Health worker shortages: policy neglect equivalent to 'institutional manslaughter’

Africa’s critical health workforce shortage is arguably the most serious obstacle to implementing global and African health frameworks and universal primary health care across the continent. In almost no other aspect of life could it be imagined that a serious issue of social justice or social and economic development could be resolved without the presence of relevant and adequately trained and resourced personnel. No government would ever contemplate legal systems without judges and lawyers, mines without miners, airlines without pilots, banks without bankers, the possibility of farming without farmers, and certainly no army could exist without soldiers.

Yet on a matter of life and death for every single African, almost every African government seems to be muddling and mumbling along on the question of financing training and retaining adequate numbers of doctors, nurses and midwives, pharmacists, dentists, and a diverse range of community, public health and hospital workers. The great unanswered question of our time is how any government believes the ‘war’ against disease and non-disease health conditions can be won without adequate numbers of well-trained and fully resourced brigades of health workers and professionals.

We therefore need to state it, and state it clearly now. Health conditions do not diagnose themselves, and medicines do not administer themselves. Only health workers and professionals can. Africa’s health crisis will never be resolved until its extreme health workforce shortage is reversed. Or put simply, unless African governments immediately develop and finance implementation of an emergency plan for training and retaining adequate numbers of health workers, the current figure of over eight million African lives lost annually to health conditions is bound to increase and with dire consequences for Africa’s future.

GLOBAL HEALTH WORKFORCE COMPARISONS AND IMPLICATIONS FOR HEALTH DELIVERY

In this context, it is crucial to appreciate the scale of Africa’s health workforce shortage and its impact on the capacity of African countries both to implement universal primary health under the African Union’s new Africa Health Strategy and to meet the health-related Millennium Development Goals (MDGs). There is no point claiming we are ‘scaling up’ when the degree of scaling is a mere fraction of what is required.

If we are to utilise a numerical comparison between key African countries and G8 countries of similar population, the scale of Africa’s problem becomes much clear than using just the ratio of health workforce to population. Whether there be one doctor per 1,000 people, one per 10,000 or one per 100,000 has little context outside the ranks of health campaigners who possess the technical grasp of the implications of these numbers on health care delivery.

Utilising four categories of country populations as a basis for numerical comparison of the impact of health worker shortages, and health financing on primary health care, Canada and Kenya for instance have populations of 32.5 million and 36.5 million respectively. Canada has 62,307 doctors along with 327,224 nurses and midwives, to Kenya’s 4,500 and 37,113, with 27,048 pharmaceutical personnel to Kenya’s 3,094.

Moving up a scale, France and the DRC have populations of 61.3 million and 60.6 million respectively, for whom France has 207,277 doctors and the DRC 5,827. Likeiwse, France has 486,006 nurses to the DRC’s 28,789, and 69,431 pharmaceutical personnel to the 1,200 employed within the DRC.

A bit higher up the population scale, Germany and Ethiopia house 82.6 million and 81 million respectively, with Germany possessing 284,427 doctors and Ethiopia 1,936. Germany has 662,000 nurses and midwives and Ethiopia just 15,544, just as the European nation has 46,953 pharmaceutical personnel to the African’s 1,342.

Even further along the population scale, Japan and Nigeria have 127.9 million and 144.7 million people respectively. Japan has 270,371 doctors along with 1.2 million nurses and midwives, while Nigeria has a mere 34,923 and 210,306 of equivalent personnel. And most crucially, Japan has 241,569 pharmaceutical personnel and Nigeria 6,344.

The impact of the numerical differences in health workers on life and death is astounding. It does not take a mathematical genius to work out that based on current numbers, millions of Africans (especially those in rural areas) will never see a doctor in their lifetime, not even to certify their death. For each pair of comparison countries, the difference in Health Life Expectancy (HLE) of citizens is roughly 30 years, with countries having more health personnel achieving HLE of at least 70 years, and those with less health personnel averaging 40 years. A brief comparison of disease and non-disease health conditions further underlines the impact of health workforce shortages on health delivery.

While Canada has 60,000 people living with HIV, Kenya has 1.3 million. For France’s 130,000 people with the disease, there are one million in the DRC. While Germany has 49,000, HIV estimates for Ethiopia range as high as 1.3 million. And for Japan and Nigeria, the equivalent figures are 17,000 and 2.9 million. Factoring in the levels of Tuberculosis-related deaths, the leading killer of HIV-positive people, Mother to Child Transmission (which is preventable), and poor health systems (especially personnel) which are all crucial for implementing prevention and treatment strategies, it is clear why Africa is losing the battle against HIV.

In the case of non-disease maternal death (or childbirth-related deaths), Canada suffers six per 100,000, while Kenya weeps at 1,000 per 100,000. France has 17 per 100,000 with the DRC suffering 990 per 100,000. Germany has 8 deaths per 100,000 and Ethiopia 850 per 100,000, while Japan has 10 per 100,000 to Nigeria’s 800 per 100,000. In real terms this means for instance that of Kenya’s female of population about 18 million, roughly 180,000 die annually from an almost one hundred percent preventable cause. The lack of adequate numbers of trained personnel to provide skilled birth support for millions of women is again the key factor.

But lest it be said that the main determinant of adequate health workforce numbers and healthier life expectancy is G8 status, we could point to a middle-income country such as Cuba boasting 67,000 doctors, while African countries of an equivalent population size of around 12 million such as Malawi, Zambia and Zimbabwe have approximately 500, 1,000, and 2,000 doctors respectively. With one of the best and least expensive primary health care systems in the world, health life expectancy in Cuba is roughly the same as G8 countries. Even compared to Nigeria, Africa’s most populous and potentially richest country with an around 140 million population over ten times bigger than Cuba’s, Cuba has twice as many doctors as Nigeria. Again the disease and non-disease comparisons between Cuba, as a medium-income country on the one hand, and Malawi, Zambia and Zimbabwe show similar disparities.

LONG TERM SUSTAINABLE HEALTH WORKFORCE FINANCING IS THE ONLY SOLUTION

But these numbers don’t just ‘happen’. Governments must invest in lives of citizens through sustainable health development and financing. By way of health financing comparison, Canada spends 17.5% of its budget on health, France 16.6%, Germany 17.6% and Japan 17.8%, compared with Kenya’s 6.1% (including external contributions of 18% of its health budget), the DRC’s 7.2% (including external donations of 23% to health), Ethiopia’s 10.8% (including 39.9% external input to health), and Nigeria’s 3.5% (including 4.8% of external input to health). This is why AU member states’ unfulfilled pledge to spend at least 15% of annual budgets on health (excluding external sources) is crucial to resolving Africa’s health crisis.

In this context, nothing glaringly exposes the apparent value of African lives more than per capita expenditure on health. While Canada, France, Germany and Japan spend $2,402, $2,646, $3,250 and $2,052 per capita on health respectively, Kenya, the DRC, Ethiopia, and Nigeria are spending $44, $6, $12, and $14 per capita. At the higher end, an African life is apparently the equivalent of one meal in a mid-level restaurant in more developed countries, and at the lower end the cost of a modest take away.

To ensure the same level of primary health coverage as Canada, France, Germany, Japan and indeed Cuba, African countries of similar populations must invest in achieving similar numbers of adequately resourced health workers while at the same time resolving other policy and infrastructure issues. A significant percentage of these costs are only required in the first 7 to 14 years of long-term plans. Education budgets that will provide the basis for science students – the health workers of tomorrow - also show similar disparities.

RESOLVING THE NIGHTMARE OF BRAIN DRAIN

But it is not just lack of sustainable health financing that is the problem. Without doubt, the brain drain from the developing to the developed world is partly to blame for making an already bad health workforce situation even worse, especially from former colonies to their former colonial ‘masters’. Countries like the US have also benefited massively from not having to train over 250,000 health workers drained from other countries at a cost of billons of dollars to those losing their healthcare professionals.

Health campaigners globally must engage governments of more developed countries and stress that recruiting health workers from less developed countries to prevent their own citizens from dying, simply means that millions of citizens of developing countries will die. Developed countries can train adequate numbers of their own health workers, and must do so to end this musical chairs of death.

Those who argue that health workers are subject to ‘market forces’ and that no health worker should be prevented from going where they want to go overlook a basic fact. African health workers leave their continent for two main reasons. One is poor pay and poor working conditions, and the other is that governments in more developed countries balance their budgets by investing less in training their own health workforce, and making up shortages by taking advantage of the situation in Africa through offering better conditions to African health workers.

The resolution of this ‘push and pull’ nightmare will not be found in any so-called ethical recruitment of health workers by developed countries. The proper, moral and sustainable solution is to ensure that more developed countries invest in training of adequate numbers of their own health workforce, and that less developed countries demonstrate full political commitment to training and retaining their health workers – where necessary with the support of more developed countries.

It is not necessary to drain health workers from less developed countries. Japan or the Scandinavian countries, for instance, do not rely on the brain drain to strengthen health systems, and neither does Cuba. In Cuba’s case, the country not only exports thousands of its own surplus doctors, it also trains thousands of African doctors for free. With the majority of health workers preferring to stay at home rather than leave behind or uproot their families in search of work, numerous staff associations and unions for health workers have underlined that decent pay and improved working conditions will make the ‘freedom of movement’ argument a non-issue for the majority of professionals.

AFRICAN GOVERNMENTS MUST IMPROVE HEALTH WORKFORCE WORKING CONDITIONS

African governments must get over the misguided idea that better working conditions for health workers somehow represents a form of discrimination against others. In many cases poor working conditions for medical personnel means going to work to issue death certificates rather than to cure patients. The negative impact this has on health workforce morale cannot be overstated. Having trained for years to save lives, I guarantee that anyone who has to go to work everyday to watch people die would become rapidly demoralised and more likely to want to work outside of their country given the opportunity.

In Nigeria one of the reasons the military gave for seizing power in the early 1980s was that the ‘hospitals had become mere consulting clinics and mortuaries.’ When the medical association went on strike to underline precisely that point following failed negotiations, the entire executive committee were jailed as ‘saboteurs’, as if their presence with inadequate tools and no medications in the ‘consulting clinics and mortuaries’ made any real difference to lives of patients.

It is of no comfort whatsoever that many of our leaders have sadly also paid the price for Africa’s health crisis. Africa holds the undistinguished position of being the continent with the greatest number of leaders passing away in foreign hospitals following “brief illness”. It is just simply difficult to imagine the leaders of Canada, France, Germany, Japan or Cuba in such sad situations. Enlightened self-interest demands that they must act urgently or continue to face the very sad embarrassment of being flown abroad to be saved, and in some cases being flown back home in coffins.

Yet at a time when all African governments should be rushing to invest in scholarships for science students, investing in more schools of medicine and nursing, investing in health systems development and better working conditions for health personnel (especially in rural areas), the health community and civil society still have to campaign, lobby, beg and fight for every additional penny for health care. While some people suggest that particular diseases are over-funded to the detriment of others, the fact is that Africa’s entire health care system is massively under-funded. Some even argue that there are other priorities more important than health.

In light of the apparent official policy in many countries that health care is the sole responsibility of the individual, future generations of Africans may yet look back and conclude such policy to be the equivalent of institutional ‘manslaughter’. Without doubt various historical injustices and the economic exploitation of Africa have weakened its capacity for development. But today the main factors responsible for its health tragedy are the lack of foresight and political will to ensure sustainable health development, financing and universal primary health care. We must find that political will if Africa is to survive and fulfil its great potential.

(1) Figures from various reports 2006 to 2008 of WHO, UNAIDS, UNDP, PMNCH, UNIFEM, UNFPA

* Sankore is Coordinator of the Africa Public Health Alliance & 15% Now Campaign, which engages African governments, global and African and institutions on implementation of the AU Africa Health Strategy, Health MDGs and fulfilling the AU Abuja pledge to allocate 15% of domestic national resources to health. He is also on the editorial advisory board of Pambazuka.

The campaign can be contacted at contactus[at]africapublichealth[dot]org, and contactus[at]africa15percentcampaign[dot]org . Reactions and comments on the write up should also be copied to editor[at]pambazuka[dot]org

© Rotimi Sankore / Africa Public Health Alliance & 15% Now Campaign. * Please send comments to [email protected] or comment online at http://www.pambazuka.org/