Spotlight Interview
With Sheila D. Tlou Conducted September 2008
Professor Sheila D. Tlou is the former Minister of Health of the Republic of Botswana and an internationally recognised leader and educator in nursing. Professor Tlou is a recent recipient of the World YWCA Women Leading Change Award in recognition of her contribution to the fight against HIV/AIDS. She has also delivered the International Council of Nurse's prestigious Virginia Henderson Memorial Lecture.
	ICHRN: As the former Minister of Health of Botswana and a prominent nursing leader in the African region, what do you see as the three most pressing challenges confronting health human resource policy makers in the region?
Sheila Tlou: a) The most pressing challenge is training sufficient numbers of health workers while maintaining standards so as to deliver proper care. b) Secondly, we need to determine the right policies regarding overall benefits for Health Care Workers (HCWs) and ensure that these policies are implemented by each Ministry of Health in every country. c) Most countries in Africa are source countries for sending health care workers to other countries with shortages. But this is undermining health systems in Africa. The challenge is to put policies and retention strategies in place that ensure there is minimal outmigration, for example ‘bonding to give back to the community’. I was supported by my government during my four years of training to become an RN and then was obliged to work in my home country for four years.
	ICHRN: In your opinion, what needs to be done in order to successfully address these key challenges?
Sheila Tlou: No one country can address these challenges alone. We need to dialogue and collaborate at the global level about what we can do regarding training, retention etc. in order for all to play our part and collectively then reach self-sufficiency.
	ICHRN: Botswana is one of the member states in the African Union that has met and surpassed the target of 15% of annual budget assigned to health. How has this impacted on the nursing workforce?
Sheila Tlou: The work environment has been strengthened in several ways: hospitals have had a physical upgrade – new equipment, paint, tiles, etc. New hospitals have been opened relieving overcrowding and bringing new technology. Antiretroviral drugs (ARVs) are freely available and more nurses have been hired – both these developments have improved HCW morale and workload. Staff accommodation has improved; for some facilities it has gone from zero housing units to 60! As I left office, it was pleasing to see that nurses were choosing to stay in the country rather than migrate.
	ICHRN: Botswana has introduced nurse practitioners. What has been the impact of this measure? What strategies are required to introduce and sustain nurses in this type of advanced role?
Sheila Tlou: Nurse practitioners were introduced in Botswana a long time ago as part of an emphasis on primary health care (PHC), especially in rural areas. In 1978 the national health strategy was based on PHC and it was decided that advanced practice nurses were key in providing quality health services to remote and rural areas that would otherwise not benefit were it not for the NPs.. As a result, when ARVs were introduced, nurses were involved from the start and we reached treatment goals quickly, compared to other countries. We had a well functioning PHC system – we just needed to add on the specifics for HIV and AIDS (CD4* testing, structural logistics, planning etc.). Retention strategies have included a higher remuneration for Nurse Practitioners (NPs) than for Registered Nurses (RNs). In some cases they are paid more than physicians. We also invested in improving working conditions, including improving the work environment and providing most of the equipment they need to properly execute their duties.
	ICHRN: Nurse mobility from the public to the private sector is growing in Botswana. What are the reasons behind these career moves and how have they affected health care delivery in your country?
Sheila Tlou: Nurse mobility from public to private sector is a double-edged sword in that our collaborating partners such as US President's Emergency Plan for AIDS Relief (PEPFAR) and the United Nations family require qualified staff and want to hire nurses. For example, most AIDS coordinators in the ministries are nurses. Whilst this worsens our staff shortages, we are proud that our citizens are engaged in other capacities for even better collaboration with the government. This is advancing the status of nurses and giving them top opportunities here in their own country. To remedy this we just have to train and retain more RNs and other health care workers.
	ICHRN: Can you highlight one example of a strategy currently being employed in Botswana to aid nurse retention and describe what effect it is having on retention?
Sheila Tlou: We introduced a Wellness programme for health care workers, for the first time sending the message that carers count. It is being rolled out to hospitals, though it still requires staffing. In some hospitals, tennis courts etc. have been built. Another strategy was the Salaries Review Commission for the whole public sector. As minister, I asked for nurse practitioners to serve on the commission in order to articulate the needs of nurses and other health care providers. The recommendations (salaries, overtime allowances etc.) were supposed to be implemented last spring but, with the change of government, most recommendations were revoked and a 15% across the board increase for nurses was applied. Then some other incentive for the public sector was introduced – called a scarce skills allowance. It covered all sectors, but in the health sector, it translated into a 40% increase for physicians, 30% for pharmacists, 20% for lab technicians etc. – but nothing for nurses. Understandably, this has not been well received by nurses and I predict a renewed outflow of nurses from the public sector and from Botswana.
	ICHRN: Can you share your perspective on the impact HIV/AIDS has on nursing personnel in Botswana? What strategies are in place to help nurses manage the demands of the epidemic?
Sheila Tlou: The impact of the HIV and AIDS epidemic has been enormous: nurses themselves have been affected and we have lost many due to the epidemic. In their workplace, nurses care for AIDS patients, resulting in impossible workloads. Then there is that demoralizing effect of seeing many patients dying when the main aim was to nurse them to health. However, this has changed as more people, including nurses, now have access to free treatment. Because of the ARV rollout with a 96% uptake, as well as new prevention strategies, there is more satisfaction and less stress at the workplace. Another positive outcome is that with the acceleration of the Preventing Mother-To-Child Transmission of HIV programme (PMTCT) to reach 100% of pregnant women, the transmission rate has been reduced from 40% to 2%, thus saving the children and their mothers.
	ICHRN: Is there anything further you would like to communicate to our readers interested in health human resource issues?
Sheila Tlou: The scarcity of health human resources is a global epidemic and it needs to be tackled at country level as well as at the global level. Just like in the case of HIV and AIDS, we all have a part to play. Notes: * CD4 is a primary receptor used by HIV-1 to gain entry into host T cells Sheila Tlou, RN, PhD is a Member of the Botswana Parliament, former Minister of Health (2004- 2008) and Professor of Nursing at the University of Botswana.