The Healthcare Worker Shortage

Topic Overview

The lack of adequate skilled birth attendants—doctors, midwives, or nurses with midwifery skills—contributes to two million maternal, stillbirth, and newborn deaths each year.i In Africa and Asia, fewer than half of women giving birth have a skilled attendant present, and the number is significantly lower in rural areas and poorer countries.

The World Health Organization estimates that 80% of all births need to be attended by an adequately equipped skilled birth attendant in order to reach Millennium Development Goal (MDG) 5’s target of reducing the maternal mortality rate by three-quarters from the 1990 level by 2015.ii Yet, worldwide, 57 countries face critical healthcare worker shortages, defined by the World Health Organization as countries that do not have the minimum number of health care workers necessary to meet the health related MDGs.iii In sub-Saharan Africa, there are fewer than five doctors per 100,000 people, far below the recommended 20 physicians per 100,000 people.iv Ultimately, these countries need to train and retain healthcare workers at a variety of levels to provide the basic care so desperately needed; in the meantime, communities are also finding creative solutions to ensure that providers at all levels are being utilized to their maximum capacity.

Background Information

Contributing Factors in the Healthcare Worker Shortage It may come as no surprise that poorer countries are served by fewer healthcare professionals. However, there are several additional factors that determine the density of healthcare workers for a given population:

Distribution of Healthcare Workers: All over the world, healthcare worker density is generally highest in urban centers with hospitals and higher income populations. In aggregate, 75% of the world’s doctors and 60% of nurses work in urban areas,v while about half the population lives in rural areas. These statistics are even more stark in developing countries. In Bangladesh over 35% of the doctors and 30% of the nurses are located in urban areas, home to only 15% of the population.vi

Healthcare workers in rural areas struggle with inadequate pay, overwhelming responsibilities, a shortage of medical supplies and equipment, fewer educational opportunities, and chronic understaffing. These poor working and living conditions in marginalized areas make it difficult to attract and retain capable healthcare workers. In Tanzania, for example, fewer than half of the enrolled medical students were willing to take rural postings, even though many had grown up in rural areas.vii A survey in South and South-East Asia found that qualified healthcare

workers avoided postings in rural areas because of lower salaries, lower prestige, and social and professional isolation.viii

Brain Drain: Another issue that contributes to the healthcare worker shortage is that talented professionals often leave their home countries in order to practice in more lucrative areas overseas. “Brain drain,” the migration of skilled healthcare workers to developed countries with better paying jobs and better standards of living, adds to the shortage in developing countries. Africa loses 20,000 skilled healthcare providers per year, with more than 60% of doctors migrating to developed countries such as Great Britain and the United States.ix The outmigration of nurses is also high: for example, 34% of nurses and midwives trained in Zimbabwe are now working abroad.x

Lack of Medical Schools: Most African countries have only one medical school for the entire country; in some countries there are no medical schools at all. Medical schools and training often focus on advanced treatments and not on primary care, prevention, rural healthcare, and basic treatment for common medical issues.

Lack of Medical Supplies: Chronic shortages of critical medications and basic supplies such as hand soap, latex gloves, facemasks, and disinfectant plague many health systems. There are also frequent power outages and interruptions in the supply of clean running water (if there is any to begin with). Such conditions make it difficult for healthcare professionals to provide care as they were trained to do. Coupled with the frustration of delivering sub-standard care, these conditions are the reasons most frequently cited by doctors and nurses for leaving rural postings for urban areas or developed countries.xi

Strategic Approaches

Countries have traditionally expected doctors and midwives to provide the full range of comprehensive emergency obstetric care services. The shortage of skilled health professionals in sub-Saharan Africa should prompt countries to explore increasing numbers of training institutions or class sizes at existing institutions. However, to do this will require a significant investment of both time and money. Many countries are looking to immediately available cadres of workers such as non-physician clinicians (NPCs) also known as mid-level providers (MLPs) to undergo shorter-term training and provide services that have formerly only been provided by physicians.

Task Shifting and Training What is task shifting? Task shifting is a process of delegation that allows lower-level healthcare providers to perform some of the tasks normally reserved for higher-level providers.xii This generally entails shifting tasks from doctors to health clinicians (MLPs), from health clinicians to registered nurses (RNs) or midwives, from RNs and midwives to community health workers, or from community health workers to expert patients (patients that are living with a chronic

disease or condition and are trained to provide support and education to others in their community.)

MLPs are trained to take on the tasks that are traditionally preformed by doctors. They receive two-to-three years of specialized training (most already have bachelor’s degrees and some graduate/master’s level education) in a particular skill area, such as anesthesia, emergency obstetric care, etc. MLPs work autonomously and are able to diagnose, treat illness, and perform designated procedures and surgeries.

Twenty-five of the 47 sub-Saharan African countries have initiated programs to train MLPs in basic emergency obstetric care (which includes administering medications, manual removal of the placenta and retained products, assisted vaginal delivery and neonatal resuscitation, but does not include surgery or blood transfusion). In a few countries, including Tanzania, medical officers, midwives, and other MLPs have also been trained to perform cesarean sections and other emergency obstetric surgeries with excellent results. A recent study of two regions of Tanzania showed that during a one-year period, 84% of cesarean sections and emergency obstetric surgeries performed in district hospitals were done by MLPs.xiii There was no difference in patient outcomes when compared to treatment by doctors. Studies in other countries using MLPs have shown the same result.xiv

This success extends to other areas of reproductive health as well. Studies have consistently shown that appropriately trained MLPs provide comparable abortion, post-abortion care and family planning care, among other health services, to that of physicians. In the last decade, competency-based training of community health workers has led to the safe provision of injectable contraceptives by this cadre of workers in more than a dozen countries, including Afghanistan, Bangladesh, Bolivia, Guatemala, Ethiopia, Haiti, Madagascar, Malawi, Nepal and Uganda.xv xvi

In areas with low contraceptive prevalence, high unmet need, poor access to methods and limited access to clinic-based services, community health worker provision of contraceptives, including injectables, can expand choice and increase uptake of family planning services in the most needy areas. Workers who are selected from an underserved community and trained to provide certain services, as has been done in Ethiopia’s Health Extension Worker program, are less likely to leave that community for other areas. Ethiopia’s 30,000 workers, mostly younger females, were originally intended to bring basic primary care and family planning services to rural villages, and are now receiving training in additional services in order to better serve their communities.

Female Healthcare Workers Female healthcare workers have an especially important role in the healthcare work force. Social or cultural barriers often prevent women from visiting male healthcare providers even when they know that they or their children are ill and need help. Especially in rural areas, husbands and elder family members often decide whether a woman may go for healthcare

outside the home, and may deny permission if the healthcare worker is a man. There is some evidence that female healthcare workers are also more likely to stay in rural areas, especially if they are connected to the area through family and social networks and do not feel isolated.

One example where female health workers have made a tremendous difference is the Lady Health Workers program in Pakistan and Afghanistan which combines task shifting with recognition of the cultural barriers facing women seeking healthcare. The prospective Lady Health Workers train for three months to learn how to provide basic health services, such as family planning, immunization, hygiene, and pre- and post-natal care. They then spend one year gaining further experience in the community and then return to provide care to their home areas.xvii While they are not able to perform deliveries, they are instrumental in ensuring that women receive prenatal care and in linking women with local health centers and, if necessary, emergency obstetric care.

Creating an Enabling Environment In order to be effective, health care workers, such as skilled birth attendants, need to work within an enabling environment, sometimes described as a well functioning health system. For the health system to function effectively, regulatory frameworks, standards and protocols for high-quality care, adequate human resource and management systems, essential drugs, supplies and equipment, a working transportation and referral system, and functioning mechanisms for quality improvement must be in place. Development of such an environment for health care workers is key to their retention and functioning.xviii

Preventing Worker Migration Training of local workers, in local languages and in skills relevant to local conditions can limit migration of these workers to other areas. Success is dependent on providing on-the-job incentives and support, and benefits from involvement of key institutions such as universities and professional associations. Other benefits, such as good pay, quality management, improved living conditions and potential for career development, are important in retaining workers.

In order to provide a global response to health workforce migration concerns, the WHO has developed a code of practice on the international recruitment of health personnelxix. The code aims to establish and promote voluntary principles and practices for the ethical international recruitment of health personnel and to facilitate the strengthening of health systems. Among the recommendations made in this code are those for ethical recruitment of health personnel, which specifically discourages active international recruitment from developing countries facing critical shortages. Destination countries are encouraged to collaborate with source countries so that both can derive benefits from international migration. All countries, as well as international organizations, donor agencies and development institutions are encouraged to provide support and assistance to developing countries to develop and maintain their health workforce.

Migration is not necessarily all bad, it can offer new professional opportunities for health personnel. Personnel who return to their home country bring the skills and experience they acquired while abroad. Countries may consider offering incentives, such as preferential rates for loans or subsidized scholarships, to encourage workers who have migrated to return to their home country. This model has been successful in the Philippines, which has been training nurses for export for many years-they constitute 76% of foreign nurse graduates in the US. Filipino health workers receive numerous social benefits if they return to the Philippines; while working abroad they often continue to contribute to the local economy by remitting significant amounts of money to their families in their home country.xx

The video module includes: ■ Interview and footage of Godfrey Mbaruku, MD, Deputy Director, Ifakara Health Institute,

Tanzania ■ Interview with Andrew Kilonzo, MD, Head of the Department of Obstetrics, Bugando

Medical Center, Tanzania ■ Interview with Lucy Mbwana, Midwife, Jhpiego, Tanzania ■ Interview with Abella Byenobi Kassori, Assistant Medical Officer, Tanzania ■ Interview with Linda Valencia, MD, Program Officer, Planned Parenthood Federation of

America, Guatemala ■ Interview with Rounaq Jahan, PhD, Senior Research Scholar and Professor, Columbia

University, United States

Discussion Guide

Opening Questions

■ What is your initial reaction to the video? ■ If you could talk to anyone in the video, who would it be? What questions would you

ask? ■ What is your impression of the health centers and hospitals in the videos? How do they

compare to those in the developed world?

Human Resource Questions ■ Keeping skilled staff in rural areas is a problem worldwide. What are some incentives

that may keep workers in rural areas? ■ What are some of the frustrations that the healthcare workers face? Can you think of

ways to address these issues?

Social Questions ■ Can you imagine seeking care in any of these clinics? What do you think the

experience would be like for you? ■ How do you think women in the developed world would feel about being treated by a

Mid-Level Provider? How would you feel?

■ What can countries do to retain critical healthcare workers?

Activities

1) Millennium Development Goals & the Human Resource Shortage In 2000, the United Nations developed eight measurable goals to address poverty in the world; all 192 UN member states, including the United States, committed to reaching these by 2015. Goal 5 is to improve maternal health.

Break the class into groups. Ask each group to find connections between at least three of the other Millennium Development Goals and the Human Resource shortage. How can task shifting affect these goals? Have the groups brainstorm possible actions that would address the Millennium Development Goals and help address the human resource shortage.

■ Goal 1: Eradicate extreme poverty and hunger ■ Goal 2: Achieve universal primary education ■ Goal 3: Promote gender equality and empower women ■ Goal 4: Reduce child mortality ■ Goal 5: Improve maternal health

o Target 5a: Reduce by three quarters the maternal mortality ratio o Target 5b: Achieve, by 2015, universal access to reproductive health

■ Goal 6: Combat HIV/AIDS, malaria and other diseases ■ Goal 7: Ensure environmental sustainability ■ Goal 8: Develop a global partnership for development

2) Brain Drain and the Human Resource Shortage:

Break the students into teams and have them interview nurses (at local hospitals or health clinics). If possible identify potential interview subjects in advance.

■ How many moved here from another country? ■ Discuss the factors that led to that decision. What, if anything, would encourage

them to return home?

3) Task Shifting and the Human Resource Shortage.

Break the class into small groups. Have the groups think through the various types of activities that need to be carried out by a functioning Maternal Newborn Child Health provider. Which tasks can be performed by a less trained individual? What are the indirect benefits of creating such opportunities at lower levels?

iUNICEF & World Health Organization. Countdown to 2015: Tracking progress in maternal, newborn and child survival: the 2010 report. 2010. http://www.countdown2015mnch.org/documents/2010report/CountdownReportAndProfiles.pdf Last Accessed 1/24/2011 ii Ibid. iii World Health Organization, The World Health Report 2006: Working Together for Health. 2006, WHO: Geneva. http://www.who.int/whr/2006/whr06_en.pdf Last Accessed 1/24/2011 ivGlobal Health Council. Health Care Worker Fact Sheet. 2011. http://www.globalhealth.org/health_systems/health_care_workers/ Last Accessed 1/24/2011 v WHO. 2006. The Global Shortage of Health Care Workers and its impact. Fact Sheet no. 302. vi Dusslat G, et al. Not Enough there, too many here: understanding the geographical imbalances in the distribution of the health workforce. Human Resource Health. 2006 (4:12) vii Yumkella F, Swai A. Worker retention in the Tanzanian health sector. Capacity Project, 2007 viii Dusslat G, et al. Not Enough there, too many here: understanding the geographical imbalances in the distribution of the health workforce. Human Resource Health. 2006 (4:12) http://info.worldbank.org/etools/docs/library/206832/Dussault%20Franceschini.pdf Last Accessed 1/24/2011 ix BBC News. Africa Being Drained of Doctors. 1/10/2008. http://news.bbc.co.uk/2/hi/health/7178978.stm x Haour-Knipe H. Davies A. Return Migration of Nurses. International Center on Nurse Migration. 2008. http://www.intlnursemigration.org/assets/pdfs/return%20migration%20ltr.pdf Last Accessed 1/24/2011 xi World Health Organizaton. World Health Report 2006: Working Together for Health. 2006. xii World Health Organization. Task shifting to tackle health worker shortages. 2007. http://www.who.int/healthsystems/task_shifting_booklet.pdf Last Accessed 1/24/2011 xiii McCord C. Mbaruku G, Pereira C, Nzabuhakwa C, Bergstrom S. The quality of emergency obstetrical surgery by assistant medical officers in Tanzanian district hospitals. Health Affairs 2009. 28(5): w876-85. xiv Pereira C, et al .A comparative study of caesarean deliveries by assistant medical officers and obstetricians in Mozambique.. British Journal of Obstetrics and Gynecology.1996;103(6):508-512 There is a list of articles that examine the use of MLPs at: http://www.midlevelproviders.org/resources.php xv World Health Organization, US Agency for International Development, Family Health International (FHI). Community-based health workers can safely and effectively administer injectable contraceptives: Conclusions from a technical consultation. Research Triangle Park (NC): FHI; 2009. xvi World Health Organization. Community-based providers in rural Guatemala can provide the injectable contraceptive DMPA safely. Geneva: WHO Press; 2009. xvii Garwood, P. Pakistan, Afghanistan look to women to improve health care. Bulletin of the World Health Organization. November 2006 (84:11) xviii World Health Organization. Making pregnancy safer: The critical role of the skilled birth attendant. Geneva: WHO Press, 2004. xix World health Organization. User’s guide to the WHO global code of practice on the international recruitment of health personnel. Geneva: WHO Press, 2010. xx World Health Report 2006: Working together for Health. Geneva: WHO Press, 2006.