Effects of scaling up antiretroviral treatment on health care systems: Evidence from Ethiopia

Objectives: In recent years, an unprecedented amount of financial resources has been invested by The Global Fund, governments and private donors aimed to stop the spread of HIV, tuberculosis and malaria. In addition to their impact on the focal diseases, these investments may have a variety of direct and indirect effects upon broader health care systems of recipient countries that could be positive or negative. The purpose of this research is to assess the effects of antiretroviral treatment (ART) on the health care system in Ethiopia, particularly on the availability of human resources, drugs, and commodities; health worker motivation; managerial processes; referral; and the availability and quality of health care services at the hospital level.

Methods: Facility- and provider-level surveys were administered in 2006 in a sample of twelve government-run hospitals located in two regions of Ethiopia: Addis Ababa and Amhara. The surveys collected quantitative and qualitative information on staffing, training, managerial processes, health worker motivation, and other topics. In addition, hospital records on staffing and use of inpatient and outpatient services at two periods of time – January 2005 and January 2006 – were examined to assess changes during a period in which the availability of ART was undergoing rapid expansion.

Results: The results suggest that ART expansion has had a range of hospital-level effects, including many that could negatively influence service quality. For example, the survey results suggest that ART scale-up has been made possible primarily through the use of currently employed health workers, many of whom spit their time between the ART clinic and other parts of the hospital, rather than new hires. This has led to an increased work burden among staff providing ART and/or non-ART services, and as a result, contributed to decreased motivation to perform their job responsibilities and increased turnover. Other effects identified include increased laboratory work-loads, and shortages of selected drugs and other essential hospital supplies associated with increased ART client volume.

Conclusions: In planning and implementing programs aimed to increase the availability of critically needed ART services, international donors, policy makers and hospital directors should anticipate and attempt to minimize possible negative spillover effects upon other health care services.