Development of Human Resources for Health in the WHO African Region: Current Situation and Way Forward

Magda Awases
Jennifer Nyoni
Khaled Bessaoud
Alimata J Diarra-Nama
Chris Mwikisa Ngenda

World Health Organization, Regional Offi ce for Africa

Corresponding author:
Magdalena Awases
Email: awasesm@zw.afro.who.int

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ABSTRACT

Human resources for health (HRH) are widely recognised as the most important assets and pillar of any health system. However the African Region is faced with severe shortages of this important human capacity. This has resulted in weak health systems with a limited capacity to achieve their national health goals. The problem is more severe in rural and remote areas where most people typically live in the countries in the African Region.

This paper provides information about the efforts and commitments by Member States and the various opportunities created by Regional and global partners, including the progress made. The paper also explores issues and challenges related to the underlying factors of the HRH crisis, such as chronic underinvestment in health systems development in general, and specifically in human resources for health development, migration of skilled health personnel as a result of poor working conditions and remuneration, lack of evidence-based strategic planning, insufficient production of health workers and poor management systems.

The paper proposes multiple actions to be undertaken by countries, including a significant increase in investment to ensure that the required health workers are in place and functional.





RÉSUMÉ

Les ressources humaines pour la santé (HRH) sont largement reconnues comme les atouts les plus importants et un véritable pilier de tout système de santé. Toutefois, la Région africaine doit faire face à de graves pénuries dans ce secteur vital des ressources humaines. Il en résulte des systèmes de santé fragiles, dotés d'une aptitude limitée eu égard à la réalisation de leurs objectifs sanitaires nationaux. Le problème est encore plus grave dans les zones rurales et isolées, où vivent typiquement la plupart des populations des pays de la Région africaine.

Le présent document fournit des informations sur les efforts et engagements des Etats membres et sur les diverses opportunités créées par les partenaires régionaux et mondiaux, y compris sur les progrès réalisés. Le document explore également des questions et des défis en rapport avec les facteurs sous-jacents de la crise dans le secteur des HRH, notamment le sous-investissement chronique dans le développement de systèmes de santé en général, et dans les ressources humaines pour le développement de la santé, la migration du personnel de santé qualifié en raison des mauvaises conditions de travail et de rémunération, le manque de planification stratégique fondée sur des preuves, la formation numériquement insuffisante du personnel de santé et les faibles systèmes de gestion en particulier.

Le document propose de nombreuses actions à entreprendre par les pays, y compris une augmentation significative en termes d'investissement afin de garantir que le personnel sanitaire requis est sur place et opérationnel.

SUMÁRIO

Os recursos humanos na área da saúde (HRH) são geralmente reconhecidos como os elementos mais importantes e o pilar de qualquer sistema de saúde. No entanto, a Região Africana é confrontada com graves faltas neste domínio importante. Tal resulta em sistemas de saúde fracos com uma capacidade limitada de atingir os objectivos nacionais de saúde. O problema é mais grave em áreas rurais ou distantes, onde a maioria das pessoas nos países da RegiãoAfricana normalmente vive.

Este documento fornece informações sobre os esforços e os compromissos assumidos pelos Estados Membros e as diversas oportunidades criadas por parte de parceiros regionais ou mundiais, incluindo os progressos atingidos. O documento também analisa assuntos e desafios relacionados com os factores subjacentes à crise dos HRH, como, por exemplo, o investimento crónico insuficiente nos sistemas de saúde em geral e, especificamente, nos recursos humanos para o desenvolvimento da saúde; a migração do pessoal de saúde qualificado, como resultado de más condições de trabalho e de remuneração; a falta de um planeamento estratégico baseado em observações factuais comprovadas; a formação insuficiente de técnicos de saúde e sistemas de gestão fracos.

O documento propõe várias medidas de acção a serem desenvolvidas pelos países, incluindo um aumento significativo em termos de investimento para assegurar que os técnicos de saúde necessários existem e estão aptos a trabalhar.


The African Region is faced with severe shortages of doctors and nurses, having only 590,198 health workers against an estimated 1,408,190 required. This situation is compounded by inappropriate skill mixes and gaps in service coverage. The estimated critical shortages of doctors, nurses and midwives alone is over 800 000(1).

Underlying factors of the problem include chronic underinvestment in health systems strengthening in general and in health workforce development in particular. The shortages of health workers has implications on the health systems, and on global and local priorities. Weak health systems and limited capacity to achieve the Millennium Development Goals (MDGs), especially MDGs 4, 5 and 6. The main bottleneck in scaling up maternal and child health hare is lack of skilled human resources for health (HRH). As a result coverage of key MCH interventions such as births attended by skilled attendants and PMTCT are low. Overall, rates of births with skilled birth attendants remain low in SSA countries averaging only 42%.

In 1998 and 2002 Member States of the WHO African Region discussed and adopted resolutions(2) to strengthen their HRH. These resolutions recommended priority interventions such as policy formulation and planning for the development of the health workforce, education, training and skills development, administration and management, research and regulation of health professions.

World Health Assembly resolutions(3) also recognized the importance of human resources in health care delivery systems and proposed possible actions for reversing the negative effects of migration, strengthening nursing and midwifery, and scaling up the production of all categories of health workers. Weak health systems limited capacity to achieve the MDGs, especially MDGs 4, 5 and 6.

In support of this process, WHO guidelines for policy formulation and planning were developed for use by countries. Tools and guidelines to ensure quality and relevance of education and training were developed and used by countries. Five WHO collaborating centres for human resources for health were established, and five Regional training centres continue to receive WHO technical and financial support.

WHO organized dialogues with professional bodies and associations, including consultation with deans, nurses and midwives, sub-Regional bodies such as ECSA, SADC, WAHO, OCEAC, and civil society groups such as EQUINET, NEPAD, on HRH and related issues,

Several approaches in health workforce management were implemented in some countries. For instance, new career profiles were established in Côte d'Ivoire and Mauritania; new contractual arrangements were set up in Benin, Kenya and Uganda; and increases of salaries with donor funding in Malawi. Various macroeconomic initiatives were used to recruit and motivate the health workforces in Cameroon, Cape Verde, Malawi and Zambia. Guidelines and recommendations for increasing access of health workers in remote and rural areas through improved retention have been developed.

Furthermore, at the World Health Assembly and 2009 Regional Committee meeting, there has been discussion and debate regarding the draft Code of Practice for international recruitment over the last two years as a tool for managing migration

The status of the health workforce in the African Region was assessed in the 46 Member States through surveys; these resulted in the development of a database and country fact sheets. An African Health Workforce Observatory was established, and national health workforce observatories have been launched in a number of countries. Health workforce managers from 40 countries were given training.

At the Regional level, the African platform for health workforce development consisting of Regional stakeholders is being established to support countries in addressing the crisis. Collaboration with partners such as the African Union, the Regional economic communities, the European Commission and the Global Health Workforce Alliance was significantly enhanced. More stakeholders and partners are willing to commit resources for health workforce development in countries.

Despite these actions and some encouraging results, the African Region is still experiencing an unprecedented crisis in the health workforce. The purpose of this paper is to provide information on the progress made and propose a range of actions for the way forward.

Issues and Challenges

Funding for health workforce development

Over the past 10 years, there have been many opportunities to invest in the development of the health workforce, but these opportunities have not all been used optimally. For example, countries are yet to fully explore the opportunities available through poverty reduction strategies; debt cancellation; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and the GAVI Alliance. Equally, although ministries of finance are supporting health systems strengthening, they are reluctant to endorse wage increases from external aid, since such funds have been demonstrated to be unpredictable and unsustainable.

Low budgetary allocations to the social sector, in particular to health, are an impediment to strategies for training, recruiting and retaining health workers. Thus, the apparent high rates of recurrent expenditure (50%–70%) for remuneration of health workers for most public budgets in real terms translate to salaries as low as US$ 23–40 per month for a general medical practitioner and much lower for other cadres. Within this context, the main challenge is how to mobilize the requisite additional financial resources from both domestic and external sources and use them appropriately to reverse the current HRH crisis.

Policy and planning for the workforce

Some 27 of the 46 Regional countries have a health workforce policy and 31 have a plan(4). Although the policies and plans have improved in quality, they are often not evidence-based, since the often lack important data and information and fail to link with the health priorities of the country. They are often not well costed and not well implemented and monitored. Most are developed without the full involvement of the private sector and other important stakeholders. The challenges include how to fully involve other stakeholders to develop comprehensive and integrated policies and plans and adequate resources to ensure their implementation. Many countries have some national level HRH technical working groups that include a range of partners and stakeholders. These generally require strengthening so that they can realize the potential to evolve into more robust forums for policy and plan development. Some countries have used these effectively while in others they are still weak. The HRH units in ministries of health that are mandated to coordinate and facilitate health workforce policy and planning, are weak in many countries in terms of capacity to perform these strategic functions amidst other challenges.

Production of human resources for health

Training institutions are not producing a sufficient and consistent supply of health workers to replenish the dwindling HRH mainly owing to attrition and years of underinvestment in institutional capacity. This underinvestment has resulted in dilapidated and inadequate health infrastructure, insufficient teaching staff and an inappropriate skills mix of graduates. Meanwhile, considerable funding is spent on training workshops for priority health programmes; however, such training is inefficiently linked with the training institutions and hence does not contribute to ensure sustainability in the production and continuing professional education of the health workforce.

Uncoordinated efforts between Ministry of Health and Ministry of Education often result in poorly articulated strategic decisions. There is some indication that intakes and outputs from medical and health sciences training institutions are increasing. Some countries such as Algeria, Benin, Burkina Faso, Cote d' Ivoire, Cape Verde, Ethiopia, Ghana, Mauritania, and Nigeria have doubled their outputs but (as indicated in Figure 1) many of them are still below the 2.3 health workers per 1000 population threshold.

Figure 1. Shortage status of doctors, nurses and midwives in the African Region (2002–2008)

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However for some of the countries the output of doctors will decline if drastic measures are not taken to increase the intake of pre-service and to retain health workers. For example, the projections made for Swaziland show a decline in medical doctors based on the current average annual intake of medical students to Cuba, Russia and South Africa,, the present average annual graduation rate, and the present attrition rate of 7.9% per annum. Figure 2 shows the projection of the number of doctors that will be in-post and the requirements by 2029. To keep pace with population increase, a total of 246 doctors are required by 2029. If loss rates, intakes and graduation rates remain the same as at present, there will be 74 doctors in post by 2029. The attrition rate is already quite high at 7.9%. A significant investment in training therefore is needed to reverse the situation depicted below in Figure 2.

Figure 2. Projection for doctors in Swaziland (average annual intake of 20; graduation rate of 20%, loss rate of 7.9%, 0.2 doctors per 1000 population)


As for the nurses and based on the present ratio of nurses to population, by 2029 a total of 2,826 nurses are required to keep pace with population growth. Figure 3 shows that if the 2009 intakes, graduation rate and loss rate were maintained, then by 2029 a total of only 1,682 nurses will be available.

Figure 3. Projection for nurses in Swaziland (average annual intake of 140; graduation rate of 96%, loss rate of 7.9%, 2.3 nurses per 1000 population)

Motivation and retention

A study(5) on the migration of skilled health workers in 2002 in six African countries showed a decline in the number of available health workers. About two-thirds of those interviewed expressed an intention to migrate, underscoring the gravity of the situation. Health workforce shortages have become acute in 36 countries in the African Region This crisis continues to worsen with the attrition of health workers resulting from the impact of HIV/AIDS on the workers themselves.

Difficult working conditions characterized by heavy workloads, lack of equipment, poor salaries and diminished opportunities for advancement contribute to the state of de-motivation and poor performance of staff. These conditions are worse in rural areas, giving rise to inequitable staff distribution compared to urban areas (as depicted in Table 1) where the majority of health workers are in provinces with major urban cities such as such as Lusaka and the Copperbelt, with 23 percent and 21 percent of all health workers respectively.

Table 1: Distribution of health workers, by Province and population

Source: Annual Health Statistical Bulletin, 2007 (draft produced August 2008).

The outcome is increased migration from public to private sector, from rural to urban areas, or emigration. One strategic challenge is to change the inequitable distribution of health workers and thus serve both rural and urban areas. In addition, some countries are unable to recruit trained workers owing to budgetary constraints.

Management

Most health workforce divisions in ministries of health do not have the capacity to carry out their human resources functions, including stewardship and leadership. Furthermore, health workforce issues are complex and go beyond the health sector. Effective management of the health workforce therefore remains a key challenge, and the responsibility of not only the Ministry of Health but also the public service authorities. Though partnerships for health workforce development may have improved, there is not enough progress at country level owing to fragmented efforts and insufficient coordination.

Information and research

The existing information and research evidence show problems of inadequacy, inconsistency, duplication and poor linkages in the available data; in addition, countries lack systems to process and manage information to ensure easy access for decision-making. One of the main challenges confronting this crucial area is how to set up mechanisms to process and manage data to ensure easy access.

Actions Proposed

Given the current situation and challenges, it is proposed that countries should substantially invest in implementing multiple and sustained actions to ensure that the required health workforce is in place and functional. The following proposed actions focus on interrelated strategic areas.

1. Create fiscal space: Countries should identify and implement innovative ways of creating fiscal space for health workforce development which should be institutionalized. These include implementing the decision to spend at least 15% of national budgets on the health sector and take advantage of existing opportunities such as debt relief. Concerted efforts should be made to increase budget ceilings to allow governments to improve wage bills that allow for recruitment of more health workers or mobilization of donor funds to increase remuneration and incentive packages. Policy decisions should be made on using a negotiated percentage of development funding for priority health programmes, to support implementation of strategic components of health workforce plans. Advocacy at Regional and global levels should continue to solicit for substantial financial investment in health systems development that includes human resources.

2. Accelerate formulation and implementation of comprehensive policies and plans: Effective planning is essential for future human resource needs based on current shortfalls and linked to the potential to recruit and retain an expanded health workforce. Therefore, countries are encouraged to develop and implement evidence-based comprehensive HRH policies and plans, with involvement from numerous sectors and stakeholders. The plans should forecast supply and demand for the whole health system, including priority programmes, and should be costed and operationalized for implementation. At the Regional level, a multidisciplinary pool of African HRH experts should be strengthened to support countries in HRH planning and key workforce interventions.

3. Produce more human resources for health: Increased investment is needed in pre-service training to produce more health workers. Countries need to strengthen the capacity of training institutions for scaling up production of health workers, including midlevel cadres to deliver promotional, preventive and curative health care in an integrated manner. Key actions for capacity building include reforming and upgrading training institutions, as well as exploring innovative ways of expanding training capacity, such as public-private partnerships, south to south and north to south collaboration. The process should start with evaluation of both private and public educational institutions to ensure an appropriate skills mix based on the health needs of the population. Accreditation mechanisms to certify academic institutions, education programmes and training performance should be prioritized. Utilization of WHO collaborating centres and Regional training institutions should be optimized for training and research.

4. Improve management systems: Countries are urged to give priority to improving the skills, equipment and status of health workforce departments to enable them to carry out their strategic functions. Professional bodies (regulatory and professional associations) should be empowered within national legislation to protect people's health, including promotion of professional ethics, as well as the interests of health workers. In order to address skills and competency gaps for effective service delivery, continuing professional education should be promoted as part of in-service training, including distance learning. Technical support for strengthening health workforce management systems in countries should be provided from the Regional level.

Emerging evidence from an on going WHO survey of health workforce divisions/units in the ministries of health show that each country has national HRH directorates within MOH, but with limited capacity such as staffing and are not well represented at decentralized levels in many of the countries. The District level HRH systems are considered weak in all the countries with many aspects of health workforce development still centralized.

5. Develop and implement retention strategies: Countries are encouraged to make policy decisions for attracting and recruiting more health workers as a matter of urgency within specific country contexts. The current employment and deployment policies and practices should be reviewed, and new opportunities for recruitment should be considered. Strategies to improve the utilization, performance, working conditions and retention of health workers should be considered. Strategies, including bilateral and multilateral agreements, for managing migration should be developed and implemented.

6. Generate evidence: Countries are encouraged to strengthen effective collection and management of human resource information with core data sets and indicators useful for policy, planning and implementation. Countries should consider establishing national observatories as mechanisms for knowledge management, information-sharing and evidence for health workforce development. The Regional Health Workforce Observatory and its national counterparts are accelerating Regional monitoring and evaluation, formulation of a research agenda and advocacy for research implementation. The Observatory also shares best HRH innovative interventions such as management of salaries and incentives, evidence for sustainability of investment into HRH, and others.

7. Foster partnerships: Countries are urged to strengthen, sustain and formalize mechanisms for intersectoral partnerships, including the private sector, NGOs and the diaspora, for health workforce development. One key role of these partnerships is to contribute to the planning, implementing and monitoring of national health workforce policies. The stewardship role of national authorities should lead the process and harness the contribution of all the players in the planning, production and utilization of health workers.

Regional level mechanisms for intersectoral partnerships should also be formalized and strengthened for coordinated support to countries. Strengthening and supporting of African institutions such as the the African Health Workforce Observatory, African Platform for HRH, the Association of Medical Schools in Africa (AMSA), and Regional economic bodies should be encouraged for following up global, international and national commitments and resolutions. Such mechanisms should address the need for additional financial resources from both domestic and external investments.


REFERENCES