Adam Briggs, final year medical student, University of Oxford.

Human resources for health are in crisis. The migration, or brain drain, of healthcare professionals from developing to developed countries is legitimised by the World Trade Organisation’s General Agreement in Trade Services and fuelled by significant push and pull factors. Push factors such as inadequate salaries, poor working conditions, and conflict all affect an employee’s decision when promised better training, higher socio-economic status, and political stability in another country.¹ Internal migration of doctors and nurses to urban areas and the private sector also has devastating effects on many poor and rural populations. Box 1 helps to put the current situation into context.

• 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.²
• Between 1998 and 2002, Ghana lost roughly £35 million of its training investment in health professionals and the UK saved £65 million by recruiting them.³
• About 20% of African-born physicians are working overseas in developed countries.⁴
• Conflict only exacerbates problems with human resources for health: in Liberia, 14 years of war have reduced the numbers of practicing doctors from 237 to less than 20.⁵

Box 1. Some of the problems in human resources for health

March 2008, saw the first Global Forum on Human Resources convened by the Global Health Workforce Alliance (GHWA) in Kampala, Uganda. The Global Forum launched the Agenda for Global Action: a plan to address human resources for health problems over the coming decade, set targets, and monitor progress and accountability. GHWA was formed in May 2006, and through many programmes and publications, such as the Human Resources for Health Action Framework, it is helping countries with their health-workforce problems.^6-8

The UK based charity, Merlin (medical relief, lasting health care), ‘responds worldwide with vital health care and medical relief for vulnerable people caught up in natural disasters, conflict, disease and health system collapse.’⁹ It is an example of a non-governmental organisation (NGO) that can help to fulfil GHWA’s Agenda for Global Action. Established in 1993, Merlin has organised missions to countries as diverse as Afghanistan, Rwanda, and Honduras. Merlin’s experience in helping restructure a health workforce in countries with significant endemic problems, known as fragile states, has shown that an appropriate living wage, workforce restructuring measures, and a meritocratic promotion system are crucial issues. Their Director of Health and Policy, Linda Doull, wrote a comment in Lancet about human resources for health in fragile states.¹⁰ In the article she stressed the need for a strategic approach to tackle human resources for health crises which encompass both short-term and long-term solutions. I spoke with her to find out more about Merlin and how they’re working to reduce inequality of human resources for health in such difficult environments.

Merlin’s mandate is to work in areas requiring acute relief, and to work with the country through to recovery; they recognise that solving health problems is a long-term issue. Merlin does this through working at the level of both the community and the government to rebuild the health system.

I asked Linda what her view was on the GHWA and whether it will be effective in solving the human resources for health crisis. She believes that putting human resources for health at the top of the global health agenda is a very positive step, which will hopefully act as a catalyst for coordinated action. She compared the GHWA to the millennium development goals - often touted as unachievable but acting as a focus for political initiative.

Linda explained that there are several stakeholders that need to act to solve the human resources crisis. Ultimately, it can be argued that the responsibility rests with the government; however, does that government have sufficient investment? Governments in fragile states are often unwilling or unable to provide basic services. “Take Liberia as an example: Merlin’s budget (in Liberia) is as big as the health budget for the ministry in Liberia. Why are those distortions there? Maybe international donors aren’t willing to invest. Maybe the ministry has money, but has chosen to invest elsewhere.” She argued that perhaps NGO funding needs to be done differently. For example, perhaps Merlin needs to engage more at a national level offering technical assistance to develop curricula. “There is no one single factor, there is a mix. (We must) recognise that that (mix) has to come together and has to come together earlier. Hopefully that’s what the global alliance will help to facilitate.”

It has been suggested that the recruitment policy of some NGOs perpetuates the drain of health care professionals away from areas of need in their local health service. Merlin protects against this by advertising vacancies and vetting those who apply rather than actively recruiting staff. If, for example, a senior health minister applied for a post then they would only consider offering the job if the ministry agreed to release the minister, rather than give that person the opportunity to leave crucial local employment. Merlin prefers to work within the existing health system, with the local health care professionals. Where there are gaps in the clinics Merlin works with the relevant country’s health ministry to identify and transfer a staff member to that hospital rather than recruit staff members themselves. However, limited resources mean that staff transfer is often not easy and staff may not want to move. As an interim solution, Merlin will often employ an international health worker.

So what can we, as students, do to help? Organisations such as Merlin need volunteers who are highly skilled at both a technical level and a managerial level; senior registrars and consultants are ideal. However, as students we can still have a role. We need to recognise global health needs and be advocates through organisations such as Medsin in order to keep the issue of human resources for health on the global political agenda. As Linda says “(Medical professionals in the developed world) are very, very lucky and every health worker should be allowed to have a level of investment that makes them a competent safe practitioner, so if nothing else remember that.”

Solving human resources for health problems is a difficult balancing act. NGOs want to employ local health care workers, but do not want to relocate them from areas of health need; overseas doctors rarely provide a permanent solution. Although acute care is essential in many situations, for lasting solutions I believe that change needs to take place at an administrative level and until this happens, the problems highlighted in box 1 will continue. Local doctors should not be blamed for wanting to leave war-torn and impoverished countries but as a medical community, from students to consultants, we should be pressurising governments through NGOs and our nominated unions for better working conditions for our international colleagues.

References

1. World Health Organisation. World health report 2006: working together for health. Geneva: World Health Organisation; 2006.
2. Robinson M, Clark P. Forging solutions to health worker migration. Lancet 2008;371:691-93
3. Martineau T, Decker K, Bundred P. “Brain drain” of health professionals: from rhetoric to responsible action. Health policy 2004;70:1-10
4. Clemens MA, Pettersson G. New data on African health professionals abroad. Human Resources for Health 2008;6:1
5. Interagency Health Evaluation, Liberia, 2005: final report. http://www.unhcr.org/research/RESEARCH/456ac0682.pdf (last accessed 12/03/08)
6. The Global Health Workforce Alliance. Strategic plan. 2006. http://www.who.int/workforcealliance/GHWA_STRATEGIC%20PLAN_ENGLISH_WEB.pdf (last accessed 12/03/08)
7. The Global Health Workforce Alliance. Working groups and task forces. http://www.who.int/workforcealliance/workingroups/en/index.html (last accessed 12/03/08)
8. HRH Action Framework. http://www.capacityproject.org/framework/ (last accessed 12/03/08)
9. Merlin. Medical relief, lasting health care. http://www.merlin.org.uk/ (last accessed 12/03/08)
10. Doull L, Campbell F. Human resources for health in fragile states. Lancet. 2008;371:626-27.

 Suvash Shrestha discusses how the causal relationship between poor health and poverty runs in both directions

About 1 billion people globally live in extreme poverty on an income of less than $1 a day, of whom 70 million live in Asia and the Pacific (1). These regions are also struggling hard to provide health facilities and services and there are high rates of mortality from conditions which could easily be prevented or treated. It is not hard to see the strong correlation between economic and health status. And since poverty breeds poor health which keeps people poor, it is a very serious and emergency condition that should receive global attention.

Both at the individual and national levels, poverty is no doubt the biggest hurdle we have to overcome to achieve satisfactory health status. There are stark disparities in health expenditure between rich and poor countries. In Nepal, the per capita total expenditure on health in 2004 was less than 0.2 % of per capita expenditure in the USA (2). 

 At the individual level

At the individual level poor people have a difficult time living hand to mouth. They have to work in adverse conditions like brick kilns and factories without any protective measures, exposing them to occupational health hazards. To add more insult, poor people can rarely afford adequate nutrition leading to undernourishment which increases their vulnerability to disease. Owing to poverty, people can not afford to maintain proper sanitation and hygiene which again predispose them to various diseases.

In addition, limited access to education leaves the poor completely oblivious of the disease conditions, their prevention and treatment. They still live with many superstitions and myths which may result in harmful health practices. Many cannot afford the luxury of TV and radios, and in Nepal where the adult literacy rate is only 48.6% (2), most poor people cannot read newspapers and magazines. This restricts access to information about health which is disseminated via the media.

Due to extreme work pressure and the need to earn few more rupees to support their family, poor people rarely have time to attend health promotion programs in their community such as training on sanitation, proper nutrition, family planning, vaccination and free health camps. Annually, the government of Nepal has been running free programs like pulse polio immunization program and vitamin A capsule distribution. But the poor, having to work from dawn to dusk, don’t get time to get their children vaccinated. So, from every way, they miss the health information and they have no idea what facilities are available for them even if there are any.

What is more, even when they fall sick, the poor have many barriers to accessing health care. The biggest of all is the financial one. The treatment services are often too expensive for them, and at centers where services are free, limited funding can mean that the range of services offered is very low. In some areas, there are fee waiver and exemption schemes to help the poor but in practice these have been found to benefit better off groups rather than the most needy. Because health services are centered in the urban areas, they have to travel a long distance to access health services, and even the cost of transport can form a major barrier.. The time spent seeking medical care also means a loss of income,a further deterrent from doing so. Thus, service availability, accessibility, prices and quality greatly affect health outcomes for the poor.

An associated problem is that the poor may not care for minor ailments. Due to a lack of knowledge and poor access to health services, they may not to get a check up until the symptoms become severe, usually at advanced stages of disease.. This makes treatment difficult, more costly and longer. Low incomes are also associated with reduced compliance with treatment regimes, since patients who have begun to recover may chose to spend money on other family needs rather than on costly medicines. thus never receiving complete treatment. This is especially true for diseases like tuberculosis. Here the problem was so grave that even when the Nepalese government provided anti-tubercular drugs for free, the poor would collect the drugs from the hospital and sell them to local pharmacists at a lower price to earn some money for their family. Thanks to the Directly Observed Treatment Short courses (DOTS), compliance with treatment has improved, but the constraints of poverty have not changed.

At the national level

At the national level, government has not been able to assure health facilities to all. If we look at the national budget distribution in Nepal, the health sector received only 9.23% of total allocations this year, as little as US $191 milion. (3) The figure clearly depicts how serious the condition is.

In poor countries, the number as well as the quality of health centers is unsatisfactory. Nepal has only 0.21 doctors per 1000 people and only 2 hospital beds per 10,000 people compared to 2.56 doctors per 1000 people and 33 beds per 10,000 people in the USA (2). Even these figures do not capture the gravity of the situation in the rural areas, since most hospitals and health services are centered in the urban centres. In remote areas, where most of the neediest live, there are only some health posts and sub-health posts which are also not sufficient and are barely equipped.

Even the so-called big centres are very ill-equipped without even an X-ray and or a US machine, let along CT and MRI scanners. In places where this equipment is available; it often remains out of working order due to poor maintenance, or unused due to a lack of trained staff. Staffing is another big problem; in Nepal, only 20% of rural physician posts are filled in comparison with 96% in urban areas (1). This is most likely because the government has failed to provide adequate salaries and other facilities. This is also the reason why most health professionals are flying away to the developed countries in search of better incomes and a better quality of life.

On account of poverty, government has failed to promote any research in the field of health. New discoveries are far-fetched things, and even the basic study of health status and disease prevalence are lagging due to very little funding. There are no proper training programs for health workers. Government has not been able to launch regular health campaigns and screening programs, and those which have been initiated are yet to reach all corners of the country. Even the donor agencies struggle to reach the needy ones due to poor transportation facilities.

The search for solutions

The definite solution lies in finding new resources and using the available ones to the maximum. Realizing that resources are always limited, we should be able to make the most out of them. The first step should be to prioritize our needs. For this proper studies should be done at the grassroots level to ensure that plans formulated are appropriate for national social, cultural and economic status.

Resources should be reallocated in favor of poorer geographic areas, and to the lower tiers of service delivery. Investments should be focused in health conditions that disproportionately affect the poor like TB, malaria, HIV, infant and child mortality, maternal ill health and malnutrition.

Curative treatment is expensive, so we should focus on the preventive aspects. We can educate village health workers about proper hygiene and sanitary practices, nutrition, the importance of vaccination, family planning and other relevant topics. Since they are from the community itself, they could deliver this information directly to our target groups and could thus be very effective.

Large health centers are too expensive to establish and maintain, as they require more manpower, resources and equipment. Instead we could run community based small health centers which would be cost-effective and easier to set up in remote areas. Regular mobile health camps could also be a very effective solution.

Since many developed countries are willing to help, the government should welcome them and provide a politically stable environment in which to work.

Conclusion

The causal relationship between poverty and health runs in both directions; poverty breeds ill health and ill health keeps people poor. It is therefore vital to break this vicious cycle for a healthy population and a prosperous nation. After all, a healthy population is more economically productive than one that is not, allowing goals in other sectors to be achieved faster.

Suvash Shrestha
Kathmandu Medical College
Kathmandu
Nepal
suvashsht@gmail.com

(1) WHO, Fact sheets, Health, poverty and MDG, accessed October 25 2007, http://www.wpro.who.int/media_centre/fact_sheets/fs_20050621.html

(2) WHO, Core health indicators; accessed October 25, 2007, http://www.who.int/whosis/database/core/core_select_process.cf

(3) National Budget, accessed October 25 2007, available from http://www.mof.gov.np/publication/speech/2007/pdf/BudgetSpeech_english.pdf