Factsheet: Health Worker Crisis in Africa

(October 2005)  Health workers – nurses, doctors, pharmacists, community health workers, laboratory technicians, physician assistants, and many more – are at the core of health systems everywhere.  Where there are health worker shortcomings, health systems will suffer, resulting in preventable death and disease.  Where health workforces are in crisis, health systems will be in crisis.  Such is the case in many countries in sub-Saharan Africa.

The Scope of the Crisis
In Africa, a mere 1.3% of the world’s health workers struggle against all odds to combat fully 25% of the global disease burden.¹   An eminent group of more than 100 global health experts estimate Africa’s shortage of health workers at 1 million; other estimates find the shortage to be even greater.²   While the numbers and types of health workers will vary by country, these statistical snapshots leave no doubt as to the scope of the crisis. 

The Causes of the Health Worker Shortage
The particular causes of shortages also vary by country, but there are common threads.  HIV/AIDS is taking a major toll on the health workforce, including through death and illness of the health workers themselves and the enormous stress AIDS is placing on health systems.  Health sectors have been massively under-funded – in 1997, least developed countries were spending an average of $11 per capita from all sources on health³  – affecting all aspects of health systems, especially health workers, who have frequently been undervalued, and whose numbers stagnated under restrictive structural adjustment policies.  

This under-funding and under-recognition has contributed to the large-scale emigration of health workers (“brain drain”).  How quickly are health workers leaving?  As of 2001, only 360 of the 1200 physicians trained in Zimbabwe during the 1990s were still practicing in the country.⁴   In 2002/2003, more than 3,000 nurses trained in South Africa, Zimbabwe, Nigeria, Ghana, Zambia, and Kenya registered in the United Kingdom.⁵   Ethiopia’s public health sector is losing about 9.6% of their physicians every year, primarily to other countries and to the private sector. ⁶

Internal Inequities
Health workers are distributed quite unevenly within countries, as richer and more urban areas have more health workers than poorer and rural areas.  For example, relative to its population, Ghana’s Greater Accra Region has thirty times the number physicians and four times the number of nurses as Ghana’s Northern Region. ⁷

Impact of the Health Worker Shortage

• In many countries, the health-related Millennium Development Goals, universal access to AIDS treatment, and other health goals cannot be reached without a strengthened and expanded health workforce.  Nor can US AIDS treatment goals be achieved without harming other health services.⁸
  
  
• In sub-Saharan Africa, a woman’s lifetime risk of maternal death is 1 in 16, compared to 1 in 2,800 in rich countries. According to the World Health Organization, “Putting in place the health workforce needed for scaling up maternal, newborn and child health services towards universal access is the first and most pressing task.”⁹

Recommendations
Health professionals leave primary because they cannot meet their needs or those of their patients.  Yet with adequate investment and improved policies, these needs can be met.  And support for capacity within communities can further expand the scope and reach of the health workforce.  The overall cost of these investments has been estimated at $2 billion in the first year, and more in ensuing years.¹⁰

• African countries must develop and implement strategic health workforce plans to increase service delivery so as to achieve the Millennium Development Goals and other health goals.  In October 2005, African health ministers committed themselves to prepare and implemented costed human resources for health development plans so as to achieve universal access to care and treatment by 2015.¹¹   The World Health Organization and other health and development agencies should provide and facilitate the necessary technical support.
  
  
• To retain health workers, donors and national governments must cooperate to ensure that health workers have safe working conditions, adequate compensation, continuous learning opportunities, effective supervision, sound management systems, and the capacity to help their patients, including sufficient levels of medicines, supplies, and equipment.  The present failure to meet these needs is driving the exodus of health workers.
  
  
• Donors and national governments should invest in pre-service training to increase countries’ capacity to educate new health workers.
  
  
• African countries should develop and implement strategies to dramatically increase the number of health professionals in underserved areas.  These could include incentives for health workers in these areas, such as hardship, housing, and transportation allowances, and recruiting students from rural areas to medical, nursing, and pharmacy schools.  Donors should provide funding to ensure full implementation of these strategies.
  
  
• African countries should develop the policies, including the skills mixes, education strategies, and non-traditional cadres of health workers that will be most conducive to achieving universal access to quality care.  This will likely include competency-based education, advanced practice roles for nurses, and training, compensation, and support for community health workers and mid-level health cadres. 
  
  
• Donors must fully support the Global Fund to Fight AIDS, Tuberculosis and Malaria should receive the funding needed to hold three new rounds in 2006-2007, including Round 6 in 2006; should continue to accept proposals on health system strengthening, and; should provide more detailed guidelines for health system strengthening proposals.  WHO and health and development agencies should increase technical support available for developing and implementing health system strengthening proposals.
  
  
• The U.S. President’s Emergency Plan for AIDS Relief should develop and fund human resource strategies to support the additions to the health workforce required meet AIDS prevention, care, and treatment goals, while enabling countries to scale-up other health services in accord with other health goals.
  
  
• Budget and wage ceilings, and fiscal and monetary policies that determine them, whether contained in agreements with the IMF and other international institutions or determined by national authorities, must be adjusted or redesigned to ensure that they do not restrict any programs critical to public health.
  
  
• Wealthy nations must stop actively recruiting health professionals from developing countries, except as part of an agreement with those countries, which should allow for recruitment to benefit both the source and destination countries.  They should also develop and implement strategies to reduce reliance on foreign health professionals, and work towards their own health workforce self-sufficiency.
  
  
• Home and community care-givers, who have become de facto health workers, should receive the compensation, training, materials, and linkages to the formal health system that they require to provide quality care.
  
  
  

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[1] Commission for Africa Report (2005), http://www.commissionforafrica.org/english/report/thereport/13chap6.pdf.

[2] Joint Learning Initiative, Human Resources for Health: Overcoming the Crisis (2004), http://www.globalhealthtrust.org/Report.html. 

[3] Commission on Macroeconomics and Health, Macroeconomics and Health: Investing in Health for Economic Development (Dec. 2001), at 54-57.

[4] EQUINET et al., (2003), http://www.equinetafrica.org/bibl/docs/healthpersonnel.pdf.

[5] James Buchan & Delanyo Dovlo, International Recruitment of Health Workers to the UK: A Report for DFID (2004), http://www.healthsystemsrc.org/publications/reports/int_rec/int-rec-main.pdf.

[7] Ghana Ministry of Health, http://www.norad.no/default.asp?FILE=items/3070/108/Oslo presentation 2.ppt.

[8] See, e.g., Christoph Kurowski et al., Human Resources for Health: Requirements and Availability in the Context of Scaling Up Priority Interventions in Low-Income Countries. Case Studies from Tanzania and Chad (2003).  Working Paper. London School of Hygiene and Tropical Medicine, London; Damascene Butera, et al., Comprehensive Assessment of Human Resources for Health in Côte d’Ivoire (Aug. 2005).  Available at: http://www.phrplus.org/Pubs/Tech072_fin.pdf.

[9] WHO, World Health Report 2005, http://www.who.int/whr/2005/en/index.html.

[10] Cost Estimates: Doubling the Health Workforce in Sub-Saharan Africa by 2010 (June 2005).  Available at: http://www.phrusa.org/campaigns/aids/costestimates.html.

[11] 2nd Ordinary Session of the Conference of African Ministers of Health, 
Gaborone Declaration on a Roadmap Towards Universal Access to Treatment and Care (October 2005), at 2(v).