In all countries profiled in this report, attrition rates are high as health care workers leave for more competitive salaries and better working conditions, in-country, regionally, or abroad. The inability to attract and keep health care workers, particularly nurses, is one of the greatest challenges to sustaining existing programmes and expanding access to HIV/AIDS care and treatment.
Increasing salaries and benefits
It is well known that adequate salaries and benefits are essential to retaining staff, especially as health systems compete for workers in a globalised economy. Almost one in five of all nurses and midwives trained in sub-Saharan Africa are now working in developed countries - mainly the UK, the USA, and Canada.26 In April 2007, MSF carried out a survey27 of 127 health care workers in Lesotho and Malawi in facilities supported by MSF - two-thirds of whom work in rural health centres - to examine general attitudes about work, assess overall job satisfaction, and identify factors affecting retention.
The MSF survey confirms other research indicating that insufficient remuneration is one of the major reasons for job dissatisfaction.28 Out of 65 nurses in Lesotho who responded to the survey, 47 (72%) said they were considering leaving their posts and 77% of these said the main factor was the need for more money. Of those who said they were considering leaving to earn more money, 53% had five or more people dependent on their monthly income.[viii] Low salaries and inadequate benefits also have an indirect impact on patient care.
For example, in Mozambique it is common for doctors to leave work mid-day to supplement salaries by working in private practices. In Malawi, participating in workshops is more lucrative than doing clinical work: typically for a five-day training, a nurse could increase her basic monthly salary by 25-40%. Although some workshops and trainings are important, the chase for stipends increases absenteeism and increases the workload for the remaining staff. Benefits and incentives are also important factors that affect retention.
Pensions, medical aid/insurance, hardship/rural allowances, education allowances for children, and transport allowances, are some of the ways in which health staff can be encouraged to stay. However, in most contexts, incentives remain a way to avoid tackling the fundamental problem of low basic salaries, leading to distortions that are difficult to manage. Donors readily support per diems and other incentives but often refuse to finance salary increases due to concerns about "sustainability." This needs to change.
Better working and living conditions
Clinic infrastructure, particularly in rural settings, is often in disrepair and lacking the most basic functions. An assessment done before MSF launched the ART programme in Lusikisiki, South Africa, showed that only one-third of the 12 existing clinics had electricity, and in half of those the supply was erratic. Only 8% had running water or a phone and half lacked nursing accommodations. Given these conditions, it is not surprising that 37% of nursing staff posts in the Eastern Cape were vacant in 2005.10 In the MSF survey in Lesotho and Malawi, poor clinic infrastructure, and lack of equipment were important reasons why nurses considered leaving work. Substandard housing and lack of security at work were also cited as major problems. In Lesotho, a number of nurses who said they were considering leaving their posts indicated that they would consider staying if work and living conditions improved.27
Other retention measures Management and supervision
Management and supervision play an important role in staff morale, motivation, and job satisfaction. In the context of taskshifting, supervision also plays a particularly important role in maintaining an acceptable level of quality. In a 2005 study of factors affecting retention of health workers in rural health centres in Lesotho, 91% of nursing staff felt that supervisory visits were important for motivation because they provided opportunities for new information and skills to be transmitted and general encouragement.28 However, half of the respondents said they had not had a supervisory visit from a doctor at all in the previous year, while over a quarter had not received a supervisory visit from a nurse during the same period.
Career advancement and training
Excessive workload and poor pay drive health workers to seek work elsewhere; the lack of any perspective that their situation will change pushes them to do so sooner. Formal training is important but often requires several months or even years "out-of-clinic," which creates more gaps. One recent promising trend is the creation of post-graduate distance learning courses focused on HIV clinical care. These are designed for nurses interested in specialising in HIV and which recognise inservice HIV clinical work, meaning that nurses do not always have to leave their clinics for a classroom to receive academic credit.[ix] So-called "bridging courses" also allow for faster professional advancement. Professional councils must adapt to the need for HIV-specific career advancement opportunities as well as perspectives for moving up the career ladder more quickly, and governments must ensure that there are commensurate increases in salary.
Keeping staff healthy
In Lesotho, Mozambique, and Malawi, death is the leading cause of health worker attrition, with a significant proportion being HIV-related. Availability of confidential HIV testing, care, and treatment services for health workers is of utmost importance. In collaboration with district health authorities, MSF supported the establishment of a specialised clinic for health staff and their immediate family members in Thyolo district. One unexpected benefit has been a reduction in absenteeism due to easier access to care of ill family members. In addition to HIV/AIDS treatment, safety and infection control in the workplace must be addressed. Because of the high stress health staff are under, mental health support also needs to be improved.