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Fewer doctors and more community involvement to scale up antiretroviral treatment

There is a pressing need to scale up antiretroviral treatment (ART) for HIV. However, weak health systems remain a major obstacle, especially in those countries of sub-Saharan Africa hit hardest by HIV and AIDS. These countries face a shortage of health staff and a growing case-load of people requiring lifelong treatment.

Researchers from the Institute of Tropical Health, in Belgium, consider the kind of model needed for effective scale up of ART programmes given workforce constraints. Current ART models are labour-intensive, requiring many qualified staff. Countries such as Mozambique, Malawi, Zambia, Rwanda and Tanzania lack sufficient skilled human resources for health (HRH) to scale up ART according to such doctor-based delivery models.

The researchers find that ART delivery involves several types of function requiring different approaches. Good organisation of logistics, supplies and distribution calls for a standardised, centrally controlled or bureaucratic approach. However, a more society-based approach is needed when providing community support to patients. The management of patients who do not fit standardised procedures requires a more professional approach. Finally, care of the individual patient requires a combination of the social and professional approaches. The researchers also outline five possible scenarios with respect to ART delivery.

The baseline scenario has no fundamental changes to the delivery model and no increase in staff or resources.
Scenario A has no fundamental changes but ART gets priority status and resources are increased including health staff.
Scenario B has enough additional resources and the ART scale-up strengthens the overall health system.
Scenario B1 (a variation of Scenario B) involves redesigning the ART delivery model, shifting tasks to lower qualified levels within the team of health professionals.
Scenario B2 involves sharing out tasks and functions as widely as possible, including patients and communities where possible.

The researchers conclude that given the HRH crisis, ART delivery models requiring much less doctor time need to be developed. Overall, there is a need to shift tasks from medical doctors to nurses and from nurses to community health workers. In particular, the patients themselves need to play an important role in the delivery of ART. The outcomes of the various scenarios are predicted.

In the baseline scenario, ART coverage is likely to stall at approximately 10 or 20 percent of the target.
In Scenario A, increased resources will improve access to treatment. However, HRH resources may be diverted from other sectors of the health system.
In Scenario B, the necessary rapid expansion of the health workforce would be difficult to achieve in countries with severe HRH shortages. It would also require sustained investment over a long period.
The task-shifting in Scenario B1 would depend on standardisation and top-down control, with a strict separation between providers and patients.
In Scenario B2 patients and community health workers would take on much of the work and have more say in care. However, a key challenge would be to combine a top-down bureaucratic approach with the social approach needed for community involvement.
The last two scenarios require ART to be de-professionalised or de-medicalised (moved away from health professionals), and would radically change the traditional doctor-patient relationship.

Most countries are likely to choose elements from all of these scenarios, depending on their local context and what reforms are taking place.

Source(s):
‘Scaling-up Antiretroviral Treatment in Southern African Countries with Human Resource Shortage: How will Health Systems Adapt?’ Social Science & Medicine, 66:10, pages 2108-2121, by Wim van Damme et al, 2008

id21 Research Highlight: 22 May 2008

Further Information:
Wim van Damme
Institute of Tropical Medicine
Nationalestraat 155 - B-2000
Antwerp
Belgium

Contact the contributor: wvdamme@itg.be

Institute of Tropical Medicine, Antwerp, Belgium

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