Dec 13, 2016 - served areas has shown promise in Democratic Republic of Congo (DRC) ... HIV/AIDS patients who received clinic-based antiretroviral therapy ...
EQUITABLE ACCESS TO A FUNCTIONAL HEALTH WORKFORCE
A Theme Paper for a Regional Forum on Strengthening Health Systems for the SDGs and UHC, 8-13 December 2016, Windhoek on the theme ‘Making Health Systems Work for Africa’
James Avoka Asamani [Consultant]
The Africa Regional Office, World Health Organisation (WHO/AFRO), Congo-Brazzaville
October 2016
Executive summary Many African countries made significant progress during the era of the Millennium Development Goals (MDGs). For instance, 43 countries in Africa recorded declines in child mortality during the 2000-2013 period compared to the period 1990-2000. Additionally, underfive mortality rate also declined by nearly 56% between 1990 and 2012 while that of infant mortality declined by 40% in the same period (1). Even though these improvements, did not meet the MDG targets, the modest achievements recorded in many African countries were not inclusive or universal, leaving large disparities within and across countries. The sustainability of the momentum of progress has also been brought to question owing to weak and fragile health systems, which were epitomised by the recent Ebola Viral Disease outbreak in West Africa. To address the gaps and unfinished agenda of the MDGs, the United Nations General Assembly (UNGASS) adopted an ambitious and bold global compact, the Sustainable Development Goals (SDGs) with Goal 3 aiming at healthy lives and the well-being of people at all ages, including Universal Health Coverage (UHC) (2). Achieving these targets requires responsive and resilient health systems underpinned by adequately available and equitably distributed health workforce. However, it has been estimated that Africa’s need-based health workforce shortage would reach 6.1 million (physicians, nurses and midwives) by 2030 (3) whilst 3.1 million would be available in the labour market during the same period. However, there are fears that against a backdrop of slow economic growth, African governments would be able to employ (based on ability to pay) only 2.4 million health workers by 2030 (4), leaving about 700,000 – 800,000 skilled health workers paradoxically unemployed. This has been exacerbated by inequitable distribution of the available health workforce occasioned by a myriad of challenges including, weak technical capacity and lack of tools; inequalities in the distribution general social goods; sub-optimal health workforce motivation, productivity and efficiency; skilled health workforce migration; and issues of health workforce typology among others. To achieve an equitably distributed functional health workforce in the Africa Region in the light of aforementioned challenges, five (5) broad priority areas for action have been proposed. These are:
Building a community of practice in evidence-based health workforce planning Strengthening Health Systems Capacity Integrating investment in training and recruitment of a functional health workforce Ensuring equitable deployment, retention and utilisation of HRH Partnerships for a functional health workforce
These priority areas of action are not only informed by available evidence but also reinforce various recommendations and efforts by WHO at the global and Africa Regional levels.
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Nonetheless, contextual adaptations of the proposed priority actions may be required at country levels since there are no ‘one-size-fits-all’ solutions.
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TABLE OF CONTENT
1. INTRODUCTION..................................................................................................................1 2. SITUATION ANALYSIS .......................................................................................................2 2.1 Health workforce availability .............................................................................................3 2.2 Maldistribution of available health workforce ....................................................................4 2.3 Clarification of concepts: Equitable Access to a Functional Health Workforce ...................5 3. CHALLENGES ......................................................................................................................8 3.1 Technical capacity and lack of tools ...................................................................................8 3.2 Health systems governance and leadership .........................................................................9 3.3 Inequitable health, social and educational infrastructure (Community and local resources) .............................................................................................................................................. 10 3.4 Health workforce motivation, productivity and efficiency ................................................ 11 3.5 Health workforce migration ............................................................................................. 11 3.6 Health workforce typology............................................................................................... 12 4. OPPORTUNITIES ................................................................................................................ 13 5. PRIORITIES FOR ACTION ................................................................................................. 14 5.1
Build a community of practice in evidence-based health workforce planning .............. 14
5.2
Strengthening Health Systems Capacity ...................................................................... 15
5.3
Integrating investment in training and recruitment of a functional health workforce .... 16
5.4
Ensuring equitable deployment, retention and utilisation of HRH ................................ 16
5.5
Partnership for a functional health workforce .............................................................. 17
6. REFERENCES ..................................................................................................................... 18
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LIST OF ABBREVIATIONS AFRO
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Regional Office for Africa
AHWO
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African Health Workforce Observatory
FHWF
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Functional Health Workforce
HRH
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Human Resources for Health
HRHP
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Human Resources for Health Planning
HWAR
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Health Workforce Availability Ratio
HWF
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Health Workforce
IMF
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International Monetary Fund
MDGs
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Millennium Development Goals
MOH
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Ministry of Health
SDGs
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Sustainable Development Goals
UHC
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Universal Health Coverage
UNGASS
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United Nations General Assembly
WHO
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World Health Organisation
WISN
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Workload Indicators of Staffing Needs
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1. INTRODUCTION Many countries in the Africa Region have made significant progress in achieving some health targets in aggregate terms since the beginning of the millennium (1). These gains have largely been driven by efforts ignited by the Millennium Development Goals (MDGs). Even though some countries in the Region did not fully achieve the health-related MDGs by the end of 2015, the momentum with which aggregate improvements were recorded at national levels does provide some hope for greater achievements. However, it has also been demonstrated that the modest achievements recorded in many African countries were not inclusive or universal, leaving large disparities within and across countries. The sustainability of the momentum of progress has also been brought to question owing to weak and fragile health systems, which were epitomised by the Ebola Viral Disease outbreak in West Africa. The United Nations General Assembly (UNGASS) in 2016 adopted a very ambitious global compact towards a more consolidated and sustainable development, the Sustainable Development Goals (SDGs). Of the 17 SDGs, Goal 3 which has 13 targets is seeking to “ensure healthy lives and well-being of all ages” (2). Ensuring universal health coverage (UHC) is at the heart of Goal 3, which also tackles the unfinished MDG agenda as well as incorporating emerging issues such as non-communicable diseases, injury prevention and environmental health. The SDGs also have a much broader agenda than the MDGs. Achieving these targets in the Africa Region requires effective, responsive and resilient health systems providing services that address population health needs using universally accessible and comprehensive package of interventions. Meeting these requires that human resources for health (HRH) are constantly available at where they are needed and delivering the required health services to address population health needs. It has been demonstrated that observed disparities in health outcomes are linked to disparities in the distribution of skilled health workforce, a phenomenon that is lingering in most countries in the Africa Region (5,6). This has raised concerns about the ability of the countries’ health systems in the Region to step up efforts for the realisation of the SDGs, particularly SDG3. This paper, therefore, examines how countries in the Africa Region would ensure a more equitable access to a ‘functional health workforce’ towards UHC and the SDGs. Using a 1
systematic approach to the literature search, relevant literature was reviewed narratively to highlight the status of HRH issues in Africa, clarify key terms and propose key actions for equitable access to a ‘functional health workforce’ as part of the broader effort of making health systems work for Africa. 2. SITUATION ANALYSIS The World Health Organisation (WHO) defines the health workforce (HWF) as “all people engaged in actions whose primary intent is to enhance health” (7). Health service delivery has been shown to be labour-intensive and labour-sensitive (8). Therefore, attaining the SDGs including UHC requires an adequate and well-functioning health workforce with appropriate skill-mix, which is accessible to the people in need of their service at the right cost that does not impose financial hardships. Many African countries made significant progress towards the MDGs. For instance, 43 countries in Africa observed much more significant declines in child mortality during the 2000-2013 period than during the 1990-2000 period. Across the continent, under-five mortality rate also declined by nearly 56% between 1990 and 2012 while infant mortality declined by 40% in the same period (1). These improvements did not meet the MDG targets. Despite some progress in improving maternal health, only Cabo Verde, Equatorial Guinea, Eritrea and Rwanda attained MDG 5 by reducing maternal mortality ratio by more than 75 percent between 1990 and 2013 (1). Contraceptive prevalence and skilled birth attendance are still low, contributing to maternal mortality as high as 289 maternal deaths per 100,000 live births compared with a global average of 210 maternal deaths per 100,000 live births in 2013 (1). These missed targets have been partly linked to inadequate health workforce availability (supply) and inequitable distribution of those available leading to disparities in both access to, and quality of health services (9,10). Exacerbated by sub-optimal health workforce productivity, the aforesaid challenges pose a significant threat to the UHC and SDG agenda.
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2.1 Health Workforce Availability The WHO Global Strategy on HRH for 2030 which was adopted in 2016 envisions to accelerate progress towards UHC and the SDGs by ensuring equitable access to a skilled and motivated health workers within performing health systems (3). Analysis based on WHO’s minimum threshold of 2.3 HWF per 1000 population put the shortage of physicians, nurses and midwives in 31 African countries at 800,000 by 2015 (11) which required at least USD2.6 billion to address. By this, the HWF Availability Ratio (HWAR), was a paltry 14.5% for doctors and 36.7% for nurses and midwives. However, these estimates appear to ignore the important roles of other categories of the HWF such as pharmacists, laboratory technicians and scientist as well as radiographers and physiotherapist among others. When these categories of the HWF were taken into account, Africa’s HWF shortage rose by nearly 71% from 820,000 to 1.4 million in 2006 (7). Thus, by ignoring the contribution of other categories of the HWF in the continuum of healthcare delivery, the HWF crisis in Africa is often understated. The concomitance of such underestimation of the crisis has not only been a chronic underinvestment in HWF production, recruitment and retention, but also a looming paradox of unemployed skilled HWF amidst needs-based shortages. For instance, against the backdrop of slow economic growth, it is projected that African governments would be able to employ (based on ability to pay) 2.4 million health workers by 2030 whilst 3.1 million would be available in the labour market during the same period (4), leaving about 700,000 – 800,000 skilled health workers paradoxically unemployed by 2030 amidst 6.1 million shortage of physicians, nurses and midwives based on the population health needs (3). Indeed, some sub-Saharan African countries, like Côte d’Ivoire, the Democratic Republic of Congo and Mali are said to have experienced this paradox of health worker unemployment in urban areas due to lack of capacity to absorb whilst shortages abound in the rural areas (12,13). These ‘paradoxical surpluses’, ceteris paribus, would seek opportunities elsewhere, thereby exacerbating the migration challenge. Figure 1 shows the HWF shortages, supply and paradoxical surplus by 2030. 3
6,1
3,1 2,4
0,7
Need based shortage
Stock
Demand based estimates (Ability to pay)
Paradoxical 'surplus'
Figure 1: Health Workforce Availability estimates for Africa, 2030 (million) Adapted from: WHO Global Health Workforce Strategy - 2030 From the foregoing, there appears to be not only a chronic underinvestment in HWF production but also a mismatch between the production investment on one hand and that of recruitment/employment on the other hand. Therefore, increasing investment in not only the production but also in the recruitment and retention of the health workforce is critical. This need to be underpinned by developing context-specific evidence-based HWF plans that include longterm needs and supply forecast in order to establish the health workforce availability gaps and determine the amount of resources required to eliminate same. 2.2 Maldistribution of Available Health Workforce The HRH literature is replete with studies that describe or attempt to measure the inequitable distribution of HRH within countries. One influential review addressed and clarified some concepts relating to imbalances in the geographical distribution of HRH (14). Others sought to examine the critical issue of maldistribution of HRH in the specific context of African countries (6,15–21). Whereas there is a consensus that HRH distribution in nearly all countries was not equitable or optimal, only a few studies (6,20) provided a metric or measure of the extent of inequity in the distribution using Gini coefficients and concentration indices. It is observed that
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the concept of equity in HRH distribution appears to be understood differently and lacks a commonly accepted metric for measurement. Also, maldistribution manifests either as aggregate (absolute) or relative (skill-mix distortions) (14). The former is a situation where the composite of the HWF is distributed in a manner skewed against geographical region(s) or special population groups. The latter concerns a situation where highly skilled health workers are concentrated in certain locations (usually urban areas) whilst low skilled workers are also concentrated in the other locations (usually rural and under-served areas). In either situation, clients would be inclined to seek care from the health facilities in locations with the requisite HWF which in turn increases workload in those facilities (22), giving rise to a legitimate clamour for more staff. If not addressed, this forms a vicious cycle of ‘inequity breeding inequity’. Generally, about 29-53% of all HWF are maldistributed whilst over 90% of pharmacists, 86% of medical specialists, 63% of general physicians and 51% of nurses/midwives in Africa work mainly in urban areas (23). However, there are wide variations across and within countries. Consequently, deliberate and pragmatic policies are needed to address this complex phenomenon of human resources shortages and maldistribution. Such measures have to be carefully crafted using evidenced-based workforce planning tools and implemented in a flexible and systematic fashion to gradually eliminate the inequities in HWF distribution whilst enhancing retention, motivation and productivity (3,13). As a starting point, countries need to develop evidence-based and context-appropriate staffing norms/standards to guide distribution to health facilities and use appropriate HWF metrics to monitor progress. 2.3 Clarification of Concepts: Equitable Access to a Functional Health Workforce The notion of ‘equity’ is generally understood in terms of fairness and justice or balancing competing needs of people in a society in an unbiased and objective manner (24). In general, policymakers often discuss equity in terms of fair distribution of some ‘good’. Therefore, central to any equity discussion is the need to explicitly define the variable of distributional interest, termed the ‘focal variable’ (25–27) and the equity criteria or normative stance upon which the
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distribution would be made. In this discussion, the focal variable is the HWF but there has not been a consensus about a common factor or criteria for the distribution of HWF (6,20). Traditionally population has been considered the underlying determinant of HRH distribution (28). This tends to be utilitarian, seeking to achieve the greatest good for the greatest number of people (29). However, if there is no homogeneity in health and disease patterns across the geographical distribution of the population, equity objectives may not be achieved distributing HRH solely on the basis of population size (6). Therefore, it appears logical to consider the concept of equality of health need, which tends to have a strong and instinctive appeal. Equity in this context means that the HWF is distributed only on the basis of population health needs (30). This principle is largely deemed as promoting horizontal equity, ‘equal treatment of equals’(31). Thus, those who have similar situations in terms of the focal variable (need) should be allocated similar numbers and quality of HWF irrespective of their financial ability, geographical location or any other non-health variable (28,31–33). However, what is deemed as ‘need’ is differently defined in different contexts (25) which tend to impact on the judgement of whether an allocation is equitable or not. One of such definitions equates healthcare need to the degree of ill-health, such that, it is those most severely ill who would be deemed to have the greatest need (24). In the context of distributing HRH to regions or districts, this stance would imply that the region(s) with poor health outcomes gets the most allocation. Empirically, it has been demonstrated that even though HRH maldistribution was apparent across regions and districts in the United Republic of Tanzania and Cameroon, the distributional inequalities become much pronounced when under-five deaths were used as an indication of health needs (6,20). However, in the case of the United Republic of Tanzania, the inequalities appeared to decline when ‘need’ was defined in terms of HIV prevalence (6). Thus, depending on what is considered as the priority health need in a given population, the extent of equity could vary. It is important that the Africa Region selects a set of proxy priority indicators (e.g. disease burden, maternal mortality, under 5 mortalities, immunisation coverage, skilled birth attendance, HIV prevalence, health promotion needs, etc.) as measures of ‘health need’ to serve as the basis for HRH equity measurement across countries. On the other hand, existing inequities in HWF distribution must be first addressed before horizontal equity can be pursued. Vertical equity, ‘unequal treatment of unequals’ (31) addresses 6
this. In the context of HRH, it requires unequal distribution of the incoming HWF to give unequal proportion to deprived or under-served locations (regions or districts) according to the extent of their deprivation (24). Simply, some form of ‘positive discrimination’ or ‘deliberate unequal distribution’ is required to address existing inequalities (34). Using staffing norms/standards to guide distribution would be useful in government-led health systems. Functional health workforce: Based upon this literature review, the attempt to coherently define the concept of a ‘functional health workforce’ appears absent. However, it has been argued that attaining universal health coverage requires a HWF that is ‘fit for purpose’ with competencies that directly addresses the priority health needs of the country or region (35,36). It has also been widely demonstrated in various dimensions of health care that competencies which were traditionally reserved for some groups of highly trained professionals could be made more accessible to the population through accelerated or tailored training or task-shifting without compromising the quality or effectiveness of service provision (28,37–40). For instance, in one Cochrane review, Kredo and colleagues (38) included ten papers of good quality evidence from Africa to conclude that shifting responsibility from doctors to adequately trained and supported nurses or community health workers for managing HIV patients probably does not decrease the quality and safety of care, and nurse initiated care may decrease the numbers of patients lost to follow-up. Such tailored or health priority focused training has shown to also enhance staff retention in under-served areas especially if the training was connected to under-served settings (16,41–43). In the context of achieving UHC, a workforce that is functional should:
Have core skills obtained through regular or tailored training that addresses the health needs of a given population (35,44) Be actively engaged in service provision that directly addresses the health needs of the given population Be readily available in appropriate quantity and mix (28) Have a supportive work environment
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KEY DEFINITIONS
Functional health workforce refers to those who possess skills that directly address the health priorities of a given population (or individuals) and actively engaged in service provision that is readily accessible to the people in need of their skills without undue hardship. Equitable access to a functional health workforce occurs when populations or individuals, irrespective of their geographical location or other circumstances, have a reasonable and reliable opportunity to the appropriate number and mix of skilled health workers from whom to receive effective and quality service that addresses their health needs.
3. CHALLENGES There are many challenges confronting the issue of availability, equitable distribution and functioning of the HWF in Africa. Whereas challenges in all areas of the health systems building blocks tend to impact on HWF availability and distribution, six (6) broad thematic areas/dimensions are discussed. 3.1 Technical Capacity and Lack Of Tools There is generally weak technical capacity within countries to use available evidence-informed tools for HWF planning (45–47). Even though some countries within the Region have national HRH policies and/or strategies, only a few have been able to conduct a comprehensive long-term forecast of their health workforce needs and possible supply. Furthermore, countries that have HRH policies and plans have recorded weak and largely uncoordinated implementation of those plans as a result of many factors including, longstanding underinvestment, weak implementation capacity at lower levels of the healthcare system among others (28,48–50). On the other hand, while evidenced-based health workforce planning tools abound and WHO/AFRO has been making efforts to encourage their usage across countries (51,52), there seem to be no commonly agreed, easy-to-use tools that can be adopted or adapted to monitor health workforce inequities across and within countries using a common metric. Linked to this is the general challenge with availability, completeness and quality of HRH data for planning due to weak information systems and lack of adequate mechanisms to generate information and evidence. Even though WHO developed the National Health Workforce Accounts (NHWA) to address this challenge (53), the NHWA do not include a specific metric to measure need-based equity in the distribution of health workforce within and across countries. Consequently, some 8
counties have used the proportion of health workers serving in rural areas versus those in urban areas as a measure of maldistribution (15) while others have also tested the use of Gini coefficient and concentration indices (6,20). Both metrics are a function of aggregate population distribution, and therefore, implicitly assumes homogeneous population demography, disease burden and health needs across regions and districts. However, since the population in most African countries vary substantially in terms of health needs across geographical locations and sometimes within the same location, as part of implementation of the NHWA there is the need to incorporate a health workforce equity metric that account for these contextual variations in levels of deprivation and health needs, not only aggregate population densities (6). This is critical for guiding and monitoring interventions to increase equity in health workforce distribution.
Key messages Weak capacity at country level to use evidenced-based health workforce planning tools Most countries’ HRH plans have not included long-term forecasting No commonly agreed metric for measuring equitable distribution of health workforce within and across countries Underinvestment and weak implementation capacity of the HRH policies and plans A key challenge at the country level is the availability, completeness and quality of HRH data for decision making.
3.2 Health Systems Governance and Leadership Related to the challenge of technical capacity, the WHO roadmap for scaling up human resources for health in Africa (47) also identifies weak governance and leadership for HRH as a priority area for intervention. A well-functioning health system with equitably distributed healthcare infrastructure underpinned by transparent and accountable leadership and governance has been shown to the influence staff acceptance of postings to district and sub-district levels (17). Appropriate leadership skills have been linked to increasing staff productivity and retention (54). However, health system structure especially at the district level in many countries are not only logistically and financially challenged, but also face leadership and managerial challenges with detrimental implications for sustainable and equitable availability of a functional HWF (45,49,55). Despite many leadership and management training interventions in some countries, there are still many districts that grapple with ill-prepared managers (56).
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Key messages Weak health systems, governance and leadership adversely affect staff productivity and retention, thereby fuelling health workforce unavailability and inequity. Many district face funding and logical challenges and as well grapple with ill-prepared managers raising concern about the functionality of the health system in that context. But a functional system begets a functional health workforce.
3.3 Inequitable Health, Social and Educational Infrastructure (Community and Local Resources) Generally, lack of quality health, social and educational infrastructure has been linked to the lingering challenge of inequitable distribution of health workforce in many resource-constrained countries, especially Africa (17,57). For instance, in one Ghanaian study, health workers considered having decent living conditions such as staff accommodation, good schools with qualified teachers for staff children, access to good drinking water, electricity, roads and transport as factors they would consider before accepting postings to rural areas (58). In addition, the HWF requires healthcare which if not adequately available could drive the HWF in rural and under-served areas to more urban or privileged areas to maximise their opportunities of getting healthcare. Also, gender-related sociocultural factors often prevent women from accepting positions in rural or under-served areas for extended periods (59). All the aforementioned perpetuate or exacerbate maldistribution and limits access to healthcare (60). This reinforces the need to address the social and infrastructural needs of the functional HWF, particularly, staff accommodation, water and electricity are sine qua non for equitable distribution of the HWF. Additionally, many health training institutions especially medical schools are not only insufficient but tend to be located in urban areas. However, it has been shown that integrative community-based practice and learning facilitates staff retention at rural and under-served areas (12,61,62). This approach of siting training institutions in under-served areas or incorporating on-site rural-setting training of health professionals and recruiting from these priority underserved areas has shown promise in Democratic Republic of Congo (DRC), Uganda, Kenya, Ghana and Namibia among others (12,35,63). It may also be useful to tie admission vacancies in health training institutions to staff needs in various locations such that prospective students do not only apply for admission but the 10
admission is contingent on the prospective student accepting posting to a particular location upon completion. The success of this measure requires appropriate enforcement mechanisms. 3.4 Health Workforce Motivation, Productivity and Efficiency It has been demonstrated that a reduction of up to 20% in nurse shortages is achievable if nurse productivity is marginally improved by only 0.5% (64). However, sub-optimal productivity of the HWF has been widely reported in many African countries (55,65–71). This has been partly due to low remuneration and incentives, which have become push factors for external or internal migration of the HWF. Also, the concomitance of weak performance management systems, poor supervision, lack of performance standards and lack of productivity improvement tools and metrics breeds low HWF productivity and inefficiency. Similarly, skill mix imbalances do not only engender distributional inequities but also inefficient utilisation of the HWF. Occupational Safety and Health issues for the HWF also affects their motivation, productivity and efficiency and therefore, needs to be addressed.
Key messages Low wage and incentives, poor supervision and weak performance management systems Low productivity Lack of a commonly adopted productivity tools, standards and metrics for the health workforce Need to focus on staff motivation (monetary and policy incentives) Need to develop/adopt productivity standards, and measurement metrics for the health workforce
3.5 Health Workforce Migration Migration of highly skilled HWF has been a drawback to Africa’s efforts to attaining adequate and equitably accessible HWF (45,48,72). Against the backdrop of fragile health systems, HWF shortages and the high cost of training highly skilled HWF, migration from African countries has further threatened the viability and sustainability of some health systems. For instance, more than 20,000 African doctors work in Europe and America (72). Consequently, the WHO introduced a code for ethical international recruitment of health workers (73) as a measure to guarantee ethical recruitment practices on the part of receiving countries. However, balancing the competing 11
interest of receiving countries, source countries and the right of the health worker to migrate has been a tightrope to walk. Also, the voluntary nature of the code relative to what the receiving countries should do tend to undermine its implementation (74). Beyond the external migration, internal migration within and across African countries poses a similar threat. For instance, one study (50) showed that, out of 723 physicians who qualified between 1980–2006 in Mozambique, 25.5% left the public sector, 37.6% of whom emigrated. About 66.4% of the internally migrated physicians worked for non-governmental organisations (NGOs), 21.2% for donor agencies, and 12.4% in the private sector in urban areas. On the other hand, other categories of the HWF such as physician assistant/medical assistant, clinical officers have not recorded the extent of emigration observed for doctors and nurses even though they may be of similar functionality. These raises legitimate concerns as to whether traditional typology of HWF that high-income countries tend to recruit are also those necessarily required to address Africa’s immediate challenges. Key messages
Despite WHO Global Code of Practice on the International Recruitment of Health Personnel, migration of highly skilled health workers continues to threaten health systems The code needs to be made more binding African countries should refocus the training of their staff to address their population health needs, emphasising on the range of skills and functions rather than titles
3.6 Health Workforce Typology Achieving universal health coverage requires a workforce with the competencies fit-for-purpose (and not necessarily about titles) to address priority health issues in each country or region (35). Besides the threat of migration, the point has been made that an output of 6,000 doctors and 26,000 nurses/midwives annually trained are too few to bridge Africa’s HWF shortages (47). Therefore, a more responsive approach to developing a workforce that is functional and serves most people would not only rapidly contribute towards UHC but would also be cost-effective and socially accountable (38). There is a body of evidence substantiating the safety, effectiveness and cost-effectiveness of 12
accelerated or tailored made of training of a responsive and functional health workforce (38– 40,75–77). For instance, in Kenya, no significant clinical differences were found between HIV/AIDS patients who received clinic-based antiretroviral therapy care versus primarily community-based care delivered by people living with HIV/AIDS who received preprogrammed personal digital assistants with decision support whilst surgically trained assistant medical officers (techno de cirurgia [TC]) in Mozambique produced similar patient outcomes as compared to physician obstetricians and gynaecologists, but at cost estimated to be one-quarter of physician specialists, and TC's provided over 90% of obstetric surgery delivered in district hospitals (78). These innovations were undertaken in the context of task-shifting which is currently widespread but in different forms. From the foregoing, the models and titles of HWF training need to be re-examined in the light of Africa’s existing and emerging challenges.
Key message Need to re-focus training on competencies and functions rather than titles Link the training of and public sector investments in health personnel with population needs and health system demands, adopting a coordinated approach to HRH planning and education.
4. OPPORTUNITIES Despite the myriad of challenges confronting equitable access to HWF, there are also some opportunities to address them. First, the HWF has been considered a priority in the global health agenda. Consequently, there are a number of global and regional efforts to ensure adequate availability, retention and utilisation of the HWF towards universal health for all. Notably, at the global level, the World Health Assembly (WHA) adopted a global strategy for the health workforce 2030 (3) in 2016. Prior to this was the roadmap for scaling up HRH in the African Region (2012-2025), which identifies strategic priority areas for action in the Region. There are also policies and guidelines including the Global code of ethical recruitment, task-sharing guidelines, guidelines on retention of health workers in rural areas among others (13,73,79). Building on these efforts provides opportunities to mainstream HWF issues in various health policies and strategies more widely and deeply.
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Second, the youth bulge in Africa also means that there is a large pool of productive population who could potentially be trained in the area of healthcare. Finally, the success of task-sharing initiatives within the Africa region (38,39,75–77) serves as an opportunity to rapidly train fit-for-purpose HWF of acceptable quality to address existing and emerging population health needs. 5. PRIORITIES FOR ACTION Based on the situation analysis and challenges contributing to the current situation, a number of coordinated priority actions need to be undertaken at the country, sub-regional, regional and global level. The priority actions proposed are largely reinforcing and contextualising existing global and regional efforts and commitments. Whilst these have been identified/proposed as priorities for equitable access to a functional HWF in the African region, due to wide contextual variations between and within member countries, it is acknowledged that context-specific adaptations are necessary as there are no ‘one size fit all’ solutions. 5.1 Build a Community of Practice in Evidence-Based Health Workforce Planning It is imperative to develop national HRH policies and strategies that are based on or informed by context-appropriate evidence. Such plans and strategies need to contain a long-term forecast of HWF requirements and supply to establish the gaps and estimate the requisite cost to guide investment in HRH production, recruitment and retention. There is also a need to establish common metrics for measuring and monitoring HRH availability and extent of equitable distribution. These metrics would enable common understanding and comparison of the HRH situation within and across countries. Member countries commit to:
Develop evidence-based staffing norms/standards by the end of 2019 to be used as a guide for recruitment planning and equitable distribution.
Develop or revise HRH policies and strategies in line with Global Strategy on HRH and Regional Roadmap on HRH to include a comprehensive long-term forecast of the needs 14
and supply of the health workforce to establish country-level aggregate gaps to guide integrated investment in the production, recruitment and retention. Member countries commit to supporting or partner with the Regional Office to:
Adopt common metrics for the measuring and monitoring of functional HRH availability and equitable distribution (example, National Health Workforce Accounts,) that would be used by all member countries.
Strengthen HRH Information Systems which should include national health workforce observatories as platform for generating/sharing evidence and information for health workforce management and planning
Participate in an annual or biennial peer review of member countries’ progress towards SDGs and UHC, including health workforce availability and equitable distribution.
5.2 Strengthening Health Systems Capacity Health systems, especially at the district level do not only face funding and logistical challenges but also sometimes grapple with ill-prepared managers raising concern about their functionality and sustainability, which adversely affects access to a functional health workforce. It is thus, imperative that in working towards the SDGs, particularly, UHC, countries in the Africa Region commit to:
Management and Leadership development training including health workforce management for managers and senior officers at all levels of the health system.
Constitute and train a core team of HRH professionals at the country level (example, Working Group on HRH) to advise and/or consider eliminating bottlenecks in the implementation of HRH policies.
Establish (for countries that do not currently have) HRH Departments/Directorates in MOH/Service delivery agencies to champion the mainstreaming of health workforce issues in all health policies and interventions at all levels of the health system.
Provide HRH managers with advisory and support staff on issues like data management, financial management, planning, etc. 15
5.3 Integrating Investment in Training and Recruitment of a Functional Health Workforce Chronic under-investment in HWF production, recruitment and retention have led to many of the current challenges including shortages, maldistribution, low remuneration and migration. Highgrade evidence has shown that establishing training institutions in rural/under-served areas or including on-site rural/under-served area training do not only enhance the uptake of postings to these areas but also promotes staff retention (63,80). Also, there is the need to provide a health workforce training/education that focuses on the range of skills relevant to Africa’s existing and emerging population health challenges rather focusing on the titles and traditional western models of education. In light of the foregoing, member countries should consider the following as priority investments/interventions:
Develop/revise training curricula that produce fit-for-purpose health workers with competencies and functions (rather than titles) that address population health needs including e-health/telemedicine.
Train the HWF at where they are needed: Establish training institutions in rural or underserved areas and/or include on-site rural training of health workers.
Recruit students from rural, under-served or targeted areas of HWF distribution with the view of posting them back to those communities to serve.
Link vacancies at training schools for admission to vacant jobs in underserved areas and tie the students up with sponsorship bonds.
Increase budgetary allocation for the recruitments and enhanced remuneration of HWF in underserved areas
5.4 Ensuring Equitable Deployment, Retention and Utilisation of HRH The concept of HWF maldistribution has been differently understood and reported with a variety of metrics, making intra-country and across country comparisons difficult. Similarly, there appear to be no objective metric for monitoring health workforce productivity, which tends to be sub-optimal and adversely impacts staff availability. There is the need to put in measures for member countries to implement the NHWA, incorporating need-based HWF equity metrics that 16
accounts for the contextual variations in levels of deprivation and health needs, not only aggregate population densities. Member countries commit to:
Develop evidence-based guidelines to effectively deploy and retain health workers in rural and under-served areas. National health policies and strategies to include staff distribution and retention strategies, especially in rural under-served areas.
Develop and/or use staffing norms/standards to guide targeted and result-oriented posting/distribution of the HWF.
Provide basic amenities such as accommodation, portable water and power source complimented by financial and policy incentives for long-term retention in under-served areas.
Develop/adopt productivity standards and common measurement metrics for monitoring HWF productivity as NHWA.
Avail adequate funds to recruit and deploy health workers as planned in the HRH strategic plans.
5.5 Partnership for a Functional Health Workforce Partnerships and collaboration have been seen as the cornerstone in attaining the SDGs including UHC. In respect of the HWF, member countries need to:
Share data with other countries for relevant national and regional HWF observatories.
Link national HRH Plans with relevant educational institutions outside of the health sector to train a functional health workforce
Commit to participate in an annual or biennial regional/sub-regional peer reviews on the road to UHC including progress made in the health workforce.
Create a pool of health workforce that countries may recruit from within Africa.
WHO/AFRO should consider creating/strengthening HRH Technical Support Unit with a network of persons with the relevant expertise to support and build the capacity of member countries in terms of HWF planning.
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