The Lancet Digest Feb 23-28
Special issue on human resources for health
This week’s edition of The Lancet is a Special Issue on Human Resources for Health, focussing on the shortage of health workers globally and in particular in sub-Saharan Africa. The shortage of health workers has been identified as one of the most critical constraints to the achievement of most international health and development goals. WHO estimates a shortage of more than 4 million health workers globally. The first ever Global Forum on Human Resources for Health will take place 2-7 March 2008 in Kampala, Uganda. The Global forum hosted by the Uganda Government and organized by the Global Health Workforce Alliance will bring together some 1000 participants including senior government leaders, leading health, development, civil society, academic and professional experts from the around the world. Issues the forum will discuss include the acute global shortage and migration of healthcare professionals, unfavourable and challenging working conditions facing health workers and inequalities in access to basic health needs. A Global Agenda for Action on Human Resources for Health will be presented on 5 March at the forum.
Countries can no longer be allowed to exploit and plunder health resources from poorer countries
The Lancet’s lead Editorial in this week’s Human Resources for Health Special Issue focuses on the crisis faced by sub-Saharan Africa, and says that “richer countries can no longer be allowed to exploit and plunder the future of resource poor nations.” The Special Issue coincides with the first-ever Global Forum on Human Resources for Health convened by the Global Health Workforce Alliance (GHWA), in Kampala, Uganda. The Editorial says: “This Forum will launch the Global Action Plan for Human Resources for Health, which will guide action over the coming decade and serve as a much needed tool to measure progress and monitor accountability. This action plan is an opportunity to make a real and lasting impact on the human resources crisis. There is a great deal at stake. Africa carries 25% of the world’s disease burden yet has only 3% of the world’s health workers and 1% of the world’s economic resources.” The Editorial looks the complexity of this huge challenge-workers being attracted both to the private sector within their own countries and to high-income countries around the world; and inadequate salaries, training, equipment and medicines. It says: “The scale and complexity of this crisis demands both top-down and bottom-up approaches. There is no one-size-fits-all solution.” But it adds: “There is cause for cautious optimism. GWHA’s Task Force for Scaling up Education and Training for Health Workers and its Health Financing Task Force are currently testing several local solutions. Task shifting-delegation of tasks to lower cadres of health workers- is also being touted as a possible way forward, and public-private partnerships, such as the skilled birth-attendance scheme in Gujarat, India, are having some success. But there remains a pressing need to consider other options.” The Editorial highlights that while more evidence is vital to guide policy makers, “The human resources crisis is a highly political topic and possible solutions that do not have full political support are doomed to failure.” It concludes: “The Kampala delegates need to be ambitious. If there is any hope of strengthening the workforce capacity in poor countries every possible local and international solution should be seriously considered, no matter how aspirational. Demanding that rich countries stop actively recruiting from poorer nations remains a viable option. The human resources crisis may be undoubtedly complex but this still does not obscure right from wrong. Richer countries can no longer be allowed to exploit and plunder the future of resource poor nations.”
Recruitment of health workers from sub-saharan africa should be viewed as a crime
Active recruitment of health workers from African countries is a systematic and widespread problem throughout Africa and a cause of social alarm; the practice should, therefore, be viewed as an international crime. These are the conclusions of authors of a Viewpoint in this week’s Human Resources for Health Special Edition of The Lancet. Dr Edward Mills, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada, and colleagues, say that high-income countries, such as UK, USA, Australia, Canada, Saudi Arabia, and the United Arab Emirates have sustained their relatively high physician-to-population ratio (PPR) by recruiting medical graduates from developing regions, including countries in sub-Saharan Africa. Meanwhile, over half of these sub-Saharan African countries do not meet the minimum acceptable PPR of one per 5000-WHO’s Health for All Standard. The authors say: “Nurses, pharmacists, and other health workers are systematically recruited from a region struggling with the greatest burden of infectious and chronic illness and the specific challenge of HIV/AIDS.” While the UK, for example, has 2·30 doctors per 1000 population, and the USA 2·56, Tanzania has just 0·02 and Ethiopia and Madagascar 0·03.*Recent reviews of health workers employed in the UK, USA, Canada, and Australia have shown the extent of this “brain drain”-estimating that more than 13 000 doctors trained in sub-Saharan Africa are now practising in these high-income countries. Despite pleas to discontinue active recruitment from local and international ministries of health, western recruitment agencies continue with this practice-including advertising in newspapers, emails, websites, recruitment workshops and other practices. O’Grady Peyton International (USA, UK) and Allied Health (Australia) are named in the Viewpoint as examples of such agencies with offices based in South Africa. The numbers of nurses and pharmacists migrating from many of these countries in sub-Saharan Africa now exceed the numbers graduating in these disciplines in those countries.The authors say: “Although the active recruitment of health workers from developing countries may lack the heinous intent of other crimes covered under international law, the resulting dilapidation of health infrastructure contributes to a measurable and foreseeable public health crisis…There is no doubt that this situation is a very important violation of the human rights of people of Africa.”The Viewpoint refers to many statements and declarations from state bodies that active health-worker recruitment is wrong, eg, The UK National Health Service’s (NHS) code on ethical recruitment-and say that recipient countries should receive new health workers only when there is compensation to the delivering state to contribute to health structure. A 2004 report estimated that Ghana has lost around £35 million of its training investment in health professionals to the UK-and the UK, by recruiting these Ghanaian doctors-saved around £65 million in training costs between 1998 and 2002. The authors conclude: “Active recruitment of health workers from African countries is a systematic and widespread problem throughout Africa and a cause of social alarm: the practice should, therefore, be viewed as an international crime.”
Shifting of antiretroviral treatment delivery is not a cure-all solution
Task shifting of HIV antiretroviral treatment (ART) delivery in sub-Saharan Africa-ie, delegation of parts of that strategy to nurses or lay workers-is welcome, but cannot be considered in isolation. In must be used in conjunction with other measures to expand the health workforce to make further ART roll out possible. These are the conclusions of authors of a Viewpoint in this week’s Human Resources for Health Special Issue of The Lancet. Dr Mit Philips, Médecins Sans Frontières, Brussels, Belgium, and colleagues, say that task-shifting is a concept already familiar in many high-income countries, eg, nurse practitioners in the USA and nurse clinicians in Sweden; and the authors look at experience and prospects for delegation of ART care to so-called ‘lower cadre’ or ‘less-qualified’ workers in sub-Saharan Africa. The lack of qualified health workers in sub-Saharan Africa is recognised as a crisis in the international community, and the advent of HIV ART and the urgent need to get it to thousands of people in Africa has further exposed the existing gaps in health staff in public health care services.Within WHO’s Treat Train, Retain (TTR) initiative, task shifting is receiving increasing attention as a measure to allow ART roll-out in countries with shortages of human resources; this drive was further boosted by launch of WHO policy guidelines in January this year. Countries such as Uganda, Ethiopia and Malawi are considering using the strategy.
The authors say that if task-shifting is adopted it is important that quality of care is maintained, and that use of lower cadres and communities can increase coverage and improve overall outcomes. But supervision and support to these lower cadre workers is essential; moreover they must not have their roles complicated by too many different tasks and need adequate pay so they sustain their output for longer periods and without the need to make patients pay for their care. They stress that task shifting does not equal a need for fewer staff. It can help relieve dependence on specific qualified cadres (eg, medical doctors) to roll out ART. The authors say: “The strategy thus promotes a more strategic mix of skills. However, task shifting alone, will not fill the gaps in the many peripheral health facilities in sub-Saharan Africa that do not presently meet the minimum requirements of qualified staff.” The Viewpoint also highlights that some sub-Saharan African countries actually have qualified people in their workforces, but there are difficulties recruiting and retaining such staff due to limits on recruitment and salary in the public sector. The authors conclude: “Task shifting is a welcome strategy but cannot be considered in isolation: it needs to be part of an overall strategy in trying to address the human resources challenges facing countries with a high prevalence of HIV…Exceptional measures are needed to address the current human resource crisis and these go beyond task shifting alone.”
Sub-Saharan Africa needs to overcome financial constraints to optimise health worker mix
To optimise the distribution and mix of health workers, policy interventions to address their pay and incomes are needed. Fiscal constraints to increased salaries might need to be overcome in many countries, and non-financial incentives improved. These are the conclusions of authors of a Health Policy paper in this week’s Human Resources for Health Special Edition of The Lancet. Dr David McCoy, Centre for International Health and Development, University College London, UK, and Dr Sara Bennett, WHO, Switzerland, and colleagues described the historical trend in the pay of civil servants in Africa over the past 40 years. They found accurate and complete data scarce-but noted that between 1989 and 1996, real wages for civil servants (including health workers) fell in 26 of the 32 sub-Saharan African countries for which data are available.
Presently, pay structures vary between countries and are often complex. The authors say: “Health workers also commonly use other sources of income to supplement their formal pay. The pay and income of health workers varies widely, whether between countries, by comparison with cost of living, or between the public and private sectors.” Further, the authors notes that large differences in pay between different types of employers can result in an internal brain drain and mitigate against a more appropriate distribution of scarce staff according to need. They call for efforts to bring greater order to the labour market for health workers. Other issues the authors raised by the authors included irregular payment, with one Zambian survey reporting that 15% of staff had not always received their regular salary payment, with 80% reporting late payments, and 10% reporting they had to pay a so-called expediter’s fee to obtain their salaries. And length of service benefits also seemed to vary widely-in Burkina Faso, pay did not increase with length of service in the public sector; while Ghanaian salaries increased by a factor of 1·7 over the working life of a doctor, and by 3·7 for midwives. They discuss the dim prospect of government budgets in sub-Saharan Africa increasing due to economic growth, and say: “For these countries, an increase in public-sector employment and pay for health workers would require sustained external or donor financing.” In conclusion, they note that increased salaries and incomes for public sector health workers are not the only solution to the health workforce crisis in sub-Saharan Africa. They conclude: “Other solutions that need to be implemented concurrently include non-financial incentives to affect the motivation of health workers. Improving job satisfaction and career progression; enhancing working conditions and the quality of supervision; addressing on-the-job safety and security concerns; redressing the unavailability of good schools for children in rural areas; and improving the structure and management of the payroll could all contribute to retention, motivation, and payment of health workers within the public sector, especially in rural regions where staffing problems are most acute.” Further, they call on WHO, The International Labour Organisation (ILO), research funders, and research institutions to urgently generate the data necessary to facilitate more effective and informed policy making.
Countries need much more evidence to help shape their policies to transform human resources for health
There is not enough evidence upon which middle- and low-income countries can draw upon to guide their policies on human resources for health. This is the conclusion of authors of an Article in this week’s Human Resources for Health Special Issue of The Lancet. Policy makers face challenges to ensure an appropriate supply and distribution of trained health workers and to manage their performance in delivery of services, especially in low and middle income countries. Dr Mickey Chopra, Health Systems Research Unit, Medical Research Council, Western Cape, South Africa, and colleagues analysed published literature from 1979 onwards for evidence of policy options that could affect the training, distribution, regulation, financing, management, organisation, or performance of health workers. They also assessed whether the policy options were equitable in their effects; suitable for scaling up; and applicable to countries with low and middle incomes. They found that only 28 of 759 systematic reviews that considered the effects above were eligible for the study, and of these only a few included studies from low- and middle-income countries. Most of the material focussed on organisational mechanisms for human resources, substitution or task-shifting between health workers, education strategies, teamwork, and changes to workflow. Of all policy options, the use of lay health workers had the greatest proportion of reviews in countries with a range of incomes, from high to low. The authors conclude: “We have identified a need for more systematic reviews on the effects of policy options to improve human resources for health in countries with low and middle incomes, for assessments of any interventions that policy makers introduce to plan and manage human resources for health, and for other research to aid policy makers in these countries…moreover, policy makers must also contend with values and beliefs; stakeholder power; institutional constraints; flows of donor funding; and other types of information such as local assessments of need, costs, and the availability of resources.”
In an accompanying Comment, William Pick, Professor Emeritus University of the Witwatersrand, Johannesburg and honorary Professor Schools of Public Health, Universities of Cape Town and Western Cape, Cape Town, South Africa, says: “At a time when there is a resurgence of interest in this field, Chopra and colleagues’ overview serves as a timely reminder that much more information is needed if we are to persuade those responsible for health services, and especially human resources for health, to take decisions that will contribute to the solution of the global crisis in staffing health systems…I hope that their appeal will not fall on deaf ears.”
Bookmark on delicious | Digg