THE CHALLENGES OF DEVELOPING HUMAN RESOURCES FOR HEALTH IN WEST AFRICA*

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
*

Lecture delivered by Prof. Kayode Odusote at the 10 AIM Inc. Public Lecture in honour of Sir Samuel Manuwa, th 12 November 2010.

th

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.2 This definition has been adopted for this lecture. At the Millennium Summit of the United Nations in September 2000, world leaders signed up to the Millennium Development Goals (MDGs) as part of an ambitious global agenda to reduce poverty and improve lives. Three of these are directly related to health viz., MDG4 to reduce child mortality, MDG5 to improve maternal health and MDG6 to combat HIV/AIDS, Malaria and other major diseases. There was an overwhelming favourable response from the global donor community to provide financial support for the agenda. Notable among these were the Global Fund for HIV/AIDS, Malaria and Tuberculosis (Global Fund), Global Alliance for Vaccines and Immunization (GAVI), US Presidents Emergency Plan for AIDS Relief (PERPFAR) and Bill and Melinda Gates Foundation. However by 2004, 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.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. There was global shortage, inequitable distribution, poor motivation and demotivating working conditions, especially in the developing countries. 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). Gradually, the health worker issue had moved from the back burner of global attention towards the front burner. THE CRISIS Health workers are the keystone of the health system. In spite of technological advancement and computerization in health, health care still depends heavily on human resources. Human beings still require and demand to be cared for by other human beings. The health workforce remains the glue that binds all the other resources together to deliver health. 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 often quoted WHO ratios for health workers appeared to be derived from the global average many years ago. In the World Health Report 1993: Investing in Health, World Bank recommended that public health and minimum essential clinical interventions require 0.1 physicians per 1000 population and 2 4 graduate nurses per physician. This recommendation appears empirical. In an attempt to measure health workforce quantity as opposed to ratio of individual cadres, 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, varying from 10.9 per 1000 population in North America to 1.0 per 1000 in Africa with a global average of 4.0 per 1000. Furthermore, the analysis showed a linear correlation between health workforce density and
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the key mortality indices of MDGs 4 and 5 that is maternal mortality, infant mortality and under-5 mortality. Countries with low-density of health workers had higher mortalities than countries with high health worker densities. All countries in West Africa fall into the category of low-worker density and high mortality. The obvious conclusion is that more workers save lives or in the other words, the fewer the workers the more lives lost. In an empirical attempt to relate health outcomes to health worker density, the JLI analysis showed a correlation between specific health worker density (aggregate of numbers of doctors, nurses and midwives) and coverage of measles immunization and skilled attendants at birth. Similar correlations have been shown with coverage of other immunizations, especially the availability of nurses and midwives.6 Based on the analysis, a minimum threshold of 1.5 workers per 1000 population was computed for 80% coverage of measles vaccination and a threshold of 2.5 workers per 1000 for 80% coverage of skilled attendants at birth. In an updated analysis, the World Health Report 2006, observed a threshold of 2.28 health care professionals per 1000 (range of 2.02 2.54/1000) for 80% coverage of skilled attendants at birth and this threshold has been adopted globally as the minimum standard for health worker density. Based on this it was estimated in 2006 that there was a global shortage of 2.4 million health care professionals (doctors, nurses and midwives) which was extrapolated to 4.3 million for all health workers. The shortage of doctors, nurses and midwives in Africa was estimated as 817,992 and this was extrapolated to a shortage of 1,472,385 for all health workers. Using the minimum threshold, the report noted that 57 countries in the world had critical shortage of health workers and 32 of these were in sub-Sahara Africa. All the countries in West Africa fall into this category. The average health care professional density for West Africa was 0.73 (range 0.05 to 1.97) per 1000. Our countries would still have shortage of health workers in 2015 based on needs and current level of production.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. Apart from the critical shortage in numbers, 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. These have been compounded by: Migration both internal and external Weak support systems. The global mobilization in support of scaling up the human resources for health led to the First Global Forum on Human Resources for Health. 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, motivated and facilitated health worker within a robust health system.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, have become the guiding beacons and targets for HRH development globally and in the region.
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TABLE 1. NUMBER OF SOME CATEGORIES OF HEALTH WORKERS IN WEST AFRICA* COUNTRIES (POPULATION)

PHYSICIANS

NURSES

MIDWIVES

PHARMACISTS

Benin (7.78m) 311 4,965 824 11 Burkina Faso (14.1m) 708 4.268 2.289 343 Cape Verde (0.47m) 231 410 0 43 Cte d'Ivoire (17.3m) 2,081 7,773 2,407 1,015 Gambia (1.42m) 156 1,168 263 48 Ghana (22.8m) 3,240 15,797 3,910 1,388 Guinee (8.97m) 987 4,061 347 530 Guinee-Bissau (1.6m) 188 912 160 40 Liberia (3.43m) 103 589 446 35 Mali (13.2m) 1,053 5,986 2,352 351 Niger (14.8m) 296 2,421 397 20 Nigeria (124.7m) 34,923 127,580 82,726 6,344 Senegal (9.90m) 594 2,606 681 85 Sierra Leone (5.40m) 162 1,211 1,299 340 Togo (5.63m) 225 1,667 270 134 * Source: World Health Report, 2006 - Includes auxiliary and enrolled nurses and midwives in countries where they are recognized.

TABLE 2.

AVAILABILITY OF SOME CADRES OF HEALTH WORKERS IN SELECTED COUNTRIES IN WEST AFRICA* POPULATION
14.731 19.262 1.709 23.478 9.37 3.75 12.3 14.2 148 5.866 6.59

COUNTRY
Burkina Faso Cte d'Ivoire Gambia Ghana Guine Liberia Mali Niger Nigeria Sierra Leone Togo
+

PHYSICIANS
921 2,746 49 2,082 1,708 51 960 427 55,376 95 622

NURSES
3,645 5,973 111 7,608 1,317 338 1,033 1,050 128,918 245 1,006

MIDWIVES
1,016 2,258 72 3,794 121 280 628 471 90,489 111 469

HCP DENSITY (/1000 POP.)+

0.38 0.57 0.14 0.57 0.34 0.18 0.21 0.14 1.86 0.08 0.32

* Source: WAHO Data 2009 - Includes only professional registered nurses and midwives. HCP - Health Care Professionals

THE CHALLENGES The challenges to developing Human Resources for Health in the region would be discussed at three levels: 1. Operational 2. Strategic 3. 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, especially the highly-skilled professionals are educated in public health institutions. Operational: For the purpose of this lecture, 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 need for scaling up production was emphasized at the 59 th World Health Assembly in 2006 and Resolution WHA59.23 of that Assembly urges member countries to be more committed to training health workers. In spite of seaming years of experience of our governments in the production of health workers, there are still challenges. As stated earlier, all the countries in the region have critical shortage of workers. Using the WHO statistics,2 we estimated that as at 2006 the region needed 255,000 more doctors, nurses and midwives and 204,000 more of other health workers. It is uncertain what the current capacity for production of health workers in the region is, being that we do not have the culture of collecting and using sound data for decision making, but in comparison with the capacity of other regions of the world, we are unlikely to be able to easily scale-up our present capacity to meet the needs. For instance, United Kingdom (UK) trains over 6,000 doctors annually for a population of 60 million9 whilst Nigeria trains about 2,300 doctors annually (Human Resources for Health Country Profile, Nigeria, 2008) for a population of over 150 million. The estimated annual production of medical schools in sub-Saharan Africa was 1011,000 in 2009.10 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. 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. 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), we like most other countries - are not sure of how many of each category should be trained in order to have the correct mix of skills at all levels. There are no gold standards and the skills
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mix varies widely between countries.11 Figure 1 shows the wide disparity in ratios of different categories of health workers between selected countries in West Africa. In spite of this, 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. 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.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.

Figure 1. Ratios of different categories of health workers in selected countries of West Africa. Data from West African Health Organisation data 2009.

Who should be trained has become a challenge for our region as for many other developing countries. The admission policy should assure equity and diversity so that all languages, ethnic groups and cultures are represented in the health workforce. The current selection criteria into training institutions for highly skilled professionals, such as doctors, dentists and pharmacists, favour the children of the rich and highly educated city-dwellers.13 The children from the rural settings (and urban lower class) are disadvantaged by the environment not by their native endowment. 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. I was fascinated by the title of a study from Tanzania wrong schools or wrong students.14 By the fifth year in the medical school, two
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thirds of the students, most of whom were children of city-dwellers, were demotivated in comparison to their initial level of motivation on admission. All those who were motivated by socio-economic considerations were demotivated by the low salaries, poor working conditions and heavy workload of doctors. Only those who had primary interest in medicine at admission remained highly motivated. If these findings are replicated in other medical schools in Africa, then we need to take a fresh look at our admission criteria. May be the current experiment at the Ghana Medical School will provide some empirical answers. 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. 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. What competence do we expect of the graduating health professional? At this point I would like to at congratulate my old medical school, this College of Medicine of the University of Ibadan for the development and approval of its new curriculum. 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. This is a departure from the traditional approach that is still the norm in medical education in Nigeria and other parts of Africa.15,16 We hope that with the inclusive participatory approach in its development, the management of change to an integrated approach would not be an uphill task. 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. Are we training health professionals for our countries, our region or the International market? In 2003, there were 643 medical graduates of the University of Ibadan, 429 of University of Lagos, 394 of the University of Nigeria, 183 of the University of Benin and 156 of the Obafemi Awolowo University, Ife, practicing in the Unites States.17 In these days of globalization, 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, are we not encouraging migration to high-resource countries? In a survey on migration, 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.18 At the West African Health Organisation (WAHO), we have embarked on the process of harmonization of the training curricula of nurses, midwives, pharmacists, doctors, dentists and medical specialists and we hope to include other cadres in due course. 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, the objective is to ensure the same quality of health care delivery through the region. Health education is life-long learning. A graduate can know all for today but would be lacking in knowledge tomorrow if he/she has not continued to learn. 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. 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.
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Apart from the core competences of the health profession, there had been calls for health professionals, especially doctors, to be trained in management before graduation. 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. The doctor prescribing 10 drugs when three are adequate, 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. Also, health care service is a team work. Even though the doctor or dentist has the primary role of finding solutions to the patients health problems, he/she cannot provide all the interventions and care alone without the collaboration and support of other health workers. This should be understood and built into the culture and psyche of the health professional before graduation. Maintenance: After production, the health worker needs to be recruited, deployed and sustained at work. 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. In the health system, especially in the public sector, 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.19 They are unable to perform the functions required to support and motivate the health worker. Except in countries where the government is decentralized and the health sector has been given some autonomy, recruitment is carried out by the Civil Service Ministry or Commission and this is based on vacancies in the established staff schedules. 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. Also the demand for health workers that is the number that government is willing to recruit, 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. Even with our insufficient production capacity, 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. This is an irony of excess supply in the face of critical shortage. In one of the countries in the region, doctors offer their services in hospitals without being officially recruited or being on the payroll. The restrictions of SAP is a major factor in most of these countries and a President of a country recently ordered the recruitment of 1,000 doctors in defiance of the creditors. 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. Figures 2 (A and B) show the geographical distribution of doctors (A) and Registered Nurses, including Registered Midwives (B) in Nigeria in 2007. Owing to the large socio-economic disparity between the urban and the rural areas in the region, there is reluctance of health workers to be deployed to the rural and remote areas. The rural areas, which have more health service needs than the urban areas, 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. This is what some call the inverse care
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law. Some countries are recruiting retired experienced health workers on contract to fill vacancies in rural and remote areas. This is a strategy that should be considered by other countries in the region if proven to be a best practice.

Figure 2a. The geographical distribution of doctors in Nigeria. Data from Ministry of Health, Country Human Resources Profile, 2007. Ratios are per 1,000 population.

Figure 2b. The geographical distribution of Registered Nurses including Registered Midwives in Nigeria. Data from Ministry of Health, Country Human Resources Profile, 2007. Ratios are per 1,000 population.

Increasing feminization of the health workforce is contributing to the deprivation of the rural areas. Whilst female health workers are less likely to emigrate abroad, they are also less likely to work in the rural areas for long periods. 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. 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. Male students, 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.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. Effective performance on the job is the outcome of effective management of the worker. This is the process of sustaining both the internal motivation and the external motivation of the worker so as to be available, competent, responsive and productive. 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 said to be responsible for absenteeism, dual practice, informal charges and drug leakage in health facilities.22 However, basic principles of human resource management states that low salaries demotivate but higher salaries do not motivate. 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, then the agitation for more starts. 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. Whilst there is no doubt that every worker is entitled to a decent living wage, motivating packages for workers should focus on non-financial incentives good working conditions, training, career development, fairness and transparency in promotion, recognition and fairness in performance evaluation, which should be corrective not punitive.23 Retention: As mentioned earlier, there is global shortage of health workers. Whilst in the lowincome countries this is due to low production capacity and low attractiveness of the health profession, in the high-income countries it is due to ageing population, increase feminization of the health workforce and growing income.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.17,18,25 Push factors include poor remuneration, poor standard of living, insufficient opportunities for post-graduate training, poor working conditions, socio-political instability and poor management. Pull factors include better remuneration, better living conditions, well maintained high-tech facilities, easier system of post-graduate education, safer environment and prestige. In addition, there is the culture of migration. In 2000, about 65,000 African-born doctors and 70,000 Africa-born nurses were working in developed countries.26 In 2003, 2,158 Nigeria doctors were working in United States (US), 1,922 in UK and 133 in Canada. In the same year the number of Ghanaian doctors were 478 in US, 324 in UK and 63 in Canada. 27 External migration is also a major contributing factor to the severe shortages of faculty in medical schools in Africa.10 External migration encourages internal migration as post in urban areas left by migrs are rapidly filled by health workers from the rural areas.
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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. 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. 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. There is no single one cap fits all solution. Each country needs to study the major factors favouring internal migration and develop appropriate retention strategies that should include financial and non-financial packages. 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. 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, opportunities for continuing medical education and supervision.28 These are issues that can be solved by good HR management. External migration would continue as long as demand for foreign health workers by high-income countries remains. For instance the number of doctors from Nigeria working legally in UK increased from 215 in 1966 to 1,922 in 2003 and the number of nurses from the same country increased from 178 in 1998 to 511 in 2003.27 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. These are voluntary and are without prejudice to the right of the individual to seek employment where ever he/she chooses. 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. 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. 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. 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. 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.

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STRATEGIC CHALLENGES The development of HRH is multi-sectoral, multi-disciplinary and multi-dimensional and it is complex. A strategic approach is required to achieve the goals of global access and good health outcomes. There are three inputs into the health system human resources, infrastructure and material resources. Of course, financial resources are required for all three. In order to be focused and goal oriented, there should be a health policy to guide and drive the health system. 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. 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. To the best of my knowledge, the first National Health Policy for Nigeria was developed and adopted under the leadership of late Prof. Olikoye Ransome-Kuti as Federal Minister of Health. These National Health Policies have a small section on Human Resources, are not adequate to meet the challenges of HRH development today. An HRH Policy should address31: 1. Planning for supply of personnel to ensure adequate numbers of different categories which are equitably distributed geographically and to all levels of care. 2. Education and training to give different categories the skills required by the objectives of the health policy 3. Management performance, which should include practice standards, evaluation and accountability, strategies for maintaining and upgrading quality and staff motivation. 4. Work conditions, which should include guidelines for recruitment and retention, career management, mechanism for mobility and methods and levels of remuneration and incentives. With the technical and financial assistance of WHO, Global Health Workforce Alliance (GHWA) and WAHO, many of our countries have developed or are developing National HRH Plans. 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. Ideally, because HRH development is multi-sectoral, multidimensional and multi-disciplinary, the Plan should be comprehensive and its development should involve all stakeholders in the country Ministries of Health, Education, Finance and Civil Service, training institutions, regulatory bodies, professional associations, labour unions, partner organizations, labour unions and Civil Society. The health sector is dynamic and it is influenced by local situations and socio-cultural values. Also the production of health workers takes 2 6 years for basic qualification and many more years for specialist qualification. Hence it is recommended that countries should have long-term plans with short-term actions and regular review. In order to do this effectively, countries need to have up-to-date information on the situation and what factors influence it. The information base for HRH decision making is weak in all our countries. No single country in the region has accurate and up-to-date information on its health workforce number, distribution and skills mix. There is no accurate information on production and annual supply level, rate of emigration or the age distribution and retirement projection. 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. Nigeria depends on
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information in the database of registration bodies, and this information includes those who have emigrated, retired or passed to the world beyond. Hence the computed health worker density of Nigeria is most likely an overestimation. Figure 4 shows a trend in the density of health care professionals in selected countries in the region. 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. Whilst some countries include enrolled nurses and midwives in the category of nurses and midwives, others limit this category to registered nurses and registered midwives only.

Figure 4. 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.

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. 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.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. This is a rich mine for our public health specialists and social scientists and we hope they would rise up to the challenge. 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. We need to know what factors motivate different cadres of health workers to accept deployment to the rural and remote areas. Many more
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questions in HRH development require local answers because of the influence of individual and socio-cultural values on health workers behaviour. As mentioned earlier, HRH development involves many stakeholders outside the Ministry of Health. Even though the leadership of the Ministry of Health is important, each stakeholder has influence on the availability, maintenance and performance of health workers. Coordination of all stakeholders behind the National HRH Plan is crucial if it is to achieve its stated objectives. This is a major lacuna in the management of HRH in our countries. 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. WHO is promoting the establishment of National Health Workforce Observatory (NHWO) for the coordination of the information and knowledge on HRH in the countries. These two initiatives have created some confusion in the minds of HRH Directors of the Ministries of Health in the region. At a recent meeting organized by WAHO, 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. This would reduce the number of committees and meetings and would likely make them more effective. 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. In some countries entire Ministries had been established for responding to the HIV/AIDS epidemic whilst in others like Nigeria, special institutions or agencies were established. Such a leadership at the top is required to get all the major stakeholders such as Ministries of Finance, Education and Civil Service behind the National HRH Plan. There is need for long-term investment in the education of health workers, especially the highly-skilled ones. There is need for budgetary allocation for financial and non-financial incentive packages. New positions need to be created in the staff establishment whilst all existing ones need to be funded and filled. 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 an ECOWAS Ministerial approved plan for retention of health workers in the rural and remote areas. The implementation of this plan requires inter-Ministerial collaboration and approval of the Cabinet in each country. The 2001 (Abuja) promise of 15% of the National budget for the health sector remains an expectation in all our countries. 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. 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. We need champions to lead this advocacy crusade.

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BEYOND HRH CRISIS Human Resources for Health is one of three major inputs in the health system. Whilst it is a key input to effective health care delivery, the system needs the balance provision of other inputs. 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. Lola Dare, personal communication). There is need for a paradigm shift in our approach to Health System performance in order to achieve desired health outcomes. 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, nothing changes. Absenteeism, dual practice, informal charges, unresponsiveness and poor patient satisfaction continue. There is need for trained leadership at the facility level. It is traditional that the most senior doctor in the facility heads the institution. 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. Whilst it is recognized that he needs some understanding of basic management human resources, financial and material resources, he/she cannot be equipped with the competences of a professional manager except he/she acquires additional certification. However, 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. The leadership functions, which can be learnt through short courses, would include: Inspire team work Mobilize resources Engage the community fully Have good relationship with local and central government Cooperate with other sectors.

The world including our region is undergoing socio-economic and cultural changes. The consumer always has a choice of how and where to solve his or her health problems. The care provider has a choice of where to offer his/her services or change profession completely. The owners of health facilities (governments, faith based organizations, 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. 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. We need to consider the health care industry as any other service industry providing consumer-oriented solutions. 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. 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
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appropriately. 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. 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. 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. 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, then one can only conclude that he allows everyone to reap the benefit of the use of the talent he has given them. We need to use the talent and resources God has given us in the region better for the health and well-being of ourselves. 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. Our children need not die before they can contribute to the growth and development of our region. Neither can we continue to let our best brains emigrate to other countries to serve their rural and remote areas. The challenge is for all of us government, training institutions, private health providers, Partners, Professional Associations, Labour Unions and Civil Society. 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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References:
1. McCoy D., Bennett S., Witter S., et. al. Salaries and incomes of health workers in sub-Saharan Africa. Lancet 2008; 37: 675 681. 2. World Health Organization. World Health Report 2006: Working together for health. Geneva. 2006 3. Narasimhan V., Brown H., Pablos-Mendez A., et. al., Responding to the global human resources crisis. Lancet 2004: 363: 1469 72. 4. World Health Organization. Progress on Global Access to HIV antiretroviral therapy - An update on "3 by 5". World Health Organization. Geneva. Switzerland. 2005. 5. Joint Learning Initiative. Human Resources for Health: Overcoming the crisis. Global Equity Initiative, Harvard University. Boston. 2004. 6. Anand S., Barnighansen T. Health workers and vaccination coverage in developing countries: an econometric analysis. Lancet 2007: 369: 1277 1285. 7. Scheffler R. M., Lin J. X., Kinfu Y., Dal Poz M. R. Forecasting the global shortage of physicians: an economic and needs based approach. Bull. World Health Org. 2008; 86: 516 523. 8. World Health Organization The Kampala Declaration and Agenda for global action. WHO. Geneva. 2008. 9. Crisp N., Gawanas B., Sharp I., Training of the health workforce: scaling up, saving lives. Lancet 2008; 371: 689 691. 10. Mullan F., Freyhwot S., Omaswa F., et. al, Medical schools in sub-Saharan Africa. Lancet 2010; Published online Nov. 11, 2010. 11. Gupta N., Dal Poz M. R. Assessment of human resources for health using cross-national comparison facility surveys in six countries. Human Resources for Health. 2009; 7: 22 (http://www.human-resources-health.com/contents/7/1/22 last accessed 6/10/10). 12. Masnick K., McDonnell G. A model linking clinical workforce skill mix planning to health and health care dynamics. Human Resources for Health. 2010; 8: 11 (http://www.human-resourceshealth.com/contents/8/1/11 last accessed 7/10/10). 13. Bourke J. How can medical schools contribute to the education, recruitment and retention of rural physicians in their region? Bull World Health Org. 2010; 88: 395 6. 14. Leon B. K., Kolstand J. R. Wrong schools or wrong students. The potential role of medical education in regional imbalances of the health workforce in the United Republic of Tanzania. Human Resources for Health 2010; 8: 3 (http://www.human-resourceshealth.com/contents/8/1/3 last accessed 6/10/10). 15. Ibrahim M. Medical Education in Nigeria Med. Teachers 2007; 29: 901 905. 16. Gukas I. D. Global paradigm shift in medical education - issues of concern for Africa Med. Teach. 2007; 29: 887 - 892 17. Hagopian A., Ofosu A., Fatusi A., et. al. The flight of physicians from West Africa: views of African Physicians and implications for policy. Social Science & Medicine. 2005; 61: 1750 1760. 18. Astor A., Akhtar t., Matallana M. A., et. al. Physician migration: views from professionals in Colombia, Nigeria, India, Pakistan and the Philippines. Social Science & Medicine. 2005; 61: 2492 2500.

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19. O'Neil M. L. Human Resource Leadership: key to improved results in health. Human Resources for Health 2008; 6: 10 (http://www.human-resources-health.com/contents/6/1/10 last accessed 6/10/10). 20. Vujicic M., Zurn, P. The dynamics of the health labour market Int. J. Health Plan. Mgmt. 2006; 21: 101 - 115 21. Wilson N. W., Couper I. D., De Vries E., et. al. A critical review of interventions to redress the inequitable distribution of health professionals to rural and remote areas. Rural and Remote Health. 2009; 10: 1060 (http://www.rrh.org.au/published articles/article_print_1060.pdf last accessed 01/10/2010) 22. McPake B., Asiimwe D., Mwesigye F., et. al. Informal economic activities of public health workers in Uganda: implications for quality and accessibility of care. Social Science & Medicine. 1999; 49: 849 865. 23. Mathhauer I., Imhoff I. Health worker motivation in Africa: the role of non-financial incentives and human resources management tools. Human Resources for Health 2006; 4: 24 (http://www.human-resources-health.com/contents/4/1/24 last accessed 6/10/10). 24. Pond B., McPake B. The health migration crisis: the role of four organizations for Economic Cooperation and Development countries. Lancet 2006; 367: 1448 1455. 25. Wuliji T., Carter S., Bates I. Migration as a form of workforce attrition: a nine country study of pharmacists. Human Resources for Health 2009; 7: 32 (http://www.human-resourceshealth.com/contents/7/1/32 last accessed 6/10/10). 26. Clemens M. A., Petterson G. New data on African Health professionals abroad. Human Resources for Health. 2008; 6: 1 (http://www.human-resources-health.com/content/6/1/1 last accessed 6/10/10). 27. Connell J., Pascal Z., Stilwell B., et. al. Sub-Saharan Africa: Beyond the health worker migration crisis? Social Science & Medicine. 2007; 64: 1876 1891. 28. Manefa O., McAuliffe E., Maseko F., et. al. Retention of health workers in Malawi: perspectives of health workers and district managers. Human Resources for Health 2009; 7: 65 (http://www.human-resources-health.com/contents/7/1/65 last accessed ). 29. Odusote K. CPD as a strategy for retention of health workers in sub-Saharan Africa. Africa Health. 2010; 32(4): 34 36. 30. Anderson F. W. J., Mutchnick I., Kwawukume E. Y., et. al. Who would be there when women deliver? Assuring retention of Obstetric Providers. Obstet. Gyanecol. 2007; 110: 1012 1016. 31. Dusault G., Dubois C. Human resources for health policies: a critical component of health policies. Human Resources for Health. 2003; 1: 1 (http://wwe.human-resourceshealth.com/contents/1/1/1 last accessed 6/10/2010) 32. Dal Poz M. R., Gupta N., Quain E., Soucat A. L. B. Handbook on monitoring and evaluation of human resources of health (with special applications for low - middle-income countries). WHO. Geneva. 2009.

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