Correspondence
Expansion of the Health Workforce and the HIV Epidemic
N Engl J Med 2008; 358:1639-1640April 10, 2008
- Article
To the Editor:
Samb and colleagues (Dec. 13, 2007, issue)1 call attention to the critical topic of shortages of health care workers in the developing world. One proposed solution involves shifting medical tasks to less skilled workers and laypersons. We are concerned that the rush to the bandwagon of “task shifting” takes the emphasis off the need to improve the jobs of health care workers in countries with severe epidemics of human immunodeficiency virus infection and AIDS (HIV/AIDS) and tuberculosis.
Our study involving South African nurses showed that working conditions and financial concerns were driving migration.2 As part of a strategy to expand health care systems, the implication is that task shifting will allow systems to provide care with lower-cost workers.3 Are the problems that have fueled shortages of health care workers in the developing world — low pay and poor working conditions — addressed by task shifting, or are they merely shifted onto an already overburdened community? Of additional concern is the burden of community-based care on women and its contribution to sex inequality.4 Integrating community members into a strengthened primary health care system is desirable, but so is the goal of decent work in the health sector.5
5 ReferencesJennifer Zelnick, Sc.D., M.S.W.
Salem State College School of Social Work, Salem, MA 01970
jzelnick@salemstate.edu Max O'Donnell, M.D., M.P.H.
Boston University School of Medicine, Boston, MA 021181
Samb B ,Celletti F ,Holloway J ,Van Damme W ,De Cock KM . Dybul M. Rapid expansion of the health workforce in response to the HIV epidemic. N Engl J Med 2007;357:2510-2514
Full Text | Web of Science | Medline2
Zelnick J ,O'Donnell M . The impact of the HIV/AIDS epidemic on hospital nurses in KwaZulu Natal, South Africa: nurses' perspectives and implications for health policy. J Public Health Policy 2005;26:163-185
CrossRef | Web of Science | Medline3
Hansen K ,Woelk G ,Jackson H , et al. The cost of home-based care for HIV/AIDS patients in Zimbabwe. AIDS Care 1998;10:751-759
CrossRef | Web of Science | Medline4
Kipp W ,Tindyebwa D ,Rubaale T ,Karamagi E ,Bajenja E . Family caregivers in rural Uganda: the hidden reality. Health Care Women Int 2007;28:856-871
CrossRef | Medline5
Somavia J . A decent-work agenda. World Work 2000;34:12-13
Medline
To the Editor:
In raising the critical issue of the global shortage of health workers, Samb et al. draw attention to the need to develop innovative methods to train and retain health workers. A focus on HIV/AIDS may inadvertently neglect the demand for health workers who can provide comprehensive care and supporting roles in health systems.1 Recent critiques of the primacy of HIV/AIDS programs should be understood as a call to action.2,3 Efforts to boost the education of health workers in the developing world are necessary to provide basic health care, address chronic diseases, and reduce the “brain drain.”
Residency training programs in the United States are rapidly adding global health opportunities and formal training tracks. These programs could increase their impact by teaching residents how they might assist health workers in the developing world. A generation of physicians eager to lead the world in advancing global health will soon be entering the workforce. The medical community should mentor and challenge them to seek innovative ways to train and collaborate with health workers in the developing world.
3 ReferencesFranklin W. Huang, Ph.D.
Washington University School of Medicine, St. Louis, MO 63110
huangf@wustl.edu Rebecca A. Berman, M.D.
Brigham and Women's Hospital, Boston, MA 021151
The Global Fund: growing pains. Lancet Infect Dis 2007;7:695-695
CrossRef | Web of Science | Medline2
Piller C, Smith D. Unintended victims of Gates Foundation generosity. Los Angeles Times. December 16, 2007:A1.
3
Halperin D. Putting a plague in perspective. New York Times. January 1, 2008:A17.
Author/Editor Response
Zelnick and O'Donnell are right to emphasize that poor working conditions and inadequate remuneration contribute to health workforce shortages and that women often shoulder the burden of community care without adequate support, equipment, or pay. Analysis of the task-shifting approach, as outlined in our article, has contributed to the development of recommendations by the World Health Organization (WHO) that address these concerns explicitly.
The WHO global recommendations and guidelines on task shifting, endorsed on January 10, 2008, in the Addis Ababa Declaration, are the result of more than a year of evidence gathering and extensive consultation. They provide a framework to help countries strengthen, expand, and decentralize essential health services, using a task-shifting approach. They identify the key elements that must be in place if the approach is to prove safe, effective, equitable, and sustainable. These elements include an appropriate policy and regulatory framework and proper support, such as standardized training and other quality-assurance mechanisms, functioning referral systems, and adequate wages for health workers, including community health workers.
However, task shifting alone is not expected to resolve the health workforce crisis. Stakeholders involved in the promotion of task shifting unanimously agree that the approach should be implemented alongside other strategies designed to increase the total numbers of health workers in all cadres. They also stress that task shifting requires financial stability and should not be seen as a substitute for other investments in human resources for health.
Huang and Berman caution against focusing on care for patients with HIV infection at the expense of other health services. Recent interest in task shifting has been fueled by the urgent need to respond to the HIV epidemic. However, as we note in our article, the impact of task shifting would not be restricted to HIV services. Task shifting is a strategic approach that makes more efficient use of the human resources currently available — for instance, by integrating community members into strengthened primary health care systems. This approach will assist in making broad progress toward the health-related Millennium Development Goals and generate long-term benefits for overall health systems.
The WHO global recommendations and guidelines on task shifting are available at www.who.int/healthsystems/task_shifting/en/.
Badara Samb, M.D., Ph.D.
Francesca Celletti, M.D.
World Health Organization, CH 1211 Geneva, Switzerland
sambb@who.int
