In September 2015, the world will launch the new Sustainable Development Goals and the post-2015 development agenda. We expect that achieving universal coverage of essential health services with access to the core services people need without financial and other barriers will be one of the main targets. Universal health coverage (UHC) will mean the design and deployment of health services in ways that assure adequate quality coverage for most of the population including vulnerable groups, with services that can tackle their most important health issues. A key element is, of course, that these services are available in ways that do not cause financial difficulties for users.
However, perhaps the most critical element in achieving coverage, ensuring good quality and having communities’ engagement with services, even with all the financial elements in place, will be the availability of a qualified health workforce. For the African continent, and sub-Saharan Africa in particular, this will remain a major challenge.
Africa and disease distribution
The MDGs which were to be achieved in 2015 remain unattained by the majority of countries, despite quite impressive improvements in reducing certain morbidities (e.g. HIV, TB and malaria).
Africa expects a 38% population increase between 2015 and 2030, more than twice the rate of increase of any other region. Africa also has to contend with a “double burden” of disease made up of a continuing high level of communicable diseases including HIV/AIDS, TB and malaria, a panoply of epidemic outbreaks (meningitis, cholera, etc.), an ongoing plethora of “neglected Tropical Diseases” (schistosomiasis, onchocerciasis, trypsonomiasis, leprosy, etc.) as well as major rises in prevalence of non-communicable diseases, with some 30% of Africans estimated to have high blood pressure compared to a global average of 22%.
Africa has had and continues to have a high proportion (20%) of the global burden of diseases, but its health workforce forms only about 2.3% of the global total ‒ a situation that has barely shifted since the early 2000s. This is in spite of significant increases in training schools (medical and nursing training schools, for example) and output of health professionals. These increases have barely been able to compete with population growth and the broadening spectrum of health issues4.
The improving economic situation in several African countries ‒ a number of whom have recently acceded into middle-income status ‒ is likely to translate into a growing demand for more sophisticated care even as the basic care packages remain difficult to deliver.
Lessons learned from the Ebola crisis
The Ebola outbreak in West Africa, the worst of its kind ever, has raised the spectre of health security incidences that can turn into global threats and ruin economies and social development when health systems are not strengthened. It is generally acknowledged that health systems were weak in the three countries most affected by Ebola; indeed, these three countries had some of the lowest availability of trained health workers found in the region5, but this was further compounded by inadequate management of human resources, with health workers often unpaid for long periods and not regularly updated. Many health workers died during the outbreak.
Another important realization that has taken place in the wake of the Ebola crisis is the need to expand community engagement with health services. Further effort is required to enhance those services that deal with outbreak alerts, health promotion and preventive services as well as working on risky health behaviours and cultures. This will require further investment in workforce management.
The current status of the workforce in Africa indicates widespread shortages. Sub-Saharan Africa has 37 of the 53 countries deemed to be facing an HRH crisis in the World Health Report of 2006. Few countries here have the estimated 2.3 core health workers (doctors, nurses, midwives) per 1,000 population needed to make an impact on key health indicators such as child and maternal mortality3. There remain significant challenges in the modelling of the health workforce, both in terms of priority types and mixes that will reflect the main health problems of each country, and in terms of the distribution of what little is available to areas of greatest need and to have these resources working in the most critical services to address the needs of the majority of the population. International migration remains a challenge, with many countries continuing to lose doctors, nurses and midwives, particularly the experienced specialists and trainers needed to sustain workforce development.
And so the question arises: if Africa has had major challenges achieving the current Millennium Development Goals (MDGs), with the three main diseases covered by MDG 6 having received significant financial and technical support, will a sustained development of health be attainable with new and broader global development goals when the pre-existing constraints have not changed significantly?
The role of the workforce in achieving universal health care
The workforce is going to be of primary importance for moving towards UHC. This goal will require a certain configuration of each health system and its workforce. In my view, countries must re-emphasize a focus on districts and community-level health needs, including a realignment and coordination of resources to these levels. This focus must not stop at the local level but will require effective networking of referrals and backstopping at provincial and national levels in order to build the resilience required to avoid a repetition of the collapse of health systems that happened when Ebola struck. Even the most basic of services ‒ such as immunizations ‒ were interrupted for unacceptable periods, thereby deepening existing health challenges in those three countries. A critical component of resilience will be the additional development of a complementary workforce, responsible for management, logistics and supplies, communications and other major areas whose weaknesses undermine sustainable health development. This is essential to build the confidence of both communities and the population as a whole and create an atmosphere that helps to align and integrate donor and partner support and investment into health systems, particularly the workforce.
Preparing the health workforce of the future in Africa will require thinking through the contextual issues affecting the continent including the double disease burden of Communicable and Non-Communicable diseases; anticipated population increases and major urbanization of populations; and understanding the roles that new mobile and telemedicine technology and innovations can play in developing, deploying, utilizing and retaining health workers. The implications are that we should prepare for changes and innovation in the skill types and mixes, as well as the scopes of practice that were often limited to only certain professions. The supply of new graduates must outstrip population growth and demand for healthcare, which will mean the containment of brain drain. What must governments and their ministries of health do in order to improve their health workforce situation?
Firstly, they must increase enrolment in existing schools, invest in building new schools, and expand the number and types of participants including the private sector in health workforce training. Secondly, it is important to prioritize needs and plan for the immediate and intermediate types of skill mixes needed and work with development partners to determine the main investments with clear results and expected impact in mind. It is going to be important to design and establish a community workforce suited to each context and its resources, as part of broader workforce and services development.
Development partners and organizations can support these efforts through supporting a regional mapping of health workforce training resources capacity, thus helping to mobilize these schools for training staff for all countries with limited facilities. Countries will require substantial investment in mobilizing and sharing of extra or unemployed health workers from other parts of Africa to places with the most severe limitations.
The successful deployment of foreign medical teams into the Ebola-affected countries has created an experience that we can build on, enabling us to focus on the service areas and practice scopes that are most needed to encourage the use of such teams to quickly develop and train local cadres.
Having the right technical support will be crucial in assisting countries to work with the appropriate tools to estimate their needs and design plans for investment in health workforce development. There will be a continuous need for research and innovation on new ways and approaches to developing and utilizing a health workforce. Ministries of Health must begin to think outside the box as regards how best to secure access and quality within a context of limited resources and financial incentives.
The Global Health Initiatives such as GAVI and GFATM must help ensure a more harmonized and non-verticalized input into building health systems and human resources. They must build the capacity to make sure that core needs, such as basic logistics and protection equipment, essential medicines and training, are available. Both development and financing partners and Ministries of Health must create a long-term vision on health systems development in order to secure the gains from the MDGs and build towards the new development goals.
A vastly expanded health workforce is going to be needed in Africa, but how do we get there? Ministries of Health and all concerned partners must take on board the lessons learned from the Ebola outbreak in terms of health systems and health security and establish the correct policies and commitments. Some large investments will have to be made in health systems and the health workforce in our countries; ensuring that these investments avoid duplications and are coordinated towards achieving the best possible results is of the utmost importance.
The Africa Region of WHO has previously engaged with its member states to agree upon a regional strategy with a roadmap formally endorsed by member states6 (in 2012) to guide the countries’ progress in this regard. The roadmap envisages six core components towards evolving an effective workforce.
- Scaling up education and training of health professionals including Community Health Workers (CHWs);
- Strengthening the leadership and governance capacity of the health workforce;
- Optimizing the distribution, retention and performance of the existing health workforce;
- Improving the health workforce information and evidence;
- Strengthening the Human Resources for Health (HRH) regulatory capacity
- Strengthening partnership and dialogue.
Africa needs to invest in strengthening health governance and management capacity at all levels. Some weaknesses in this area have undermined the ability of health systems in Africa to respond effectively to their populations’ needs. The WHO is currently in the process of consultations towards developing a new Global Strategy on Human Resources for Health. The Africa Region has been part of these consultations and the hope is that countries in the region will be able to rejuvenate their health workforces. Without a credible workforce, there will be no universal health coverage.