THE CHALLENGES OF DEVELOPING HUMAN RESOURCES FOR HEALTH IN WEST AFRICA

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The attainment of the highest possible state of health is a human right recognized by many countries, guaranteed by law in some but neither recognized nor guaranteed in the countries of the West African region. Formal health care services were commenced in the colonial era in these countries to cater primarily for the expatriates, civil servants and their families. With time, general hospitals were established in state and provincial capitals to provide services for the general population. At the onset, health care services were provided by expatriates and these were joined by a handful of Nationals. Health workforce development started with the training of middle-level professionals. The training of higher-level health professionals started after the Second World War. Post-independence, national governments extended services to more areas of the countries with emphasis on infrastructures whose locations were driven more by political imperatives than equitable distribution of health care services. As more hospitals and clinics were built, there was need to train more health professionals. The Ministries of Education, through the Universities, took on the responsibility for training doctors, dentists and pharmacists whilst the Ministries of Health established institutions for training other cadres of health workers. This dichotomy in responsibilities for education of health workers without a mechanism for consultation and collaboration between training institutions and health care provider institutions meant that training was not linked to service needs both in quantity and quality. Each sector developed and implemented its plans without recourse to the other. Major advancement in science and medical technology since the Second World War has greatly impacted on health status globally. Even in developing countries, health indices had improved and life expectancy had been elongated by a couple of years. Then came the economic crisis of the 80s and 90s and the imposed Structural Adjustment Policies and Programmes (SAP). The prescribed health reforms froze recruitment and wages and investment in education and training was capped1. The tottering health system in the region became weakened, the training institutions stagnated and brain drain was catalyzed. In Africa, especially Eastern and Southern Africa, the effect on the health system was compounded by the HIV/AIDS epidemic, which took its toll on the lives of health workers and increased their work load significantly. The World Health Organization (WHO) defined health system as the sum total of all the organizations, institutions and resources whose primary purpose is to improve health. Based on this definition, health workers are people engaged in actions whose primary intent is to enhance health.2 Since the health system is made up of the formal and the informal health delivery services, which includes home care therefore traditional healers, mothers at home and other carers and volunteers are part of the health workforce. However, because of difficulty in being able to count and plan for this large workforce, human resources for health (formal
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Lecture delivered by Prof. Kayode Odusote at the 10 AIM Inc. Public Lecture in honour of Sir Samuel Manuwa, th 12 November 2010.

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0 per 1000 in Africa with a global average of 4. health care still depends heavily on human resources. In spite of technological advancement and computerization in health. Malaria and other major diseases. There was global shortage. varying from 10. Gradually. World Bank recommended that “public health and minimum essential clinical interventions require 0. Furthermore.1 physicians per 1000 population and 2 – 4 graduate nurses per physician”. Malaria and Tuberculosis (Global Fund). US President’s Emergency Plan for AIDS Relief (PERPFAR) and Bill and Melinda Gates Foundation. This recommendation appears empirical. especially in the developing countries. In the World Health Report 1993: Investing in Health. it became clear that the extra funding was not going to achieve the desired goals due to insufficient human capacity to absorb and apply the newly mobilized resources. inequitable distribution..3 The progress report on the WHO “3 by 5” initiative stated that lack of doctors and nurses to deliver anti-retroviral therapy (ART) was a major bottleneck to scaling up access to treatment.4 More than two decades of neglect has taken its toll on the key input to a system that is labour intensive. A series of highlevel Ministerial meetings followed this realization and this culminated in the declaration of 2006 – 2015 as the decade of Health Workers by World Health Organisation (WHO).9 per 1000 population in North America to 1. In an attempt to measure health workforce quantity as opposed to ratio of individual cadres.health workers) has been defined as paid workers that are engaged in organizations and institutions whose primary intent is to improve health and those whose personal actions are primarily intended to improve health but work in other types of organizations. MDG5 to improve maternal health and MDG6 to combat HIV/AIDS. world leaders signed up to the Millennium Development Goals (MDGs) as part of an ambitious global agenda to reduce poverty and improve lives. the analysis showed a linear correlation between health workforce density and 2 . Three of these are directly related to health viz. the health worker issue had moved from the back burner of global attention towards the front burner. The health workforce remains the glue that binds all the other resources together to deliver health.0 per 1000. However by 2004. The population ratio is the conventional method of assessing and measuring the adequacy of the health workforce but there is no international agreement on a norm or minimum standard. the concept of health workforce density (aggregate sum of all health workers) was introduced by the Joint Learning Initiative (JLI) analysis.5 The analysis showed a wide regional variation in health workforce density between regions of the world. Notable among these were the Global Fund for HIV/AIDS. The often quoted WHO ratios for health workers appeared to be derived from the global average many years ago. At the Millennium Summit of the United Nations in September 2000.2 This definition has been adopted for this lecture. THE CRISIS Health workers are the keystone of the health system. Human beings still require and demand to be cared for by other human beings. Global Alliance for Vaccines and Immunization (GAVI). MDG4 to reduce child mortality. There was an overwhelming favourable response from the global donor community to provide financial support for the agenda. poor motivation and demotivating working conditions.

The average health care professional density for West Africa was 0.992 and this was extrapolated to a shortage of 1. nurses and midwives) and coverage of measles immunization and skilled attendants at birth. a minimum threshold of 1. The global mobilization in support of scaling up the human resources for health led to the First Global Forum on Human Resources for Health.73 (range 0. The shortage of doctors.4 million health care professionals (doctors.54/1000) for 80% coverage of skilled attendants at birth and this threshold has been adopted globally as the minimum standard for health worker density.05 to 1. These have been compounded by:  Migration – both internal and external  Weak support systems.5 workers per 1000 for 80% coverage of skilled attendants at birth.6 Based on the analysis. have become the guiding beacons and targets for HRH development globally and in the region. the fewer the workers the more lives lost.97) per 1000. Our countries would still have shortage of health workers in 2015 based on needs and current level of production.28 health care professionals per 1000 (range of 2. Apart from the critical shortage in numbers. All the countries in West Africa fall into this category.02 – 2. All countries in West Africa fall into the category of low-worker density and high mortality. the World Health Report 2006.the key mortality indices of MDGs 4 and 5 that is maternal mortality.472. Based on this it was estimated in 2006 that there was a global shortage of 2.3 million for all health workers. observed a threshold of 2. nurses and midwives in Africa was estimated as 817. infant mortality and under-5 mortality. Countries with low-density of health workers had higher mortalities than countries with high health worker densities. the JLI analysis showed a correlation between specific health worker density (aggregate of numbers of doctors.385 for all health workers. The obvious conclusion is that more workers save lives or in the other words. especially the availability of nurses and midwives. Similar correlations have been shown with coverage of other immunizations. nurses and midwives) which was extrapolated to 4. 3 .8 This along with the HRH goal as stated in the World Health Report 2006 – “to get the right health worker with the right skills in the right place doing the right thing”. motivated and facilitated health worker within a robust health system”. In an empirical attempt to relate health outcomes to health worker density. the report noted that 57 countries in the world had critical shortage of health workers and 32 of these were in sub-Sahara Africa. In an updated analysis.5 workers per 1000 population was computed for 80% coverage of measles vaccination and a threshold of 2. Using the minimum threshold.7 Table 1 shows the WHO statistics of health workers in the countries of the region and Table 2 shows the updated total health workforce and computed health care professionals’ density in some of the countries. the health workforce in the region as in most developing countries is characterized by:  Inequitable distribution  Inappropriate skills mix  Poor performance associated with poor motivation and poor working conditions. The vision for HRH as adopted by the Forum and stated in the Kampala Declaration and Agenda for Action is that “All people everywhere shall have access to a skilled.

3 14.78m) 311 4.006 ‡ MIDWIVES 1.38 0.773 2.726 6.709 23.262 1.63m) 225 1.608 1.667 270 134 * Source: World Health Report.081 7.86 0.489 111 469 ‡ HCP DENSITY (/1000 POP.344 Senegal (9.75 12.14 1.061 347 530 Guinee-Bissau (1.)+ 0.053 5.866 6.376 95 622 NURSES 3.258 72 3.3m) 2.40m) 162 1.317 338 1.08 0.240 15.6m) 188 912 160 40 Liberia (3.18 0.033 1.TABLE 1.57 0.289 343 Cape Verde (0. TABLE 2.43m) 103 589 446 35 Mali (13.910 1.645 5. NUMBER OF SOME CATEGORIES OF HEALTH WORKERS IN WEST AFRICA* COUNTRIES (POPULATION) PHYSICIANS NURSES‡ MIDWIVES‡ PHARMACISTS Benin (7.478 9.016 2.7m) 34.388 Guinee (8.34 0.47m) 231 410 0 43 Côte d'Ivoire (17.168 263 48 Ghana (22.37 3.57 0.973 111 7.015 Gambia (1.2 148 5.8m) 296 2.8m) 3.2m) 1.Includes auxiliary and enrolled nurses and midwives in countries where they are recognized.965 824 11 Burkina Faso (14.32 * Source: WAHO Data 2009 .797 3.794 121 280 628 471 90.211 1.268 2.Health Care Professionals 4 .352 351 Niger (14.050 128.Includes only professional registered nurses and midwives.59 COUNTRY Burkina Faso Côte d'Ivoire Gambia Ghana Guinée Liberia Mali Niger Nigeria Sierra Leone Togo ‡ + PHYSICIANS 921 2.708 51 960 427 55.407 1.082 1.986 2.918 245 1.923 127.580 82. HCP .21 0.14 0.746 49 2. 2006 ‡ . AVAILABILITY OF SOME CADRES OF HEALTH WORKERS IN SELECTED COUNTRIES IN WEST AFRICA* POPULATION 14.97m) 987 4.299 340 Togo (5.421 397 20 Nigeria (124.731 19.42m) 156 1.1m) 708 4.606 681 85 Sierra Leone (5.90m) 594 2.

300 doctors annually (Human Resources for Health Country Profile. Our experience from a recent survey of training institutions in Burkina Faso showed that admission into most government training institutions exceeded their training capacity and this may not be unique to that country. The need for scaling up production was emphasized at the 59 th World Health Assembly in 2006 and Resolution WHA59. Strategic 3. nurses and midwives and 204. The estimated annual production of medical schools in sub-Saharan Africa was 1011. Nigeria.2 we estimated that as at 2006 the region needed 255. Though our governments have established institutions to train almost all cadres of health workers that are required by our health system (but not for all medical specialists).000 more doctors. There are no gold standards and the skills 5 . In spite of seaming years of experience of our governments in the production of health workers.000 more of other health workers. United Kingdom (UK) trains over 6. only the following would be considered:    Education Maintenance Retention Education: Education and training have been the traditional approach to HRH development globally and governments proffer production of health workers as the solution to health workforce issues.THE CHALLENGES The challenges to developing Human Resources for Health in the region would be discussed at three levels: 1. For instance.23 of that Assembly urges member countries to be more committed to training health workers. being that we do not have the culture of collecting and using sound data for decision making. Using the WHO statistics. Political The Political is important in developing countries such as ours as over 70% of doctors and over 50% of other health workers are employed in the public sector and most of them.are not sure of how many of each category should be trained in order to have the correct mix of skills at all levels.000 in 2009. but in comparison with the capacity of other regions of the world. there are still challenges. all the countries in the region have critical shortage of workers. we like most other countries .10 There is no doubt that we would need to build more institutions to train health workers as existing institutions may not have room for expansion.000 doctors annually for a population of 60 million9 whilst Nigeria trains about 2. we are unlikely to be able to easily scale-up our present capacity to meet the needs. Operational 2. As stated earlier. Operational: For the purpose of this lecture. It is uncertain what the current capacity for production of health workers in the region is. especially the highly-skilled professionals are educated in public health institutions. 2008) for a population of over 150 million.

ethnic groups and cultures are represented in the health workforce. Figure 1. we should not continue to produce different categories without adequate information on the optimal mix of the different categories based on the structure of our health system and the service demands at every level. two 6 . The current selection criteria into training institutions for highly skilled professionals.mix varies widely between countries.13 The children from the rural settings (and urban lower class) are disadvantaged by the environment not by their native endowment. In spite of this.11 Figure 1 shows the wide disparity in ratios of different categories of health workers between selected countries in West Africa. The admission policy should assure equity and diversity so that all languages. favour the children of the rich and highly educated city-dwellers. I was fascinated by the title of a study from Tanzania – “wrong schools or wrong students”. dentists and pharmacists.14 By the fifth year in the medical school. There are approaches available for determining these and new models are being developed though some of these are complex and use data elements that are not normally available in most developing countries. Who should be trained has become a challenge for our region as for many other developing countries. The Nigerian quota system for admission into Universities was meant to address this but its application based on “state of origin” not “state of residence” completely defeats the intention. Ratios of different categories of health workers in selected countries of West Africa.12 We could use of our limited training capacity and resources more efficiently if we plan production based on the needs for optimal skills mix in our health system. Data from West African Health Organisation data 2009. such as doctors.

our region or the International market? In 2003. I believe the design of the new curriculum of this medical school was conscious of this challenge and had included appropriate measures in its educational methods. A graduate can “know all” for today but would be lacking in knowledge tomorrow if he/she has not continued to learn. 429 of University of Lagos. One recalls the effort to introduce an innovative medical education in a Medical School in Nigeria a few decades ago that failed after a number of years because of the resistance of the faculty to change. practicing in the Unites States. This is a departure from the traditional approach that is still the norm in medical education in Nigeria and other parts of Africa.15. The current trend is for graduates to “know-how” so that they would be able to indentify gaps in their competences and know how to compensate for this throughout their professional life. are we not encouraging migration to high-resource countries? In a survey on migration. Ife. the management of change to an integrated approach would not be an uphill task. then we need to take a fresh look at our admission criteria. this College of Medicine of the University of Ibadan for the development and approval of its new curriculum. the objective is to ensure the same quality of health care delivery through the region. should our health workers not be competent enough to recognize and manage health problems of visitors and migrant workers? If they are of International Standards. It is assumed that most of these are joining the programme because of primary interest in medicine and not socio-economic consideration and they would remain motivated throughout their medical career. Are we training health professionals for our countries. midwives. pharmacists.18 At the West African Health Organisation (WAHO). doctors. All those who were motivated by socio-economic considerations were demotivated by the low salaries. Even though this would facilitate the implementation of the ECOWAS protocol on free movement of goods and services in the region and encourage internal migration. dentists and medical specialists and we hope to include other cadres in due course. there were 643 medical graduates of the University of Ibadan. May be the current experiment at the Ghana Medical School will provide some empirical answers. one of the push factors identified was acquisition of knowledge and skills that could not be used at home and are better used abroad where better technology and facilities exist.thirds of the students. What competence do we expect of the graduating health professional? At this point I would like to at congratulate my old medical school. most of whom were children of city-dwellers. poor working conditions and heavy workload of doctors. were demotivated in comparison to their initial level of motivation on admission. Only those who had primary interest in medicine at admission remained highly motivated. 394 of the University of Nigeria.16 We hope that with the inclusive participatory approach in its development. If these findings are replicated in other medical schools in Africa. we have embarked on the process of harmonization of the training curricula of nurses. Health education is life-long learning. 183 of the University of Benin and 156 of the Obafemi Awolowo University. 7 . I understand that this is the first fully home grown medical curriculum and that it is based on the integrated approach to medical education and the use of modern teaching methodologies.17 In these days of globalization. The school has started a parallel programme that could be called “Executive MBBS” where graduates (adult students) are admitted into an intensive four year programme and are all interviewed before admission.

This is an irony of excess supply in the face of critical shortage.19 They are unable to perform the functions required to support and motivate the health worker. especially doctors. The number of funded established posts has little bearing on the health needs of the people and has more to do with the financial situation of government. the X-Ray technician constantly under-exposing films or the nurse wasting dressing lotions and sterile packs are all poorly managing the limited resources of the institution. Inequitable distribution of highly skilled health workers is a continuous challenge to HRH development in the region as in most parts of the world including the high-resource countries of Europe and North America. have fewer number of health facilities and these are manned mostly by young inexperienced health workers who are serving their mandatory period of rural deployment. health care service is a team work.000 doctors in defiance of the creditors. This should be understood and built into the culture and psyche of the health professional before graduation. Maintenance: After production. Owing to the large socio-economic disparity between the urban and the rural areas in the region. these functions are fragmented into different Ministries and those who performed them are personnel administrators who have been trained in the civil service system to handle routine civil service procedures and policies. In one of the countries in the region. there had been calls for health professionals. Even though the doctor or dentist has the primary role of finding solutions to the patient’s health problems. the health worker needs to be recruited.Apart from the core competences of the health profession. This is justified as consumption of material resources in the health sector is controlled directly or indirectly by the health worker and he/she should be conscious of his/her role in the effective and efficient use of these resources. This is what some call the “inverse care 8 . the demand for health workers is less than the supply in most countries especially for doctors and nurses who are produced in larger numbers than other categories. there is reluctance of health workers to be deployed to the rural and remote areas. These Human Resources management functions are part of the regular activities of the Human Resources Department of an organization and are expected to the performed by trained professionals. Even with our insufficient production capacity. Also the demand for health workers that is the number that government is willing to recruit. The restrictions of SAP is a major factor in most of these countries and a President of a country recently ordered the recruitment of 1. including Registered Midwives (B) in Nigeria in 2007. recruitment is carried out by the Civil Service Ministry or Commission and this is based on vacancies in the established staff schedules. Figures 2 (A and B) show the geographical distribution of doctors (A) and Registered Nurses. In the health system. The doctor prescribing 10 drugs when three are adequate. The rural areas. doctors offer their services in hospitals without being officially recruited or being on the payroll. deployed and sustained at work. which have more health service needs than the urban areas. he/she cannot provide all the interventions and care alone without the collaboration and support of other health workers. Also. has no relationship with the supply that is number of fully qualified health workers willing to accept to work in the health sector. The demand by government is determined by the wage bills and the size of the budget allocated to salaries20 regardless of the need to save lives. Except in countries where the government is decentralized and the health sector has been given some autonomy. to be trained in management before graduation. especially in the public sector.

000 population. Ratios are per 1. 2007. Figure 2a. This is a strategy that should be considered by other countries in the region if proven to be a best practice. Data from Ministry of Health. 2007. Country Human Resources Profile. The geographical distribution of Registered Nurses including Registered Midwives in Nigeria. Data from Ministry of Health. The geographical distribution of doctors in Nigeria. 9 . Country Human Resources Profile. Ratios are per 1. Some countries are recruiting retired experienced health workers on contract to fill vacancies in rural and remote areas.000 population.law”. Figure 2b.

then the agitation for more starts. easier system of post-graduate education. competent.21 However rural exposure during training has minimal effect and may have a negative effect if the students were all urban dwellers from the upper class. recognition and fairness in performance evaluation. Whilst in the lowincome countries this is due to low production capacity and low attractiveness of the health profession. fairness and transparency in promotion. Low salaries and allowances have featured in every survey on motivation of health workers and they are the usual reason for going on strike. they are also less likely to work in the rural areas for long periods.10 External migration encourages internal migration as post in urban areas left by émigrés are rapidly filled by health workers from the rural areas. motivating packages for workers should focus on non-financial incentives – good working conditions.000 African-born doctors and 70.25 Push factors include poor remuneration. Whilst female health workers are less likely to emigrate abroad. about 65. there is the culture of migration. basic principles of human resource management states that low salaries demotivate but higher salaries do not motivate.922 in UK and 133 in Canada.158 Nigeria doctors were working in United States (US). Effective performance on the job is the outcome of effective management of the worker.17. well maintained high-tech facilities. which should be corrective not punitive. 27 External migration is also a major contributing factor to the severe shortages of faculty in medical schools in Africa. This is the process of sustaining both the internal motivation and the external motivation of the worker so as to be available. Male students. safer environment and prestige.Increasing feminization of the health workforce is contributing to the deprivation of the rural areas. insufficient opportunities for post-graduate training. We are all familiar with the unending cycle of strikes for increase pay in the health sector in Nigeria and this situation is the same in most countries in the region. Pull factors include better remuneration.000 Africa-born nurses were working in developed countries. Whilst there is no doubt that every worker is entitled to a decent living wage. Studies have shown that selection of students for admission into the medical school is an important factor in the willingness of the graduate to accept deployment to the rural areas. responsive and productive. 2. socio-political instability and poor management. better living conditions. In the same year the number of Ghanaian doctors were 478 in US. who are older and have parents living in the rural area are more likely to accept such deployment14 so are those who had their primary or secondary education in the rural area. in the high-income countries it is due to ageing population.23 Retention: As mentioned earlier.24 The migration of workers from the low-income countries to high-income countries is favoured by “push factors” at home and “pull factors” abroad.18. 1. In 2000. training. poor standard of living. informal charges and drug leakage in health facilities. In addition. 10 . They are said to be responsible for absenteeism. poor working conditions. 324 in UK and 63 in Canada. increase feminization of the health workforce and growing income. The effect of any salary increase last for as long as it takes to adjust to the increased income level and for it to be depreciated by inflation. career development.26 In 2003. dual practice. The story is told of a class of midwives who were single on graduation day but all arrived with certificates/attestation of marriage a few days later when they were to be recruited and deployed.22 However. there is global shortage of health workers.

For instance the number of doctors from Nigeria working legally in UK increased from 215 in 1966 to 1. Retention of these workers in these areas is becoming an issue as well and their concerns are less with financial rewards but more with career development. There is no single “one cap fits all” solution. This has been discussed at different meetings organized in the region by WAHO and last year an action plan for mitigating this was proposed and approved by the Assembly of Health Ministers of ECOWAS. Each country needs to study the major factors favouring internal migration and develop appropriate retention strategies that should include financial and non-financial packages. One strategy that we believe would stem external migration (emigration) of high-skilled health workers especially doctors is the establishment of specialist training in the countries. opportunities for continuing medical education and supervision. They do not seem to have stemmed the international recruitment of health workers and low-income countries are being encouraged to go into bilateral agreement with high-income countries in order to manage the situation better for the mutual benefit of all. External migration would continue as long as demand for foreign health workers by high-income countries remains. These are voluntary and are without prejudice to the right of the individual to seek employment where ever he/she chooses. We noted that the postgraduate training programmes of West African College of Physicians and West African College of Surgeons are keeping more doctors in the region29 and have ensured the training and retention of obstetricians in Ghana30 (Figure 3). Figure 3.922 in 2003 and the number of nurses from the same country increased from 178 in 1998 to 511 in 2003. A number of countries have trained community health workers as part of the middle-level cadre for the primary health care services in rural areas.28 These are issues that can be solved by good HR management.Internal migration from the rural and remote areas to the urban areas and from the public sector to the private sector is a daunting challenge to HRH development in the region. 11 . Also WHO has recently published guidelines on retention of health workers in rural and remote areas which it hopes governments would use in enacting policies and plans for motivating their health workers to remain in the rural and remote areas.27 Codes of conduct for more responsible recruitment have been adopted by the government of UK in 2001. the Commonwealth Health Ministers in 2003 and at the 63rd World Health Assembly in 2010. Annual average of doctors sitting the examinations of the West African College of Physicians (WACP) and West African College of Surgeons (WACS) over a 10 year period. This is because most medical students want to specialize after graduation and post-graduation education has been identified as one of the pull factors for emigration.

Of course. Most countries depend on the payroll database for information on health workers employed in the public sector with no information on health workers in the private sector. These National Health Policies have a small section on Human Resources. In order to be focused and goal oriented. rate of emigration or the age distribution and retirement projection. A strategic approach is required to achieve the goals of global access and good health outcomes. The information base for HRH decision making is weak in all our countries. Finance and Civil Service. the Plan should be comprehensive and its development should involve all stakeholders in the country – Ministries of Health. countries need to have up-to-date information on the situation and what factors influence it.STRATEGIC CHALLENGES The development of HRH is multi-sectoral. mechanism for mobility and methods and levels of remuneration and incentives. career management. distribution and skills mix. Ideally. there should be a health policy to guide and drive the health system. regulatory bodies. Hence it is recommended that countries should have long-term plans with short-term actions and regular review. In order to do this effectively. Nigeria currently has a National HRH Strategic Plan (2008 – 2012) but I wonder how many people here present know about it and how many non-Ministry of Health stakeholders participated in its development. To the best of my knowledge. The health sector is dynamic and it is influenced by local situations and socio-cultural values. Education and training to give different categories the skills required by the objectives of the health policy 3. There is no accurate information on production and annual supply level. evaluation and accountability. professional associations. labour unions and Civil Society. training institutions. Nigeria depends on 12 . partner organizations. multidimensional and multi-disciplinary. Planning for supply of personnel to ensure adequate numbers of different categories which are equitably distributed geographically and to all levels of care. are not adequate to meet the challenges of HRH development today. many of our countries have developed or are developing National HRH Plans. multi-disciplinary and multi-dimensional and it is complex. labour unions. An HRH Policy should address31: 1. No single country in the region has accurate and up-to-date information on its health workforce – number. With the technical and financial assistance of WHO. because HRH development is multi-sectoral. 2. financial resources are required for all three. From this policy should derive the HRH policy that would guide and drive the development of HRH for achieving the goals of the Health Policy. Education. Management performance. the first National Health Policy for Nigeria was developed and adopted under the leadership of late Prof. Global Health Workforce Alliance (GHWA) and WAHO. which should include practice standards. The development of National Health Policies in our countries started with the adoption of the Health for All by the year 2000 and the need to have a strategy for achieving it. Work conditions. strategies for maintaining and upgrading quality and staff motivation. infrastructure and material resources. There are three inputs into the health system – human resources. which should include guidelines for recruitment and retention. Also the production of health workers takes 2 – 6 years for basic qualification and many more years for specialist qualification. 4. Olikoye Ransome-Kuti as Federal Minister of Health.

Figure 4 shows a trend in the density of health care professionals in selected countries in the region. Hence the computed health worker density of Nigeria is most likely an overestimation. retired or passed to the world beyond. Many organizations including WAHO are working with Ministries of Health to put in place comprehensive HRH Information systems that would capture real time information on the health workforce in the countries so that they can have sound data for monitoring their HRH plans and make appropriate decisions. others limit this category to registered nurses and registered midwives only. This should be interpreted with caution as data collection instruments are not yet standardized and information provided to different organizations may very particularly with regard to the definition of different categories of health workers. Comparison of density of health care professionals in selected countries between 2004 WHO (World Health Organization) data and 2009 WAHO (West African Health Organisation) data. This is a challenge also as most countries lack the skilled manpower to collect and analyze data as well as Information and Communication Technology resources to manage data. Figure 4. We need to know what factors influence intention to study medicine or any of the health disciplines and their effect on deployment and migration after graduation. and this information includes those who have emigrated. This is a rich mine for our public health specialists and social scientists and we hope they would rise up to the challenge.information in the database of registration bodies. Many more 13 . We need to know what factors motivate different cadres of health workers to accept deployment to the rural and remote areas. Whilst some countries include enrolled nurses and midwives in the category of nurses and midwives.32 Research is necessary to determine the factors that are responsible for the observed outcomes of the implementation of the plans and identify best-practices that can be replicated elsewhere in the country or in the region.

All these need high level decision which may sometime be against the dictates and directives of creditors and donor organizations. As mentioned earlier. There is need for long-term investment in the education of health workers. each stakeholder has influence on the availability. As mentioned earlier.questions in HRH development require local answers because of the influence of individual and socio-cultural values on health worker’s behaviour. Coordination of all stakeholders behind the National HRH Plan is crucial if it is to achieve its stated objectives. POLITICAL CHALLENGE The coordinating mechanism for HIV/AIDS works in all countries in the region is effective because of the leadership provided by the Presidencies. We need champions to lead this advocacy crusade. Education and Civil Service behind the National HRH Plan. GHWA is promoting the use of Country Coordination Framework (CCF) for getting the involvement and commitment of all stakeholders in the countries to resolve the HRH crisis. Such a leadership at the top is required to get all the major stakeholders such as Ministries of Finance. The implementation of this plan requires inter-Ministerial collaboration and approval of the Cabinet in each country. These two initiatives have created some confusion in the minds of HRH Directors of the Ministries of Health in the region. WHO is promoting the establishment of National Health Workforce Observatory (NHWO) for the coordination of the information and knowledge on HRH in the countries. At a recent meeting organized by WAHO. In some countries entire Ministries had been established for responding to the HIV/AIDS epidemic whilst in others like Nigeria. New positions need to be created in the staff establishment whilst all existing ones need to be funded and filled. 14 . There is need for budgetary allocation for financial and non-financial incentive packages. Even though the leadership of the Ministry of Health is important. All those who have interest in saving lives of mothers and children in the region must join hands in the advocacy drive to get the ears of our Presidents on the HRH crisis. HRH development involves many stakeholders outside the Ministry of Health. The 2001 (Abuja) promise of 15% of the National budget for the health sector remains an expectation in all our countries. maintenance and performance of health workers. This would reduce the number of committees and meetings and would likely make them more effective. We have the challenge to place the HRH issue on the priority list of the Presidents of our countries and get their commitments and engagement if we are to have the health workforce required to begin to significantly move towards achieving the MDGs which they signed unto. This is a major lacuna in the management of HRH in our countries. there is an ECOWAS Ministerial approved plan for retention of health workers in the rural and remote areas. it was proposed that both the CCF and NHWO should be seen as approaches to be adopted by the Human Resource for Health section of the National Health System Strengthening mechanism that are being established by the countries. especially the highly-skilled ones. special institutions or agencies were established.

which can be learnt through short courses. We need to consider the health care industry as any other service industry providing consumer-oriented solutions. his/her primary role as head of the institution should be that of leadership and he/she should be supported by administrators/managers who are trained to perform management functions. Whilst it is a key input to effective health care delivery. faith based organizations. If we recognize that every human being has a right to the attainment of the highest possible state of health and are conscious of the changing socio-economic and cultural environment then we need a paradigm shift in the way our health system is view and organized. informal charges. the system needs the balance provision of other inputs. It is traditional that the most senior doctor in the facility heads the institution. Absenteeism. However. dual practice. It is recognized that he or she is not trained as a manager and does not have the competence to do more than administer the institution following civil service rules and procedures. It is a frequent commentary from HRH Directors of the Ministries of Health that health workers were always on strike for better wages but after getting what they want. would include:      Inspire team work Mobilize resources Engage the community fully Have good relationship with local and central government Cooperate with other sectors. Then we would be able use lessons learnt from similar industries to remodel our health system at all levels to deliver responsive and satisfying solutions to all who call with their health problems. There is need for trained leadership at the facility level. This is with the realization that the nature of the health problems and the characteristic of the consumers would be continuous variables and the team of health workers (health care management team) must understand this and respond to it 15 . Lola Dare. unresponsiveness and poor patient satisfaction continue. financial and material resources. nothing changes.BEYOND HRH CRISIS Human Resources for Health is one of three major inputs in the health system. Ongoing learning site interventions in Ondo State of Nigeria by CHESTRAD has shown that health outcomes can be markedly improved without increasing health workforce by effective management of material resources and listening to health workers (Dr. Whilst it is recognized that he needs some understanding of basic management – human resources. The consumer always has a choice of how and where to solve his or her health problems. personal communication). The care provider has a choice of where to offer his/her services or change profession completely. There is need for a paradigm shift in our approach to Health System performance in order to achieve desired health outcomes. The owners of health facilities (governments. The leadership functions. The world including our region is undergoing socio-economic and cultural changes. private investors and health management organizations) have the choice as to how many health workers to demand for with or without consideration for the health needs of the population. he/she cannot be equipped with the competences of a professional manager except he/she acquires additional certification.

Partners. This approach has all the promises for us to retain and grow our share of the consumer health market against competition from the informal health system and improve the health indices of our countries.appropriately. Labour Unions and Civil Society. We need to use the talent and resources God has given us in the region better for the health and well-being of ourselves. Professional Associations. training institutions. then one can only conclude that he allows everyone to reap the benefit of the use of the talent he has given them. The challenge is for all of us – government. The outcome would not always be perfect as death and disability would still occur but the customer and his/her relations would be satisfied with our genuine efforts to solve his/her health problems. private health providers. The health workforce should have all the “know-how” competences to proffer solutions to the problems and the management should have the flexibility to provide the resources to deliver the solutions to the satisfaction of the customer at all times. Our children need not die before they can contribute to the growth and development of our region. There is no reason why our mothers should continue to die giving life a thousand times more frequently than in other parts of the world. 16 . Neither can we continue to let our best brains emigrate to other countries to serve their rural and remote areas. CONCLUSION Does God love Africans more than Japanese which is why he calls them to himself early and leave the Japanese to live well above the Biblical three score and ten years? If we say that he is a just God. We all need to be committed to achieving the goal of having the right health worker with the right skills at the right place doing the right things.

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