To date, PEPFAR’s strategy has focused on the second and third approaches. Its policy is

to provide support, within national plans and priorities and the principles of the “3 ones”, for policy reform to promote task-shifting from physicians and nurses to community health workers; development of information systems; human resources assessments; training support for health workers, including community health workers; retention strategies; and twinning partnerships. (OGAC, 2006c, p. 7)

Retention strategies Shortages of health care personnel for ART are a problem in all focus countries, but the nature of the problem varies greatly, both qualitatively and quantitatively, among countries. Some countries with well-established medical and nursing schools that meet foreign standards are particularly subject to “brain drain” to Europe, Canada, and the United States. Moreover, the presence of donors and nongovernmental organizations in the country can offer a number of attractive, better-paid alternatives for physicians and nurses relative to direct patient care, with the result that brain drain is internal as well as external. The problem of retention has plagued sub-Saharan Africa for many years and is far more acute now that ART is under way (Chankova, 2006; Huber, 2006; Wonodi, 2006).

Appropriate distribution of health care workers is difficult to accomplish, as it has been in the developed world. Many health care workers prefer not to work in rural areas, to which transportation is limited and erratic, and where professional communication is constrained and housing is poor. Physicians, clinical officers, and nurses that the Committee encountered in such settings often expressed to the Committee a desire to return to a large city once their term of rural service was over.

PEPFAR is supporting a number of activities focused on retention of health workers (OGAC, 2006c). In the process, Country Teams are increasingly able to identify techniques that work and can be shared across countries. In Zambia, for example, the Country Team is collaborating with the Ministry of Health to support a physician retention scheme that provides incentives to 30–35 physicians who serve in rural areas throughout the country, such as housing, hardship allowance, transportation, and educational stipends for their children. PEPFAR estimates that this initiative will result in an additional 5,000 people receiving ART services. In Namibia, the Ministry of Health provides a package of benefits, including medical benefits, housing support, paid maternity leave, a “13th cheque” on workers’ birthdays, and competitive salaries. A nongovernmental organization in Uganda retains lay health workers who provide ART follow-up care in remote areas by providing, along with a supportive work environment, field and transportation allowances, refunds for medical expenses, and salary increments for good performance (OGAC, 2006c).

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