A holistic solution for the global health workforce shortage

If improved health care - and access to it - is a cornerstone of the Millennium Development Goals, then 57 countries are at serious risk of failing to meet their targets. A main culprit is the severe shortfall of health workers, especially in the world’s poorest countries.

The shortage, which the World Health Organization brought to worldwide attention in a 2006 report, raises serious concerns: Without more health workers, health disparities between rich and poor countries will grow, progress toward achieving important health outcomes, such as improving maternal health and lowering infant mortality rates, will stall, and gains will be lost. The crisis has long been overlooked and will worsen if the health workforce and resources are not expanded, health experts caution.

WHO suggests that achieving a 80 percent coverage rate for skilled birth attendance and child immunization - two basic primary health care targets - requires a minimum average of 2.5 health care professionals - physicians, nurses and midwives - per 1,000 residents. Against this backdrop, the public health scenarios for nations facing critical shortages are grim.

A look at sub-Saharan Africa illustrates the gravity of the situation. With just 9 percent of the world’s population, the region shoulders 25 percent of its disease burden, according to WHO. Many health systems are utterly overwhelmed by HIV/AIDS, malaria, and tuberculosis. Africa is equipped with only 3 percent of the world’s health workforce operating on less than 1 percent of the world’s financial resources for health. In its estimate of a global shortage of 4.3 million trained health workers and all support personnel, the WHO says 1.5 million are needed in Africa alone.

For instance, Mozambique, a largely rural nation of more than 20 million people, had 514 physicians in 2004, according to the WHO. Research conducted last year by Merlin, the U.K.-based health charity, discovered that the Central African Republic did not have a single trained anesthesiologist. In other parts of the world, the situation is similar. In 2007, the Laputta township of Myanmar’s remote Ayeyarwaddy Delta region, for instance, one government-appointed doctor was assigned to the township’s 350,000 residents.

“In too many countries, people live and die without ever having seen a health worker,” said Dr. Mubashar Sheikh, executive director of the Global Health Workforce Alliance, a broad alliance of stakeholders that is administered by the WHO and serves as the world’s leading platform for tackling the crisis. “Almost a billion people don’t have access to health care. It’s unacceptable and disturbing to the global community.”

In the face of conflict, natural disaster, looming new pandemics and the “brain drain” - the exodus of much-needed medical staff from poor nations to fill lucrative posts in Western countries - global health experts and practitioners face a daunting challenge. The urgency of the crisis begs for a quick and effective response. It also challenges experts to view development goals through a new lens.

“This is truly a global crisis, affecting rich and poor, north and south, east and west,” Sheikh said.

He noted that while developing countries have resources, they are also severely understaffed in the health sector. And as their populations age and require more care, the problem will certainly worsen with time.

In March 2008, health experts, donors and ministers of health, education and finance drafted the Kampala Declaration and the Agenda for Global Action at a GHWA meeting in the Ugandan capital. The two documents provide a framework for effectively coordinating, expanding and supporting the health workforce over the next decade. They also urge government leaders to form public-private partnerships and invest significantly in “scaling up” of community and mid-level health workers. Calls for rigorous accreditation and government quality standards and an emphasis on close cooperation between professional organizations went in line with an emphasis on education, training and curriculum development.

Sheikh said there is a need for a comprehensive “life-span” view of the health worker, from entry into the workforce to exit. “One important message here is that we need to focus beyond the classic approach,” he added, emphasizing the need to train more doctors and nurses. Overcoming staffing gaps, Sheikh said, “requires space to innovate and invest in new categories of workers and bringing them into the system.”

Investing in human resources for health is an obvious starting point and an important programming component for her organization, said Fiona Campbell, head of policy for Merlin. In November, health charity launched an awareness and advocacy campaign called “Hands up for Health Workers.”

“What we are trying to do is make the conditions better in the country where [health care staff] are working, so that leaving isn’t the only option,” Campbell said.

One approach used in war-ravaged Liberia involves incentive payments, often referred to as “topping up.” During hospital visits, Campbell observed a considerable lack of much-needed medical equipment, drugs and supplies. She also met with health staff, such as nurse aides, who continued to work without pay.

“We want to support them in the areas that are hindering them and obviously one of those is salary,” Campbell said, adding that data from one county indicated that only 20 percent of hospital staff were salaried.

“It is a short-term, interim measure” until the government provides its health workers a proper salary, Campbell said. She stressed the importance of ensuring that payment falls within a realistic range, one the government can pay in the future. Additionally, incentive payments require consistency between agencies and coordination between various stakeholders, including the ministry of health.

Financial motivation is not the only factor that will keep health staff in the workforce. “They need to feel they are professionally developing and supported,” Campbell stressed.

Dr. Clare Chandler, a lecturer in social sciences at the London School of Hygiene and Tropical Medicine, concurred. She said that certain types of health workers find it difficult to establish the clear professional identity afforded a doctor, nurse or midwife. Such workers are not supported and are highly demotivated, said Chandler, who has researched factors that influence clinical decision-making among Tanzania’s non-physician clinicians. In Tanzania, as in other countries, these health professionals are increasingly relied upon to expand health care in rural areas. Yet they lack the professional status and standards that support the responsibilities they’ve been given. As a result, the quality of care diminishes.

“They have been very neglected in the health workforce crisis,” she said. “My recommendation is to implement a professional organization for mid-level cadres. Then health care workers could implement a code of conduct and organize themselves for better conditions of work and higher salaries.”

To improve Africa’s fragile health systems, more than supplies and resources are needed, Chandler stressed. The widespread lack of management and supervision in the health sector must be addressed, she said.

“The management side is really missing,” Chandler argued.

The Center for Educational Development in Health, a national human resources development institute operating in Arusha under Tanzania’s Ministry of Health, offers one-year diplomas and short-courses in a wide range of disciplines for health personnel. Chandler noted that professionals with skills in human resource management have a lot to contribute, particularly when it comes to guiding curricula and management training.

“Institutions such as CEDHA may well be open to speculative applications from experts in the human resources field for training their trainers and contributing to guidelines for managers,” she said.

To complement HR and training, health information systems - which are now being pushed widely across Africa - will need information technology experts, Chandler added. Chandler and Sheikh agreed that given proper support, supervision and training, greater health cadres with well-defined and expanded responsibilities can assume a key role in addressing the shortage. Known as “task shifting,” this practice re-allocates non-specialized duties from the scarce pool of highly trained medical practitioners and health professionals to general health staff and community health workers.

Ironically, the global lack of health workers reached a crisis point despite an enormous boost in awareness and financial resources to battle HIV/AIDS, malaria, and TB. It is at this intersection of crisis and opportunity that global health experts have found how good intentions can go awry. For instance, the mushrooming of “vertical funding” and “vertical programming,” by which donors direct their funds toward specific diseases such as TB, malaria or HIV/AIDS, has helped to undermine public health systems in fragile states, siphoning off much-needed staff from the public sector and basic health care at the community level.

Primary care, Chandler said, is “completely warped” by vertical funding and the priority is often placed on eradicating the three diseases TB, malaria and HIV/AIDS. Not only is there a widespread tendency to over-diagnose malaria in Africa, she added, but in 2007, more African children died of pneumonia than malaria.

The push for donors to reconsider funding cycles and application requirements is now reflected in the latest call for grant proposals for the Global Fund to Fight AIDS, Malaria and Tuberculosis. Commonly referred to as the Global Fund, the institution finances large-scale projects; its board urges fund seekers to take the fight against HIV/AIDS, malaria and TB to a broader platform and “consider utilizing this opportunity for strengthening health systems.” In their proposed country programs, applicants must identify the health system’s barriers and their ability to achieve and sustain scaled-up interventions. And, acknowledging varying challenges for differing settings, the Global Fund intends “to allow applicants maximum flexibility in addressing these weaknesses and gaps” in health systems.

Health policy experts have put pressure on non-governmental organizations as well. Aggressive recruiting practices that take much-needed and well-trained professionals away from health ministries, hospitals and other health institutions has contributed to staffing shortages.

Last May, 25 organizations signed onto the “NGO Code of Conduct for Health Systems Strengthening.” Drafted by a number of leading service and advocacy organizations, such as Physicians for Human Rights, Oxfam U.K. and the Health Alliance International, the code outlines responsible hiring practices of national health staff that minimize bureaucratic burdens on health ministries.

Dr. Amy Hagopian, senior health workforce planning and policy advisor for HAI, is also an assistant professor at the University of Washington’s Department of Health Services. Her early research in U.S. rural health led to an interest in what is readily recognized as the other half of the shortage equation: the migration of doctors and other specialized health professionals from poor, developing nations to wealthier, developed ones.

“I became interested in the people and the mechanisms that brought them here,” she said, “and how we have built-in policy to lure and attract them without much regard to the consequences to the communities they leave behind.”

Today, one in four doctors in the U.S. is from a foreign country, according to the WHO; 60 percent of these foreign physicians are from a low- or low-to-middle-income country.

Foreign trained doctors have become essential to staffing hospitals since U.S. medical school graduates only fill 66 percent of the total medical residency positions available each year. Hagopian noted that Medicare, the government’s health insurance program for the elderly and disabled, essentially determines U.S. policy on the quantity of international medical graduates the U.S. will “import.” The mechanism by which Medicare does this, she explained, “is by funding significantly more residency training positions for foreign medical graduates than we have U.S. medical school graduates.”

Hagopian, along with other experts, have suggested a number of strategies to address international workforce shortages. One is academic “twinning,” or the establishment of sister universities for the education and training of health workers.

“Through academic partnerships between states, and with the aim of producing more faculty - better trained faculty - we can work together on research so we can learn from each other,” Hagopian said.

Her own university department has gone a step further.

“We try to attract foreign nationals who can go back and work in their ministries of health to build capacity and that of health workers in their countries,” she said.

One recent graduate from Haiti will return to her home country and work in its Ministry of Health on workforce issues.

A key step toward addressing international health staffing shortages, Hagopian said, echoing the position held by many experts in the field, “In the U.S., we need to be self-sufficient in our own workforce.”