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Scaling-up antiretroviral treatment in Southern African countries with human resource shortage: How will health systems adapt?


  • Van Damme, Wim
  • Kober, Katharina
  • Kegels, Guy


Scaling-up antiretroviral treatment (ART) to socially meaningful levels in low-income countries with a high AIDS burden is constrained by (1) the continuously growing caseload of people to be maintained on long-term ART; (2) evident problems of shortage and skewed distribution in the health workforce; and (3) the heavy workload inherent to presently used ART delivery models. If we want to imagine how health systems can react to such challenges, we need to understand better what needs to be done regarding the different types of functions ART requires, and how these can be distributed through the care supply system, knowing that different functions rely on different rationales (professional, bureaucratic, social) for which the human input need not necessarily be found in formal healthcare supply systems. Given the present realities of an increasingly pluralistic healthcare supply and highly eclectic demand, we advance three main generic requirements for ART interventions to be successful: trustworthiness, affordability and exclusiveness - and their constituting elements. We then apply this analytic model to the baseline situation (no fundamental changes) and different scenarios. In Scenario A there are no fundamental changes, but ART gets priority status and increased resources. In Scenario B the ART scale-up strengthens the overall health system: we detail a B1 technocratic variant scenario, with profoundly re-engineered ART service production, including significant task shifting, away from classical delivery models and aimed at maximum standardisation and control of all operations; while in the B2 community-based variant scenario the typology of ART functions is maximally exploited to distribute the tasks over a human potential pool that is as wide as possible, including patients and possible communities. The latter two scenarios would entail a high degree of de-medicalisation of ART.

Suggested Citation

  • Van Damme, Wim & Kober, Katharina & Kegels, Guy, 2008. "Scaling-up antiretroviral treatment in Southern African countries with human resource shortage: How will health systems adapt?," Social Science & Medicine, Elsevier, vol. 66(10), pages 2108-2121, May.
  • Handle: RePEc:eee:socmed:v:66:y:2008:i:10:p:2108-2121

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    References listed on IDEAS

    1. Cohen, Desmond., 2002. "Human capital and the HIV epidemic in sub-Saharan Africa," ILO Working Papers 993581133402676, International Labour Organization.
    2. repec:aph:ajpbhl:10.2105/ajph.2004.040121_9 is not listed on IDEAS
    3. repec:ilo:ilowps:358113 is not listed on IDEAS
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    Cited by:

    1. Rhodes, Tim & Bernays, Sarah & Terzic, Katarina Jankovic, 2009. "Medical promise and the recalibration of expectation: Hope and HIV treatment engagement in a transitional setting," Social Science & Medicine, Elsevier, vol. 68(6), pages 1050-1059, March.
    2. Wouters, Edwin & Masquillier, Caroline & Ponnet, Koen & le Roux Booysen, Frederik, 2014. "A peer adherence support intervention to improve the antiretroviral treatment outcomes of HIV patients in South Africa: The moderating role of family dynamics," Social Science & Medicine, Elsevier, vol. 113(C), pages 145-153.
    3. McCarthy, Carey F. & Kelley, Maureen A. & Verani, Andre R. & St. Louis, Michael E. & Riley, Patricia L., 2014. "Development of a framework to measure health profession regulation strengthening," Evaluation and Program Planning, Elsevier, vol. 46(C), pages 17-24.
    4. Tulloch, Olivia & Taegtmeyer, Miriam & Ananworanich, Jintanat & Chasombat, Sanchai & Kosalaraksa, Pope & Theobald, Sally, 2015. "What can volunteer co-providers contribute to health systems? The role of people living with HIV in the Thai paediatric HIV programme," Social Science & Medicine, Elsevier, vol. 145(C), pages 184-192.
    5. Boyer, Sylvie & Clerc, Isabelle & Bonono, Cécile-Renée & Marcellin, Fabienne & Bilé, Paule-Christiane & Ventelou, Bruno, 2011. "Non-adherence to antiretroviral treatment and unplanned treatment interruption among people living with HIV/AIDS in Cameroon: Individual and healthcare supply-related factors," Social Science & Medicine, Elsevier, vol. 72(8), pages 1383-1392, April.
    6. Wouters, Edwin & Van Damme, Wim & Van Loon, Francis & van Rensburg, Dingie & Meulemans, Herman, 2009. "Public-sector ART in the Free State Province, South Africa: Community support as an important determinant of outcome," Social Science & Medicine, Elsevier, vol. 69(8), pages 1177-1185, October.
    7. Hejoaka, Fabienne, 2009. "Care and secrecy: Being a mother of children living with HIV in Burkina Faso," Social Science & Medicine, Elsevier, vol. 69(6), pages 869-876, September.
    8. Standing, H. & Chowdhury, A. Mushtaque R., 2008. "Producing effective knowledge agents in a pluralistic environment: What future for community health workers?," Social Science & Medicine, Elsevier, vol. 66(10), pages 2096-2107, May.


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