Want to help doctors and nurses? Invest in health systems

BARCELONA — The world’s health care workers — 70% of which are women — are key to achieving universal health coverage and guaranteeing global health security. Yet the World Health Organization predicts a shortfall of 18 million health care workers by 2030.

Across many low- and middle-income countries, nurses, midwives, doctors, and community health workers already faced daunting challenges such as severe underfunding, lack of resources, and accessing necessary training. Now, the pandemic is exacerbating those problems.

“Health care workers are, if not all of the time, [then] most of the time, underpaid, unappreciated, and undervalued,” said clinical research nurse Jose Maria “Lloyd” Nunag, who currently works in London where he is pursuing a master’s degree in public health after practicing in his home country of the Philippines for four years.

Health care workers continue to fight on the frontlines, putting themselves at risk. But what challenges do they face to doing their jobs more efficiently — and most importantly — safely? And what should governments and donors do to help?

Ensure health staff's physical and mental well-being

At least 90,000 health care workers worldwide have so far been infected with COVID-19, but the number could be twice that according to reports by the International Council of Nurses.

Dr. Khaled Abderrahman, tropical medicine specialist and deputy head of mission at Médecins Sans Frontières in Sudan told Devex that health workers were worried about the lack of personal protective equipment, or PPE.

The risk of contracting the virus and infecting loved ones adds to this stress.

“People are not confident that they will be protected, they don’t feel they have enough gear,” Abderrahman said. “Of course people don’t only fear for themselves ... but also for their families, their parents, and kids.”

For Nunag, keeping up morale during this period is extremely difficult.

“Aside from dealing with the stress from the pandemic, I’m seeing people die at a very high rate like I’ve never seen before,” he said. “We also have to face the pressure of missing a colleague, and at the same time having an extra workload ... many of my work mates are either sick or already self-isolating.”

Some organizations offer resources to help staff cope with the stress and maintain their mental health.

In the Democratic Republic of the Congo, for example, the International Committee of the Red Cross provides psychosocial support to ICRC staff.

“When needed, we can reach out to stress advisers based in the field or at headquarters,” said Silas Muriungi Mukangu, deputy health coordinator at ICRC in the DRC. “My management is also very supportive, encouraging us to take rest and days off when needed.”

Better-trained health care professionals

Currently, 45% of WHO member states report to have less than 1 physician per 1,000 inhabitants. Many governments are attempting to boost this number, but challenges remain.

“We have to multiply the people who are educated, and we have to be careful because some countries [have] too many doctors, not enough nurses, or sometimes the contrary,” said Dr. Agnes Binagwaho, vice chancellor of the University of Global Health Equity and former Rwandan minister of health.

Many LMICs also face issues of "brain drain," as health staff leave for more competitive jobs elsewhere. In the past decade, the number of migrant nurses and doctors working in Organisation for Economic Co-operation and Development countries has risen by 60%. According to Binagwaho, high-income countries need to “stop stealing their skilled people ... because the country invests in their education, and when they are good, they just receive a better contract and they go abroad,” she added.

Ensuring health care staff are available where they are needed most — especially in rural communities, refugee settlements, or conflict-affected areas — is also crucial. While it’s encouraging to see an increasing number of people graduating in medical studies in countries such as Sudan, those challenges are not well addressed in eastern Sudan or in the conflict-affected Darfur area, MSF’s Abderrahman said.

“Nobody knows how many nurses we need, where they are needed, and what skills are needed in these areas. It’s not only a data gap, it’s a context knowledge gap,” he said.

With the spread of coronavirus, training medical staff quickly is becoming an urgent priority. In Sudan, MSF worked with the ministry of health and WHO to train staff in more than 95 health facilities to support better triage systems that minimize hospital infections and help detect cases early on. But to effectively respond to COVID-19, “their knowledge sometimes needs to be updated, and additional skills are required,” Abderrahman said.

Technology can help overcome some of these problems, and it doesn’t have to be sophisticated. To ensure 60,000 health care workers have the necessary information to respond to the ongoing pandemic, for example, Dr. Caroline Mbindyo, CEO at Amref Enterprises explained how Amref Health Africa repurposed the mHealth platform Leap to give virtual training to health workers in Kenya. The platform can be used on any basic phone and doesn’t require an internet connection, she explained.

Other organizations such as Smile Train, a nonprofit providing corrective surgery for children with cleft lips and palates, were forced to postpone many surgeries but have continued to support staff at their partner hospitals using telemedicine. Health workers are now using WhatsApp and video calls to follow up with patients and promote adherence to treatment.

Crucial investments in the health workforce must be made

Despite the United Nations launching an appeal for $6.7 billion to address immediate needs in vulnerable countries fighting the pandemic, more long-term funding is needed.

In the short-term, the International Monetary Fund will cover debt repayments over the next six months for 25 of its poorest members. In addition, between Jan. 1 and May 10 of this year, donors have committed a total of $15.9 trillion to combat the impacts of coronavirus.

But debate rages on whether this is little more than a band-aid solution, especially if funds previously committed to other development priorities are diverted to the response.

To respond to the pandemic — and prepare for future crises — investments in strong health workforces will be crucial. According to WHO’s report “Recommendations to Transform the Health Workforce for the SDGs,” “investing in health workers is one part of the broader objective of strengthening health systems and social protection and essentially constitutes the first line of defence against international health crises.”

Yet large disparities in health spending continue to exist. Across low-income countries, average health spending was only $41 per person in 2017, compared with an average of $2,937 per person in high-income countries. So how can these countries sustainably finance their health workforces?

The report outlines 10 recommendations to help maximize future returns on investments in health, including “the need to stimulate investments in creating decent health sector jobs, particularly for women and youth, with the right skills, in the right numbers and in the right places.” It also emphasizes the need to raise adequate funding from domestic and international sources — public and private where appropriate — and to consider broad-based health financing reform where needed.

Financial investment in public health is important. But coordination and political will to prioritize the health sector is also vital as countries such as Cuba show, where health reforms stemming from the 1970s have proved effective, and the country has been lauded for its model public health system.

Health care workers are the backbone of strong health systems, yet the support they need hasn’t materialized in many countries.

“I realize in this pandemic that people always prefer to call health care workers heroes instead of just giving them the equipment, the resources, and the environment that they need to do their jobs safely,” Nunag said.

As the pandemic ravages health systems across the globe, it is becoming evident that no one group will be able to solve these challenges alone.

“The doctors are looking for more support from the government, and the government is looking for and expecting more support from donors and the international community,” said MSF’s Abderrahman. “It really comes down to a chain of collaboration.”

Visit the Duty of Care series for more coverage on how health systems can function better so that health care workers are supported and protected. You can join the conversation using the hashtag #DutyOfCare.