WORLD HEALTH DAY: Mozambican Nurses to the Fore with ARV Distribution

Ruth Ansah Ayisi

MAPUTO, Apr 3 2006 (IPS) – With World Health Day (Apr. 7) rapidly approaching, public attention is being directed this week to the widespread shortage of health workers. The theme for World Health Day 2006, Working together for health , was chosen to add momentum to efforts at resolving the crisis something that is nowhere more evident than in Mozambique.
According to the 2005 Human Development Report , issued by the United Nations Development Programme, there are two physicians for every 100,000 people in this Southern African country (compared to 549 per 100,000 in the United States).

In addition, the doctors are mostly based in Maputo even though only about 10 percent of Mozambique s 18.2 million people live in the capital.

At the best of times, this low doctor-patient ratio and poor distribution of medical staff would pose a challenge to maintaining national health. Factor AIDS into the equation, and the situation becomes even more problematic: official figures put HIV prevalence among 15 to 59 year-olds at 16.2 per cent, one of the world s highest rates. Currently there are over 1.5 million people living with HIV and AIDS in the country.

As part of its response to this situation, Mozambique recently decided to allow nurses to administer and monitor the anti-retroviral (ARV) treatment that is needed to keep AIDS patients alive tasks normally performed by doctors.

We don t have doctors in every district, and the doctors that are there also need extra support in ARV treatment, Martinho Dgedge, the spokesperson for the Ministry of Health, told IPS.
It is estimated that over 200,000 Mozambicans now need ARVs (anti- retroviral drugs) to prolong their lives. By January this year, 20,375 people were receiving the medication from government, which is supported in this by various non-governmental groups.

Most of the 40 ARV treatment sites are in the provincial capitals or concentrated in the southern parts of this vast, sparsely-populated country. The majority of people living in rural areas, especially in the northern regions, do not have access to ARVs.

The training of nurses to treat patients with ARVs is key to the decentralisation of ARVs, said Dgedge.

Nurses receive just two years of clinical training in Mozambique, much less than doctors.

But, says George Jagoe, country director of the Clinton Foundation HIV/AIDS Initiative in Mozambique, We can t look dogmatically at United States and European models when we are treating in Africa because there is not the luxury of so many doctors and the same conditions. The HIV/AIDS epidemic is saying I am everywhere, so the treatment has to be integrated in the rural health services. (The Little Rock-based Clinton Foundation was started by former U.S. president Bill Clinton to promote development in a number of areas, including health. It has played a prominent role in reducing the cost of AIDS medication for those in poor countries.)

The first batch of trainees this year consisted of 25 students representing all 11 provinces in Mozambique. Custodio Francisco Bambo was amongst them. Although he had already worked with experienced doctors treating AIDS patients in Maputo for three months, the two-week practical and theoretical training consolidated what I had learnt, he told IPS.

His consultations with new patients starting ARV treatment average between 20 to 30 minutes. The patient will then collect the drugs every two weeks for the first month of treatment, and on a monthly basis thereafter.

Adherence is key.

In order to achieve adherence it is important to take time to learn all about each individual patient: for example, his or her responsibilities at home, his or her diet, his or her income, support from family members and how far he or she needs to travel to get his or her supply of ARV drugs, said Bambo.

On occasion, however, patients can fall through the cracks.

Bambo recounts that when he first started his job, a 25-year-old man was brought by his brother from his home village in southern Gaza province to Maputo for treatment. The man s CD4 count was less than 25. (The CD4 count measures the level of immune cells in a person living with HIV and AIDS. When the count is less than 200, the person should go on ARVs).

The young man began taking the drugs, but returned to his village within the first two weeks of treatment.

He became so sick, and as he was too weak to return to Maputo he turned to a traditional healer, said Bambo. We should have found out who he could stay with in Maputo during those early stages of his treatment. The man died.

Another challenge, he added, was to be mentally agile to keep track of advances in HIV and AIDS treatment. He also emphasised the importance of linking ARV therapy with mother and child healthcare, and tuberculosis and malaria treatment.

Asked whether he would be prepared to work in a rural area, Bambo said he had no objections to doing so and that he in fact already had rural experience under his belt, having nursed for more than a year in a remote district hospital in the northern province of Niassa.

But, he added, It is the lack of infrastructure there that is a problem.

At the Niassa facility, electricity was only available for a few hours a day, from 16.00 until 21.00 local time (15.00 to 20.00 GMT).

There was no doctor, and the ambulance was out of action for most of the time because the hospital was situated 400 kilometres from a garage that sold batteries.

But the most difficult problem is the feeling of being cut off from the latest developments in healthcare, said Bambo. This would be a challenge for HIV and AIDS treatment.