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

Human Resources for Health, Sep 2015

Background The 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. Methods This study is a review of published and unpublished “grey” literature on human resources for health in five disparate countries: Mali, Sudan, Uganda, Botswana and South Africa. Results Health 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. Conclusion There 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.

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

Willcox et al. Human Resources for Health Human resources for primary health care in sub-Saharan Africa: progress or stagnation? Merlin L Willcox 0 Wim Peersman 2 Pierre Daou 6 Chiaka Diakité 5 Francis Bajunirwe 1 Vincent Mubangizi 1 Eman Hassan Mahmoud 4 Shabir Moosa 3 Nthabiseng Phaladze 8 Oathokwa Nkomazana 7 Mustafa Khogali 4 Drissa Diallo 5 6 Jan De Maeseneer 2 David Mant 0 0 Nuffield Department of Primary Care Health Sciences, University of Oxford , Oxford , UK 1 Department of Community Health, Mbarara University of Science and Technology , Mbarara , Uganda 2 Department of Family Medicine and Primary Health Care, Ghent University , Ghent , Belgium 3 Department of Family Medicine, University of Witwatersrand , Johannesburg , South Africa 4 Ahfad University for Women , Omdurman , Sudan 5 Department of Traditional Medicine, National Institute for Public Health Research , Bamako , Mali 6 Faculty of Medicine , Pharmacy and Dentistry , University of Bamako , Bamako , Mali 7 School of Medicine, University of Botswana , Gaborone , Botswana 8 School of Nursing, University of Botswana , Gaborone , Botswana Background: The 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. Methods: This 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. Results: Health 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. Conclusion: There 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. Human resources for health; Primary health care; Review; Sudan; Mali; Uganda; Botswana; South Africa - Introduction Primary health care is widely recognized as the most costeffective strategy for delivering essential health interventions, for example, to reduce maternal and child mortality [1-3]. According to the Declaration of Alma-Ata, primary health care “addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly…. [it] relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community” [4]. Reducing maternal and child mortality are key public health aims, embodied in the Millennium Development Goals [5]. Although there are good evidence-based interventions to achieve these goals [2], an important constraint in implementing them is the shortage of human resources, particularly in primary health care. © 2015 Willcox et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommon (...truncated)


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Merlin L Willcox, Wim Peersman, Pierre Daou, Chiaka Diakité, Francis Bajunirwe, Vincent Mubangizi, Eman Mahmoud, Shabir Moosa, Nthabiseng Phaladze, Oathokwa Nkomazana, Mustafa Khogali, Drissa Diallo, Jan De Maeseneer, David Mant. Human resources for primary health care in sub-Saharan Africa: progress or stagnation?, Human Resources for Health, 2015, pp. 76, 13, DOI: 10.1186/s12960-015-0073-8