##### THE IMPACT OF HIV/AIDS ON HEALTH SYSTEMS AND THE HEALTH WORKFORCE IN SUB-SAHARAN AFRICA

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> USAID, Bureau for Africa, Office of Sustainable Development

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##### THE IMPACT OF HIV/AIDS ON HEALTH SYSTEMS AND THE HEALTH WORKFORCE IN SUB-SAHARAN AFRICA

Prepared by

Linda Tawfik and Stephen N. Kinoti

June 2003

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### Support for Analysis and Research in Africa (SARA) Project

### USAID, Bureau for Africa, Office of Sustainable Development

The Support for Analysis and Research in Africa (SARA) project is
operated by the Academy for International Development with
subcontractors Tulane University, JHPIEGO, Morehouse School of Medicine,
and Population Reference Bureau. SARA is funded by the U.S. Agency for
International Development through the Bureau for Africa, Office of
Sustainable Development (AFR/SD/HRD) under Contract
AOT-C-00-99-00237-00.

The opinions expressed herein are those of the authors and do not
necessarily reflect the views of USAID.

For further information, please contact:

Support for Analysis and Research in Africa (SARA) Project

Academy for Educational Development (AED)

1825 Connecticut Avenue, NW

Washington, DC 20009 USA

Tel: 202-884-8000

Fax: 202-884-8447

E-mail: sara@aed.org

## Table of Contents

**Acknowledgements iv**

**Introduction 1**

**The Impact of HIV/AIDS on Health Systems and the Health Workforce 2**

The Impact of HIV/AIDS on Health Systems 2

The Impact of HIV/AIDS on the Health Workforce 5

Lessons Learned from Private Sector Firms about Human Resource Impacts
11

**The Relevance and Impact of Health Reforms in Strengthening the**

**Health Workforce in the Era of HIV/AIDS 14**

**Some Recent Initiatives and Their Role in Addressing Human Resources**

**Strengthening in the Health Sector 17**

Health Workforce Issues in Operationalizing the Global Fund for

AIDS, Tuberculosis, and Malaria 17

The World Bank Multi-Country HIV/AIDS Program for Africa 17

Leadership and Investment in Fighting an Epidemic: A Global AIDS
Initiative 18

Millennium Challenge Account 18

**Assessing the Impact of HIV/AIDS on the Health Workforce:**

**Available Tools and Their Use 19**

Indicators for Human Resource Impacts 20

Development of Future Assessment Tools and Indicators 20

**Tools for Assessing Impacts of HIV/AIDS on Health Workforce 16**

Indicators for Human Resource Impacts 17

Development of Future Assessment Tools and Indicators 18

**Conclusions and Recommendations 23**

Summary of Findings 23

What is Known 24

Gaps in Knowledge 25

Recommendations 27

**References 29**

## Tables

Table 1: Mortality Rates among Nurses, Zambia (1980-1991) 6

Table 2: Examples of Potential Human Resource Impact Assessment
Indicators 21

**Boxes**

Box 1: Factors Associated with Increased Demand for Services 5

Box 2: Morbidity and Mortality Due to HIV/AIDS in the Health Workforce 8

Box 3: Impact Assessment Questions 9

Box 4: Issues related to Health Workforce Supply and Management 10

## Acknowledgements

The authors and the SARA project of the Academy for Educational
Development are grateful to Professor Alan Whiteside, Director of the
Health Economics and AIDS Research Division of the University of Natal,
Dr. Gina Dallabetta, Director, Technical Division, Family Health
International, and Dr. Bill Rau, independent consultant, for their
review of this paper and their very useful comments.

Many thanks go to the representatives of seventeen sub-Saharan African
countries who reviewed and used this paper to guide their deliberations
during the Consultative Meeting on Improving Collaboration between
Health Professionals, Governments, and Stakeholders in Human Resource
Development for Health held in Addis Ababa, Ethiopia, January
28-February 1, 2002.

This paper was also disseminated and used as background material at the
pre-congress meeting on human capacity development organized by USAID
and the World Bank at the HIV/AIDS Congress, Barcelona, July 2002. The
Directors' Joint Consultative Committee of the ECSA Health Community
also reviewed it and encouraged wider dissemination of the paper to
stimulate more action of human resources development and improved
management.

The encouragement to prepare this paper from the Health Sector HIV/AIDS
Group, coordinated by Ishrat Husain, Senior Technical Advisor, USAID,
Bureau for Africa, Office of Sustainable Development, is gratefully
acknowledged.

## Introduction

Before the HIV/AIDS pandemic, the health systems of sub-Saharan Africa
were steadily improving the overall health status of the population.
This could be attributed to higher quality of and increased access to
various health services. However, with more than 35 million Africans
having been infected with HIV since the beginning of the pandemic and
over 28 million still living with HIV infection, the impact on the
health sector over the next decade will be greater than in the past two
decades combined.

What is the impact of HIV/AIDS on the health systems and on the health
workforce in sub-Saharan Africa? Until recently, there has been little
effort to document this impact. To begin, HIV/AIDS has substantially
increased the demand for health services. Patients seeking treatment for
more traditional illnesses are being crowded out to peripheral health
facilities. This has led to congestion at the secondary and tertiary
levels, while weakening services at the primary level. Additionally,
impacts of the epidemic on the health workforce include attrition due to
illness and death, absenteeism, low morale, increased demand for
provider time and skills, diversion of resources, budgetary and
managerial inadequacies, and other effects of managing systems under
stress.

The purpose of this paper is to advocate for and guide planners in the
collection and use of appropriate information to develop and manage the
health workforce in a manner that enables health systems to respond to
the service demands created or worsened by HIV/AIDS. The paper also
intends to guide the development of tools for assessing impacts of
HIV/AIDS on the health sector. Such tools can assist policymakers,
planners, and advocacy groups shape and accelerate the implementation of
national HIV/AIDS policies and programs throughout the continent.

Information for this paper came from review of abstracts, web sites,
journal articles, published papers, news briefs, books, and personal
communication with researchers and international health program experts
knowledgeable in the subject. Data came from 225 abstracts presented at
the XIII International AIDS Conference 2000 in Durban, South Africa and
the XIV International AIDS Conference 2002 in Barcelona, Spain, 280
abstracts from the AIDSLINE bibliographic database, and approximately
200 abstracts from the POPLINE bibliographic database. Some unpublished
material from African countries has also been used.

The Impact of HIV/AIDS on Health Systems and the Health Workforce

***The Impact of HIV/AIDS on Health Systems***

HIV/AIDS affects the performance of health systems by increasing demand
for services in both quantity and complexity and by reducing the supply
of services by its impact on the numbers and performance of the health
workforce (World Bank 1999; Bollinger and Stover 1999). These processes
are associated with increased costs at a time when funding for health
care is diminishing, particularly in developing countries. Shortages of
staff, supplies, and medicines and limited maintenance of health
infrastructure have been attributed to the fact that governments in
sub-Saharan Africa place a low priority on health and welfare as
reflected in the national budget allocations for the health sector (WHO
1994). Another reason for the shortages is the impact of structural
adjustment programs that have forced governments to cut back recruitment
of new staff or filling of vacant positions resulting from attrition due
to HIV/AIDS on national healthcare expenditures (Osborne 1997). Thus, as
summarized in *AIDS in the 21st Century* by Tony Barnett & Alan
Whiteside, the HIV/AIDS epidemic is affecting the lives of millions of
people---not only those who become ill and die, but also their families,
households, communities, and nations.

In 1997, public health spending for AIDS alone already exceeded 2
percent of the gross domestic product (GDP) in 7 of 16 African countries
sampled, a staggering figure in countries where total health spending
accounts for 3.5 percent of the GDP. In the mid-1990s, it was estimated
that treatment for people with HIV consumed 66 percent of total health
spending in Rwanda and over a quarter of health expenditures in Zimbabwe
(UNAIDS 2000). As the AIDS epidemic increases costs, it reduces supply
in all other sectors. AIDS will increase the share of healthcare in
national expenditure (World Bank 1999). The effect of this is the
disproportionate increase in expenditure on HIV/AIDS-related illnesses
compared with other illnesses.

A number of factors have contributed to the changing landscape of health
and disease and the service needs. These include the resurgence of
previously well controlled diseases such as malnutrition, tuberculosis,
diarrhea, and other opportunistic infections whose prevalence has
increase due to HIV/AIDS. This has further caused a "crowding out
effect" by HIV/AIDS patients of patients suffering from other illnesses.
On the services side, there is an increased demand for safe blood
supply, need for new medical procedures and protocols, voluntary
counseling and testing (VCT), prevention of mother-to-child transmission
of HIV, and the provision of new HIV/AIDS therapies including
antiretroviral drugs.

Health facility assessments suggest that the epidemic is crowding out
patients suffering from conditions that are seemingly less severe than
HIV/AIDS, thus denying them their right to care. In South Africa, which
is experiencing the fastest growing HIV/AIDS epidemic in the world,
patients are turned away from hospitals due to limited beds (Russell
2000). Kenya has seen increased mortality among HIV-negative patients,
who are being admitted at later stages of illness (UNAIDS 2000). From
1988 to 1992, the average number of people *not* infected with HIV
admitted per day to a Nairobi hospital, decreased by 18 percent, while
the number of those who were HIV-positive more than doubled. The
severity of the illness suffered by HIV-negative patients rose. Their
mortality rate increased from 14 to 23 percent, while the mortality rate
of hospitalized HIV-positive patients remained stable during that same
period (World Bank 1999).

In poor countries, where blood screening and needle sterilization were
lacking before the epidemic, resources needed to maintain the quality of
care in the face of AIDS can be substantial (World Bank 1999). Even with
safe blood banks, a transfusion can infect recipients with hepatitis B
or HIV through exposure to infected equipment. Transmission risks and
exposure to opportunistic infections increase under conditions of
crowding, where needles and other instruments are not always sterilized
and where providers lack rubber gloves or even soap. Although one study
suggests that occupational risk among health staff is minimal from
injuries on duty, for ethical and financial reasons, staff need to
enforce safety protocols (de Villiers 2000).

The exploding tuberculosis (TB) epidemic in countries most heavily
affected by HIV has human resource implications. TB has become the
leading cause of death among people infected with HIV, accounting for
one-third of AIDS deaths worldwide. The World Bank estimates that 25
percent of HIV-negative persons dying of TB would not have been infected
with the bacillus in the absence of the AIDS epidemic. Each of these new
TB infections represents increased demand for service providers trained
in its management. Many national TB programs may be forced to use a
community-based model whereby health workers supervise TB treatment. The
current model, which involves hospitalizing most patients for at least
the first two months of therapy, is overwhelming hospitals (Raviglione
et al. 1997). Recent clinical trials have shown that TB preventive
therapy can reduce TB and HIV-associated morbidity and mortality
cost-effectively (Bell et al. 1999). [^1]

Voluntary counseling and testing (VCT) for HIV/AIDS is increasingly
being adopted as an important prevention and control strategy.
Unfortunately, access to VCT services remains limited. Most HIV testing
is hospital based and is provided mainly for those presenting with
late-stage disease and in pilot VCT and PMTCT services. While much of
health providers' training has been in disease prevention, few have been
trained to counsel people with the disease or to treat HIV-related
symptoms and opportunistic infections, even within higher level
facilities. Symptomatic treatment that is provided is often guided by
non-HIV specialists who do not recognize, much less attend to, other
HIV-related clinical manifestations (Gilks et al. 1997; Schietinger and
Sanei 1998). Same-day test results are generally not available, so a
significant proportion of those who travel a long way from home do not
follow-up to obtain their test results (Makhubele 2000; Schietinger and
Sanei 1998). Even after testing people for HIV, some health providers
simply discharge clients without telling them their diagnosis because of
the belief that nothing can be done for them.

A study by Cornia et al. 2002, indicated that the epidemic's impact on
the health systems is devastating, as it has created increased burden of
disease, shifted the demand for services, caused a substantial increase
in health expenditure, and eroded the capacity of the health systems to
respond adequately, particularly as it affects the health workforce.

Making changes and maintaining subsequent high levels of service
performance cannot be achieved in any organization without good human
resource management (Martinez and Martineau 1998). With health reforms
and the introduction of new prevention, care, and treatment approaches
to the epidemic, human resource planning is a larger task than producing
the numbers and types of health staff to match the health services. For
example, a study from Côte d'Ivoire suggests that the introduction of
new therapies will involve systemic responses for client follow-up and
appropriate counseling. In response to the inequity in providing
antiretrovirals between the developed countries and resource-poor
countries, the Côte d'Ivoire Ministry of Health and UNAIDS launched an
initiative to provide antiretroviral therapy and other AIDS-related
therapies at reduced cost to HIV/AIDS patients. Criteria for enrollment
included patient's clinical status, biologic parameters, and the ability
of the patient to pay for drugs (with or without national subsidies).
Assessment results indicated, however, that since the initiative began
in 1998, 40 percent of 1,874 patients presenting for eligibility
screening did not return (Djomand et al. 2000). Focused assessments can
provide useful information for understanding the extent to which
counseling by health service personnel influences a person's probability
of returning for therapy. On the broader perspective, it is has become
clear that an expanded response to the HIV/AIDS epidemic requires an
integrated approach combining the core interventions that include
primary prevention, prevention of mother-to-child transmission linked to
voluntary and confidential counseling and testing, treatment of sexually
transmitted infections, improved blood supply, treatment of
opportunistic infections, and care and support of people living with
HIV/AIDS.

An emerging issue with an ongoing debate has been highlighted in the
review by Ingelquist et al. 2002, which suggests that HIV infections in
sub-Saharan Africa (SSA) may not be explained by sexual and vertical
transmission, implying that transmission could be linked to unsafe
medical care. This is an issue that requires serious study of the health
service delivery standards especially because there is increasing
concern that the integrity of the health system infrastructure has
deteriorated over the last three decades in SSA.

***The Impact of HIV/AIDS on the Health Workforce***

Few countries have fully understood the epidemic's impact on human
resources in the health sector. AIDS-related illness and death of
employees reduces the quality of services provided and increases
expenditures due to replacement and training of new employees.
Information is needed on the supply of healthcare that is being impacted
by factors, such as loss of staff through HIV/AIDS-related deaths,
increased out-migration of highly trained staff, or reduced training
outputs of universities. A lack of rigorous study in this area
represents a key gap in information needed to design better mitigation
strategies.

What evidence is available on the impact of the epidemic on human
resources within the health sector? Very little data has existed until
recently. Despite the scarcity of thorough analyses, anecdotal evidence
and some recent African studies suggest that the health systems may lose
one-fifth of their employees to HIV/AIDS over the next several years
(USAID 1999). Given the variation of the epidemic's severity in
different geographical areas, projections have been developed based on
specific HIV/AIDS prevalence rates. Demographic profiles of health
personnel are required to develop more refined analyses of health sector
impacts.

Like the general population, healthcare workers may become infected with
HIV as a result of their personal sexual behavior (World Bank 1999, Buve
et al. 1994). Health service personnel also face additional occupational
risks from handling non-sterile injecting equipment or accidental
exposure to blood or blood products. This risk is generally smaller than
the risk from sexual contact, although there is variation in
occupational risk across professional cadres and between developed and
resource-poor countries. The HIV seroconversion risk among surgeons in
tropical Africa may be 15 times higher than in developed countries
(Consten et al. 1995). A study conducted in a South African hospital
investigated the potential for HIV transmission occurring as the result
of sharp instrument injuries, the major cause of injuries on duty. Of
one hundred on-duty injuries reported over a two-year period, 41 percent
occurred among nurses, 38 percent among cleaners, and 6 percent among
administrators. Cleaners comprised 16 percent of the total personnel of
the hospital but reported 38 percent of all injuries on duty. Nearly
half of reported injuries were needle-stick related. The average period
of leave after injury was four days (range 1- 40 days) (de Villiers
2000). In Senegal, an impact assessment showed that, although 91 percent
of surveyed health workers recognize that body fluid contamination is
risky for HIV or hepatitis transmission, only 25 percent take necessary
precautions. The additional risk of HIV/AIDS encountered by health
personnel may therefore depend on their adherence to proper protocols
and procedures as well as on the availability of sterilization
equipment, surgical power tools, and supplies.

Assessments of the impact of HIV/AIDS on the health workforce conducted
in Botswana suggest that the age profile of health workers may differ
significantly from that of the general population aged 20-64. Moreover,
one major feature of the demographic profile of health workers in
Botswana is that women outnumber male health workers by a ratio of 1.9
to 1 with 4,829 males and 9,387 females (Abt Associates South Africa
2000). Hence, human resource plans ideally should incorporate projected
staffing losses based on demographic, gender, and socioeconomic factors.

Results of another study demonstrating the impact of HIV/AIDS on human
resources in the health sector are presented in Table 1 below. In this
study, data was collected on mortality among female nurses at two
hospitals in Zambia due to a great concern within the ministry of health
about a perceived increase in absenteeism and mortality among health
personnel. Based on an examination of death certificates, the observed
increase in mortality was attributed largely to HIV infection. The
seroprevalence rates from sentinel surveillance sites indicate that, in
1990, the HIV seroprevalence rates in pregnant women were 24--25 percent
in Lusaka and 30 percent in the peri-urban areas of Solwezi; these rates
correspond closely to those of the nurses in this study.

#### Table 1: Mortality Rates among Nurses, Zambia (1980-1991)

+----------------------------+-------------+-------------+-------------+
|                            | 1980-1985   | 1986-1988   | 1989-1991   |
+----------------------------+-------------+-------------+-------------+
| Hospital A                 | 1           | 1           | 9           |
|                            |             |             |             |
| Number of deaths           | 2.0         | 3.0         | 25.5        |
|                            |             |             |             |
| Mortality rate (per 1000)  |             |             |             |
+----------------------------+-------------+-------------+-------------+
| Hospital B                 | No data     | 3           | 8           |
|                            | available   |             |             |
| Number of deaths           |             | 14.5        | 28.2        |
|                            |             |             |             |
| Mortality rate (per 1000)  |             |             |             |
+----------------------------+-------------+-------------+-------------+
| Total                      | 1           | 4           | 17          |
|                            |             |             |             |
| Number of deaths           | 2.0         | 7.4         | 26.7        |
|                            |             |             |             |
| Mortality rate (per 1000)  | (0.05-11.0) | (2.0-18.8)  | (15.5-42.7) |
|                            |             |             |             |
| 95% confidence limits      |             |             |             |
+----------------------------+-------------+-------------+-------------+

Source: Buve A, Foaster SD, Mbwili C, Mungo E, Tollenare N and Zeko M.
1994. Mortality among Female Nurses in the Face of the AIDS Epidemic: A
Pilot Study in Zambia. *AIDS* 8(3): 396.

Projections have been made on the proportion of healthcare providers who
will die from AIDS each year, assuming a constant rate of HIV infection
given a 10-year or a 5-year median time from infection to death. A
country with a stable 15 percent HIV prevalence, for example, can expect
that between 1.6 and 3.3 percent of its healthcare providers will die
from AIDS annually. This attrition from AIDS deaths may substantially
increase the cost of healthcare. Assuming that labor costs are at least
half of total healthcare costs and training or recruiting a replacement
worker requires a one-time expenditure equal to the worker's annual
salary, then a 7 percent increase in attrition would increase total
costs in the health sector by at least 3.5 percent (World Bank 1999).

Although HIV transmission related to medical care comprises a small
proportion of HIV transmission in sub-Saharan Africa (estimated at less
that 0.4 percent of total incidence in Tanzania's Mbeya Region),
districts should ensure safe blood supplies as well as safe injection
and sterilization practices. This will require health personnel,
especially technicians, to be adequately trained in safe blood supply
techniques, safe injection techniques, and sterilization practices. The
introduction and monitoring of protocols for quality service provision
should be part of a minimum set of standards of protection for health
personnel. Scaling up the safety level can be costly, but ignoring the
importance of additional hygiene, sterilization, and blood screening
could be substantially more costly in human and financial terms in the
long run.

A study on the impact of HIV/AIDS on human resources in the Malawi
public sector covering the period 1990-2001 reported high attrition
rates (1.6%-15%), high morbidity and absenteeism, high vacancy levels,
increased work load, and implied decline in productivity (implied
because this was not measured in the study) by the remaining workforce.
One major problem noted was the lack of accurate data due to lack of an
efficient information management system in the Malawi public sector.
Nevertheless, the study concluded that death was the largest cause of
attrition in the ministry of health and population.

As in Malawi, there have not been assessments by health ministries nor
local governments on the impact of HIV/AIDS on the demand for these
services and on the capacity to provide these services. In 1996, the
doctor-to-population ratio ranged from 1:673 in the Republic of South
Africa to 1:35,051 in Ethiopia. For areas of limited coverage, such as
Mozambique, the loss of one or more health personnel could be
catastrophic (World Bank 1999).[^2]

Employee benefits are perhaps the most obvious area in which HIV/AIDS is
having a large impact on health sector human resource costs. A
prerequisite for achieving a minimum level of acceptable performance is
an adequate reward package, such as a living wage, job security,
pensions, sick and maternity leave, etc. For government-employed
personnel these conditions of service should be sufficiently better than
those offered in the private sector (to offset the higher salaries
offered) and include free or preferential health services to the whole
family (Martinez and Martineau 1999). Assessments should attempt to
address medical schemes to ensure that care is cost-effective and
affordable, given the scale of the epidemic. To manage the benefit
schemes for employees with HIV/AIDS it will be important to limit the
increases in cost to affordable levels for the employer and employees
and ensure that available resources are used as effectively as possible
(Abt Associates South Africa 2000).

Human resource impacts, including absenteeism and funeral attendances,
reduced productivity, a demoralized and stressed workforce, additional
staff recruitment, and training and retraining of new personnel, have a
direct negative impact on the quality of services provided. Health
policies can play a key role in responding to these human resource
impacts. Work-based programs (e.g., to improve safety standards) can
mitigate the stress associated with caring for HIV/AIDS patients,
improve morale, and increase productivity.

First, lost work days due to HIV/AIDS have profound effects on the
supply of human resources. Absenteeism begins before people develop
full-blown AIDS. Reports indicate that the average person living with
AIDS can be absent from work for up to 50 percent of their final year of
life. Calculations have shown that in Botswana, if the average person
working in the health sector uses just 60 days of sick leave in their
last year of life, the public health sector could lose around 23,000
work days to AIDS in 2003 and 31,000 in 2005. Using a full six months of
sick leave, these losses could be in the magnitude of 42,500 work days
in 2003 and 57,000 in 2005. Additional absenteeism for funerals and care
of dependents is likely to be considerable (Abt Associates South Africa
2000).

The case of Swaziland demonstrates a striking interrelationship between
human resource policies, absenteeism, productivity, staff recruitment,
and training. As of the mid-1990s, public sector staff in Swaziland
could receive one year of continuous sick leave with the first six
months on full pay and the second on half salary. Moreover, staff could
not be replaced until their claim for benefits expired. Because economic
structural adjustment programs keep many institutions from replacing
staff on sick leave, such policies, combined with absenteeism, reduce
productivity significantly. A lengthy illness or death of even a few
healthcare workers can create severe supply shortages (Anonymous 1995).

Secondly, labor effectiveness is reduced by the fear factor, the
associated stress of caring for infected patients, and by inadequate
HIV/AIDS-related knowledge and practices. The underlying causes of
ineffective performance include fear of contracting the disease from
patients, stigma associated with caring HIV/AIDS patients discomfort
with the sexual dimensions of the disease, and a sense of professional
inadequacy due to high mortality rates (Masini and Mwapeta, 1993).
Perhaps the main cause of stress is the realization that they share the
risks that resulted in the infection of patients in the first place.

Thirdly, health workers also have to cope with role expansion, having to
bear responsibilities in situations for which they are untrained. This
stress is exacerbated when patients are from the same community and may
be more pronounced when patients are friends or relatives. Health
personnel often do not have the psycho-social support capabilities that
are important to deal with patients' emotional traumas. Some may feel a
great social distance from clients and patients who are commercial sex
workers or individuals with sexually transmitted infections. A Tanzanian
study found that 96 percent of health workers at one hospital did not
sympathize with infected sex workers, homosexuals, or drug abusers
(Masini and Mwampeta 1993). Staff may have cultural, social, or moral
objections to the advice that they are supposed to convey (e.g., the use
of condoms). Moreover, personnel may inadvertently be blamed for
shortages of drugs and equipment resulting from the scale of the
epidemic and system impacts (Drysdale et al. n.d.).

Good performance requires, among other things, a willingness to perform
well and the requisite skills to do the job (Martinez and Martineau
1998). Several studies have shown that the effectiveness of HIV/AIDS
counseling and prevention work on hospital wards depends on the health
workers' knowledge and attitudes regarding HIV infection (Mungherera et
al. 1997; Horsman and Sheeren 1995; Ngoumo et al. 1995; Louw et al.
1994). The Tanzanian study on the societal response, discrimination, and
stigmatization of HIV/AIDS has indicated a great deficiency in the
provision of quality care due to inadequate knowledge and negative
attitudes among staff. Forty-six percent (46%) of health personnel
sampled in one hospital had no education and no counseling skills for
AIDS prevention. Fifty-eight percent (58%) said that confidentiality of
HIV testing results is not practiced, though 80 percent felt it should
be (Masini and Mwampeta 1993). To mitigate the impact of the epidemic on
health system staff, programs can provide training to improve knowledge
and shift attitudes as well as provide and care for HIV-infected health
personnel.

Training health workers in new knowledge and skills for treatment, care,
and support requires specific targeting by cadre. A cross-sectional
study of 155 physicians and nurses at the main national referral
hospital in Uganda revealed that 80 percent of physicians, compared to
59 percent of nurses, referred patients for HIV counseling (Mungherera
et al. 1997). In another Ugandan study of 56 physicians and nurses, 40
percent of doctors and 24 percent of nurses reported they never talk to
inpatients about HIV. Twenty percent of these providers reported they
are frightened of taking care of HIV-infected patients (Mungherera et
al. 1996). Because individuals respond to perceived risk rather than
actual risk, perception of risk may be increasing the cost of care
(World Bank 1999).

# 

# 

Lessons Learned from the Private Sector about Human Resource Impacts

***Lessons Learned from the Private Sector about Human Resource
Impacts***

An increasing number of analyses are appearing from the private sector
as forward-thinking companies in high HIV prevalence countries begin to
look beyond prevention of new infection to the inevitable dent that the
disease will make in their workforces and profits, (Kolehmainen-Aitken
2000). The public sector needs to look at these lessons and utilize
similar approaches in strengthening human resources and services for
increased productivity. Like businesses, the health workforce has an
important contribution to make in the overall national economic
development.

AIDS-related illnesses and deaths of employees reduce productivity,
increase expenditures, and reduce revenues. For this reason, firms have
begun to monitor the loss of staff and quantify impacts of HIV/AIDS on
the associated healthcare costs, absenteeism, benefits and compensation,
labor turnover, training, and recruitment. Private sector employees,
like the general population, are most likely to become infected with HIV
as a result of sexual contact. Certain occupational categories like
mining and trucking have been identified as particularly high risk due
to associated life-style factors related to migration and mobility.

Few attempts have yet been made to quantify the effects of HIV/AIDS
morbidity and mortality on the profitability of private sector firms
(Thea et al. 2000). A few studies and assessments have been carried out
by private businesses to date. In a study to examine the impact of
AIDS-related costs on human resources carried out among four Kenyan
firms, the most significant factor in increased labor costs was
absenteeism due to HIV or AIDS, which accounted for 52 percent of total
AIDS-related costs (Roberts and Rau 1994). In terms of cost per
employee, the companies spent an average of US\$ 30 per capita in 1994.
Although this figure may seem insignificant, the impact may be profound
as time goes on. The study estimates that between 1992 and 2005, the
cost of HIV/AIDS is expected to increase from US\$ 20,339 to US\$ 48,402
in heavy industry; from US\$ 67,183 to US\$ 163,685 in transportation;
and from US\$ 285,847 to US\$ 866,217 on sugar estates. Because AIDS is
likely going to increase labor costs and reduce company profits,
appropriate prevention measures should be implemented at the workplace.

In the studied commercial farms in Kenya, illness and death have already
replaced old-age retirement as the leading reason why employees leave
service. Retirement accounted for only 2 percent of all employee
drop-out by 1997. A quarter of the workforce was infected with HIV on
one sugar estate in this study. Direct cash costs related to HIV rose
dramatically, company spending on funerals increased five-fold between
1989 and 1997, and direct health expenditure increased ten-fold. The
estate's managers reported greatly increased absenteeism, lower
productivity (a 50 percent drop in the ratio of processed sugar to raw
cane between 1993 and 1997), and higher overtime costs as workers were
paid to work extra hours to fill in for sick colleagues. A flower farm
in another part of the country experienced a similar ten-fold rise in
spending on employee health costs from 1985 to 1995. This expenditure,
which was estimated at over one million U.S. dollars for a company with
7,000 employees, diminished profits so heavily that the owners sold the
company (UNAIDS 1999). According to one Ugandan study (Government of
Uganda 2000), the HIV/AIDS epidemic has more than doubled the expected
number of deaths among the workforce of some enterprises. Thus,
workplace prevention programs may be a cost-effective response.

Private sector employers are starting to reconsider the benefits they
are able to pay if employees sicken or die in service. This has led to a
dilemma of benefit packages and insurance payments. Many organizations
are increasingly hiring staff on casual or rolling short-term contracts,
thus escaping the need to pay disability, death, or other benefits. A
significant number of companies are working together with the insurance
industry to work out policies and benefit packages that meet the needs
of terminally ill people and their families without bankrupting the
companies themselves. There are two points worth noting. First, only a
tiny fraction of people in countries hit hard by AIDS are covered by
formal health insurance and benefits schemes. Secondly, even those who
are covered will inevitably see health and death benefits decline
significantly because insurance companies and employers will pass on
some of the rising costs to beneficiaries and employees, including those
who are not infected with HIV (UNAIDS 1999).

The private sector has, though not so quickly, found out that it may be
more cost-effective overall for an employer to supply antiretroviral
drugs than to bear the increased costs of recruitment, training, and
payment of healthcare, disability, and death claims. Thus, some studies
have provided the evidence to support the notion that treatment, care,
and support for the infected members of the workforce is more cost
effective than simply not providing these services or recruiting new
staff and training them. The Debtswana Diamond Co. of Botswana provides
an example of this. Based on results of a study undertaken by the
company with the assistance of the Health Economics and AIDS Research
Division of the University of Natal, Debtswana is providing treatment,
care, and support to all its infected employees (HEARD 2000). It has
developed a comprehensive program of prevention, treatment, care, and
support for its employees, their families, and the local community. If
this approach is adopted by most companies and the public sector, it
could completely change the impact of HIV/AIDS on the insurance industry
and, indeed, on the workforce (Andrew 2000).

It is noteworthy that many businesses have started prevention programs
in the workplace to try to protect their investment in human capital.
Workplace activities for AIDS prevention can potentially reach an
enormous number of employees in a cost-effective manner. AngloGold, the
largest gold-mining company in South Africa, disseminates AIDS leaflets
in various languages to miners and their girlfriends and hires
specialists to train "peer educators" among miners. These miners teach
other miners as well as commercial sex workers (CSWs), who in turn teach
other CSWs. South African Breweries conducts role-playing exercises to
show how fast infection can spread. Both AngloGold and South African
Breweries offer voluntary HIV testing and counseling and free treatment
for other sexually transmitted infections (The Economist 2001). These
are examples of how private industry has become engaged in prevention
and care interventions.

*Lessons Learned from Private Sector Firms*

There are some key lessons learned from the private sector:

-   Mathematical models developed on the economic impact of AIDS on
    developing country firms and private sector research frameworks
    could potentially be used or adapted to demonstrate impacts on the
    health sector. Such examples can reinforce the paradigm that health
    should be viewed as a production function.

-   Studies in Kenya have shown that the most significant factor in
    increased labor costs, out of total AIDS-related costs, was
    absenteeism due to HIV or AIDS. While the absolute cost per person
    may initially appear not to be significant, the impact may be
    profound as time goes on.

-   Variations in HIV status by type of industry, employees' income
    levels, residence, age, and sex of employees suggest that
    organizations should think strategically to target high-risk
    categories for prevention, diagnosis, care, and support.

-   The HIV/AIDS epidemic has more than doubled the expected number of
    deaths among the workforce of some enterprises. Workplace prevention
    programs may be a cost-effective response. This is a weak area in
    the public health sector.

-   Organizations can work together with the insurance industry to work
    out policies and benefit packages that optimally serve the interests
    of all stakeholders, especially HIV/AIDS patients, in order to
    improve access to services. This could be extended to the public
    sector.

-   It may be more cost-effective for an employer to supply new
    therapies (e.g., antiretroviral drugs) than to bear the increased
    expenditures of recruitment, training, personnel illness,
    disability, and death claims.

-   With the evidence of human resource impacts supported by data,
    business managers, researchers, and policymakers can more accurately
    understand the relative impact of AIDS on different production
    units. Data can be used to improve both company and government
    strategic planning capabilities.

    **The Relevance and Impact of Health Reforms in Strengthening the
    Health Workforce in the Era of HIV/AIDS**

Healthcare reforms require fundamental changes to the ways in which the
health workforce is planned, managed, and developed within national
health systems. While issues involved in such transition remain complex,
their importance and the need to address them in a proactive manner are
vital if reforms are to achieve their key policy objectives (Martinez
and Martineau 1998). Data are necessary to understand how these reforms
will affect, both positively and negatively, the existing human resource
capacities and, more importantly, to determine the changes needed,
depending on the types of reforms that are implemented.

A clear trend in health reform is toward integration and
decentralization. Integrating programs for HIV/AIDS and sexually
transmitted infections with family planning/ maternal and child health
programs is a potentially cost-effective response to the epidemic. The
rationale is based on the fact that family planning and maternal and
child health services have, over the past 30 years, developed a solid
infrastructure in sub-Saharan Africa that can also be used for HIV/AIDS
and STD control programs. The decentralization strategy aims to provide
HIV/AIDS care and support to the many families who can afford neither
the time nor the cost of seeking care in higher-level facilities
(Schietinger and Sanei 1998). Health reform initiatives in countries
such as Ghana and Zambia have decentralized services to the local level
and spawned cost-recovery programs to increase the local availability of
healthcare (Gilks et al. 1997). The extent to which human resource
management has been linked to these reforms, though not well documented,
is clearly limited.

There is a distinction between decentralization of services and
decentralization of decision-making powers. Decentralization of services
occurs where people living with HIV/AIDS can receive drugs and treatment
in local clinics and be cared for at home. The decision-making component
of decentralization is an issue of authority and power; it has only
begun to be realized in some countries. In areas where the transition of
power has been delegated beyond the central ministry to local
authorities, new management systems (e.g., recruitment, performance
appraisal, and local pay bargaining) need to be developed. New roles
will need to be determined at the regional/provincial/ district level as
reforms are implemented. These new roles may need to change several
times during the process of reform as systems become established
(Martinez and Martineau 1998). Situation analysis and HIV/AIDS-impact
assessments should thus provide information on how reforms are
progressing, along a continuum from centralized to local decision-making
authority, to effectively guide policy and program development. This is
particularly important because of the increasing demands that are being
placed on the whole health system from primary to tertiary levels.

Health reforms are generally aimed at expanding successful interventions
and bringing them closer to the people. In South Africa, a 1992 study of
the appropriate levels of care for HIV/AIDS patients found that 60
percent of visits could safely be treated at the primary-care level. As
the severity of HIV infection increased, the percentage of patients who
could be treated at a primary-care level fell (p\<0.0001) and that of
patients requiring tertiary care increased (p\<.0001) (Metrikin et al.
1995). Reforms grounded in research-based evidence should be closely
linked to human resource management. This task will include:

-   Liaising more closely with other ministries, such as education,
    local governments, and finance, concerning the balance between
    salary and non-salary costs and changes to established health posts.

-   Liaising and negotiating with professional bodies and unions,
    especially where the reforms involve changing conditions of service,
    job roles, or initial training.

-   Overseeing changes in organizational structures and staffing levels
    from a human resource perspective to ensure that essential parts of
    the system continue to function (Martinez and Martineau 1998).

Despite trends in integrated and decentralized health service packages,
evidence is not overwhelmingly clear what this package should be. There
are mixed results on whether home care is more cost-effective than
hospital care for HIV/AIDS patients. Preliminary results from a study of
the costs of home-based care in Zambia indicate that community-initiated
care is considerably cheaper than hospital-initiated alternatives. The
average duration of a visit by a healthcare worker was typically longer
with the community-initiated home care compared to hospital care (Chela
et al. 1994). However, evidence from a representative review of
community and home-based care programs in Zimbabwe has shown that most
home care programs are more expensive than hospital care. While the cost
of personnel may be cheaper for home-based care, 56-75 percent of the
total cost per visit is spent on getting the health worker to the
patient. The home-based care programs studied generally achieved limited
coverage; coverage rates of 2-4 percent of actual need are not uncommon.
Overall, results of this study indicate that the cost of one home visit
is equivalent to between one and three days in a hospital. These
apparent contradictions in study findings may be explained in several
ways. First, cost-effective approaches to home care that achieve
sufficient coverage and provide adequate care are feasible in urban
areas, but require careful planning and monitoring in rural areas and
other resource constrained settings (Kerkhoven et al. 1999). Secondly,
various study methodologies or analytic approaches may yield different
results. This emphasizes the need for most locally relevant and
well-designed operations research results to determine the intervention
package to implement. Such an intervention package would then be the
basis for determining human resource needs.

Human resource development and deployment should ultimately be linked to
the most cost-effective package of services for a particular setting.
Different human resource needs are required for the different types of
packages, with decentralization requiring increased capacity at the
primary healthcare and community levels. Local data is needed to define
the specific linkages and personnel requirements as reforms are planned
and implemented. For example, the need for medical, economic, and
emotional support implies that the best care might be provided by a
multi-disciplinary team (Brugha 1994; Cohen and Trussell 1996). Perhaps
the best-known model of hospital-initiated service is the Chikankata
program in Zambia, initiated in 1987. The mobile home-care team consists
of a clinical officer, a nurse, an assistant AIDS educator, and a driver
who visits between five and eight people each day, three days a week
(Chela and Siankanga 1991; Cohen and Trussell 1996). Experimental
HIV/AIDS prevention programs in South Africa and Mozambique confirm the
benefits of using the prestige, credibility, and availability of
traditional healers to promote condom use. Healers are major sources of
care for sexually transmitted infections in southern Africa. A training
assessment of 1,510 South African healers trained in HIV/AIDS prevention
and symptom identification indicated that healers can play a role in
prevention and possibly referral (Green et al. 1995).

Another dimension of the issue is that human resource planning will be
required for bringing to scale new models of service provision. Although
discrete HIV/AIDS care programs are critical local responses to the
needs of people living with HIV/AIDS and their families, overall they
only reach a small percentage of people who are in need of support and
care (Gilks et al. 1997). Meeting the demand for care will require
extensive multiplication of such programs, which is happening slowly.
Program expansion will require strengthening health workforce capacities
in terms of training, supervision, and financial investment to match the
appropriate constellation of staffing patterns at each level of the
health system. This is particularly critical now that many countries
have declared interest in, and in some cases commitment to, providing
treatment including the use of antiretroviral therapy.

What will be the impact of health reforms on the health workforce? The
public sector should examine the human resource implications of
innovative interventions that have significant positive impacts from two
perspectives. These are service needs and human resource capacity.

**Critical questions relating to the service needs are:**

-   What are the human resource management capacities of ministries of
    health and other organizations?

-   What is the most cost-effective package of services for which to
    plan future health workforce?

-   Is a referral system established and functioning efficiently and
    effectively to integrate services?

-   How are the facility-based services linked to the community-level
    care and support programs?

-   How can public and private health services harmonize regulation,
    standards, education, and compensation as a way to mitigate against
    HIV/AIDS and improve performance?

    **Critical questions relating to human resource capacities:**

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-   What numbers of trained staff are in place and should be at all
    levels to provide care and support at various stages of an
    individual's disease and, more importantly for programs, at various
    stages in the epidemic?

-   Who will provide HIV/AIDS prevention, care, and support services
    under various models of care?

-   Which promising models exist for integrating maternal and child
    health/family planning with HIV/AIDS control programs?

-   How will the health workforce be brought to scale to correspond with
    the new models of service provision?

-   How are medical, nursing, and paramedical schools responding to
    changing staffing needs and orienting their curricula?

    **Some Recent Initiatives and Their Role in Addressing Human
    Resources Strengthening in the Health Sector**

    There is overwhelming agreement that human resources strengthening
    in the health sector is a central and critical function if a scaled
    response to the HIV/AIDS is to be achieved. Concern has been
    expressed that recent global initiatives aimed at responding to the
    epidemic have not adequately provided funding for strengthening
    human resources especially in the case of the health workforce.
    Among these are the Global Fund for AIDS, Tuberculosis and Malaria
    (GFATM), the World Bank Multi-country HIV/AIDS Program (MAP), and
    the United States Presidential Initiatives, such as the Leadership
    and Investment in Fighting an Epidemic Global AIDS Initiative (LIFE)
    and the Millennium Challenge Account (MCA).

    ***Health Workforce Issues in Operationalizing the Global Fund for
    AIDS, Tuberculosis, and Malaria***

Review of the proposals submitted to the Global Fund for AIDS,
Tuberculosis, and Malaria (GFATM) shows that in general, human resources
development (HRD) is not highlighted in the proposals, despite the GFATM
guidelines on this aspect. Out of the 27 Round 1 proposals, 12 did not
have explicit human resource activities/items, and out of the 50 Round 2
proposals, 33 did not explicitly deal with HRD. Most of the proposals,
however, did include human resource training activity. Training is
mentioned in 8 of the Round 1 proposals and 8 in the Round 2 proposals.
General \"capacity building\" is mentioned in 5 of the Round 1 and 11 of
the Round 2 proposals.

African policymakers recognize the need to provide staff
salaries/incentives but have not adequately catered for this or are
financially unable to do so. Funds for staff salaries were approved for
Ghana to increase the participation of 360 private providers of TB/DOTS
services, but there is no indication that approval of staff incentives
for civil servants doing GFATM-funded work has been approved.

Staff recruitment was approved for two of the Round 1 proposals and two
of the Round 2 proposals:

-   Burundi: to make available suitable health workforce for HIV/AIDS
    programs in NGOs/CBOs

-   Rwanda: recruitment of additional staff for HIV/AIDS and TB programs

-   Botswana: recruitment and training of staff to provide AIDS
    treatment, care, and support

-   Southern Sudan: staff recruitment for TB program

    The revised GFATM guidelines have now included human resources
    strengthening as a fundable component.

    ***The World Bank Multi-Country HIV/AIDS Program for Africa***

The World Bank Multi-Country HIV/AIDS Program (MAP) for Africa was
launched in September 2000 and committed substantial resources while
leveraging funds on a country-by-country basis through the International
Partnership Against AIDS in Africa (IPAA). MAP made an initial
allocation of US\$500 million in flexible and rapid funding available to
African countries to assist in scaling up national HIV/AIDS efforts. The
World Bank also approved an additional US\$500 million in IDA financing
in 2002 for the second stage of the Multi-Country HIV/AIDS Program (MAP)
for Africa. The overall development objective of MAP is to dramatically
increase access to HIV/AIDS prevention, care, and treatment programs,
with an emphasis on vulnerable groups, such as youth, women of
childbearing age, and other groups at high risk. A key feature of MAP is
direct support to community organizations, NGOs, and the private sector
for local HIV/AIDS initiatives. While this emphasis is good, in Africa
however, the public sector plays a major role in providing prevention
and care services for HIV/AIDS and related illnesses as showed in the
discussion above. One of the limiting factors is the lack of adequate
numbers of health workers who have the necessary skills mix and
management capability to guide and implement scaled up programs. A
recent review of the MAP program could have emphasized this fact more.

***Leadership and Investment in Fighting an Epidemic: A Global AIDS
Initiative***

In July 1999, the White House announced the Leadership and Investment in
Fighting an Epidemic Global AIDS (LIFE) Initiative. This initiative
targets countries with the most severe epidemics and the highest numbers
of new infections and where the potential impact of the interventions is
greatest.

Although strengthening of the health workforce is not a mandate of the
LIFE Initiative, it does have an objective to develop capacity and
infrastructure, including disease surveillance and HIV/AIDS program
monitoring, evaluation, and management. Human resources could therefore
be strengthened as part of capacity development.

***Millennium Challenge Account***

In 2002, the Unites States established the Millennium Challenge Account
to provide assistance to countries that have demonstrated a commitment
to ruling justly, investing in people, and encouraging economic freedom
for general development including responding to the HIV/AIDS crisis.
Countries were selected for the Millennium Challenge Account based on
clear, objective, and concrete criteria that measure commitment to
ruling justly, investing in people, and encouraging economic freedom. As
stipulated in the presidential statement, recipients are encouraged to
"identify uses for Millennium Challenge Account funding through
participatory processes involving local and national elected officials,
civil society, and development partners such as non-governmental
organizations and private voluntary organizations." Millennium Challenge
Account support would be provided in the form of grants that will be
delivered in innovative and efficient ways to maximize economic growth
and poverty reduction. These are critical elements in the fight against
HIV/AIDS. As investing in people is seen as an important criteria for
receiving the funds, it is equally important that the funds be used to
recruit, retain, train, and manage people in the workforce so that they
can participate fully in the development process that must include
responding to the HIV/AIDS crisis in Africa.

**Assessing the Impact of HIV/AIDS on the Health Workforce: Available
Tools and Their Use**

Hardly any sub-Saharan African country has developed a comprehensive
system for assessing the impact of HIV/AIDS on the health system,
particularly as it relates to human resource needs and capacities for an
expanded and accelerated response to the epidemic. With personnel costs
consuming 70--80 percent of the budget of most health organizations, it
is essential to identify human resource impacts and to address them.

A number of tools for assessing the impact of HIV/AIDS on health
workforce have been developed and used in a limited way. These include:

-   The *Multisectoral AIDS Toolkits* incorporating the government
    response component developed by Abt Associates Inc. and the
    University of Natal in South Africa. This tool provides checklists
    for various departments in the public sector to identify impacts of
    HIV/AIDS on the sector and the sectors response to the impacts.

-   The *Human Resource Development Assessment Tool* developed by
    Management Sciences for Health in the USA. This tool focuses on the
    performance of the health workforce at the facility level.

-   *AIDS* *Policy: Business Managing AIDS, A Guide for Managers*;
    private sector manual developed by Mathew Roberts, Bill Rau and Alan
    Emery for FHI, 2002.

-   Study instruments for the "Impact of HIV/AIDS on Human Resources in
    the Malawi Public Sector", Malawi Government and UNDP, February
    2000.

-   AIDS Impacts Model, Futures Group

-   AIDS/Treat Cost tool developed by PHRplus to help policymakers plan
    and cost comprehensive antiretroviral therapy programs

-   USAID guidance ADS 203: Stipulates that all HIV/AIDS programs
    supported by US government funds must use common indicators that are
    provided by the Bureau of global health.

The *Multisectoral AIDS Toolkits* have been successfully used in
Botswana for a health sector assessment and in South Africa for the
education and public services administration sectors. Their purpose is
to facilitate the ability of government ministries to respond to
HIV/AIDS. Beginning with an assessment of the prevalence and incidence
of the disease, the toolkit can be used to guide projections of the
human resource needs based on increased service demand.

Management Sciences for Health has produced the *Human Resource
Development Assessment (HRDA) Tool* that has successfully been used in
Zambia, Albania, and Bolivia by public- and private-sector health
organizations. Its purpose is to provide users with an assessment
instrument to identify the organization's characteristics with respect
to the core functions of a human resource system and develop an action
plan to address problems.

The *Multisectoral AIDS Toolkits* and *Human Resource Development
Assessment Tool* differ in emphasis but not in approach. Both assist
organizations in assessing their own human resources by involving key
actors. Assessments which actively involve staff: (1) increase the
buy-in of key actors, thereby enhancing the likelihood that they will be
used; (2) encourage the organization to be critical of outputs; (3)
allow for familiarity with the sector in the country or province being
studied, hence improving the validity, conclusions, and recommendations.
These tools can be used to demonstrate that human resource development
has an integrated purpose, that the health system should be viewed as a
production function, and that by investing in human resources, an
organization invests in enhanced productivity and improved social
welfare.

Assessment tools may not always critically address certain gross or
subtle factors related to health impacts. In countries with relatively
young epidemics, for example, there is significant denial and a failure
to recognize certain impacts as being HIV/AIDS-related. Routine
quantifiable data (e.g., rates of attrition or absenteeism) may be weak
mainly because systems may not desire to maintain accurate human
resource information for various reasons or they do not have the
capacity to do so. Thus, it is important to recognize that current
approaches and tools may continually need to be refined as certain
issues become significant and prioritized in future years.

***Indicators for Human Resource Impacts***

Indicators will need to be defined as new tools are developed for future
assessments of the impact of HIV/AIDS. Steps in this direction have
already been undertaken as part of the toolkits reviewed above. A tool,
*Guide to Monitoring and Evaluation of National AIDS Programs*, also
consolidates existing data collection instruments to create a framework
within which improved instruments can be developed. This guide also
outlines a few indicators that currently exist for monitoring human
resources issues in the context of the epidemic:

-   The proportion of formal-sector employers sampled with
    non-discriminatory policies and practices in recruitment,
    advancements, and benefits for employees with AIDS

-   The rate of accidental transmission in healthcare settings

-   The percent of medical personnel trained in AIDS

This list needs to be expanded and complemented with standardized,
appropriate tools for collecting data. First, the resulting core set of
indicators should be used to collect baseline data for monitoring and
evaluating HIV/AIDS programs. Secondly, these indicators should be
linked to the more detailed needs of individual programs to prevent and
mitigate the impacts of HIV. An example of suggested indicators follows
in Table 3 below.

## *Development of Future Assessment Tools and Indicators*

The existing human resource assessment tools described could form a
basis for the development of locally adapted rapid assessment tools in
sub-Saharan Africa. This would lead to the development of simple sets of
core indicators for use at national, district, and service levels. For
example, critical indicators from other instruments, such as the MEASURE
health facility assessment, could be used in individual projects for
gathering data at the facility level. (These instruments are described
in Annex 2 at the end of this document.) The *Multisectoral HIV/AIDS
Toolkits* and the *Human Resource Development Assessment Tool* have
already been field tested. This review recommends that they be adapted
and linked to an agreed-upon set of indicators to standardize the
monitoring and evaluation of the epidemic's impacts on a broader scale.
Of utmost importance is their introduction into AIDS control programs
through a process that enhances ownership and transparency.

**Table 2:**

**Examples of Potential Human Resource Impact Assessment Indicators**

+-----------+----------+----------------------+-----------------------+
| COMPONENT | PURPOSE  | TYPES OF POTENTIAL   | EXAMPLES OF           |
|           | OF       | ASSESSMENTS          | INDICATORS            |
|           | AS       |                      |                       |
|           | SESSMENT |                      | (# and/or %)          |
+===========+==========+======================+=======================+
| Employee  | Baseline | \* Review of human   | Staff by cadre/skill  |
| data      | capacity | resource/            | level                 |
|           |          |                      |                       |
|           |          | personnel files      | Staff by location     |
|           |          |                      |                       |
|           |          | \* Semi-structured   | Staff by gender       |
|           |          | interviews with      |                       |
|           |          | employees            | Staff by salary level |
+-----------+----------+----------------------+-----------------------+
| Employee  | Baseline | \* HIV prevalence    | HIV-infected staff    |
| i         | epid     | estimates based on   | currently             |
| nfections | emiology | regional/provincial  |                       |
| and       |          | HIV prevalence       | AIDS deaths           |
| susce     | Mo       |                      |                       |
| ptibility | tivation | \* Rough estimate of | New infections among  |
| to        | for      | multiplier           | staff                 |
| infection | planning |                      |                       |
|           |          | effect for           | Reported condom use   |
|           |          | service-based        |                       |
|           |          |                      | Reported sex with \>1 |
|           |          | ministries (e.g., \# | partner in            |
|           |          | employee             |                       |
|           |          |                      | previous year         |
|           |          | AIDS deaths X \#     |                       |
|           |          | service              | Knowledge, attitude,  |
|           |          |                      | and practices (KAP)   |
|           |          | recipients per       | of health staff       |
|           |          | employee)            | regarding prevention  |
|           |          |                      | and treatment of      |
|           |          | \* Semi-structured   | HIV/AIDS              |
|           |          | interviews with      |                       |
|           |          | employees            |                       |
+-----------+----------+----------------------+-----------------------+
| Ab        | Planning | \* Review of sick    | Reported days sick    |
| senteeism |          | leave utilization,   | leave (past 3 years)  |
| and       | Restr    | absenteeism,         |                       |
| pro       | ucturing | operational          | Days of other         |
| ductivity | work     | implications and     | absenteeism           |
|           | p        | costs                |                       |
|           | rocesses |                      | Unit measures of      |
|           |          | \* Review of work    | productivity (clients |
|           |          | processes and        | treated per employee, |
|           |          |                      | etc.)                 |
|           |          | interviews with key  |                       |
|           |          | personnel            | Projected sick leave  |
|           |          |                      | and costs under       |
|           |          | to identify areas    | current benefit       |
|           |          | vulnerable to        | structure             |
|           |          |                      |                       |
|           |          | s                    |                       |
|           |          | toppages/bottlenecks |                       |
|           |          |                      |                       |
|           |          | \* Review of sick    |                       |
|           |          | leave policies       |                       |
|           |          |                      |                       |
|           |          | \* Calculation of    |                       |
|           |          | projected sick       |                       |
|           |          |                      |                       |
|           |          | leave and work       |                       |
|           |          | stoppages            |                       |
+-----------+----------+----------------------+-----------------------+
| Human     | Planning | \* Review of budget  | Budget allocated for  |
| resource  |          | allocated for        | human resource        |
| de        |          |                      | development           |
| velopment |          | human resource       |                       |
| budget    |          | development          |                       |
+-----------+----------+----------------------+-----------------------+
| Rec       | Planning | \* Skills audits     | Days from vacancy to  |
| ruitment, |          |                      | filled post for       |
| hiring,   |          | \* Review of staff   | various personnel     |
| and       |          | turnover             | categories            |
| training  |          |                      |                       |
|           |          | \* Review and        | Costs of recruiting,  |
|           |          | analysis of          | hiring, and training  |
|           |          |                      | personnel at various  |
|           |          | recruitment costs    | levels                |
|           |          |                      |                       |
|           |          | \* Review of         | Staff trained in      |
|           |          | training plan        | HIV/AIDS-relevant     |
|           |          |                      | protocols,            |
|           |          |                      | counseling, VCT, ARV, |
|           |          |                      | MTCT, opportunistic   |
|           |          |                      | infections, pain      |
|           |          |                      | management, etc.      |
+-----------+----------+----------------------+-----------------------+
| Job       | Restr    | \* Review of job     | Rating of job         |
| class     | ucturing | descriptions         | classification system |
| ification | work     |                      | (documented and used  |
| system    | p        | \* Review of human   | in reality)           |
|           | rocesses |                      |                       |
|           |          | resource/personnel   |                       |
|           |          | manual               |                       |
|           |          |                      |                       |
|           |          | \* Interviews        |                       |
+-----------+----------+----------------------+-----------------------+
| Morale    | Mo       | \* Focus groups      | Employees affected by |
|           | tivation |                      | HIV illness or death  |
|           |          | \* Anonymous         | of family members,    |
|           | Planning | employee surveys     | friends, colleagues   |
|           |          |                      |                       |
|           |          |                      | Types of impacts      |
|           |          |                      | experienced by        |
|           |          |                      | employees             |
|           |          |                      |                       |
|           |          |                      | Attitudes to          |
|           |          |                      | workplace support     |
+-----------+----------+----------------------+-----------------------+
| Benefits  | Mo       | \* Review of sick    | Employer              |
|           | tivation | leave policies       | contributions schemes |
|           |          |                      |                       |
|           | Benefit  | \* Calculation of    | Death claims          |
|           | restr    | projected sick       |                       |
|           | ucturing |                      | Disability claims     |
|           |          | leave and other      |                       |
|           |          | absenteeism and      | Ill health            |
|           |          | costs                | retirements           |
|           |          |                      |                       |
|           |          |                      | Costs of above        |
+-----------+----------+----------------------+-----------------------+
| Gender    | Mo       | \* Workplace survey  | Women in management   |
|           | tivation |                      | level                 |
|           |          | \* Focus groups with |                       |
|           | Planning | external             | Staff changeover by   |
|           |          |                      | gender                |
|           |          | facilitator          |                       |
+-----------+----------+----------------------+-----------------------+
| Capacity  | In       | \* Review of         | Employees reached by  |
| to        | creasing | employee HIV/        | workplace prevention  |
| respond   | effec    |                      | and care programs     |
|           | tiveness | AIDS prevention      |                       |
|           |          | programs             | Budgetary capacity    |
|           | Planning |                      | for prevention        |
|           | new      | \* Survey of line    |                       |
|           | inter    | managers             | KAP among employees   |
|           | ventions |                      | by category           |
|           |          | \* Evaluation of     |                       |
|           |          | employee             | Users and non-users   |
|           |          |                      | of employee           |
|           |          | assistance programs  | assistance programs   |
|           |          |                      | by cadre              |
|           |          | \* Focus groups or   |                       |
|           |          | semi-structured      |                       |
|           |          | interviews with      |                       |
|           |          | users and non-users  |                       |
|           |          | of employee          |                       |
|           |          | assistance programs  |                       |
+-----------+----------+----------------------+-----------------------+
| Occ       | Ethical  | \* Interviews and    | Personnel injured on  |
| upational | respon   | surveys              | duty (e.g., rate of   |
| safety    | sibility |                      | accidental            |
|           |          | \* Use of            | transmission)         |
|           | F        | appropriate          |                       |
|           | inancial | routinely            | Staff using sterile   |
|           | respon   |                      | techniques            |
|           | sibility | available data       |                       |
|           |          | (e.g., staff files,  | KAP of staff on       |
|           |          |                      | safety of contact     |
|           |          | supply lists of      |                       |
|           |          | gloves)              | with patients by      |
|           |          |                      | cadre                 |
+-----------+----------+----------------------+-----------------------+
| Policy    | Policy   | \* Review of         | Rating score for      |
| and       | dev      | personnel policy     | human resource/       |
| le        | elopment |                      | personnel policy      |
| gislation | and      | manual               | manual                |
|           | planning |                      |                       |
|           |          | \* Interviews on     | Rating of human       |
|           |          | labor law            | resource/personnel    |
|           |          |                      |                       |
|           |          | compliance           | policies regarding    |
|           |          |                      | HIV/AIDS              |
|           |          | \* Review of         |                       |
|           |          | policies on          | Orga                  |
|           |          | disclosure of        | nizations/departments |
|           |          | HIV-positive status  |                       |
|           |          |                      | with                  |
|           |          |                      | non-discriminatory    |
|           |          |                      | policies              |
+-----------+----------+----------------------+-----------------------+

Adapted from "AIDS Toolkits: Planning Tools" and "Human Resource
Development Assessment Tool."

**Conclusions and Recommendations**

This review has identified key areas of study and information gaps on
human resource impacts. These studies are described in greater detail in
Annex 1 at the end of this document. Findings and recommendations for
future assessments are summarized below.

***Summary of Findings***

Given the scarcity of assessments carried out to date on the impact of
HIV/AIDS on human resources in the health sector, immediate action is
required. Evidence indicates that there is an increased demand for
health services as a result of the epidemic. Studies suggest there are
changes in the disease profiles and thus the type of services required
across sub-Saharan Africa. Simultaneously, the epidemic is decreasing
the number and productivity of health service providers as they are lost
to their own illness and death as well as factors such as stress and
demands from family members who die from the disease.

Where impacts of HIV/AIDS on human resource assessments have been
undertaken involving stakeholders, the results have been promising. The
experience from South Africa *Using impact assessments to mobilize
political commitment and action against HIV/AIDS: The experience of
Gauteng Province, South Africa; 1997-1998*, demonstrates that such
assessments are powerful mechanisms for creating a forum to inform and
improve advocacy, canvassing, and resource commitment for an improved
response to the epidemic. This health sector human resource assessment
resulted in the establishment of an interdepartmental AIDS program, a
ten-fold increase in the HIV/AIDS budget over the previous year, and the
development of an HIV/AIDS strategy which is currently being
implemented. Results continue to be used by stakeholders to mobilize
commitment and provide data for planning. Evidence from private
businesses across various sectors in sub-Saharan Africa has provided
valuable lessons on potential benefits of workplace prevention programs,
insurance policies, and benefit packages that optimally serve the
interests of all stakeholders and the provision of new therapies, such
as antiretroviral drugs.

***What Is Known***

There is general agreement on the following points based on research
carried out to date on human resource impacts:

-   **Crowding out effects.** Health facility assessments suggest that
    the epidemic is crowding out patients suffering from conditions that
    are seemingly less severe than HIV/AIDS. Health service providers at
    the peripheral facilities are overburdened and require additional
    skills to deal with the changing disease burden.

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-   **Health worker knowledge, attitudes, and practices**. Several
    studies in sub-Saharan Africa indicate that certain health personnel
    working in a variety of health service capacities have less than
    optimal knowledge and skills for managing HIV/AIDS cases, fearful
    attitudes, and unsatisfactory practices which compromise quality of
    care and their own safety.

-   **HIV rates among healthcare workers.** Private sector
    epidemiological studies show that there are variations in HIV status
    by type of industry, employees' income levels, residence, age, and
    sex of employees. A study of HIV prevalence among healthcare workers
    from Africa suggests that doctors and nurses are at least as likely
    to become infected as other people in the general population.
    Although, HIV transmission from injuries on duty among health staff
    is minimal, it does pose an added risk.

-   **HIV/AIDS mortality among health personnel.** However, a separate
    health sector assessment conducted in Botswana suggests that
    projections of HIV-related mortality cannot be based on general
    prevalence rates alone but should consider the demographic profile
    of health workers. Age-specific death rates can be used to project
    the ratio of health personnel to population over time.

-   **The health personnel versus population ratios in selected
    countries**. Data exists on the ratio of health personnel to
    population, although urban/rural distinctions may not be available.
    Such information is useful to advocate for making human resource
    development a priority and for projecting potential impacts of the
    loss of health personnel.

-   **Human resource development.** Data generally exists at the
    ministry level on the number of staff by cadre/skill level,
    location, gender, and salary level, however it may not be compiled
    in such a way for readily available use in human resource planning.

-   **Refining assumptions on supply and demand for services.** The
    epidemic is dynamic and study results and new advances on
    confronting the epidemic are emerging daily. Assumptions on which
    the projected demand and supply of services are based should be
    continually refined. For example, the assumption that the increased
    demand for healthcare services occurs only during the last year of
    life may ignore the additional demands of children of HIV-positive
    mothers, of newly infected persons within the six-to-ten year time
    span and for tuberculosis services (Anonymous 1995).

# Gaps in Knowledge

There is limited data, evidence, and knowledge on the following issues:

-   **Supply and attrition of health sector staff.** Data are extremely
    limited in the health sector on the degree of attrition of workers
    due to HIV/AIDS. No studies are available on employee susceptibility
    to HIV or opportunistic infections. Demographic profiles of health
    workers are rare. The thorough assessment conducted in Botswana
    cautions that verifiable data could only be obtained for ten percent
    of health workers and sample sizes differed for different categories
    of workers.

    There could be no assurance that the sample was not significantly
    biased. To date, no studies in sub-Saharan Africa have evaluated the
    impact of increased out-migration of highly trained staff or reduced
    training outputs of universities due to HIV/AIDS.

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-   **Absenteeism and productivity.** Determining the epidemic's impact
    on health workforce in terms of absenteeism and productivity is
    essential for forecasting future health system costs and
    performance. Only rough data exist on the number of cases of known
    or suspected HIV/AIDS among health staff at particular hospitals.
    The analyses conducted by private sector firms in Kenya can be used
    as models because there is little information on the most
    significant factors in increased medical costs due to
    HIV/AIDS-related illness.

-   **Recruitment and hiring policies**. Anecdotal evidence from
    Swaziland is available on the outdated policies that constrain
    institutions from replacing staff on sick leave. No studies could be
    identified on the number of days from vacancy to filled post for
    various personnel categories in the health sector or the costs of
    recruiting and hiring personnel at various levels of the system,
    which have profound effects on supply shortages.

-   **Employer contribution schemes.** The lack of information on
    impacts on employee benefits is a serious omission from health
    sector assessments. However, the private sector has shown that data
    on the number and costs of death and disability claims is a
    foundation for developing future compensation policies.

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-   **Health worker knowledge, attitudes, and practices**. Four studies
    in Senegal, Tanzania, Uganda, and Zambia indicate that in-depth
    research is still needed to identify the basis of health workers'
    fears in treating HIV/AIDS patients, their reluctance to work in
    high HIV prevalence areas, reasons they are not providing effective
    counseling and testing, and why safety standards are not followed.

-   **Training and counseling capacity and effects**. The extent to
    which health service personnel have been trained in counseling and
    testing, mother-to-child transmission, management of opportunistic
    infections, provision of antiretroviral therapy, and other specific
    topics, needs to be determined. The effects of training on various
    cadres of staff regarding prevention, care, and support of
    HIV-infected individuals need to be explored to assure quality care.

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-   **Health sector reforms and scaling up.** While training is
    certainly an important component of human resource management,
    without strategic human resource planning, good performance in the
    health system will not be achieved (Martinez and Martineau 1998).
    Assessments will need to address the implications of decentralized
    decision-making and services. This includes scaling up innovative
    models such as DOTS and TB preventive therapy, the introduction of
    antiretroviral therapy, and community and home-based care of people
    living with HIV/AIDS. Studies have not yet identified the human
    resource requirements of scaling up workplace prevention and care
    programs nor the costs and benefits.

# Recommendations

The specific recommendations aim to facilitate the collection of
appropriate and up-to-date data on HIV/AIDS impacts on health workforce
and promote their use at the national level for designing mitigation
responses. Results should be communicated to key policymakers, program
decision makers, and other stakeholders to ensure appropriate policies,
strategies, and interventions, such as strengthened political and
executive leadership in the field of HIV/AIDS, commitment of funds, and
recruitment and retention of providers and development of provider
skills to meet the changing patient mix, disease profiles, and
diagnostic, care, and support services.

***Specific recommendations:***

1)  Undertake human resource needs assessments in the health sector
    across sub-Saharan Africa to improve the performance of national
    AIDS control programs. Initially, select three countries to empower
    African institutions to develop and adapt the existing tools. Hold a
    workshop in one of the selected countries to develop the tool and
    plan for the three assessments.

2)  Identify and form partnerships of stakeholders who will work
    together to establish national coordinating bodies, adapt the
    proposed set of indicators, develop the tools, undertake
    assessments, and use the results to design locally relevant
    interventions and actions. Involving stakeholders encourages the
    organization to be critical of outputs and ensures that assessments
    lead in a pre-planned way into strategy development.

3)  Provide donor funds and commit resources for initial assessments
    and, ultimately, ongoing and replicated assessments across countries
    and funding to actually strengthen the health workforce based on the
    results of assessments and local situation analysis.

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4)  Develop a core set of standardized human resource indicators for the
    health sector to collect baseline data, monitor, and evaluate
    mitigation responses. These indicators should be developed to
    collect information on human resource capacity at the district and
    national level and be standardized for aggregation at the regional
    level. A more comprehensive list of potential indicators for
    individual projects should be considered.

5)  Adapt the existing tools such as the "HIV/AIDS Toolkits" and the
    "Human Resource Development Assessment Tool" during the first
    workshop. Tools should ultimately be able to assess:

-   the effects of the epidemic on labor absenteeism caused directly by
    higher staff morbidity

-   exceptional mortality amongst different cadres of workers to
    identify probable losses of skilled, professional, and other
    employees by age, sex, and geographical area

-   the direct costs to the health sector due to absenteeism, labor
    turnover, and replacement (including recruitment, training, health
    and medical costs, and support for dependents)

-   the indirect effects due to human resource losses, including
    qualitative evaluation of the effects of morbidity and mortality on
    morale, attitudes,

-   and social cohesion within institutional settings

-   estimation of the probable effects on health sector capacity over
    the next five to ten years to inform planning

-   existing policies and programs requiring action by the government,
    donors, and other institutions (religious organizations, NGOs,
    professional associations, etc.)

-   the implications of scaling up programs, by comparing the costs and
    benefits within and between programs.

6)  Explore the use of mathematical models developed on the economic
    impact of AIDS on private sector companies and other sectors in
    sub-Saharan Africa. Examine private sector research frameworks to
    demonstrate relevant impacts on the health sector. Such examples can
    reinforce the paradigm that health should be viewed as a production
    function. Linked with financial data, future impacts can be
    projected and can provide valuable information for advocacy purposes
    and program interventions. Explore the feasibility of adapting
    computer-based economic models to examine the impact of AIDS on the
    health sector.

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7)  Use the adapted data collection tools to undertake impacts
    assessments and use the data to plan health workforce development
    and management at service and national levels in respective
    countries in Sub-Sahara Africa.

8)  Establish an ongoing monitoring and evaluation of HIV/AIDS impacts
    on the health systems and specifically on the health workforce and
    the national response.

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11) Refine assumptions as assessment results provide new data for
    decision-making. There is a whole "second level" of more detailed
    knowledge that eventually should be explored to ensure the validity
    of impact assessments. For example, if may be more cost-effective
    for a private sector employer to supply new therapies than to bear
    the increased expenditures of recruitment, training, and personnel
    illness, disability, and death claims, what is the implication for
    the public sector?

As Africa scales up AIDS programs and undertakes assessments across
countries to meet the challenges ahead, human resource policy and
management must be considered a priority investment. National indicators
for monitoring the performance of HIV/AIDS control programs should
include human resource indicators. Results of the monitoring and those
from HIV/AIDS impact assessments should be the basis to design locally
relevant interventions and actions. The U.S. Agency for International
Development (USAID), partners, new and existing global initiatives
should provide funding specifically for human resources strengthening to
support and guide national efforts in the fight against HIV/AIDS. In
this respect, the health sector could borrow a leaf from the experience
(USAID Africa Bureau Brief, 2002) in the education sector in which an
African Mobile Task Team (MTT) has facilitated undertaking of assessment
of HIV/AIDS in the education sector and assisted in the development of
response actions successfully in 12 countries in East and Southern
Africa.

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![](media/image2.wmf){width="0.9798611111111111in"
height="0.6590277777777778in"}

Prepared by the Support for Analysis and Research in Africa (SARA)
Project which is operated by the Academy for Educational Development.
SARA is funded by the United States Agency for International Development
(USAID), Bureau for Africa, Office of Sustainable Development
(AFR/SD/HRD), under Contract AOT-C-00-99-00237-00.

[^1]: Directly Observed Therapy, Short-course (DOTS)

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