From the MSF Report:
HELP WANTED: Confronting the health care worker crisis Click here
South Africa is classified as a middle-income country but has a vast disparity in wealth and access to health care, a lasting legacy of apartheid. As elsewhere in sub-Saharan Africa, tuberculosis is the leading killer of people with HIV/AIDS in South Africa, and this has been aggravated by the proliferation of multi-drug resistant (MDR) and extensively drug-resistant (XDR) TB, further straining an already overburdened and understaffed health system.9
MSF HIV/AIDS treatment programmes Since 2000, MSF has been working in Khayelitsha, a poor periurban township on the outskirts of Cape Town (see panel). Antenatal HIV prevalence in Khayelitsha is approximately 30%, nearly double the provincial average of 17.5%.
In December 2002, MSF started a second project in South Africa in Lusikisiki sub-district (population 150,000) in Eastern Cape Province. Lusikisiki is serviced by one hospital and 12 clinics and is one of the poorest and most densely populated rural areas of South Africa. Less than half the population live in formal housing and up to 80% live below the poverty line. The number of doctors in Lusikisiki is 14 times below the national level; in 2005 37% of nursing posts in the Eastern Cape were vacant.
The implementation of HIV care at the primary care level allowed a rapid scale-up of treatment. This was accomplished through task-shifting to nurses, community mobilisation, and the use of lay workers (especially people living with HIV/AIDS) and community volunteers. By October 2006, 2,200 people were receiving ART. Clinical outcomes were good, with 81% of patients initiated at health centres remaining in care at 12 months.10 Following a gradual handover over a period of 18 months, MSF transferred full responsibility for the programme in Lusikisiki to provincial health authorities in October 2006.
National human resource situation South Africa's private sector employs half of the country's nurses and two-thirds of the doctors. The shortage of nurses in the public sector has grown substantially worse between 2000 and 2005. For example, the number of enrolled nurses has dropped from 60 per 100,000 to 52 per 100,000 and the number of professional nurses has dropped from 120 per 100,000 to 109 per 100,000.11
One of the objectives of South Africa's new National Strategic Plan on HIV/AIDS for 2007-2011 is to offer care and treatment to 80% of all people in need. An alarming 35,000 people in need of ART are presently on waiting lists according to the Department of Health and an estimated one million people are in need of ART.12
The National Strategic Plan predicts that by 2011 most people in need of ART will receive their treatment from nurses in primary care clinics rather than doctors in hospitals. However, the Department of Health's Human Resources for Health Plan, which was developed in isolation from the National Strategic Plan, does not take into account HIV/AIDS. Neither increased demand nor the direct impact of HIV/AIDS on the workforce is considered.13
Although overall supply of health care workers in South Africa is not an acute problem, unequal distribution between the private and public sectors and between urban and rural areas - due to low salaries and poor working conditions - combines with the overwhelming need for treatment to create a crisis.