Inequities in the Global Health Workforce: The Greatest Impediment to Health in Sub-Saharan Africa

Abstract

Health systems played a key role in the dramatic rise in global life expectancy that occurred during the 20th century, and have continued to contribute enormously to the improvement of the health of most of the world's population. The health workforce is the backbone of each health system, the lubricant that facilitates the smooth implementation of health action for sustainable socio-economic development. It has been proved beyond reasonable doubt that the density of the health workforce is directly correlated with positive health outcomes. In other words, health workers save lives and improve health. About 59 million people make up the health workforce of paid full-time health workers world-wide. However, enormous gaps remain between the potential of health systems and their actual performance, and there are far too many inequities in the distribution of health workers between countries and within countries. The Americas (mainly USA and Canada) are home to 14% of the world's population, bear only 10% of the world's disease burden, have 37% of the global health workforce and spend about 50% of the world's financial resources for health. Conversely, sub-Saharan Africa, with about 11% of the world's population bears over 24% of the global disease burden, is home to only 3% of the global health workforce, and spends less than 1% of the world's financial resources on health. In most developing countries, the health workforce is concentrated in the major towns and cities, while rural areas can only boast of about 23% and 38% of the country's doctors and nurses respectively. The imbalances exist not only in the total numbers and geographical distribution of health workers, but also in the skills mix of available health workers. WHO estimates that 57 countries world wide have a critical shortage of health workers, equivalent to a global deficit of about 2.4 million doctors, nurses and midwives. Thirty six of these countries are in sub- Saharan Africa. They would need to increase their health workforce by about 140% to achieve enough coverage for essential health interventions to make a positive difference in the health and life expectancy of their populations. The extent causes and consequences of the health workforce crisis in Sub-Saharan Africa, and the various factors that influence and are related to it are well known and described. Although there is no "magic bullet" solution to the problem, there are several documented, tested and tried best practices from various countries. The global health workforce crisis can be tackled if there is global responsibility, political will, financial commitment and public-private partnership for country-led and country-specific interventions that seek solutions beyond the health sector. Only when enough health workers can be trained, sustained and retained in sub-Saharan African countries will there be meaningful socio-economic development and the faintest hope of attaining the Millennium Development Goals in the sub-continent.

Full text

Int. J. Environ. Res. Public Health 2007, 4(2), 93-100
International Journal of
Environmental Research and Public Health
ISSN 1661-7827
www.ijerph.org
© 2007 by MDPI
© 2007 MDPI. All rights reserved.
Inequities in the Global Health Workforce: The Greatest Impediment to
Health in Sub-Saharan Africa
Stella C. E. Anyangwe*, and Chipayeni Mtonga
World Health Organization Country Office, Andrew Mwenya/Beit Roads, P. O. Box 32346, Lusaka, Republic of Zambia,
Africa
*Correspondence to Dr. Stella Anyangwe; Email: stellaanyangwe@yahoo.com
Received: 29 January 2007 / Accepted: 30 April 2007 / Published: 30 June 2007
Abstract: Health systems played a key role in the dramatic rise in global life expectancy that occurred during the 20th
century, and have continued to contribute enormously to the improvement of the health of most of the world’s
population. The health workforce is the backbone of each health system, the lubricant that facilitates the smooth
implementation of health action for sustainable socio-economic development. It has been proved beyond reasonable
doubt that the density of the health workforce is directly correlated with positive health outcomes. In other words,
health workers save lives and improve health. About 59 million people make up the health workforce of paid full-time
health workers world-wide. However, enormous gaps remain between the potential of health systems and their actual
performance, and there are far too many inequities in the distribution of health workers between countries and within
countries. The Americas (mainly USA and Canada) are home to 14% of the world’s population, bear only 10% of the
world’s disease burden, have 37% of the global health workforce and spend about 50% of the world’s financial
resources for health. Conversely, sub-Saharan Africa, with about 11% of the world’s population bears over 24% of the
global disease burden, is home to only 3% of the global health workforce, and spends less than 1% of the world’s
financial resources on health. In most developing countries, the health workforce is concentrated in the major towns
and cities, while rural areas can only boast of about 23% and 38% of the country’s doctors and nurses respectively. The
imbalances exist not only in the total numbers and geographical distribution of health workers, but also in the skills mix
of available health workers. WHO estimates that 57 countries world wide have a critical shortage of health workers,
equivalent to a global deficit of about 2.4 million doctors, nurses and midwives. Thirty six of these countries are in sub-
Saharan Africa. They would need to increase their health workforce by about 140% to achieve enough coverage for
essential health interventions to make a positive difference in the health and life expectancy of their populations. The
extent causes and consequences of the health workforce crisis in Sub-Saharan Africa, and the various factors that influence
and are related to it are well known and described. Although there is no “magic bullet” solution to the problem, there are
several documented, tested and tried best practices from various countries. The global health workforce crisis can be
tackled if there is global responsibility, political will, financial commitment and public-private partnership for country-led
and country-specific interventions that seek solutions beyond the health sector. Only when enough health workers can be
trained, sustained and retained in sub-Saharan African countries will there be meaningful socio-economic development
and the faintest hope of attaining the Millennium Development Goals in the sub-continent.
Keywords: Health workforce, human resources for health, health worker, crisis, skills mix.
Introduction
The World Health Report 2006 [3], a clarion call for
action, is dedicated entirely to the human resources for
health crisis amidst growing concerns that the global targets
such as the Millennium Development Goals (MDGs) may
not be attainable in the face of this crisis. This paper describes
the extent of the global health workforce crisis and focuses on
the reasons for, and the effects of the crisis in sub-Saharan
Africa. A description is then made of the tested and tried
strategies and documented best practices used in addressing the
crisis, and these include country-led and country-specific

Int. J. Environ. Res. Public Health 2007, 4(2)
94
actions. Global responsibility and collective solidarity,
including solutions beyond the health sector, are needed if
the health workforce crisis is to be successfully tackled for
positive impact on health outcomes in the overall context of
human development.
Findings
The global face of the human resources for health (HRH)
crisis
There is growing recognition globally that the
health workforce shortage has reached epic proportions.
The shortages affect nearly all countries across the globe.
The World Health Organization estimates that a total of
4¼ million health workers are needed to fill the gap [1].
The Global health workforce by density
Amidst the shortages, the serious issue of global
mal-distribution of health workers reflects inequities that
are even more marked than inequities in health status. To
achieve the MDGs, the minimum level of health
workforce density is estimated at 2.5 health workers per
1,000 people [1]. Out of 46 countries in the sub-Saharan
Africa region, only 6 have workforce density over 2.5
per 1,000 people. Indeed, Africa’s health workforce
density averages 0.8 workers per 1000 population,
significantly lower compared to the other regions and to
the world median density of 5 per 1,000 population [2].
Table 1: Global health workforce, by density
Source: World Health Report (WHR) 2006
Asia, with about 50 percent of the world’s population,
has 30 percent of the global stock of doctors, nurses, and
midwives. Together, Europe and North America have 20
percent of the world’s people, but have almost half of the
physicians and 60 percent of the nurses. Africa has only an
average of 2.3 health workers (all categories combined) per
1000 population, compared to 18.9 and 24.8 for Europe and
the Americas respectively (Table 1) [3]. The availability of
health workers has now become an indicator that
differentiates the “haves” from the “have-nots”, the
developed countries from the developing, and the rich
nations from the poor ones, with the nations of Europe and
North America having the highest densities of trained health
workers.
Human resources for health and national wealth
In general, countries with higher per capita GDP and
incomes have more health workers (Figure 1). Norway and
the United States of America are among the countries with
the highest per capita income and the greatest density of
health workers per 1000 population. Most countries in sub-
Saharan Africa have the lowest per capita income as well as
the lowest health worker density. However, some exceptions
exist where countries with abundant material resources and
high income (e.g. Gabon and Equatorial Guinea) still have
relatively inadequate numbers of health workers. Inequities
also exist within countries, with urban, wealthier areas having
greater proportions of all trained health workers than rural
and poorer areas of countries.
Source: WHR 2006
Figure 1: Higher income—more health workers
Distribution of health workers and burden of disease
Ideally, countries with the highest burden of disease
should have the greatest numbers of skilled health workers.
Unfortunately, this is not the case in today’s world. Between
regions, sub-Saharan Africa faces the greatest challenges
(tables 2, 3 and figures 2, 3). The region has about 11% of the
world’s population, bears over 24% of the global disease
burden, is home to only 3% of the global health workforce,
and spends less than 1% of the world’s financial resources on
health. On the other hand, the Americas (mainly USA and
Canada) are home to 14% of the world’s population, bear
only 10% of the world’s disease burden, but have 37% of the
global health workforce and spend about 50% of the world’s
financial resources for health. It is worthy of note that a good
proportion of the health workforce in the Americas originates
from sub-Saharan Africa. Details are presented later on in
this paper. Table 2 summarizes the differences between the
Americas and sub-Saharan Africa. Sub-Saharan Africa
carries about 74% of the global burden of communicable
diseases (table 3, fig. 2), among which are the three biggest
causes of morbidity and mortality, namely malaria,
tuberculosis and AIDS-related illnesses.

Int. J. Environ. Res. Public Health 2007, 4(2)
95
Table 2: The summary of some differences between the
Americas and sub-Saharan Africa
The Americas Sub Saharan Africa
14% of the World
Population
11% of the World Population
10% of the Global Burden
of Disease
25% of the Global Burden o
f
Disease
42% of the World’s Health
Workers
3% of the Worlds Health
Workers
>50% of the Global Health
Expenditure
<1% of Global Health
Expenditure
Source: World Health Organization (2006); The Global
Shortage of Health Workers and Its Impact.
Fact sheet N° 302 April 2006, http://www.who.int
/mediacentre/factsheets/fs302/en/print.html [1]
Table 3: Estimated Burden of Disease in Africa Relative
to the Rest of the World, 1999
Source: United States Agency for International
Development Bureau for Africa, Office of Sustainable
Development (2003). The Health Sector Human
Resource Crisis in Africa: An Issues Paper; Support for
Analysis and Research in Africa (SARA) Project,
Academy for Educational Development (AED) 1825
Connecticut Ave., NW Washington, DC 20009, USA (3)
0
10
20
30
40
50
60
70
80
Africa The Rest of the
World
Total
Communicable Diseases Non Communicable Diseases Injuries
Source: Adapted from “United States Agency for
International Development Bureau for Africa, Office of
Sustainable Development (2003). The Health Sector
Human Resource Crisis in Africa: An Issues Paper; Support
for Analysis and Research in Africa (SARA) Project,
Academy for Educational Development (AED) 1825
Connecticut Ave., NW Washington, DC 20009, USA [3].
Figure 2: Percentage burden of disease in Africa and in
the rest of the world, 1999.
Source: WHR 2006
Figure 3: Distribution of health workers by burden of
disease, by WHO region
The urban-rural divide regarding HRH
In general, amidst the inter-country and inter-regional
imbalances in the density of the health workforce, there are
also intra-country inequities, with greater numbers and
better trained health workers concentrated in urban areas, to
the detriment of rural areas (fig. 4).
0
10
20
30
40
50
60
70
80
Proportion
Doctors Nurses Others
Source: Adapted from the WHR 2006
Figure 4: Average global urban-rural distribution of health
service providers.
Many factors influence the geographical distribution of
health worker density world-wide. The most common
factors that force health workers away from jobs in rural
areas are the lack of incentives and amenities, as well as
limited opportunities for career progression. With the very
low salaries of health workers in sub-Saharan Africa, health
workers in urban areas tend to compensate through
unauthorized private practice, or resort to predatory
behaviour such as extracting under-the-counter payments
from patients, or misappropriating drugs or other supplies
(4). In Tanzania, the capital city of Dar-es-Salaam alone has
nearly 30 times as many medical officers and medical
specialists as any of the rural districts [5].
The extent of the HRH crisis in sub-Saharan Africa
The global problem of inadequate human resources for
health is most acute in sub-Saharan Africa where the scope
Items Africa
Rest of the
World
Total
% Communicable
disease
73.7% 32.1% 42.8%
% Non-
Communicable
disease
17.1% 52.4% 43.3%
% Injuries 9.2% 15.5% 13.9%

Int. J. Environ. Res. Public Health 2007, 4(2)
96
of the health workforce crisis is alarming. There is
simply insufficient adequately trained human capacity, of
all cadres, in the region to absorb, apply and make
efficient use of the interventions being offered by many
new health initiatives. Among the key problems
contributing to the shortages are the insufficient training
opportunities. Africa is woefully lacking in facilities to
train health workers. Two-thirds of sub-Saharan African
countries have only one medical school, and 11 sub-
Saharan countries have no medical school at all. In
general, the health personnel to population ratios in sub-
Saharan African countries have been higher than those of
the rest of the world (5). In the 1980s, one doctor catered
for 10,800 persons in sub-Saharan Africa, compared to 1
for 1,400 in all developing countries combined, and 1 for
300 in industrialized countries. In the same period, one
nurse catered for 2,100 persons in Africa, compared to 1
for 1,700 persons in all developing countries combined,
and 1 for 170 in industrialized countries [6]. In
Mozambique in 2006, 3 physicians and 21 nurses cater
for 100,000 inhabitants, a workforce density most
certainly incompatible with the possibility of achieving
or sustaining 80% of essential health priority program
me goals [6].
In selected sub-Saharan African countries, between
20% and 60% of all physicians trained in these countries
now work abroad (table 4). The migration of skilled
health workers, infamously known as the “brain drain”,
is one of the most prevalent causes of the health
workforce crisis in the region.
Table 4: Doctors Trained in sub-Saharan Africa
Working in OECD Countries
Source: WHR 2006
Forces influencing the HRH Crisis in sub-Saharan
Africa
There are numerous forces (“push” and “pull”
factors) that influence the health workforce crisis in sub-
Sahara. These range from “driving forces” to “workforce
challenges” (figure 5) seeking to describe and to explain
the extent and the rationale of the crisis.
Source: WHR 2006
Figure 5: Forces driving the workforce
Health needs
The high burden of disease and epidemics, especially
the HIV/AIDS pandemic, has put a terrible strain on the
health workforce, given that the production of health
workers has not kept pace with the need. Besides, the
HIV/AIDS pandemic has also taken its dreadful toll on the
health workforce itself. With the increasing deaths from
AIDS, the numbers of those who are supposed to help fight
the disease are dwindling. In many sub-Saharan African
countries, between 18% and 41% of the workforce is
already infected with HIV [5]. Burnout of remaining
practicing health workers is cause and consequence of the
HRH crisis.
Health systems
Poor economic growth and successive fiscal difficulties
appear to be the immediate causes of the crisis. On the one
hand, budgetary stringency under health sector reforms that
accompany structural adjustment programmes has reduced
African governments’ ability to attract, employ and retain
well-trained health workers. Likewise, inadequate
investment in the health sector, with unmet needs in the
training of all cadres of health workers, and in the
refurbishment of health care facilities, has resulted in
inadequate numbers and skills of health workers, and in the
migration of health workers.
Global context
The low birth rate in developed countries, with the
resulting low numbers of persons training to be health
workers, as well as the increasingly large populations of the
elderly that require high levels of care, pull large numbers
of health workers from the developing to the developed
countries.
Diverse workforce challenges
1. The shortages of health workers in the public sector
while there are large numbers of unemployed, trained
and skilled health workers in-country (health and/or
public sector reforms).

Int. J. Environ. Res. Public Health 2007, 4(2)
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2. Presence of health workers with skills not suited for
the health needs of their countries or communities
(skill mix). For both doctors and nurses, African
countries have largely focused on clinical training
and specialties, rather than on the more relevant
public health training. Example of doctors in the
Philippines retraining themselves as nurses to pursue
lucrative opportunities in changing export markets.
3. Internal mal-distribution (unequal and inequitable
distribution) of health workers, with most located in
urban areas, and moving from the public to private
sector.
4. International migration of skilled health workforce
(brain drain) from the developing to developed
countries.
5. Dismal working conditions for health workers,
including unsafe workplaces, inadequate
compensation and incentives (financial and
otherwise), and insufficient or no career
development opportunities.
Overall, the combined effects of accelerated
retrenchment, voluntary retirement and departure,
internal and external migration for all reasons, and
sickness and death from communicable and non-
communicable diseases, place sub-Saharan Africa at the
epicentre of the global health workforce crisis.
Effects of the HRH crisis
The global shortage of human resources for health is
a crisis of epic proportions, posing an ominous threat to
health development in the overall context of human
development. Health care delivery is a labour-intensive
service industry. Health service providers are the
backbone of a health system’s core values: they treat and
care for people, ease pain and suffering, prevent disease
and mitigate risk, and are the link connecting knowledge
to health action. There is ample evidence that health
worker numbers and quality health care are positively
correlated, especially in the domains of immunization
coverage, primary care, and infant, child and maternal
survival (figure 6). Pressing health needs across the
globe cannot be met without adequate numbers of well-
trained and available health workers.
Source: WHR 2006
Figure 6: Relationship between the probability of
survival and density of the health workers: “HEALTH
WORKERS SAVE LIVES”
The attainment of the Millennium Development
Goals (MDGs), a blueprint agreed upon by countries and
leading development institutions for meeting the needs
of the world’s poorest people, faces major impediments
on account of the health workforce crisis. The goals to
reduce child mortality, improve maternal health, combat
HIV/AIDS and other diseases such as tuberculosis and
malaria, and to ensure access to essential medicines will
not be met in sub-Saharan Africa if there is no drastic
and immediate improvement in the availability and
quality of essential health workers. Emerging global
threats such as outbreaks of avian influenza will
overwhelm local and national health systems and will
undoubtedly not be contained by the present global
levels of health workers.
The HIV/AIDS pandemic is a uniquely vicious peril to
the health workforce. HIV/AIDS is responsible for a lot of
the attrition of the health workforce through HIV-related
mortality. A Kenyan study cites hospital-bed occupancy
rates that have reached 190% due to HIV/AIDS [8].
Increased need for testing and follow-up of suspected HIV-
infected patients has also been noted as an additional
burden on already over-stretched staff, thus increasing
overall workload requirements.
In the HIV/AIDS literature, scaling up treatment with
antiretroviral drugs was estimated to require between 20%
and 50% of the entire available health workforce in four
African countries, but less than 10% of health workers in
the other 10 countries surveyed [9]. In addition to that, the
opportunity costs for treating HIV have proven immense in
the presence of the health workforce crisis. A recent review
in Zambia showed that as Anti Retroviral Therapy (ART) is
scaled up, there is a decline in routine immunization
coverage. The limited number of available health workers
cannot adequately manage to carry out both tasks
effectively [10].
The critical shortages in human resources for health
constitute one of the key causes of exclusion to access to
quality health care, and this is especially true in rural
Africa. The WHR 2006 while acknowledging that many
more mothers and children currently have access to
reproductive, maternal and child care entitlements than
ever before in history, also observes that in many
countries, however, universal access to the goods, services
and opportunities that improve or preserve health is still a
distant goal. The report observes that in too many
countries a varying but large proportion of the populations
remains excluded from the health benefits that others in
the same country enjoy. This is particularly true for most
sub-Saharan countries where the health worker crisis
results in the exclusion of the rural poor to quality health
care. In the 42 countries that in 2000 contributed 90% of
all deaths of children under five years of age, 60% of
children with pneumonia failed to get the antibiotic they
needed, and 70% of children with malaria failed to receive
treatment [11]. The lack of trained health workers in most
instances contributed heavily to the failure to receive
treatment.

Int. J. Environ. Res. Public Health 2007, 4(2)
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Tackling the HRH Crisis
The High Level Forum on MDGs held in Abuja in
December 2004 acknowledged that unless action is taken
urgently to address the human resource for health crisis,
many countries will fail to reach their Millennium
Development Goals and this would not merely represent
a missed deadline but a real calamity for the
impoverished citizens of the affected countries (5).
The three dimensions to the crisis in human
resources for health namely, the overall shortage, the
mal-distribution and the low productivity of health
workers need to be addressed to tackle the crisis.
Although no one solution is available or feasible, the
overall goal of any remedial action will be to get the
right health workers with the right skills in the right
place and doing the right things. Each country is unique
but each can and should learn from the experiences of
others. Best practices abound and need to be shared.
Some of the plausible solutions for tackling the health
workforce crisis are outside the health sector and
countries need to employ multi-faceted approaches to
achieve the highest gains. Some of the most promising
approaches are described below and they all target the
training, retention and sustenance of skilled health
workers.
Increase investment in pre-service training (intake and
output)
The number of trained health workers in sun-
Saharan Africa has historically been inadequate, with
severe scarcities of almost all cadres due to economic
and fiscal difficulties. The most obvious response to a
shortage of human resources is to train more. An
effective approach for quick short-term gains would be
to train large numbers of health workers with basic
clinical skills (enrolled nurses, midwives, clinical
officers) and community health workers, especially
trained to meet the health needs of their localities.
Providing scholarships for poor students, for those from
remote rural areas, and for high academic achievers is
one way of attracting students to and keeping students in
the health professions.
In some cases it may be helpful to relax entry
requirements into health institutions. This can be done in
conjunction with the introduction of catch-up courses to
fill in gaps left by poor secondary school education. In
Malawi this approach has made it possible to expand the
medical school yearly intake from 20 to 60 [5].
Efforts to expand pre-service training should go
hand in hand with the availability of trainers or else the
efforts may falter if trainers are not readily available, as
was the experience in Ghana [14]. Pre-service training
for health workers should take into consideration
measures to attract and retain tutors and trainers.
For training of sufficient numbers of health workers,
the private sector needs to partner with the public sector
and national governments need to provide incentives to
private institutions to encourage them to train health
workers.
Improve income and living wage
The single most crucial factor in the infamous ‘brain
drain’ is the issue of salaries and conditions of service. All
measures considered, improvement in health workers’ pay
rates will not reduce health worker outflows. Failure to
improve conditions of service will lead to coping
mechanisms such as ‘private practice’ within public
institutions. In some countries like Bangladesh and Egypt,
the majority of all physicians in the public sector see private
paying patients to supplement income from their regular
jobs, while in Kazakhstan “informal payments” are
estimated to add 30% to the national health care bill [12].
Wage increases usually target the cadre with the highest net
outflow rates. However, implementation of pay rises is
fraught with numerous barriers and constraints, including
public wage bill expenditure ceilings, and other fiscal
constraints.
One effort to improve pay was Ghana’s Additional
Duty Hours Allowance which is claimed to have had an
immediate short term effect on retaining staff. However,
there has not been a comprehensive evaluation and
anecdotal evidence suggests that the long-term effect on
health worker retention is negligible [5]. In Tanzania the
Selective Accelerated Salary Enhancement scheme has
provided an opportunity for ministries to raise levels of
remuneration for high priority groups but the long term
effect is yet unknown [13].
De-linking health workers from the civil service can be
an alternative approach to improving their wages without
involving the entire civil service. This was attempted in
Zambia but the proposal encountered resistance from
professional groups and eventually was not implemented.
Ghana, on the other hand, has successfully de-linked tax
collectors and bank employees from the civil service but not
yet health workers [14].
Providing better housing, reducing occupational risks
of contracting HIV and other infections, lowering
workloads, improving supervision, making it easier for
health workers to remain in employment whilst
accompanying their spouses on postings or bringing up a
young family, are measures which countries can attempt to
implement. It is very important though that the health
workers are consulted and are on board all time.
Extend retirement ages
Retirement age in most sub-Saharan African countries
is early compared to countries in Europe. In Zambia for
instance, the retirement age for health workers is 55 years.
Often, the retiring health workers are still in good health,
are highly skilled and are able to perform their duties well
with little supervision. This group is an untapped resource-
pool that could make a difference. In Malawi, it is estimated
that there are 800 to 1200 nurses currently not working in
their field. In Ghana where the retirement age is 60 years,

Int. J. Environ. Res. Public Health 2007, 4(2)
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government has issued a call to reappoint retired health
professional and up to two thirds of eligible doctors and
nurses have applied. They are given two-year renewable
contracts till the age of 65years [5, 14]. Some countries
have changed the retirement ages or planned to change
these in order to extend the working life of their staff.
Recruit from abroad
Wealthier countries recruiting from less endowed
ones is the root of the infamous “brain drain”, and is to
be decried. However, recruitment can be done from
countries that have an abundance of health workers. In
sub-Saharan Africa, many governments have agreements
with Cuba to recruit their doctors. Ghana, for example,
employs over 200 Cuban doctors on two-year contracts
and these doctors serve some of the most remote areas in
the country [5].
In the past, donor (developed) countries provided
expatriate health workers to work in sub-Saharan
countries, but the practice has been largely abandoned
for reasons of cost and sustainability. In Zambia, the
Dutch government has converted the funds which once
served to pay expatriate Dutch doctors to work in
Zambia, into the “Health Workers Rural Retention
Scheme”. These funds are used for improving the overall
pay package and conditions of service for Zambian
doctors who work in the rural districts of the country.
Anecdotal evidence suggests that this project is a great
success with Zambian doctors now getting deployed to
even the most rural districts where previously no
Zambian doctor was willing to serve.
Achieve a more appropriate mix of skills
To alleviate the health worker crisis in sub-Saharan
Africa, there is need to remove some of the hitherto
unrealistic standards and barriers to professional practice
that exist. Clinical, surgical and obstetrical diagnosis and
treatment should not be the preserve of doctors, surgeons
and obstetricians alone. Certain functions need to be
assumed by lower skilled cadre of health workers in
order to achieve a more sustainable skills match for
wider health worker coverage. Different countries have a
variety of indigenous health professionals trained locally.
There are “Clinical Officers” in Malawi and Zambia,
“Surgical and Medical Technicians” in Mozambique,
“Assistant Medical Officers” with surgical and obstetric
skills in Tanzania, and “Medical Assistants” in Ghana.
The Medical licentiates and clinical officers in Tanzania
have been trained to diagnose, treat and prescribe and
can therefore fulfill many of the functions in district
hospitals that the shortage of doctors would otherwise
have made impossible. Nurse practitioners in Swaziland
and enrolled nurses in Malawi have likewise played
immense roles in their health systems, particularly in
remote areas where it is difficult to get better-qualified
health professionals to practice. These cadres typically
have 2-3 years post-secondary training rather that the 5-6
required for training medical doctors.
Improve the Distribution of Human Resources
Equitable distribution of health workers is always a
dilemma is sub-Saharan countries. The remote and under-
developed areas with poor or no social amenities are always
difficult to post staff to, without innovative incentives.
Ghana’s ‘Deprived Area Incentive Scheme’ and Zambia’s
“Health Workers Rural Retention Scheme”, that include
housing or housing allowances, fast-track promotion and
career development opportunities, car or car loans and
education grants for staff children among other things, are
seemingly successful in keeping doctors in under-served
areas. These schemes now need to be extended to the other
cadre of health workers to improve their distribution and
retention in the most rural districts too.
The report on the High Level Forum on Health MDGs
[5] is very cautious about obligatory government service or
“bonding” of newly-graduated health workers. The report
contends that though the graduates can be posted to rural
areas in obligatory government service, this means that
these areas get the least experienced staff and that these
graduates are often poorly supervised at a crucial stage in
their career development. The report further states that
obligatory service also tends to foster corruption as a
‘market’ emerges for transfers to more desirable posts. In
extreme cases, obligatory social service may cause some
graduates to emigrate.
Conclusion
The global health workforce crisis is immense and
universal but its effects are certainly worse in sub-Saharan
Africa. The crisis is as much a political as a fiscal one.
Difficult political decisions must be made. Governments
must have the political will to acknowledge the presence
and extent of the crisis, and the commitment to convince
their parliaments to approve the huge sums of money
needed to tackle the different dimensions of and possible
solutions for the crisis. Money freed up by debt relief
should also target this immense crisis in the health sector.
There is no “magic bullet” solution for the crisis but best
practices and promising innovative interventions abound
and should be shared and implemented. For these to
succeed there must be close collaboration between
governments, the private sector and the health workers
themselves. Furthermore, there needs to be better dialogue
and cooperation between developed “health worker-
recipient” countries and developing “health worker-donor”
countries, so that agreement can be reached on a more
humane and mutually-beneficial migration of health
workers. The Millenium Development Goals should not be
achieved in some parts of the world at the expense of sub-
Saharan African countries which, with the present levels of
health worker availability and the incapacity to train more
quickly enough, will undoubtedly not achieve the MDGs. It

Int. J. Environ. Res. Public Health 2007, 4(2)
100
should be remembered that if remedial action seems too
costly, inaction is definitely suicidal.
Dedication: This paper is dedicated to Dr. C. Mtonga (Co-
Author), who died suddenly on Sunday: January 7, 2007.
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