The
gender dimension
Another important
issue in discussing the HRH crisis in the context of HIV/AIDS is the gender
dimension. One of the MDGs is to promote gender equality and empower women. In
fact, more
women than men are
affected by the epidemic directly, and indirectly as caregivers. The attrition
rate
of front-line workers
in the health sector is exacerbated by HIV/AIDS because more women than men
serve at the
operational level, women are leaving clinical nursing services, and more women
than men
are dying of AIDS due to
increased disease risk.
Front-line health
workers in sub-Saharan Africa are
largely female at the
operational level, while top
management and policy
levels have been mainly male. In Ghana in the late 1990s, 59% of all public
health staff was
female, but this reduced to 33.5%
at the Ministry of
Health headquarters. Only 17%
of doctors were female
as compared to 87.4% of registered nurses and 90.2% of enrolled nurses (13).
In Malawi in 2003, 75%
of service providers leaving clinical service provision were women (14). A
disproportionate risk
of HIV infection has been
linked to male/female
power differentials (15) to
wage differentials, to
nurses’ subordination to physicians (16) and to the undervaluing of caring
labour in the formal
economy (17). Policies must respond to gender-related impacts.
Health
system effects of HIV/AIDS
HIVAIDS has changed
the landscape of disease in the
developing world,
especially in Africa, due to
the resurgence of
common conditions and therefore increased demand for preventive and curative
services to respond to
the epidemiological and clinic
al impacts of the
pandemic. These effects include
increased burden of
disease, increased service needs associated with
caring for these
illnesses and for
HIV/AIDS itself, and
the inadequate and diminishing capacity to respond to these needs, central to
which is the limited
human resource capacity.
The
increased disease
burden
due to increased cases
of illnesses
such TB, malnutrition,
diarrhoea, meningitis, pneumocystis carinii pneumonia (PCP) in
the form of
opportunistic infections associated
with HIV infection
means that prevention and care
and treatment
programmes must be modified to
respond to the new
scenarios. Public health specialists, clinicians, pathologists, counselors and
various
others cannot use the
traditional skills to deal with
the changing
epidemiology and clinical dimensions
of the epidemic. In
Malawi, over the last two decades TB case notification rates have increased
five-fold, and the reported cases per 100 000 population have risen from 95 in
1987 to 275 in 2001
(18). In
Swaziland, for
example, the rate of TB, per 100 000 population increased by almost four times
from
around 210 in 1990 to
820 in 2004. (It is widely accepted that HIV/AIDS drives the incidence of TB.)
As suggested by Figure
4, “Reported TB patients, Swaziland, 1991–2004”, the increase in TB rates
has had a marked
effect on hospitals and staff responsibilities, despite increasing emphasis on
ambulatory and
home-based care for TB. Although the
average length of stay
for TB has fallen due to
a policy change, the
length of stay for TB remains
around 14 days, the
highest of all major diagnoses
(19).
Figure
4. Reported TB patients in Swaziland, 1991–2004
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
1991
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
As shown in Figure 5,
data reported by Cheluget etal.
(20) indicate that admissions in sampled
facilities in Kenya
increased overall from 4379 in 1996 to 6450 in 1999 to 7545 in 2002. About 48%
of these were
AIDS-related.
Figure
5. Caseload in Kenyan
facilities,
1996, 1999 and 2002
In addition to their
existing duties, health workers are called upon to assist with recently
introduced
HIV/AIDS services such
as voluntary counselling an
d testing (VCT) and
training family members for
home-based care. Their
assessment results showed
an overload for the
service providers for VCT and
prevention of
mother-to-child-transmission (PMTCT) programmes. Ideally, a counsellor was expected
to have an average of
160 clients per month. These data showed that they catered for about two to
three times this
number.
“We no longer know
what to do, as we are expected to be here and there. The Government
needs to guide us,
especially those of us who are doubling as counselors.” Focus group
participant
(21). The complexity of services
needed for prevention,
diagnostics, care and treatment of HIV/AIDS
disease with ARVs and
the associated opportunistic infections means that systems will have to change
Admissions
by Diagnosis, Kenya-1996, 1999 &
2002
(n=18,191)
1%
51%
48%
HIV/AIDS and
related illnesses
Other illnesses
Unknown
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