CHAPTER 2: LITERATURE REVIEW
2.2 FACTORS IMPACTING ON HEALTH CARE PROVIDERS …
2.2.4 Morbidity and Mortality …
The impact of HIV and AIDS on the health workforce has placed a huge burden on health systems in developing countries, which already have problems of poor infrastructure, insufficient health care providers, lack of essential drugs and are often poorly managed (Tawfik and Kinoti, 2006). Health care providers who constitute a large fraction of the health care workforce in Africa are mainly affected by HIV and AIDS (Tawfik and Kinoti, 2002 cited in Pendukeni, 2004). Apart from the risk of contracting HIV at the workplace, health care providers like any other people can contract HIV through any of the modes of transmission. In the study that was conducted in Zambia on health workers, Dieleman et al., (2007a) reported that health care providers are also dying like other people because they are also people. However, health care providers are the educators and counselors of proper and safe health practices. The manager of a hospital in Zambia stated that there were members of the staff who were HIV positive and died without having disclosed their status, apparently because they feel embarrassed to have contracted the disease (Dieleman et al., 2007a).
Health care workers may decide to leave their profession and focus on other things because of the conditions of patients they are caring for. Furthermore, in the long run countries with a high prevalence of HIV may end up with low enrollment in health training institutions with people deciding to pursue other professions and avoiding the health care profession in the process (Jackson, 2002). Health workers that reported leaving the public sector in Malawian hospitals had found jobs in other institutions. Forty one percent reported that they were going to work for nongovernmental organizations, 35 percent were going to work for private hospitals and 24 percent were going to teaching institutions (CRHCS/(USAID/AFR)/SARA, 2004).
Some of the reasons for high attrition among health workers are death and illness. A study conducted in six selected districts of Malawi observed that the main cause of attrition among health care workers in these districts is death followed by resignation and early retirement (CRHCS/(USAID/AFR)/SARA, 2004). Since 1996, the health sector in Malawi lost between 200 and 300 health care workers (ibid). The death rates among health care workers continued increasing since 1996. In some of the districts in Malawi the mortality rates among health care providers doubled between 1998 and 2002. The number of deaths peaked in 1999 at 303 (CRHCS/USAID/AFR/SARA, 2004). Therefore, HIV/AIDS aggravated the rates of death among health care providers in many countries particularly in Sub-Saharan Africa where the prevalence in extremely high.
The AIDS epidemic has not only distorted the structure of the general population but even the workforce as well. The majority of deaths in Malawian workforce occurred among the 30-39 age group (CRHCS/USAID/AFR/SARA, 2004). This group falls under the most economically productive working age population and also have only recently joined the health sector. The data also suggest that 57 percent of all the deaths occurred between 1998 and 2002 happened among male health workers (CRHCS/(USAID/AFR)/SARA, 2004). One particular district in Malawi, Lilongwe, was more heavily affected by the death of its health workers when it lost 18 percent of them through death from 1996 to 2006 (ibid).
The data from the Ministry of Health and Population on health care workers in Malawi reveal that the highest rates of death occurred among clinicians and nurses (CRHCS/(USAID/AFR)/SARA, 2004). However, the pattern changed in 1998 and the highest rate of deaths occurred among administrators (ibid). The high rate of deaths among health care providers in Malawi caused a terrible shortage among staff. Studies in Mozambique highlight that in the Tete province nearly 20 percent of student nurses in the training school died of AIDS related disease during 2000 alone and 8.6 percent in the Zambezi Province (Derveuw, 2001 cited in Jackson, 2002). The analysis of death certificates among health workers by Kegels and Marchal (2000) indicated that between the period 1997 and 2001, 13 percent of deaths occurred among health workers and they emanated from AIDS related illnesses such as tuberculosis.
Furthermore, HIV and AIDS make other diseases hard to cure therefore many deaths occur due to those opportunistic infections. Jackson (2002) suggests that AIDS has fueled the increase of deaths from causes such as tuberculosis, malaria and cholera. The Malawian TB control programme reported that 77 percent of TB cases that have been treated are associated with HIV and AIDS (CRHCS/USAID/AFR/SARA, 2004). Deaths among health care providers in Mozambique nearly tripled from 1995-1999 and occurred increasingly among younger age groups (Derveuw, 2002) cited in (Jackson, 2002).
HIV and AIDS epidemic is also prevalent among health care providers in countries that are highly affected by the disease. The prevalence among midwives and nurses in Lusaka, Zambia in 1991-1992 was 39 percent and 44 percent respectively. In 2004 Shisana and colleagues released a report on the impact on the AIDS epidemic on South African health workers. The study indicated that 15.7 percent of health workers were living with HIV/AIDS in 2002 (Shisana et al., 2004). The prevalence was relatively high among young health workers. The estimated prevalence among the age group 18-35 was 20 percent. The HIV prevalence among non-professional health workers was 20.3 and 13.7 percent for professionals (ibid).
In 2007, another study conducted in South Africa on the prevalence of HIV infection and median CD4 counts among health care workers revealed that HIV prevalence among health care workers in general was 11.5 percent. The prevalence by occupation was 13.8 percent among student nurses and that was the highest and for nurses it was 13.7 percent.
The group that was highly affected was aged 25-34 with a prevalence of 15.9 percent (Connelly, 2007). Among the HIV positive participants that provided blood samples 19 percent of them had CD4 count of less than or equal to 200 mg, 28 percent had count of 200-350 mg, 18 percent had a count of 351-500 mg and 35 percent had a count of above 500 mg (ibid). The findings suggest that 18 percent of nurses are HIV positive in South Africa and have a CD4 count of less than 200 mg and by definition, those nurses are classified as having AIDS (Shisana, 2007). Again, these health care workers are eligible for antiretroviral therapy. The estimates indicate that given this percentage about 181 nurses in South Africa have AIDS and national extrapolations estimate that 1097 nurses in South Africa have AIDS. However, this excludes nurses who were absent from work because of AIDS related illnesses (ibid). Some of these health workers are already dying and others are critically ill. Looking at the HIV prevalence of 13.7 percent among nurses in this country the estimates indicate that of 6 997 nurses in Gauteng, about 958 were living with HIV in 2005 (Shisana, 2007).
The situation in South Africa is even more upsetting when looking at the nurses that are HIV positive and have a CD4 count of 201-350 mg. There are about 272 nurses who are at this stage in Gauteng and the extrapolations to the nation implies that about 1648 nurses are at this stage where they begin to develop opportunistic infections (Shisana, 2007). Kirton et al. (2001:45) suggest that at this stage of HIV infection “there is a greater degree of immune impairment and an increased likelihood of symptoms”.
Therefore, it becomes easy for health care providers to be attacked by opportunistic disease such as TB, diarrhea and other illness. Kirton et al. (2001) also point out that people who are HIV positive are at high risk of becoming infected with organisms that cause TB and the infection is much more likely to progress rapidly and may result in
death if not treated. The health sector is then faced with large number of its staff being absent from work or working less hours than expected.