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Dr. Gloria Mfeka, Nkabinde's fiancée, recently completed her mandated year of community service in rural Bethesda Hospital. She notes that though rural work can be rewarding, its difficulties can also be overwhelming for a young physician. "If we got the bare necessities in outlying hospitals, like an ECG machine . . . that would make a world of a difference. In the outlying hospitals, to get CD4-count results there's a 6-week waiting list. . . . It's just crazy."
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Africa has been hit the hardest by the crisis: according to the WHO's World Health Report 2006,1 the continent bears 24% of the global burden of disease but has only 3% of the health care workforce and 1% of the world's financial resources. The report identified 57 countries that cannot meet a widely accepted basic standard for health care coverage by physicians, nurses, and midwives; 36 of these "critical countries" are in sub-Saharan Africa (see map). The WHO estimates that it will take an additional 2.4 million physicians, nurses, and midwives to meet the needs, along with an additional 1.9 million pharmacists, health aides, technicians, and other auxiliary personnel. And the WHO projects that if all training were to be completed by 2015, it would cost an average of $136 million per country per year, necessitating an average increase in health care expenditures of $2.80 per person per year (range, $0.40 to $11.00). But these estimates focus only on numbers of doctors, nurses, and midwives; they don't take emigration into account; and they exclude the payment of salaries, which would cost at least $311 million per country per year.
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Other efforts to retain workers focus on the health care system more broadly, building on the belief that providing workers with needed resources for care motivates them to stay and work in their home countries. Health workers in Ondo State, Nigeria, for example, reported severe shortages of medicines, supplies, and equipment. After the state government increased funding for these resources, the percentage of nurses in the state working in rural areas increased from 28% to 66% over a 3-year period — though other infrastructure projects, such as improvement of roads and therefore access, may have contributed to this increase. In rural Haiti, the international public health organization Partners in Health provides care and essential medicines for patients free of charge. Jim Yong Kim, cofounder of Partners in Health, says that health workers who have left Haiti tell him, "I love my country and I love my people; I just got sick of being a morgue attendant. All I was doing was presiding over more and more deaths of my countrypeople." Partners in Health has been successful in retaining health care workers in Haiti, notes Kim, in part because "we are giving Haitian physicians the tools to care for fellow Haitians in a decent and competent and effective manner."
One obvious key to retention is improved wages: salary support can help motivate health care workers to remain in their countries, even if it means working with fewer resources. Not all efforts at providing such support have been successful, however. In Ghana, an "additional duty hours allowance," implemented in 1998 to compensate doctors for overtime work, initially doubled salaries in several geographic areas. But once all physicians began to expect the additional allowance, the program rapidly became too costly to sustain and was restructured. It also caused resentment among nurses, who received lower allowances than doctors and were therefore increasingly inspired to emigrate.
Other types of inducements have been offered to health workers. In Uganda, a lunch allowance was included in workers' benefit packages; Ghana has tested the offering of car loans and affordable housing.
To address internal inequities, some countries have begun to recruit trainees from rural areas. In South Africa's Mosvold District, for example, some local students receive scholarships for health care training on the condition that they agree to return to the district to practice. According to Eric Friedman, senior global health policy advisor at Physicians for Human Rights, a study of the program found that trainees from rural areas were three to eight times as likely as those from urban areas to practice in rural regions after graduation.
Zambia provides incentives for physicians who agree to serve for 3 years in a rural area. These benefits include a hardship allowance, an education allowance for children, housing, and some funding for postgraduate training. In Kenya, unemployed nurses are being hired under contracts that include a requirement to stay in rural areas. The program, with international funding, has supported salaries for 2500 nurses to date.
In some countries where the underproduction of health care workers is a major problem, initiatives have targeted task-shifting and the assembly of new cadres of workers. In Lusikisiki, South Africa, a system of care has been developed whereby HIV–AIDS cases are triaged to various levels of health workers. Physicians attend only to complex cases, whereas nurses prescribe antiretroviral drugs and manage opportunistic infections. The new positions of "adherence counselor" and "pharmacy assistant" have been created to fill gaps in care, and the role of the community caregiver has been expanded to include duties such as counseling and testing. This coordination and expansion of the system has paved the way for universal coverage in Lusikisiki. Partners in Health's Kim cautions, however, against thinking that new types of workers can be unpaid: "The poorer the people are, the more important salary becomes."
Though additional health workers will be necessary for any solution, simply churning out more members of the workforce will not be enough. Workers will need to be adequately trained and equipped to make a difference to their patients. Increasing numbers of trainees may also overload the existing training programs in critical countries. Zimbabwe, for example, "has doubled or tripled enrollment in medical schools," according to Friedman, "but they haven't increased the number of professors. This is probably going to lead to lower quality."
Throughout Africa, innovative programs are testing approaches to ameliorating the shortage. Once effective pilot programs have been identified, scaling up will be the next hurdle: programs that are found to work on a small scale or in a particular environment may not be easy to expand or replicate.
Despite the challenges, the world has taken its first steps toward needed changes. In addition to receiving attention from the Group of Eight industrialized countries and the United Nations World Summit, the shortage of health care workers recently inspired the American Public Health Association to pass a policy statement on "Ethical Restrictions on International Recruitment of Health Professionals to the United States." The policy addresses the role of the United States in exacerbating the international crisis, calling on employers to adopt voluntary codes for ethical recruitment and on the government to contract only with employers who have done so. In addition, it advocates the training of greater numbers of U.S. health care professionals and more equitable distribution of those we have.
Though the worker shortage has a long history, "it's only in the past 3 to 5 years that the political advocacy has been loud enough that this issue has been put on the political agenda," says the WHO's Dayrit. He acknowledges that "there are no magic bullets" against brain drain — "eventually, the local economy competes with the global economy, and it [is] futile to try to put up barriers. Over time, people find ways around them." Nevertheless, he says, "I have to be optimistic. What we're doing is trying to increase the dialogue and engagement among countries and identify concrete steps . . . so that you can create a cascade of events that lead to amelioration."
Source Information
Dr. Kumar is a resident in the Harvard Affiliated Emergency Medicine Residency, Boston.
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