Human resources for health in Africa
http://www.100md.com
《英国医生杂志》
Better training and firm national policies might manage the brain drain
African countries have a very low density health workforce, compounded by poor skill mix and inadequate investment.1 Yet trained healthcare staff continue to migrate from Africa to more developed countries. The World Health Organization has estimated that, to meet the ambitious targets of the millennium development goals, African health services will need to train and retain an extra one million health workers by 2010.2
It is too simplistic and misleading to define or try to resolve the crisis in human resources for health in Africa by looking only at overall numbers and density of workers, not least because these vary from country to country.3 4 Furthermore, the poor performance of health services in African countries is often compounded by shortages of drugs and other essential supplies, broken equipment, and poor logistical support. Africa needs balanced investment in human resources, infrastructure, drugs, logistics and other supportive services that will enhance the capacity to deliver health care.
Seven main principles should guide the debate on developing and refining African health services (box). African leaders are beginning to work together on this, supported by the regional office of the World Health Organization, the New Partnerships for Africa's Development, and the African Council for Sustainable Health Development. Each country needs clear policies on human resources, based on objective analyses of needs and opportunities and aimed at strengthening the healthcare system in a sustainable way.
Such policies must include strategies for dealing with migration of health staff to developed countries.5 6 Mass migration of health personnel is often a symptom of the "sick system syndrome," in which many essential components of healthcare services are malfunctioning and mismanaged. Policies on migration policy must tackle the "pull factors" which induce trained personnel to seek better living conditions abroad as well as the "push factors" which make disaffected and frustrated health workers seek employment elsewhere. The "anchor factors" which encourage workers to remain in public service are important too.7-9 These may include well designed training programmes that increase workers' skill and competence, boost their morale, increase their job satisfaction, and improve the performance of services.
Ghana has developed two training programmes which successfully combine appropriate curriculums and policies for developing human resources. With guidance and support from the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynaecologists, two Ghanaian medical schools now operate the Ghana Residency Programmes in Obstetrics and Gynaecology.10 11 This programme provides trainees with sound clinical knowledge and appropriate skills for practising in both hospital and community settings. The programme has produced a steady stream of obstetric specialists, practically all of whom are still working in Ghana. A programme for training midwives in lifesaving skills, run by the Ghana Registered Midwives Association in both the private and public sectors, has successfully enabled midwives to deal alone with some emergencies and also stabilise patients before referral for more specialised emergency obstetric care.12
Such training might be partially funded by health services in the countries which welcome health workers from Africa, thereby providing mutual benefit. And countries such as Nigeria, which produces more trained health personnel than its health system can use effectively, might benefit from a programme of managed emigration.
Africa's health authorities—with financial and technical support from national, regional, and international partners—need to design and implement creative policies for managing their human resources. In turn, development partners, some of which may have followed only their own globally focused agendas in the past, must show that they respect the national goals and priorities of African countries.
Guidelines for developing Africa's response to the crisis in human resources for health
Strong African leadership to direct debate and discussions
Analysis within countries to establish national and local needs for health workers
Regional consultations and networking to share relevant lessons
Diagnostic approaches to inform evidence based action: Identify signs and causes of the "sick system syndrome" Generate information about the distribution and flow, both internally and externally, of health workforces
Development of policies on human resources which are relevant, affordable, and sustainable and are realistic about migration of trained staff.
Adoption of and respect for policies on human resources by national authorities and development partners
Evaluation and review within and between African countries of relevant experience and innovations
Adetokunbo O Lucas, adjunct professor
Harvard University, Cambridge, MA 02115, USA
Competing interests. AOL was professor of preventive and social medicine, University of Ibadan, Nigeria.
References
Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, et al. Human resources for health: overcoming the crisis. Lancet 2004;364: 1984-90.
World Health Organization. High level forum on the health MDGs. Addressing Africa's health workforce crisis: an avenue for action. 2004. www.hlfhealthmdgs.org/Documents/AfricasWorkforce-Final.pdf (accessed 22 Sep 2005).
Norad. Overcoming the crisis—taking the Abuja action agenda forward. www.norad.no/default.asp?V_ITEM_ID=3011&V_LANG_ID=0
Habte D, Dussault G, Dovlo D. Challenges confronting the health workforce in sub-Saharan Africa. World Hosp Health Serv 2004;40(2): 23-6, 40-1.
Dugger CW. An exodus of African nurses puts infants and the ill in peril. New York Times 2004 Jul 12;: A1, A6-7.
Bach S. Migration patterns of physicians and nurses: still the same story? Bull World Health Organ 2004;82: 624-5.
Dovlo D. Taking more than a fair share? The migration of health professionals from poor to rich countries. PLoS Med 2005 May;2: e109.
Stilwell B, Diallo K, Zurn P, Vujicic M, Adams O, Dal Poz M. Migration of health-care workers from developing countries: strategic approaches to its management. Bull World Health Organ 2004;82: 595-600.
Ahmad, OB. Managing medical migration from poor countries BMJ 2005;331: 43-5.
Martey JO, Elkins TE, Wilson JB, Adadevoh SW, MacVicar J, Sciarra JJ. Innovative community-based post-graduate training for obstetrics and gynecology. Obstet Gynecol 1995;85: 1042-6.
Martey JO, Hudson CN. Training specialists in the developing world: ten years on, a success story for West Africa. Br J Obstet Gynaecol 1999;106: 91-4.
Marshall MA, Buffington ST. A life-saving skills manual for midwives. 3rd ed. Washington, DC: American College of Nurse-Midwives, 1998
African countries have a very low density health workforce, compounded by poor skill mix and inadequate investment.1 Yet trained healthcare staff continue to migrate from Africa to more developed countries. The World Health Organization has estimated that, to meet the ambitious targets of the millennium development goals, African health services will need to train and retain an extra one million health workers by 2010.2
It is too simplistic and misleading to define or try to resolve the crisis in human resources for health in Africa by looking only at overall numbers and density of workers, not least because these vary from country to country.3 4 Furthermore, the poor performance of health services in African countries is often compounded by shortages of drugs and other essential supplies, broken equipment, and poor logistical support. Africa needs balanced investment in human resources, infrastructure, drugs, logistics and other supportive services that will enhance the capacity to deliver health care.
Seven main principles should guide the debate on developing and refining African health services (box). African leaders are beginning to work together on this, supported by the regional office of the World Health Organization, the New Partnerships for Africa's Development, and the African Council for Sustainable Health Development. Each country needs clear policies on human resources, based on objective analyses of needs and opportunities and aimed at strengthening the healthcare system in a sustainable way.
Such policies must include strategies for dealing with migration of health staff to developed countries.5 6 Mass migration of health personnel is often a symptom of the "sick system syndrome," in which many essential components of healthcare services are malfunctioning and mismanaged. Policies on migration policy must tackle the "pull factors" which induce trained personnel to seek better living conditions abroad as well as the "push factors" which make disaffected and frustrated health workers seek employment elsewhere. The "anchor factors" which encourage workers to remain in public service are important too.7-9 These may include well designed training programmes that increase workers' skill and competence, boost their morale, increase their job satisfaction, and improve the performance of services.
Ghana has developed two training programmes which successfully combine appropriate curriculums and policies for developing human resources. With guidance and support from the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynaecologists, two Ghanaian medical schools now operate the Ghana Residency Programmes in Obstetrics and Gynaecology.10 11 This programme provides trainees with sound clinical knowledge and appropriate skills for practising in both hospital and community settings. The programme has produced a steady stream of obstetric specialists, practically all of whom are still working in Ghana. A programme for training midwives in lifesaving skills, run by the Ghana Registered Midwives Association in both the private and public sectors, has successfully enabled midwives to deal alone with some emergencies and also stabilise patients before referral for more specialised emergency obstetric care.12
Such training might be partially funded by health services in the countries which welcome health workers from Africa, thereby providing mutual benefit. And countries such as Nigeria, which produces more trained health personnel than its health system can use effectively, might benefit from a programme of managed emigration.
Africa's health authorities—with financial and technical support from national, regional, and international partners—need to design and implement creative policies for managing their human resources. In turn, development partners, some of which may have followed only their own globally focused agendas in the past, must show that they respect the national goals and priorities of African countries.
Guidelines for developing Africa's response to the crisis in human resources for health
Strong African leadership to direct debate and discussions
Analysis within countries to establish national and local needs for health workers
Regional consultations and networking to share relevant lessons
Diagnostic approaches to inform evidence based action: Identify signs and causes of the "sick system syndrome" Generate information about the distribution and flow, both internally and externally, of health workforces
Development of policies on human resources which are relevant, affordable, and sustainable and are realistic about migration of trained staff.
Adoption of and respect for policies on human resources by national authorities and development partners
Evaluation and review within and between African countries of relevant experience and innovations
Adetokunbo O Lucas, adjunct professor
Harvard University, Cambridge, MA 02115, USA
Competing interests. AOL was professor of preventive and social medicine, University of Ibadan, Nigeria.
References
Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, et al. Human resources for health: overcoming the crisis. Lancet 2004;364: 1984-90.
World Health Organization. High level forum on the health MDGs. Addressing Africa's health workforce crisis: an avenue for action. 2004. www.hlfhealthmdgs.org/Documents/AfricasWorkforce-Final.pdf (accessed 22 Sep 2005).
Norad. Overcoming the crisis—taking the Abuja action agenda forward. www.norad.no/default.asp?V_ITEM_ID=3011&V_LANG_ID=0
Habte D, Dussault G, Dovlo D. Challenges confronting the health workforce in sub-Saharan Africa. World Hosp Health Serv 2004;40(2): 23-6, 40-1.
Dugger CW. An exodus of African nurses puts infants and the ill in peril. New York Times 2004 Jul 12;: A1, A6-7.
Bach S. Migration patterns of physicians and nurses: still the same story? Bull World Health Organ 2004;82: 624-5.
Dovlo D. Taking more than a fair share? The migration of health professionals from poor to rich countries. PLoS Med 2005 May;2: e109.
Stilwell B, Diallo K, Zurn P, Vujicic M, Adams O, Dal Poz M. Migration of health-care workers from developing countries: strategic approaches to its management. Bull World Health Organ 2004;82: 595-600.
Ahmad, OB. Managing medical migration from poor countries BMJ 2005;331: 43-5.
Martey JO, Elkins TE, Wilson JB, Adadevoh SW, MacVicar J, Sciarra JJ. Innovative community-based post-graduate training for obstetrics and gynecology. Obstet Gynecol 1995;85: 1042-6.
Martey JO, Hudson CN. Training specialists in the developing world: ten years on, a success story for West Africa. Br J Obstet Gynaecol 1999;106: 91-4.
Marshall MA, Buffington ST. A life-saving skills manual for midwives. 3rd ed. Washington, DC: American College of Nurse-Midwives, 1998