programs to strengthen laboratory capacity, ensure safe blood supplies, promote safe medical practices and proper handling and disposal of medical waste, strengthen supply chain management, empower communities, strengthen information systems, promote registration of births and orphans, and change inheritance laws (OGAC, 2005a, 2006a,b,c,f,g) have benefits that are not exclusive to the HIV/AIDS response. However, any such benefits and any unintended negative consequences will not be fully appreciated if the initiative is evaluated only with respect to HIV/AIDS targets. To be certain that PEPFAR is strengthening and not undermining existing public health systems, accountability for its impact on public health and public health systems overall is critical. Measures of this impact need to include workforce and infrastructure, as well as other health outcomes, such as infant mortality and all-cause mortality (WHO et al., 2004). Implementation of these measures in turn will require continued PEPFAR support for strengthening national public health monitoring and evaluation systems.
ART is a complex intervention that is being expanded in areas already short of personnel (IOM, 2005). It is widely acknowledged that the lack of trained health workers is a major challenge to further scaling up of AIDS services, particularly ART (IOM, 2005; Gilks et al., 2006; UNAIDS, 2006). The UNAIDS Global Steering Committee, for example, has ranked this as one of the major obstacles to scaling up the HIV/AIDS response (UNAIDS, 2006). Likewise, policy makers and field staff in some of the most affected countries cite the lack of human resources for health as the single most serious obstacle to scaling up treatment. While there are no estimates available of the additional health personnel needed to respond to the global HIV/AIDS crisis, the World Health Organization (WHO) had estimated it would be necessary to train an extra 100,000 health workers just to meet its “3 by 5” program target of treating 3 million people by 2005 (WHO, 2004a).
Plans for ART scale-up developed by some host countries and in progress in others include specific efforts to increase the health care workforce, with an emphasis on numbers of nurses, clinical officers, and pharmacists, among others (Kober and Van Damme, 2004; UNAIDS, 2006). Conceptually, there are three approaches to addressing the shortage of human resources:
Train more personnel.
Retain the personnel already in place.
Increase the efficiency of existing personnel by providing training in ART and shifting responsibilities from the scarcest groups to others.