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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


     

 

 

FINAL REPORT

 

The Impact of HIV/AIDS on Health Service Personnel

at Two Public Hospitals in Johannesburg

 

www.sega2.org.za/lib/download.php?doc_id=190%20&%20doc_url=190.doc

Prof. Y Veriava, Principal Investigator

Dr. D Connelly Sevilla, Lead Researcher

RN A Jordan, S Roberts, and J Tsotetsi, Research Team

Asst Profs Mary Bachman and Sydney Rosen, Consultants (Boston University)

 

Health Economics Research Office (HERO)

Wits Health Consortium, University of the Witwatersrand

Tel: 011 276-8888 (HERO office)    Email: dsevillag@yahoo.com

 

Technical assistance from the

Joint Economics Aids and Poverty Programme (JEAPP)

 

November 1, 2005


 

 I.  Background and Objectives

Much has been written about the burden placed on the health sector in South Africa by HIV/AIDS.  Most of this work focuses on the increased demand for health services created by AIDS and the costs of providing hospital care to HIV-infected patients.  Little has been published about the impact of HIV/AIDS on nurses, doctors, and the other trained professionals who are responsible for keeping increasingly over-burdened public healthcare facilities functioning.  Little is known about the contribution of AIDS to the high attrition of healthcare personnel, the impact of HIV/AIDS on healthcare worker labour productivity, or the actual financial and human capital costs of the disease to the public health system.

To help fill this gap in knowledge, a research team from Helen Joseph Hospital and Coronation Hospital in Johannesburg, working through the Health Economics Research Office at the University of the Witwatersrand (HERO) and with technical assistance from the Joint Economics Aids and Poverty Programme (JEAPP) and Boston University’s Center for International Health and Development (CIHD), analyzed the impact of HIV/AIDS on health care personnel at these two sites.  

The overall objective of this study was to describe and analyze the impact of HIV on professional-level health care workers in order to assist the National Department of Health, provincial health departments, hospitals, training institutions, and other public sector agencies to develop more effective strategies for maintaining productivity and managing costs in the public health system.  To achieve this general objective, we collected and analysed data in four specific areas: 1) levels of termination and replacement of nurses; 2) reasons for termination among nurses; 3) HIV prevalence in the workforce; and 4) costs of HIV/AIDS in the nursing workforce.  Our analysis focused on the nursing workforce, for which we had the most complete data sets. 

II. Levels of Termination and Replacement of Nurses

We obtained retrospective data from the Gauteng Shared Services Centre (GSSC) database on all healthcare professionals at our two study sites who left employment for any reason between 2001 and 2004 and all healthcare professionals who were appointed in that period.  Results for professional and staff nurses are shown in Table 1.  Although attrition (terminations) of nurses was fairly constant over the period studied, rates of hiring (replacement) declined substantially. As a result, the two hospitals had approximately 100 fewer nurses at the end of 2004 than at the beginning of 2001. Most nurses who left service (83%) had fewer than five years of service.  A very small proportion (5%) of those terminating service did so due to death or ill health, suggesting that nurses’ own illness due to HIV infection is not a major contributor to overall attrition.  

Table 1. Turnover of nurses at Helen Joseph and Coronation Hospitals, 2001-2004

 

Year

Total no. nurses at beginning of period

No. nurses leaving during period*

No. nurses hired during period

Annual attrition rate (% of total) (b/a)

Annual hiring rate (% of total)

(c/a)

Hiring/ attrition ratio

(e/d)

 

a

b

c

d

e

f

2001

760

45

210

7.5

28.6

3.68

2002

868

86

62

9.9

7.1

0.72

2003

843

52

19

6.2

2.2

0.37

2004

810

43

1

9.1

0.2

0.05

*Attrition data were truncated for 2001 (starting 3/16) and 2004 (ending 7/31).  Rates for these years have been annualised. 

Hiring data were truncated for 2004 (ending 7/31).  Rate for 2004 has been annualised.

III. Reasons for Termination among Nurses

To understand why attrition among nurses is relatively high (particularly among younger staff), we conducted exit interviews of all terminating staff over a 12-month period and held more than 34 focus group discussions involving approximately 100 current staff on reasons for staff termination. 

Rankings of reasons for termination by both focus group participants and exit interview participants are shown in Table 2.  Among focus group participants, the reasons offered for nurse resignations were largely related to compensation and administrative/managerial issues.  HIV/AIDS played a role in aggravating working conditions, however.  Three quarters of nurses included an HIV-related reason among the top ten reasons for nurse resignations, and nearly half placed an HIV-related reason among their top five.    

Focus group discussions inevitably involved only nurses who have not (yet) terminated service.  To explore reasons for leaving among those who had decided to resign, we conducted exit interviews with approximately 90% (n=72) of nurses who handed in their resignations between March and August 2004.  Those leaving service were primarily African (62%) and female (90%). A majority (63%) stated that they were the primary wage-earner in the family. More than three quarters of participants reported that they already had a new job, suggesting substantial “pull” from other employers, in addition to work dissatisfaction internally (“push”).  Of those with a new job, 48% planned to work in the private sector, and 37% planned to work elsewhere in the public sector.  Exit interview participants were also asked in a separate question about the influence of HIV on their decision to leave, and 30% stated that HIV had at least somewhat affected their decision to leave.

Table 2. Reasons for nurse resignations: exit interviews (EI) and focus groups (FG)

Reason

Ranking by participants of:

 

EI

FG

Insufficient salary.

1

1

Excessive work burden/too many patients.

2

2

No career development/professional development.

 

3

Managerial/supervisory incompetence and unresponsiveness.

3

4

Family reasons or family member relocating

4

not ranked

Poor work  environment

5

not ranked

Difficult and inflexible work schedule.

6

5

Insufficient benefits

7

not ranked

Insufficient hospital equipment, infrastructure, medicine.

not ranked

6

Strained interpersonal relationships at work.

not ranked

7

Better working conditions overseas or in private sector.

not ranked

8

No recognition of the harshness of the nature of the work.

not ranked

9

Stress/depression from increased HIV among patients (burnout).

8

10

Insufficient training in HIV management.

not ranked

11

No grief counselling/ emotional support for staff.

not ranked

12

Fear of occupational exposure to HIV through needle pricks.

not ranked

13

Socially and economically vulnerable patients are very demanding.

not ranked

14

Demoralizing/frustrating caring for AIDS patients.

not ranked

15

IV.  HIV Prevalence in the Workforce

We conducted a voluntary, anonymous, unlinked sero-prevalence survey of all healthcare workers at our study sites. To protect the anonymity of the survey, participants were not given their test results.  Instead, they were referred to a VCT and ARV treatment clinics on and off siteSignificant groundwork aimed at obtaining support for the survey from workers, unions, hospital management and staff was conducted prior to the testing through meetings, focus groups, social events, and written informational posters and handouts.  Participants chose whether to give a blood or an oral fluid sample, and along with either sample, we recorded the age, sex, race, and job level of each participant and ran CD4 counts on all blood samples.  Participants were given a T-shirt as a gift for their participation and potential discomfort during the survey.

Results are summarized in Tables 3 and 4.

Table 3.  HIV prevalence by job category and age

Variable

Present on testing days (no.)

Tested (no.)

Response rate (%)

HIV positive (no.)

Prevalence (%)

Overall

1,613

1,444

89.5%

171

11.8%

Job category*

 

 

 

 

 

Allied staff

278

247

88.8%

14

5.7%

Nurses

708

644

91.0%

88

13.7%

Student nurses

66

65

98.5%

9

13.8%

General assistants

561

488

87.0%

60

12.3%

Gender

 

 

 

 

 

Female

 

1315

 

158

12.0%

Male

 

178

 

14

7.9%

Age

 

 

 

 

 

18-24

 

105

 

7

6.7%

25-34

 

327

 

52

15.9%

35-44

 

530

 

69

13.0%

45-54

 

393

 

40

10.2%

55+

 

138

 

4

2.9%

*Participation by medical doctors was not sufficient to generate valid results, and medical doctors are therefore not included in the job category results.  Medical doctors are included in the results by gender and age, however.

Table 4.  CD4 counts of HIV-positive survey participants

CD4 cell count

Number of persons

Percent of total

<=200

14

18.9%

201-350

21

28.4%

351-500

13

17.6%

>500

26

35.1%

Total

74

100%

Overall mean=451; SD=286;