(Photo Credit: World Health Organization)

One of the topcis I have spent quite a bit of time of late thinking about is the question of how to build and sustain an effective health workforce in sub-Saharan Africa. I had actually hoped to devote my dissertation to this topic, however, severe data shortages prevented me from looking at most of the questions I was really interested in. However, one of the things that would drive me crazy about this topic was that whenever I told someone about my research interests in health workforce issues in Africa, I would always get: “oh, you mean like brain drain?”. To this, I would reply: “No, I don’t.”

It is not that I think brain drain is not an important issue, it is just that I really think it is a second order problem. The first order problems related to health workforce have much more to do with the barriers to demand and supply of health workers. In general, on the demand side, it is not like there are thousands of unfilled posts and no one to fill them because everyone has migrated (sometimes there are unfilled posts, true, but it is usually due to some bureaucratic inefficiency that prevents the position from being filled), it is that there is a big difference between the true “need” for health workers and the actual “demand”, that is spots for them in the public service or elsewhere. On the supply side, pre-service training is a severe constraint. Even if there were more jobs, which might induce more people to want to become a health worker, it is likely that there would not be enough training spots in medical and nursing schools for them to get training.

Finally, there is now some good research out there that makes this point quite clearly. Kinfu, Dal Poz, Mercer, and Evans from the WHO has recently published a nice piece in the Bulletin of the WHO that makes the best use of the spotty data out there and logic to make an important point. Even under relatively conservative assumptions about natural rates of outflow from the health work force (death, retirement, etc), current pre-service output is barely above average replacement rates in 12 sub-Saharan African countries (half above average and half below). If you then factor in population growth, no country will keep pace. If you then also expect it to try to acheive any of the major new global health initiatives we donors so hope to implement, forget it. The output of health workers in Africa is far, far to low, and everything else is a second order issue.

Some of my research in Ghana has also identified this constraint. Ghana is a country that gets a lot of airplay about how bad outward migration has been, but in reality, Ghana’s real problems have very little to do with migration. In the 50 years since Ghana gained independencance from the UK, it has only ever had 2 medical schools, one started soon after independence and the other during the 1990s. Combined, these medical schools have only ever produced roughly 3000 doctors…IN 50 YEARS. Even if every single one of these doctors were alive and working today, a completely unrealistic assumption, Ghana would still be an order of magnitude below health density levels advocated by the WHO (ignore for the moment whether one believes in these ratios or not). Ghana probably has somewhere over 2000 doctors currently practicing in the country today, reasonably good levels, considering, but this point never gets any attention. I was at one point trying to see if Ghana was actually a net importer of doctors trained outside of Ghana, but the data was a bit too messy to allow me to show this, but I suspect it might be close in recent years.

So I am really happy to see this new article. The authors get my highest level of priase for making the most of the paucity of data available on this topic.

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1 Response » to “Identifying first order problems in the health workforce of sub-Saharan Africa”

  1. James H. says:

    Very true point indeed.

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