To the Editor:
At the start of 2004, an estimated 39 million people worldwide were infected with HIV, 6 million of whom were in urgent need of antiretroviral therapy (ART).1 Now that substantial funds have been pledged for HIV care and treatment, in many developing countries the lack of financial resources is no longer the primary impediment to adequate provision of services. Instead, policy makers now see the lack of trained health professionals as the major barrier to rapid scale-up.2-5
In 2001, we implemented a large-scale program for the prevention of mother-to-child HIV transmission (PMTCT) within the government-run district health system of Lusaka, Zambia. In this network of clinics, more than 10,000 infants are born to HIV-infected mothers yearly.6 Because of numerous external factors-including a temporary hiring freeze for clinic staff within the Lusaka district and limited flexibility within the district health care budget-we were unable to hire new medical staff to assist in this program. Instead we devised a strategy whereby off-duty nurse counselors would work extra shifts for supplemental pay. This approach is well known to district workers, many of whom have made similar arrangements within the private sector. We describe our experiences and their applicability to other settings.
In Lusaka, the district health department employs nearly 1000 nurses and midwives. As government employees, the duties and work schedules for these health care workers are well structured. In a given month, a member of the obstetric nursing staff rotates through antenatal clinics, day labor ward shifts, and night labor ward shifts. As part of this schedule, nurses and midwives are granted significant time off-duty. For example, nurses and midwives working the night labor ward shift are given 1 week off before returning to their day-time rotations. Nurses may be off-duty 1-2 days during the week while working day clinic shifts. Staff members also receive 4 weeks of leave per year. Currently, a nurse-counselor employed by the Lusaka district earns the Zambian Kwacha equivalent of US $180 per month. This base salary is not competitive with the local private sector or with positions abroad.
In October 2001, the Lusaka District PMTCT Program was started in 2 district clinics and gradually expanded to the other 22 district health facilities and the University Teaching Hospital in the following 2 years.6 This program includes services for universal HIV counseling, voluntary HIV testing, and dispensation of short-course antiretroviral prophylaxis to HIV-infected women and their newborn infants. Rather than relying upon those working regular shifts, we implemented a system that would pay off-duty staff to perform these duties. Financial compensation is based on existing overtime rates within the district: approximately US $4 for an 8-hour shift. Because these duties can be physically demanding and emotionally exhausting, a maximum of 5 patients are counseled (with or without testing) by each nurse during her shift. Unlike the base salary, these off-duty rates are comparable for similar work in the private sector.
In the first 36 months of operation, the Lusaka District PMTCT Program paid off-duty staff US $115,288 to work 28,822 8-hour shifts. Assuming that a nurse works an average of 5 off-duty shifts each month, a minimum of 161 nurses would require PMTCT training to cover this total number. (In reality, >320 Lusaka district nurses were trained as part of broader district initiative.) The total cost over the 3 years would thus be US $211,888. If the initial training was considered an investment cost and divided evenly among the 3 years, then the average annual cost is US $70,629. The total cost per shift is US $7.35.
In contrast, we estimate that hiring and training dedicated PMTCT nurses to do the same work would have cost US $261,960, according to local personnel costs (Table 1). The relatively higher costs for regular salaries and the structured nature of full-time employment all contribute to this estimate. When training is divided evenly among each of the first 3 years, the average annual expenditures would be US $87,320 or 124% greater than the off-duty strategy. The cost per shift with this strategy is US $9.83. With either approach, the annual expenditure in subsequent years would increase if provisions were made for continuing education and follow-up training workshops. Despite the greater training requirements in the off-duty strategy (161 vs. 37 nurses in the regular hiring strategy), the use of newly hired, dedicated PMTCT staff is more costly in the long term.
In addition to offering cost savings, this strategy of off-duty employment has been acceptable for nursing staff. Because of the steady demand for PMTCT services, nurses have the opportunity to work more shifts (thus earning more supplemental pay) as compared with private facilities. Most now participate in the monthly, district-based schedule, some in addition to sporadic shifts within the private sector. This strategy has also led to a more rapid integration of PMTCT services into the regular obstetrical care. Because the same district nurses and midwives are working in both areas, there is a continuity of care for patients that might have otherwise been lost. Because the shift work for nurses is highly structured with substantial time off, we have had few complaints about the quality of care, either for the routine clinical services or off-duty counseling. The impact of this program on the private sector has not been investigated, though it is believed to be minimal.
In this report, we present a possible solution to the immediate human resource crisis facing many African countries. In our local, urban setting, this strategy is effective, has been readily accepted, and has offered substantial cost savings. Anecdotally, it has also encouraged health workers to remain in their public sector posts by decreasing the financial disparities between their current position and other opportunities. Several situational factors have contributed to this program's feasibility in Lusaka: a reasonable pool of qualified staff; a highly regimented work schedule with significant off-duty time; an appropriate level of clinic-level management and centralized oversight; and an accepted local practice of working off-hours within the private sector.
Although the employment of off-duty personnel can maximize the utilization of existing health care workers, this strategy remains dependent on the number of staff members available. Ultimately, there is still an absolute number of work shifts these professionals can provide. As service programs such PMTCT and HIV treatment expand in scope and complexity, these limits will likely be reached, particularly in rural settings. Although we believe this strategy can assist in solving immediate personnel needs, policy makers should continue to devise more sustainable human resource solutions,7,8 including use of nonclinical staff such as lay counselors.
Benjamin H. Chi, MD*
Moses Sinkala, MBChB, MPH*†
Elizabeth M. Stringer, MD*
Yvette McFarlane, MSc, MBA*
Catherine Ng'uni, DMS, RN, RM*
Elizabeth Myzece, RN, RM*
Robert L. Goldenberg, MD*
Jeffrey S. A. Stringer, MD*
*Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; and †Lusaka Urban District Health Management Board Zambian Ministry of Health Lusaka, Zambia
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