Sarah Nafere has just finished a long night shift as the only nurse tending to 80 patients spread across two wards at Nkhata Bay Hospital in northern Malawi.
She is one of just 18 nurses, five clinical officers and one doctor that staff this district hospital, where the ARV clinic alone provides treatment to 926 patients.
"Each ward is supposed to have three or four nurses, and one nurse is supposed to attend to 10 to 12 patients a day," said Nafere. "But here one nurse is attending to more than 100 patients a day. Do you think she can provide good services?"
The shortage of healthcare workers is a global crisis, but developed countries can afford to throw money at the problem, attracting nurses and doctors from developing countries with vastly better salaries and working conditions.
While the HIV/AIDS epidemic has multiplied the need for doctors and nurses in southern Africa, the pool of workers has shrunk. Those remaining in their countries face a daily, demoralising struggle to manage impossibly heavy patient loads with scare resources. Many take their skills to the private or NGO sectors or flee the profession altogether. An unknown number of others have succumbed to the disease (see sidebar).
In Malawi, the fourth poorest country in the world, where UNAIDS has put HIV prevalence at 14 percent, the health worker shortage is so acute that the ministry of health and international donors are now treating it as an emergency.
"There is a profound human resources crisis in this country," said Dr Michael O'Carroll, a technical advisor the government has appointed to oversee a six-year US$275 million plan to address the problem. "The World Health Organisation says no developing nation can expect to go anywhere without a ratio of one physician to 5,000 of the population. We have one doctor per 60,000, which puts us in one of the worst situations in the world."
Sixty-four percent of nursing posts in Malawi are unfilled and there are 100 doctors working in public hospitals serving a population of 12 million. Anyone requiring the attention of a neurologist, dermatologist or a number of other specialists must travel outside the country.
|The Human Cost|
|There are plenty of reasons for Malawi's chronic health worker shortage. The "poaching" of doctors and nurses by developed nations tends to get the most attention. Less well-documented are the numbers of health workers who have died from AIDS-related illnesses.
Alice Kadzanja, who has been nursing for 26 years, is one of only two in the country who is open about her HIV-positive status. In the last 10 years she has watched hundreds of colleagues succumb to the virus, in large part because of the institutional stigma that prevented them from being tested or accessing treatment, even when it was available.
"HIV has played a big role in the health worker shortage," she said. "So many staff have died."
Over the years, Kadzanja has kept a count of the health workers she suspects have been lost to the disease, and claims the number is in the region of 2,000.
She left the public sector in 2000, the same year she revealed her status, and now works for Dignitas International, a Canadian NGO that runs the ARV clinic at the district hospital in Zomba, about 70km east of Blantyre, in partnership with government. The clinic opened in 2004 and currently provides treatment to 1,700 patients.
Despite a national policy of prioritising treatment for health workers, according to Kadzanja, only 20 patients at Zomba are doctors or nurses. Dignitas hopes that a new ARV clinic, opening soon and aimed specifically at health workers, will reach them in greater numbers. The clinic will serve as a pilot project and, if successful, will be replicated in other districts.
District hospitals like Nkhata Bay, with an average of 250 beds, should have 175 nurses, said O'Carroll. None has more than 40. "That leads to some very serious issues from a patient point of view, but also for the health workers themselves. You have large numbers of people crying for services and you have nurses that are on their feet 18 hours a day. It's a situation that creates an enormous amount of tension," he said.
Given the scale of the problem, it is something of a miracle that Malawi has managed to keep its ambitious anti-AIDS treatment plan on target. As of the end of September, 70,000 Malawians were accessing antiretroviral (ARV) treatment, about 62,000 of them at public health services. According to the five-year plan, an additional 40,000 patients will begin receiving treatment in 2007 and another 45,000 in each of the following three years.
Dr Bizwick Mwale, director of Malawi's National AIDS Commission, admitted that human resources would be the biggest challenge.
In 2005, with funding from Britain's international development agency (DFID), pubic healthcare workers received a 52 percent wage top-up and a campaign was mounted to lure nurses back from the private sector. Money from the Global Fund to Fight AIDS, Tuberculosis and Malaria is being used to expand the capacity of Malawi's training institutions and provide extra incentives for health workers in remote, rural areas.
Until these efforts yield results, some of the countries that have lured health workers from Malawi are loaning their doctors to fill the gap. About 25 percent to 30 percent of Malawi's doctors are sourced from overseas: some are United Nations volunteers; others come with Britain's Voluntary Services International or through agreements with European governments.
None of these measures is enough to keep pace with the additional 90,000 HIV-infected Malawians who need ARV treatment every year. As ARV clinics at district hospitals rapidly reach their limit, the treatment programme will need to roll out to smaller health centres, where qualified health workers are even scarcer. The only way to move forward, said Mwale, was "to simplify the delivery of ARV treatment".
By developed world standards, Malawi's approach is fairly basic: clinics mainly use diagnostic assessments rather than laboratory tests to determine when patients are ready to begin treatment, and nearly 95 percent of patients are prescribed the same combination of three drugs. After the first six months on treatment, patients are only required to return to clinics once every two or three months.
The next step is to train less qualified health workers to administer the drugs. Rural health centres are usually staffed by one or two nurses and medical assistants, and several health surveillance assistants (HSAs). HSAs are Malawi's least qualified health workers.
Recruited locally, they receive just 10 weeks of training but are an invaluable resource because of their close links with the community. There are 5,200 of them, but the government plans to double that number and train about 1,000 of the new recruits to work exclusively in HIV/AIDS. The eventual goal, explained Mwale, is for HSAs to assist patients who merely need to receive their new drug supplies.
Not everyone is comfortable with cutting corners when it comes to ARV treatment, but no one can deny that the situation demands extreme measures.
"I'm quite worried about further and more rapid scale-up, given the human resources restrictions we're facing," said O'Carroll, "but we have life-saving drugs and we're going to give them to as many people as we can, now."
Sarah Nafere has no plans to leave Malawi for greener pastures, but so far she has seen little evidence of the government's efforts to retain its health workers: "Salaries for we Malawians are not adequate, but I can't leave my relatives suffering here because of money," she said. "If the government can motivate us, if they can renovate our buildings and give us enough money, I think we can improve, we can work happily."