An adequate workforce: essential to dealing with dangerous unforeseen outbreaks
April 9, 2015
An adequate workforce: essential to dealing with dangerous unforeseen outbreaks
At the Consortium of Universities for Global Health (CUGH) annual conference, held in Boston, March 26 – 28, the global shortage of trained health workers was a theme that underpinned many of the sessions. From the panel focusing on the nursing and medical workforces in Tanzania and Uganda, to the plenary on lessons learned from the Ebola outbreak, to a discussion on the attacks on health workers and facilities in Syria, the need for a robust, better trained, and fully supported workforce was highlighted – or at least hinted at – by different experts across diverse topics. Indeed, the World Health Organization identifies a shortage of skilled health professionals in 83 countries and warns of a global deficit of 12.9 million health care workers by 2035. While not explicitly the focus of the conference, it was clear that this shortage will need to be addressed in order to achieve any number of global health targets, including the Sustainable Development Goals and the Global Health Security Agenda.
For those who followed the recent Ebola epidemic in West Africa, this comes as no surprise: at the start of the outbreak, Guinea, Liberia, and Sierra Leone figured among the 11 countries in the world with the smallest and least skilled health workforce. This severe deficit of health workers in Ebola-affected West African countries was fundamental to the region’s health crisis, bringing this reality to the fore, and forcing an examination of root causes and potential solutions in the medium to long-term to remedy the situation.
The Liberian example is illustrative. With 9,712 Ebola cases and 4,332 deaths as of March 29, Liberia remains a long way off from employing even the bare minimum number of health workers required to provide basic services. Statistics show Liberia with 3 doctors, nurses, and midwives per 10,000 people, well below the 23 per 10,000 people recommended by the World Health Organization. And the Ebola epidemic made the situation significantly worse—Liberia has lost 180 health workers to the disease. (A total of 495 health workers have died across Liberia, Sierra Leone, and Guinea.)
Market forces – the brain drain – are arguably the starkest structural factors contributing to the human resource crisis. Liberia is one of the Sub-Saharan African countries most affected by the emigration of physicians. For years, most graduates from Liberia’s only medical school—the A.M. Dogliotti College of Medicine—have taken their talents out of the country. Approximately 77 percent of Liberian physicians, trained domestically and abroad, practice in the United States and they can also be found in Australia, Canada, and Great Britain. Realities in Liberia itself fuel the exit of health professionals: Liberia’s decrepit health facilities, insufficient medical supplies, low salaries, and the low confidence Liberians have in their health system.
Awareness of this problem may be rising. During a January CSIS visit to Liberia to capture the reflections of those who lived through and responded to the crisis, we were struck by the increased perception of just how critically important health workers are to ensuring elementary health security. We heard that prior to the outbreak, powerful secret societies and years of corruption had left the population feeling deeply suspicious of health workers and the government. This mistrust is reflected in the chilling nickname given to Monrovia’s government-run John F. Kennedy (JFK) Hospital since the 1990s: the “Just for Killing” Hospital. Similarly, during the early stages of the response, there were instances in which health workers were attacked by a fearful population that believed that the health professionals were to blame for the disease.
By January 2015, we observed a promising shift in attitude. A theme that ran through our conversations with citizens, health workers, non-governmental organization implementers, and national leaders was the need for a robust health workforce that is distributed across the country and present at all entry points into the health system. This shift in perception stemmed in part from pride and recognition of the courageous efforts and sacrifices made by Liberian health workers in the fight against Ebola. As we walked through the Ministry of Health and Social Welfare, we saw signs that read: “We are TIME magazine’s person of the year” taped to most office doors. We also heard many anecdotes about how the Ebola Treatment Unit at the Eternal Love Winning Africa Hospital operated by Dr. Jerry Brown (featured on the cover of TIME magazine’s Person of the Year issue) had the highest survival rate and number of graduation ceremonies for survivors.
As Liberia presents its health recovery plan at the World Bank Group and International Monetary Fund Spring meetings in Washington, D.C. in mid-April, it will be essential to prioritize investments in health workers and the systems that support them and take a realistic, patient, and long-term view of what will truly be required to create a resilient health workforce. According to a March 2015 study commissioned by the Frontline Health Workers Coalition, approximately $106 million is needed to double Liberia’s health workforce and add a comprehensive health worker program over the next five years. That seems affordable, and indeed should be a top priority. However, this alone will not necessarily guarantee that newly trained Liberian health professionals will choose to stay in Liberia, versus migrate with their families to more stable, comfortable, and remunerative professional opportunities. External market forces will persist, as will difficult conditions inside Liberia.
Liberia provides only one example of the challenges in building and maintaining a strong health workforce. The Ebola epidemic clearly demonstrates the devastating consequences that are possible when a dangerous and unforeseen outbreak occurs in a place where there are insufficient health workers. The global community will need to develop effective models to address these current human resource challenges if we are to build effective health systems and reach the diverse goals laid out at the CUGH conference.
