The costs of HIV/AIDS among professional staff in the Zambian public health sector
Central Board of Health
Research Team: Rich Feeley (principal investigator), Sydney Rosen, Matthew Fox, Mubiana Macwan'gi, Arthur Mazimba
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Despite their high level of training and medical knowledge, health professionals remain a
population that is vulnerable to HIV/AIDS. AIDS-related mortality has been recognized
as a significant factor in the loss of trained health staff in high prevalence countries, but
little empirical research has been done to quantify the damage. In this study, we applied
a case/comparison methodology to estimate the costs of HIV infection in the professional
workforce at three Zambian healthcare institutions: Lusaka District Health Management
Team, University Teaching Hospital (the national tertiary care hospital) and Kasama
District Hospital and Health Management Team. Deaths or medical retirements among
professional staff were analyzed wherever the complete personnel records were available,
with the exclusion of cases resulting from violence, accident or disease of sudden onset.
108 cases were identified over a three-year period ending in October 2003. Each case
was matched with two comparisons of similar age, sex and professional training. Data
were collected for both cases and comparisons on absenteeism, compensation and
medical care and reimbursement. Data were also collected on death and retirement
benefits paid, or owed, to the cases.
Between November 2002 to October 2003, death rates were 0.4 percent for doctors, 2.8
percent for clinical officers and 3.5 percent for nurses working at the study sites. Because
some records were missing, we could not determine the exact proportion of deaths due to
AIDS or related chronic diseases. In the final year of employment, those who left the
workforce because of illness recorded an average of 28 additional days of leave. Costs
associated with this additional leave, plus death or retirement related payments averaged
$4,056 for a doctor, $2,678 for a clinical officer and $3,674 for a nurse.
Although we collected data on hospital admissions and medical reimbursements, no
information was obtained on many of the cases, suggesting that such records are
incomplete, or that individuals choose to be treated away from their normal place of
employment. The records confirmed an increase in the utilization of health care by those
who died, and we have added an allowance of $200 for the incremental health costs
associated with AIDS. Total costs were approximately 3.6 percent of the current payroll
for these classes of professionals in these institutions.
We were we not able to quantify overtime payments or loss of the productivity as a result
of absenteeism and illness. In addition, there is undoubtedly some HIV/AIDS related
absenteeism included in the comparisons. For these reasons, our results underestimate
the total cost of HIV in healthcare workers.
Perhaps the most disturbing finding is the cumulative impact that these death rates have
on trained health cadres. For doctors, mortality is not the largest reason for attrition from
the work force, nor the most important factor contributing to the high-observed vacancy
rates. But for clinical officers and nurses, death is the largest single reason for loss. The
average age at death for all health professionals was 37.7 years. Clinical officers die with
57 percent of their normal career remaining; nurses die halfway through the normal career. The current output of clinical officers would have to increase by 80 percent to offset observed AIDS mortality. Graduating classes of nurses would have to expand by a
50 percent to offset current mortality.
HIV prevention, though essential, will not reduce the number of existing infections in
health professionals. Expanding the output of training classes is a longer-term solution; it
will be several years before higher training quotas can offset increasing vacancy rates. In
the short- to medium-term, the most effective way to reduce attrition and vacancies
among nurses and clinical officers is through the effective treatment of AIDS. If
effective antiretroviral treatment is provided, it should be possible to increase the
productive life span of HIV positive professionals by five years or more. If such
treatment costs $500 per person per year, the costs (that we have been able to document)
incurred with each death will purchase six to eight years of antiretroviral therapy. If all
professionals who need antiretroviral therapy were to receive it in a timely fashion,
vacancy rates at the end of five years should be 10 percent to 15 percent lower than they
would be in the absence of such treatment.