Putting Health Workers at the Heart of the Health MDGs
07/26/2010
How do we support health workers in the field?
Progress on the health MDGs, particularly in maternal, newborn and child health, requires equitable access to quality, essential health services. Nowhere is this more evident than in fragile contexts, where levels of morbidity and mortality are highest and where progress on the MDGs is most off-track. This is a huge challenge, but one that must be met if we are to reach the millennium targets and realise the right to health for all.
Globally, more than 2 million more doctors, nurses and midwives are needed - the number balloons to 4 million if managers and other public health workers are included. These figures, however, mask particular shortages, both between and within countries.
Fifty-seven counties currently fall below the WHO target of 2.3 health workers (doctors, nurses and midwives) per 1,000 population - the minimum health worker density needed to deliver essential health care. For many sub-Saharan African countries and some parts of Asia, the distribution is far less than 1.15/1000.
The global lack of health workers and their uneven distribution has a number of causes. One is the changing patterns of morbidity and mortality and the fact that the investment in human resources has not always followed suit.
Another major factor is the financing of health services. On average, countries devote just over 40 percent of total government health expenditure to paying for the health workforce. The amount available is obviously dependent on the overall allocation to the sector, which is often well below target. For instance, despite African countries signing up to the Abuja declaration, only six out of 53 African Union Member States have so far met their commitment to allocate 15 percent of their budget to health.
The situation has not been helped by the fact donors have traditionally preferred to fund capital rather than recurrent costs, such as health worker salaries. These challenges are often exacerbated in fragile contexts where conflict and chronic underinvestment in health have had a devastating impact. A good example of this is Liberia. Before the conflict, there were an estimated 237 doctors. Following the peace agreement, this number had reduced to just 23.
There are also growing opportunities encouraging movement of health workers in search of better professional and economic opportunities, often from the countries where they are needed most. Though the situation is complex, in many cases migration is a symptom of a deteriorating health system characterized by low wages, poor working conditions, few incentives, as well as a lack of technology and facilities to carry out their roles effectively.
Ensuring staff receive adequate pay for their work is key to retention. However it is not just salary that is important. In many contexts, the low numbers of trained health staff in remote areas is due to the lack of supporting infrastructure and opportunities for staff and their families. In fragile contexts, these factors include poor living conditions, the lack of safety and security in the workplace, and the absence of continuous professional development.
If the current health worker crisis is to be tackled and access to health services made a reality, it is critical that international efforts are scaled up significantly.
Hands Up For Health Workers, a campaign launched by Merlin, calls for action on key areas, especially in fragile states, to realize the opportunities that exist to increase the numbers of health workers and ensure they remain in the places where they are most needed.
The campaign calls for the development and funding of national health workforce plans to support the longer term vision and to promote coordination of efforts such as training opportunities for both current staff and new recruits. These plans should be in place from the earliest opportunity in all contexts and need the commitment of national governments and the support of international donors. More emphasis needs to be placed in-country on how much revenue is devoted to the health system, as well as from external sources, to improve both the quantity and quality of the allocation to the health sector.
Once health workers are trained, appropriate resources need to be available for covering salaries, good working conditions, performance management and professional development. Ensuring that health staff are adequately rewarded for their efforts as well as other benefits to motivate them in their roles, is critical.
Linked to supporting health staff in the system is managing the migration of health staff. Efforts within the country need to be matched by international efforts. The Code of Practice for international recruitment that was unanimously passed at the recent World Health Assembly is laudable. A significant step forward for the sector, it is important that all countries and organizations, including NGOs, do what they can to being an end to systemic brain drain in the health sector.
For our part, Merlin is continuing to provide practical solutions to health service provision in the countries in which we work, while also using our experience and learning to influence for better policies and practices for human resources in the future, both at national and international levels. Only if we work together as a global community will we be able to make progress on the global commitment to the MDGs. Ensuring that human resources for health is at the heart of these efforts is the key to their success.
Fiona Campbell is head of policy at Merlin.
Great subject and discussion. However, we need to be honest about health workers and health care systems: if we build them as non profit, charitable, there will be no money for health workers and there will be fluctuation services. If we build health services profitable - population cannot afford them. So at the end of the discussion the question is - should it be socialized medicine or private? I think the answer for poor countries - they should have socialized medicine. However, socialism is viewed as an evil and there is great propaganda against it. So, let’s wait and see what private services can bring charitable services for poor countries - not much so far.
— Tatiana on 2010-08-03
Great points made in this post and I’m glad to hear of Merlin’s work on these issues. A recent trip to Ghana by the World Bank’s Results-Based Financing for Health team brought these same issues to the forefront of program design. We hope RBF can make a difference in this area. Health workers are key to achieving the MDGs, and helping them succeed is crucial.
Visiting Pat, a health worker in rural Ghana and hearing the difficulties she faces (while still succeeding) makes it clear that a top priority is finding the right tools when designing health programs, be it performance incentives, transportation, or skills development. An RBF program will hopefully “give Pat the needed performance incentives to help increase the quantity and quality of preventive and public health services provided in communities, districts and beyond. It’s also intended to reward Pat’s hard work and ensure that her efforts don’t go unnoticed.”
— Kim Bumgarner on 2010-08-18