Human resources for primary health care in sub-Saharan Africa: progress or stagnation?

Abstract

BackgroundThe World Health Organization defines a “critical shortage” of health workers as being fewer than 2.28 health workers per 1000 population and failing to attain 80% coverage for deliveries by skilled birth attendants. We aimed to quantify the number of health workers in five African countries and the proportion of these currently working in primary health care facilities, to compare this to estimates of numbers needed and to assess how the situation has changed in recent years.MethodsThis study is a review of published and unpublished “grey” literature on human resources for health in five disparate countries: Mali, Sudan, Uganda, Botswana and South Africa.ResultsHealth worker density has increased steadily since 2000 in South Africa and Botswana which already meet WHO targets but has not significantly increased since 2004 in Sudan, Mali and Uganda which have a critical shortage of health workers. In all five countries, a minority of doctors, nurses and midwives are working in primary health care, and shortages of qualified staff are greatest in rural areas. In Uganda, shortages are greater in primary health care settings than at higher levels. In Mali, few community health centres have a midwife or a doctor. Even South Africa has a shortage of doctors in primary health care in poorer districts. Although most countries recognize village health workers, traditional healers and traditional birth attendants, there are insufficient data on their numbers.ConclusionThere is an “inverse primary health care law” in the countries studied: staffing is inversely related to poverty and level of need, and health worker density is not increasing in the lowest income countries. Unless there is money to recruit and retain staff in these areas, training programmes will not improve health worker density because the trained staff will simply leave to work elsewhere. Information systems need to be improved in a way that informs policy on the health workforce. It may be possible to use existing resources more cost-effectively by involving skilled staff to supervise and support lower level health care workers who currently provide the front line of primary health care in most of Africa.

The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa

“…As such, not only do insufficient and sub-optimally allocated resources attend the health needs of populations with some of the more complex health challenges in the world, but people's trust in health systems is shaken by frequent stock-outs of essential medicines [68][69][70] and overstretched health personnel, particularly in low-level health facilities and poor areas. 71,72 People's access to health services is in many cases is further obstructed by long distances, high travel costs, high out-of-pocket (OOP) payments, cultural beliefs, and queues. Barriers to access have been primarily researched for rural settings, but are equally relevant for those hard to reach in urban settings.…”

“…71,277 In some countries it will be decades before the minimum thresholds are reached. Therefore, much more investment is needed in pre-service education and training to increase the supply of all types of health workers, including less familiar cadres that are relatively quick to train and able to meet local health needs.…”

An assessment of equity in the distribution of non-financial health care inputs across public primary health care facilities in Tanzania

“…This contributes to the limited evidence base on the equitable distribution of human resources at the facility level [64], and it is the second study, to our knowledge, to look at equity in the distribution of drugs, medical equipment and supplies from the district level down to the facility level [55]. …”

“…To date, benefit incidence studies have generally found that the distribution of government health budgets tends to be pro-rich, with the better-off having better access to publicly-funded health services [55]. This is partly due to the concentration of health care inputs (funds, staff, medical supplies, drugs and equipment) at facilities located in urban areas that are more accessible to wealthier groups [9, 64]. Similarly, a study in Tanzania found that 20% of the population with the fewest health workers per capita had only 8% of health workers, compared to 46% in the 20% of the population with the most health workers [39].…”

Work Pressure and Safety Behaviors among Health Workers in Ghana: The Moderating Role of Management Commitment to Safety

“…Ghana's doctor and nurse population ratio is 1:10,452 for doctors and 1:1,251 for nurses, as per the 2012 annual report on the Ghana Shared Growth and Development Agenda [6]. There is no agreed international standard for overall staffing of primary health care [7]. However, in 2006 the World Health Organization (WHO) defined countries as having a critical shortage of health workers if they had fewer than 2.28 doctors, nurses, and midwives per 1,000 population and if they failed to reach the target of 80% of deliveries being attended by a skilled birth attendant [8].…”