scaling Up Antiretroviral Treatment in the Public Sector in Nigeria: A Comprehensive Analysis of Resource Requirements. [Online]. Available: http://www.phrplus.org/Pubs/Tech037_fin.pdf [accessed February 8, 2005].


Martineau T, 2004. Staffing Options for Emergency HIV/AIDS programs. Unpublished draft.


Smith O. 2004. Human resource requirements for scaling up antiretroviral therapy in low resource countries. In Scaling Up Treatment in the Global AIDS Pandemic. Washington, DC: The National Academies Press. Pp 292–308.


UNAIDS. 2004. 2004 Report on the Global AIDS Epidemic. [Online]. Available: http://www.unaids.org/bangkok2004/report_pdf.html [accessed February 7, 2004].

USAID (U.S. Agency for International Development). 2003. The Health Sector Human Resource Crisis in Africa: An Issues Paper. [Online]. Available: http://www.aed.org/ToolsandPublications/upload/healthsector.pdf [accessed February 18, 2005].


WHO (World Health Organization). 2003. Human Capacity-Building Plan for Scaling Up HIV/AIDS Treatment. Geneva, Switzerland: World Health Organization.

WHO. 2004. WHO Online Global Atlas for Health Workers [Online]. Available: www.who.int/GlobalAtlas/home.asp [accessed February 7, 2005].

World Bank. 2004. World Development Indicators Database. [Online]. Available: http://www.worldbank.org/data/dataquery.html [accessed February 7, 2005].

Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
×
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
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Suggested Citation:"Appendix C Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries." Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. doi: 10.17226/11270.
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Healers Abroad:Americans Responding to the Human Resource Crisis in HIV/AIDS calls for the federal government to create and fund the United States Global Health Service (GHS) to mobilize the nation�s best health care professionals and other highly skilled experts to help combat HIV/AIDS in hard-hit African, Caribbean, and Southeast Asian countries. The dearth of qualified health care workers in many lowincome nations is often the biggest roadblock to mounting effective responses to public health needs. The proposal�s goal is to build the capacity of targeted countries to fight the HIV/AIDS pandemic over the long run. The GHS would be comprised of six multifaceted components. Full-time, salaried professionals would make up the organization�s pivotal �service corps,� working side-by-side with other colleagues already on the ground to provide medical care and drug therapy to affected populations while offering local counterparts training and assistance in clinical, technical, and managerial areas.

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