"As the only nurse here, I have to do the work of at least four nurses. I take blood samples, sputum, do both ante-natal and post-natal cases, and do curative cares for general patients, baby deliveries, etc. If I have to go somewhere, the clinic remains closed. Most nurses have left for the UK or South Africa. As a matter of fact, if I was younger, I would also have gone by now!" - Emily Makha, 70, Nursing Sister/Midwife, Kena Health Centre, Lesotho Population: 1.8 million
Life expectancy: 35.2 years
Adult HIV prevalence: 23.2%
No. of people with HIV/AIDS: 270,000
No. of people in need of ART: 57,000
No. of people initiated on ART: 17,700
Treatment deficit: 39,300
Proportion of national budget spent on health: 9.5% Lesotho is a small, poor, mountainous country with the third highest HIV prevalence in the world, the fourth highest TB incidence, and a growing problem of MDR-TB.
MSF HIV/AIDS treatment programme MSF began providing HIV/AIDS care and treatment in Lesotho in January 2006, supporting government and Christian Health Association of Lesotho facilities in Scott Hospital Health Service Area through the district hospital and 14 rural primary health care clinics. There are an estimated 35,000 people living with HIV/AIDS in Scott Hospital HSA; of these approximately 5,000 are in urgent clinical need of ART.
In order to reach more people MSF helped to decentralise HIV care and treatment to the clinic level, where nurses are responsible for running services. Nearly all the nurses in the Health Service Area have been trained to diagnose and manage HIV-related conditions and initiate ART. MSF has also trained community members, primarily people living with HIV/AIDS, to work as lay counsellors providing HIV testing and adherence support. In just over one year, the project has provided ART for 1,393 people.
There are only four doctors working for Scott Hospital - less than two per 100,000 people. As of May 2007, not a single one of the 14 health centres has the minimum staffing complement, and the number of nurses has decreased in the past year. In 2006, more than 25 nurses left the Health Service Area for other jobs and as of May 2007, 54% of professional nursing posts at health centres were vacant. This left trained nursing assistants, who receive just two years of training, to carry much of the burden of clinical work.
Largely due to HIV, those nurses that remain face a sharp increase in workload, which is projected to increase dramatically in the coming years, further increasing the shortfall of nurses (see graph).[vii] 15
National human resource situation The human resource crisis in Lesotho is critical. Countrywide there are just 89 doctors, and 80% of these are foreigners from other African countries, most of whom are awaiting certification in South Africa where they can get higher paying jobs.16 The shortage of doctors makes lower cadres such as nurses even more valuable in the provision of care, but they are also in short supply: from 1994 to 2004 the number of employed nurses fell by 15%. Only six of 171 health centres in the country have the minimum staffing required.17
The government of Lesotho recognises health care worker shortages as a major challenge to expanding HIV/AIDS treatment and has taken some steps to respond. The Ministry of Health and Social Welfare acknowledges that ART scale-up will not be possible without allowing nurses to initiate ART and lay workers to carry out key support tasks.
In addition, the government has established an Emergency Human Resources Task Force, proposed raising pay of health care workers, and launched a plan to recruit 200 nurses from within Lesotho and outside the country (particularly Kenya). But the Task Force has no terms of reference and has yet to be convened, the salary raises are stalled, the nurse initiative has so far identified only a handful of nurses in the country, and the external recruitment plan is yet to be finalised.
Donors and other international actors in Lesotho recognise the human resource problem but, with a few exceptions, do little to address it. For example, the US Millennium Challenge Account is committing an unprecedented $US 140 million to improve physical infrastructure at health facilities. However, it is estimated that 600 additional health care workers will be needed to staff these new and rehabilitated health structures, and plans to fund or recruit for these posts have not been foreseen.
"When I was a nursing student I had to ask myself why am I going into nursing at all and I even considered leaving the field because I had the feeling I was just learning how to move patients from the consulting room to the mortuaries. Now that the ARVs are here, all that has changed. I feel motivated again that there is hope. Now my only problem is the shortage of staff. We are just two at this clinic." - Mpeo Kompi, 26, Nursing Sister, Matelile Health Centre, Lesotho