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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 June 2; 334(7604): 1133.
PMCID: PMC1885316

People with AIDS are dying because of inadequate staffing, says MSF

Some of the poorest people in the world with AIDS, whose lives might be prolonged through proper treatment, are dying because there are far too few healthcare workers, says a new study by Médecins Sans Frontières (MSF).

The humanitarian aid agency has carried out a survey of healthcare conditions across countries in southern Africa where it runs programmes. It says that staff shortages are exacerbated by the fact that many employees have themselves contracted the virus and become ill and die. Furthermore, pay is extremely low and working conditions very difficult.

The data were gathered in Lesotho, Malawi, Mozambique, and South Africa. Although South Africa has better resources in terms of healthcare staff, a large proportion of these work in the private sector, the survey found.

The report says that the acute shortage of healthcare workers means that many people who would otherwise be able to receive life prolonging antiretroviral drugs are unable to gain access to the treatment.

The charity says that higher salaries and benefits, more obvious career paths, and better living conditions for staff are needed.

Mozambique fares particularly badly, with only 2.6 doctors and 20 nurses for every 100 000 inhabitants. By contrast South Africa has 74.3 doctors and 393 nurses per 100 000 inhabitants; these figures, however, include staff working in the private sector. The United States, the report says, has 247 doctors and 901 nurses per 100 000 people.

Life expectancy has already dropped alarmingly in a couple of the countries. Life expectancy in Malawi is 39.7 years, while that in Lesotho is 35 years. In Malawi 170 000 people need antiretroviral treatment and 85 000 are receiving it, and the report says that with more healthcare workers the other 85 000 could be receiving antiretrovirals too.

The report says, “To compensate for the lack of doctors, Malawi relies on clinical officers and medical assistants. However, due to shortages across the spectrum of health staff, the government has created a new cadre, health surveillance assistants, who receive 10 weeks of training and are responsible for multiple tasks including: immunisation, dispensing of essential drugs, and more recently, HIV testing and counselling.” However, only half the assistant posts are filled in some areas, the report adds.

Malawi has what the report calls an “internal brain drain” of personnel who leave the public service in order to work for non-governmental organisations. In other countries, such as South Africa, this internal brain drain sees staff moving to the private sector too, as well as to non-governmental organisations and other foreign funded non-profit projects. Many of these types of job pay better than the local public sector jobs. Figures quoted in the report show that in South Africa two thirds of doctors and half of all nurses work in the private sector. This means that these people serve the needs of around seven million South Africans who can afford private health care, while the remaining 45 million citizens are underserved by the rest.

The report complains that in several countries salaries are capped by, among other constraints, ceilings set by the International Monetary Fund (IMF). It says, “The IMF encourages countries to set limits on public spending, and these limits are based on domestic resources rather than on need.”

Many donors, the report says, do not allow their funding to be used for salaries. In Mozambique, because of this policy, many nurses graduating from college have had to wait up to four years before being able to get a job.


Help Wanted: Confronting the Health Care Worker Crisis to Expand Access to HIV/AIDS Treatment—MSF Experience in Southern Africa is available at

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