Task sharing in Zambia: HIV service scale-up compounds the human resource crisis

BACKGROUND: Considerable attention has been given by policy makers and researchers to the human resources for health crisis in Africa. However, little attention has been paid to quantifying health facility-level trends in health worker numbers, distribution and workload, despite growing demands on health workers due to the availability of new funds for HIV/AIDS control scale-up. This study analyses and reports trends in HIV and non-HIV ambulatory service workloads on clinical staff in urban and rural district level facilities. METHODS: Structured surveys of health facility managers, and health services covering 2005-07 were conducted in three districts of Zambia in 2008 (two urban and one rural), to fill this evidence gap. Intra-facility analyses were conducted, comparing trends in HIV and non-HIV service utilisation with staff trends. RESULTS: Clinical staff (doctors, nurses and nurse-midwives, and clinical officers) numbers and staff population densities fell slightly, with lower ratios of staff to population in the rural district. The ratios of antenatal care and family planning registrants to nurses/nurse-midwives were highest at baseline and increased further at the rural facilities over the three years, while daily outpatient department (OPD) workload in urban facilities fell below that in rural facilities. HIV workload, as measured by numbers of clients receiving antiretroviral treatment (ART) and prevention of mother to child transmission (PMTCT) per facility staff member, was highest in the capital city, but increased rapidly in all three districts. The analysis suggests evidence of task sharing, in that staff designated by managers as ART and PMTCT workers made up a higher proportion of frontline service providers by 2007. CONCLUSIONS: This analysis of workforce patterns across 30 facilities in three districts of Zambia illustrates that the remarkable achievements in scaling-up HIV/AIDS service delivery has been on the back of sustained non-HIV workload levels, increasing HIV workload and stagnant health worker numbers. The findings are based on an analysis of routine data that are available to district and national managers. Mixed methods research is needed, combining quantitative analyses of routine health information with follow-up qualitative interviews, to explore and explain workload changes, and to identify and measure where problems are most acute, so that decision makers can respond appropriately. This study provides quantitative evidence of a human resource crisis in health facilities in Zambia, which may be more acute in rural areas

What do recent advances in quantifying climate and carbon cycle uncertainties mean for climate policy?

Global policy targets for greenhouse gas emissions reductions are being negotiated. The amount of emitted carbon dioxide remaining in the atmosphere is controlled by carbon cycle processes in the ocean and on land. These processes are themselves affected by climate. The resulting ‘climate–carbon cycle feedback’ has recently been quantified, but the policy implications have not. Using a scheme to emulate the range of state-of-the-art model results for climate feedback strength, including the modelled range of climate sensitivity and other key uncertainties, we analyse recent global targets. The G8 target of a 50% cut in emissions by 2050 leaves CO2 concentrations rising rapidly, approaching 1000 ppm by 2300. The Stern Review’s proposed 25% cut in emissions by 2050, continuing to an 80% cut, does in fact approach stabilization of CO2 concentration on a policy-relevant (century) timescale, with most models projecting concentrations between 500 and 600 ppm by 2100. However concentrations continue to rise gradually. Long-term stabilization at 550 ppm CO2 requires cuts in emissions of 81 to 90% by 2300, and more beyond as a portion of the CO2 emitted persists for centuries to millennia. Reductions of other greenhouse gases cannot compensate for the long-term effects of emitting CO2

Business-managed democracy: The trade agenda

The architecture of global governance that has emerged in the past two decades has been strongly influenced by transnational policy actors. This article examines the role of transnational corporate agency in social policy by focusing in particular on the role of business coalitions, elite networking bodies and policy planning groups in fostering unity amongst corporate actors and enrolling political actors into managing democracies in the interests of business. The example of the General Agreement on Tariffs and Trade (GATT) and the World Trade Organization (WTO) is used to examine how corporate agency is wielded through elite networking organizations and how this is eroding national social policy