Challenges Confronting Health Care Workers in Government's ARV Rollout: Rights and Responsibilities

South Africa is renowned for having a progressive Constitution with strong protection of human rights, including protection for persons using the public health system. While significant recent discourse and jurisprudence have focused on the rights of patients, the situation and rights of providers of health care services have not been adequately ventilated. This paper attempts to foreground the position of the human resources personnel located at the centre of the roll-out of the government's ambitious programme of anti-retroviral (ARV) therapy. The HIV/AIDS epidemic represents a major public health crisis in our country and, inasmuch as various critical policies and programmes have been devised in response, the key to a successful outcome lies in the hands of the health care professionals tasked with implementing such strategies. Often pilloried by the public, our health care workers (HCWs) face an almost Herculean task of turning the tide on the epidemic. Unless the rights of HCWs are recognised and their needs adequately addressed, the best laid plans of government will be at risk. This contribution attempts to identify and analyse the critical challenges confronting HCWs at the coalface of the HIV/AIDS treatment programme, in particular the extent to which their own rights are under threat, and offers recommendations to remedy the situation in order to ensure the successful realisation of the ARV rollout.

The subsequent HIV and AIDS and STI National Strategic Plan 2007-2011(NSP 2007-2011 acknowledged that there was an imbalance between the public and private health sectors in respect of the availability and training of health care personnel, with the informal and rural areas being most disadvantaged. 20 The policy cited the introduction of a rural and scarce skills allowance and the "improvement of conditions of work in the public sector" as remedial measures taken to improve the human resource shortage. 21 However, the policy did not explain what improvements were to be implemented in the work environment or to what extent these measures have been successful. The current significant lack of adequate human resources is a clear indication that these mechanisms have been unsuccessful in achieving the desired outcome. 22 The latest NSP 2012-2016 is rather thin on the question of the human resource capacity required for the implementation of the plan. The issue receives passing 18  The WHO and International Labour Organisation (ILO) have noted that, 'although health workers are at the frontline of national HIV programmes, they often do not have adequate access to HIV services themselves '. 29 The WHO advocates primary, secondary and tertiary prevention programmes to curb the risk of and/or effectively treat occupational exposure to HIV and TB. 30 Primary prevention includes measures aimed at preventing exposure to pathogens (for example respiratory and eye protection, immunisation against Hepatitis, and safe needle technology) and evidence of its efficacy has been well documented. 31 Primary prevention measures are closely related to environmental factors and are only as effective as the working conditions permit, as will be explained in the following section.
In contrast to primary prevention measures, documentation on the efficacy of secondary prevention (the prevention of disease following exposure, for example post-exposure prophylaxis) is limited. 32 Tertiary prevention encompasses the treatment and rehabilitation of the HCW once disease has manifested. 33 These measures are aimed primarily at allowing HCWs to return to work as soon as possible. As such, it has been suggested that national policies are necessary in order to prioritise the health workers' access to prevention, treatment and care services with respect to occupation-related diseases. 34 In November 2008 South Africa developed the Employee Health and Wellness Strategic Framework for the Public Service (Employee H&W Framework). 35 The initiatives and interventions in the framework embrace four broad objectives: prevention in order to reduce the incidence of HIV; the provision of treatment, care and support to infected employees; the protection of human rights and access to 29 WHO 2006 www.who Although the document outlines the framework for the integration of health, wellbeing, and safety in order to build and maintain a healthy workforce, 37 it does not provide details on the specific plan of action or practical steps to be implemented in order to achieve this. However, since the launch of the framework, the policy instituted for HIV/AIDS and tuberculosis is reported to be 'progressing well'. 38

Environmental challenges
It is a reasonable assumption that a safe and well-equipped work environment is conducive to increased productivity, a healthier workforce and improved patient management. For the purposes of this paper, the 'work environment' will be dealt with in terms of the 'physical' environment or the actual structure of the workplace (such as space and ventilation), and the 'functional' environment which includes the tools required for efficient service delivery (personal protective equipment and medical consumables).
The physical environment or infrastructure with regard to the health care facilities refers to the state of maintenance of the buildings; the availability of basic services (such as water and electricity); the availability of and access to the necessary technology (for example communication systems and laboratory data information systems); and the availability of functional medical and non-medical equipment. 39 Infrastructure such as viable surrounding roads and a transport system is also Several studies have revealed that poor infrastructure leads to both negative patient perceptions of the quality of care they are likely to receive at the facility and dissatisfaction amongst HCWs with regard to their working conditions. 41 A major concern with regard to the physical environment is the lack of space in many ARV clinics. 42  Research conducted by a group of South African Municipal Workers Union (SAMWU) members at 38 municipal clinics over an 18-month period revealed minimal legal compliance with respect to health and safety requirements. 52 The study also revealed that many clinics 'did not even have such basic supplies as soap'. 53

Treatment challenges
The most significant challenge with regard to treatment is that of the limited and often inadequate supply of antiretroviral drugs at several ARV facilities. 54 This is also referred to as drug 'stockouts' and has a detrimental effect on the ARV rollout programme.
In In the course of treatment of HIV/AIDS and its complications, it is sometimes necessary to transfer patients to a regional or provincial hospital for specialised (step-up) care, or to ARV clinics for continuation of treatment in uncomplicated cases (step-down). In either case, the availability of ARV medication at the referral centre is not guaranteed or otherwise ascertained. For example, the Inkosi Albert Luthuli Hospital in KZN, which is the referral centre for KZN and some Eastern Cape hospitals, does not stock ARV medication for their in-patients. 61 The second treatment-related challenge faced by HCWs is that of non-compliance, due either to the sometimes severe side-effects or to the lack of patient motivation. This is the primary cause of drug resistance. 62 Many ARV regimens are complicated and patients have to take multiple tablets at specific time intervals. There are also many adverse side-effects and drug interactions associated with ARV medication. 63 These factors contribute to non-compliance and hence treatment failure, especially if the patient has not been adequately counselled regarding the importance of the taking of the drugs as prescribed.
Non-compliance also includes patients' reluctance to practise safe sex. This can result in unplanned pregnancies and co-infection with a more virulent strain of HIV. 64

Treating children with HIV/AIDS
The treatment of children with HIV/AIDS poses additional challenges. Furthermore, there is an added burden of having in some instances to forcibly restrain and incarcerate patients. A case in point is the isolation for example of patients suffering from the highly infectious extensively drug-resistant tuberculosis (XDR-TB), which was determined by a court to be legal and justifiable. 76 HCWs in such instances have to contend with complicity in the potential violation of the human rights of their patients, as well as the emotional trauma of being party to the use of extreme and often inhumane measures in dealing with their patients.
Although these emotional challenges are recognised by the HCWs themselves, as well as the supervisors of the health facilities, it appears that many HCWs do not have access to facilities to assist them in dealing with these issues.

Remedial measures
This section outlines some remedial measures advocated in order to alleviate the problems faced by HCWs. The efficacy of these measures will also be assessed as they apply to the South African context.
It should be noted that HCWs are also the bearers of fundamental rights protected by the Constitution, as well as the National Health Act, which protects them against unfair discrimination on account of their health status, and special measures to minimise injury and disease transmission. 77 In addition, there is a plethora of legislation related to their employment and occupational injuries, as well as legislation which regulates their professional conduct. 78

Human resources
The entails the training of lesser-qualified HCWs to perform tasks which they were previously not qualified to do, or tasks that were beyond the scope of their practice, such as allowing trained nurses to initiate antiretroviral therapy. 80 The WHO defines task shifting as 'the rational redistribution of tasks among health workforce teams '. 81 The WHO acknowledges that shortages of HCWs are particularly acute in countries that face a high HIV burden. 82 Although the recommendations and guidelines provided by the WHO are meant to alleviate the staffing crisis to some degree, they recognise that task shifting alone will not solve the problem. Hence this process needs to be implemented along with other remedial measures in order to increase the total health care workforce. 83 Task shifting is not a new strategy. It has been implemented in Zambia since 2004 with promising results. 84 Other countries that have implemented task shifting in varying degrees have formed part of the observational studies conducted by the WHO in order to formulate the recommendations and guidelines on task shifting. 85 South Africa has implemented task shifting since 2010. 86 To date, no large scale objective study has been undertaken with regard to the success, efficacy and/or shortcomings of this approach. 87 It is submitted that task shifting will be a viable option only if the lower-qualified personnel are adequately trained and if the quality of patient care is not compromised. If these standards are not monitored and maintained, then the risk of complications from incorrectly administered antiretroviral treatment will be detrimental to the process in the long term. It is therefore vital that task shifting be implemented along with other measures to increase and maintain the workforce, such as increasing the number of students training for employment in the health care sector and improving the current working conditions to an acceptable Campaign, which shows that many clinics have adopted task shifting to some degree. However, some of the nursing staff initiating antiretroviral treatment are not adequately trained.
level. In particular Lund, 88 for example, cautions against the 'gendered implications' of task shifting as a greater burden may be placed on women (the majority of nursing staff) in both institutional and home-based settings.
Many health care workers migrate to developed countries in pursuit of better working conditions and remuneration. In order to curb this, the South African government entered into agreements with certain developed countries. 89 As was stated earlier, these restrictions appear to have achieved the opposite effect. 90 It is submitted that a secondary disadvantage of these restrictions is that HCWs who supplement their knowledge or acquire new skills in the developed countries are unlikely to return to South Africa and promote training and development in this country.

Infection
The South African Department of Health has based its infection control policy on the preferably employee-driven, will assist in highlighting the health concerns faced by employees, and in the formulation of policies to address these concerns.

Work environment
The current physical environment or infrastructure of health care facilities has been found to be in a poor condition as well as inadequate in addressing the needs of the patient population served. 103 The 2007 study by Lutge and Mbatha recommended the rehabilitation and maintenance of existing infrastructure to ensure safety and planning for infrastructure development, in order to accommodate an increased patient population. 104 It is submitted that these recommendations should be expanded to include diagnostic and monitoring equipment essential for patient management.
Despite current budget constraints, the provision of adequate space and ventilation in order to protect patients and HCWs from air-borne infection cannot be compromised. A related and equally important requirement is the provision of private consulting rooms, which need to be designed to protect patients' dignity and privacy, especially during clinical examination.
Although it is common knowledge that drinkable water and an uninterrupted electricity supply are essential for the provision of safe health care many hospitals, especially those in the Free State and Eastern Cape, are forced to operate without running water. 105 The SAMWU 2004 study revealed that, in the health facilities evaluated, 'no proactive or preventive procedures are in place for identifying hazards, evaluating risks, preventing workplace injury and illness, and maintaining a safe workplace'. 106 It was also revealed that the supply and use of PPE was inadequate. 107 The inconsistent use of PPE may be due partly to the lack of education and motivation and partly to the overwhelming workload. These factors increase the health and safety risks faced by HCWs on a daily basis.

Treatment
Ensuring an adequate supply of ARV medication and preventing interruptions in patient treatment require a guaranteed supply of drugs from the manufacturer, This translates into a R4.7 billion saving. 112 The NSP 2012-2016 envisages initiating 'at least 80% of eligible patients on antiretroviral treatment (ART), with 70% alive and on treatment five years after initiation' 113 for the period of the plan. It is submitted that in order to realise this goal, a cheaper, equally effective and uninterrupted ARV drug supply is required. The study also made the following recommendations: extend the clinic hours; simplify the referral processes and schedule appointments at the convenience of patients; improve the communication between treatment facilities to ensure the continuity of care; improve the tracking of patients who transfer between facilities; and, where possible, employ a loss-to-follow-up counsellor who can offer assistance with small barriers to returning to care, such as paperwork, scheduling, and disclosure to families. 117 It is submitted that although these recommendations are reasonable, their implementation is not practical in view of the current staff shortages taken together with the environmental constraints described above.
114 Rosen et al 2007PLoS Medicine. 115 Avert 2011www.avert.org. 116 Miller et al 2009 refers to patients who are initiated on ARV treatment but thereafter default on their treatment and fail to attend subsequent clinic visits. There are various reasons for loss-tofollow-up, including the lack of motivation, the lack of access to treatment, and the disability or death of the patient. Ensuring the availability of effective PPE, reducing the number of hours spent on duty per shift, and ongoing education of the workforce with respect to infection control could dramatically decrease the incidence of adverse events in the workplace. Ongoing in-service training aimed at improving overall skills as well as specific training in dealing with paediatric cases will increase HCWs' confidence and result in more effective service delivery.

Paediatric ARV
HCWs treating patients living with HIV/AIDS experience significant psychological and emotional stress. Mechanisms should be in place to ensure that these individuals have timeous access to counselling and support facilities.
HCWs are the backbone of the ARV rollout programme. Thus, their complaints and grievances need to be urgently addressed. To this end, efficient monitoring and evaluation of all ARV rollout facilities should be undertaken in order to identify the deficiencies and institute remedial measures. The involvement of HCWs in the decision-making process, as well as setting time limits for the completion of specific interventions, will contribute to a more transparent process and better outcomes.
The government has made a commitment to expand the ARV rollout programme.
The success of this programme will depend greatly on the HCWs implementing it.
Furthermore, a key objective of the proposed National Health Insurance 127 is 'to strengthen the under-resourced and strained public sector so as to improve health systems performance.' It is imperative that due cognisance be paid to the rights of HCWs if we are to succeed in achieving these lofty objectives.