The global health

workforce crisis: Task

shifting as the solution
Case study: Nigeria
Ranga Fernando

A dissertation submitted to the University of Manchester for the degree of Intercalated BSc (Hons) in Global
Health, in the Humanitarian and Conflict Response Institute.

Word Count: 10,361
Student number: 7546872

Abstract

There is no doubt there is a global health workforce crisis. This dissertation
examines the factors involved in the global health workforce crisis, explores
possible strategy solutions and evaluates the use of task shifting as a possible
strategy to help address the growing gap between health worker supply and
demand. 57 nations worldwide have critical shortages of health workers
which impedes the delivery of essential health services in areas where the
burden of disease is highest. However, simply increasing the numbers of
workers is not enough. There are wide urban and rural divides in equity of
access. Important factors to consider to remedy this situation are the training,
management and retention of workers with a special focus on migration. This
dissertation examines to what extent task shifting can help solve the
aforementioned issues. Evidence suggests that task shifting can markedly
improve health worker numbers. In addition, they can ensure greater
equitable distribution of access to care. They are cheaper to train than
conventional cadres of health workers, can provide equitable if not better
standards of primary healthcare to populations and are a category of workers
that has proven to be easy to retain in the health service. Currently due to
their skillsets task shifted workers such as community health workers are
mainly effective in delivering non-specialised primary health care. Further
efforts need to be implemented to increase the coverage of specialised health
care. This dissertation explores these issues in detail through a case study of
Nigeria. The Nigerian case confirms that task shifted workers can increase
the supply of health workers and that they are also effective in delivering
many essential services and health education programmes. In short, task
shifted workers can positively impact in all three key areas of health worker
coverage: supply, management and retention. However, it is important to
remember that their effectiveness only extends to primary interventions.


Abstract .......................................................................................................... 2
1. Introduction................................................................................................ 5
1.1 Global health crisis ......................................................................................................... 5
1.2 HSS lens ........................................................................................................................... 5
1.3 Justification for research ................................................................................................... 6
1.3 Methodology ................................................................................................................... 6
1.5 Chapter overview .............................................................................................................. 7
2. The global health workforce crisis ........................................................... 8
2.1 The global health workforce crisis .................................................................................. 8
2.1.1 What is a health worker? ............................................................................................... 8
2.1.2 How widespread is the issue? ....................................................................................... 9
2.1.3 Why is this important? ................................................................................................. 9
2.1.4 Management of health workers. .................................................................................. 10
2.2 What is causing this crisis? ............................................................................................. 11
2.2.1 Training issues. ........................................................................................................... 11
2.2.2 Management of health workers. .................................................................................. 11
2.2.3 Retention issues .......................................................................................................... 12
2.2.4 Migration issues .......................................................................................................... 13
2.3 Solutions ............................................................................................................................ 13
2.3.1 Training solutions. ...................................................................................................... 14
2.3.2 Management of existing workers. ............................................................................... 16
2.3.3 Retention solutions. .................................................................................................... 17
2.3.4 Migration solutions .................................................................................................... 19
2.4 Task Shifting ..................................................................................................................... 19
2.4.1 What is task shifting? ................................................................................................. 19
2.4.2 Benefits ........................................................................................................................ 21
2.4.3 Drawbacks ................................................................................................................... 22
2.5 Summary ......................................................................... Error! Bookmark not defined.
3. Case Study: Nigeria ................................................................................ 24
3.1 Nigeria overall situation ................................................................................................. 24
3.2 Healthcare ......................................................................................................................... 24
3.2.1 Method of health delivery ............................................................................................ 24
3.2.2 Health workforce ......................................................................................................... 25
3.3 Problems ........................................................................................................................... 26
3.3.1 Training issues ............................................................................................................ 26
3.3.2 Management of existing workers ................................................................................ 27
3.3.3 Retention issues .......................................................................................................... 28
3.3.4 Migration issues .......................................................................................................... 29
3.4 Solutions ............................................................................................................................ 29
3.4.1 Training solutions. ...................................................................................................... 29
3.4.2 Management of existing workers ................................................................................ 30
3.4.3 Retention solutions ..................................................................................................... 30
3.4.4 Migration solutions .................................................................................................... 31
3.5 Task shifting programme ............................................................................................... 31

3.5.1 Community Health Extension Workers ...................................................................... 31

3.5.2 Progress so far ............................................................................................................. 32
3.6 Summary ......................................................................... Error! Bookmark not defined.

4. Conclusions & recommendations ......................................................... 33

4.1 Original brief .................................................................................................................... 33
5. Glossary of terms ........................................ Error! Bookmark not defined.
6. Bibliography ............................................................................................. 37

1. Introduction

1.1 Global health crisis

Health systems depend on the health workforce to act as the gateway to
health. In 2006 the World Health Organisation determined that 2.3
physicians, nurses and midwives per 1000 people is the minimum density
needed to sufficiently cover the population with essential health services. 57
priority countries were identified with critical shortages, misdistribution, low
motivation and inconsistent performance of health worker (WHO 2006). The
workforce crisis is arguably the greatest health system constraint on nations
pursuing the 2015 Millennium Development Goals (MDGs).

In light of this, the Global Health Workforce Alliance laid out the Kampala
Declaration and Agenda for Global Action in 2008 outlining a plan for global,
national and local action to remedy the situation. Despite encouraging
progress such as the WHO Global Code of Practice on International
Recruitment of Health Personnel and commitments from many nations,
health workforce shortages continue to hinder a number of health systems
from distributing vital services. As of 2010, none of the 57 countries with a
human resources for health (HRH) crisis had reached the necessary health
worker density ratio (WHO 2006).

In tackling these myriad issues, the end goal appears a simple one.
Implement sufficient numbers of health service providers, with the correct
skills, in the right places, performing the correct tasks. One approach will not
work for all, as an effective health plan must be matched to the disease profile
of a country. Therefore it is not prescient to create a single blueprint, but an
exploration of overarching strategies for when people enter the workforce,
their time in the workforce and exit from the workforce.

1.2 HSS lens

The recent international focus on health system strengthening has galvanised
the impetus to provide health system reform to provide effective, equitable
service delivery. One of the most effective methods of strengthening a health
system is to ensure adequate supply, support and management of its
workforce (Chen 2004).

1.3 Justification for research

Health system effectiveness is dependent on the health workforce. The WHO
identified that a minimum worker density of 2.3 per 1000 population is
required to delivery essential services consistently. This is doubly relevant
today, as the WHO has also identified the health workforce as a key aspect of
the current drive for global health system strengthening.

Demographic and epidemiological transitions in the coming decades will
push changes in population grounded health issues that may exacerbate the
crisis. Demand for health providers will increase in all nations in the coming
decades. The United Nations estimate the global population peaking around
2050 at 9.1 billion and then stabilise (UN 2012). The wealthier nations face
aging populations and low fertility resulting in an accelerating shift in non-
communicable diseases (NCDs) such as diabetes and heart disease requiring
specialised and continual care demands (WHO 2006). Modern societys
waning willingness to care for the elderly will increase basic care needs,
resulting in a service gap that will exert pressure on the supply of workers
from poorer nations (Spieza 2002). In poorer nations increasingly large
numbers of swiftly urbanising youth will join ageing populations to inflict a
double burden of infectious disease and emerging incidence of NCDs
(Mathers 2006). This will all place stress on already strained and understaffed
health systems, underlining the importance of strategies to combat this
service gap.

A continuum of care is required to deal with the double burden of disease in
the 57 crisis countries identified. One of which is Nigeria. It has a disease
profile of both developed and developing nations; the double burden of
communicable and non-communicable diseases. Immunisation rates are
below 70%; maternal mortality rates are approximately 1 in 10 and
contraceptive prevalence of 13% (Odusanya 2008). The problems of the
health workforce in Nigeria include low salaries; health worker deficits
principally in rural areas, skill mix inequities with a curative bias, a negative
working environment, the challenge of HIV/AIDS, significant worker
migration and insufficient financing. As such, Nigeria can be considered a
nation with many of the issues typically exhibited by the 57 countries with an
HRH crisis and suitable for a case study, in the context of which to explore the
use of task shifting to counter the crisis.

1.3 Methodology

To identify global health workforce issues and trends this dissertation has
made use of numerous sources. Grey literature such as WHO reports,
government strategy documents and were utilised to gain a general picture of
the current health workforce situation both nationally and internationally.
These were mainly accessed online. To explore current theories for the
training, management and retention of the health workforce this dissertation
used academic research papers accessed through PubMed. PubMed was also
utilised for accessing papers on the topics of migration patterns, task shifting
examples across the world and task shifting systematic reviews. The above
sources were used to identify a global issue; the factors involved and identify
possible solutions. Through application of the possible strategies to Nigeria,
an evaluation was possible on the effectiveness of task shifting there.

1.5 Chapter overview

Chapter 1: Introduces the topic of the global health crisis. It sets the health
system strengthening context and details the justification for research and
research methodology.

Chapter 2: Further explores the global health workforce crisis. It defines what
a health worker is and expands on the health system strengthening context. It
further investigates the causes of the crisis, the solutions and task shifting as a
strategy.

Chapter 3: The case study of Nigeria first examines the overall health
workforce situation in the nation. It then expands on the method of
healthcare delivery and the composition of the health workforce. It then
details the problems and solutions using the three lenses of training,
management and retention of workers. It evaluates the measures Nigeria has
already put in place and then examines the existing use of the task shifting
programme.

Chapter 4: Drawing on information from both global examples and the
Nigeria case study, conclusions and recommendations are given regarding
the implementation of task shifting to help solve the health workforce crisis in
both Nigeria and the wider global context.

2. The global health workforce crisis

2.1 The global health workforce crisis

This chapter firstly defines the global health workforce crisis before
identifying the key causes and solutions. It argues that task shifting is a
viable strategy that will have the most effective impact across many sectors
using evidence from around the globe.

2.1.1 What is a health worker?

When discussing a health workforce crisis, it is important to define who is

considered a health worker. One widely used definition is all people
engaged in the promotion, protection or improvement of the health of the
population (Stillwell 2004). However this can even include family members
looking after the ill, vulnerable and disabled. Unpaid caregivers and
volunteers are not counted in the global system of health workers due to lack
of data and the need to establish boundaries for the health system. Even so,
demarcating paid health workers into categories is still a challenge as a
classification system that examines the paid actions of the individual or the
employer exclusively cannot discern between individuals who work to
improve health employed by non-health entities such as a nurse working for a
mining company nor those who work in a non health capacity for health
entities such as a maintenance worker in a hospital.

Therefore, it is important to split the health workforce into health service
providers (HSPs) and health management and support workers (HMSWs).
There is a conservatively estimated 59.2 million full time health workers
globally. Two thirds consist of service providers such as doctors, nurses and
midwives. The remaining third is made up of health management and
support workers such as technicians, managers and pharmacists (WHO 2006).
A truly accurate measure of the global worker pool is difficult because health
workers who are employed by non-health entities are omitted in official
counts as they are grouped with the industries they work in. An estimated
14-37% of all HSPs in nations with census data come under this category,
resulting in an underestimated set of government figures.

2.1.2 How widespread is the issue?

57 nations lie below this threshold density and are designated as having a
critical shortage. 36 of the 57 are located in sub-Saharan Africa and for all
these nations to reach target levels of health worker density would require an
additional 2.4 million health workers (doctors, nurses and midwives) globally
(WHO 2006). It is unclear if this figure is in line with projected population
increase or hypothetical immediate expansion. Additionally, if this number
of health workers were distributed in current urban/rural patterns there may
be still areas of poor coverage. The average ratio of health workers to doctors,
nurses and midwives is 1.8 in WHO regions. Multiplied by 2.4 million, the
total figure of the health worker deficit may approach 4.3 million. The
greatest numerical deficit is in South East Asia, mainly in India, Bangladesh
and Indonesia. However, the largest relative deficit is in sub-Saharan Africa
where an increase of almost 140% is required to meet the recommended levels
of workers.

These estimates serve to underscore the need for more human health
resources to meet basic coverage levels for essential health services for
countries in the greatest need. They cannot replace national sufficiency
assessments and must not diminish other important determinants such as
income levels, education and gender equality.

2.1.3 Why is this important?

It is important to consider the significance of distribution of health workers

and to what degree uneven distribution can be considered an issue. Perfectly
equitable distribution is not practical and not necessarily appropriate. This
raises the issue of health worker sufficiency. There is no absolute manner of
assessing how many health workers are enough, but one possible avenue of
exploration is essential health needs and their coverage. As a result of
estimates of health worker density required to achieve Millennium
Development Goals, human health resource deficits have been acknowledged
within mainly low-income nations. The WHO health report 2005 projected
that 334000 skilled birth attendants need to be trained globally by 2015 to
meet 72% coverage of births (WHO 2005). The Joint Learning Initiative (JLI)
indicated that generally nations with less than 2.5 health care workers per
1000 people fail to achieve 80% coverage rate for deliveries by skilled birth
attendants. A cross country econometric study confirms an inverse correlation
between health worker density and mortality outcomes (infant, under 5 and

maternal mortality) (Anand and Barnighausen, 2004). The effect of health

worker density in reducing maternal mortality is larger than reducing child
mortality. This possibly due to qualified health workers being better able to
address diseases that put mothers at risk.


2.1.4 Management of health workers.

The number of health workers is only part of the picture. Where they work
and on what financial basis are also significant. Most current data on the mix
of global public and private sector workers is based on the primary
establishment of employment of the worker. At face value this evidence
indicates that the bulk of HSPs in least developed and developing nations are
mainly located in the public sector. Over 70% of physicians and 50% of other
HSPs appear to work in the public sector but there is evidence that many
service providers work mainly in private practice despite being on the payroll
in the public sector (WHO 2006). Many nations with principally public sector
workers still operate on a private basis through out of pocket fees,
moonlighting and prescription fraud. This inequitable distribution skews
access to care towards the wealthier in society and out of pocket fees impact
the poorest the most. Increasing the efficiency and transparency of health
finance is one piece of the puzzle to combat the global workforce crisis.

Paradoxically, nations with the highest burden of disease generally have the
lowest number of workers. Conversely, while North & South America only
shoulder 10% of the global disease burden, 37% of the worlds health workers
live in this area and spend more than half of the worldwide fiscal funds for
health. The African region has 24% of the global disease burden but only has
3% of health workers and less than 1% of financial resources, including aid
grants and loans (WHO 2006).

Even within nations there is inequity in health worker density. There are
many different factors contributing to the geographical variation. One of the
most common patterns involve areas in which teaching hospitals are located
and high incomes generally attract health workers most as residents can
afford to pay for their health. These attributes are often correlated with urban
areas. As such, health worker density is generally higher in urban than rural
areas. This trend will only worsen with increasing urbanisation across the
globe if unchecked.

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2.2 What is causing this crisis?

This section identifies the three key causes of the health workforce crisis.
Training, management and retention issues; with a special focus on
migration.

2.2.1 Training issues.

Globally the numbers of health training institutions are skewed towards

doctors and nurses. There are 1691 and 5492 respectively, whereas only 914
schools or pharmacy and only 375 schools of public health (WHO 2006) To be
able to respond to shortages or surpluses requires accurate data, foresight and
capacity to train different types of workers. The initial investment cost is high
to bolster training institutions but is cheaper in the long term than depending
on foreign graduates.

The classical focus on inpatient and subspecialty acute care has shifted over
time to archetypes of care espousing self management, community based care
and pre-hospital public health care. (Tollman 1991) This change in thinking
requires a shift in the manner of training to prepare health workers for a
continuum of care (Kerber 2007).

As a result of MDG projects, many in service training programmes have been
instituted. The aim of most of these sessions is to prepare workers with skills
needed to bestow essential disease specific services. While prepared in good
faith, these sessions have severe opportunity costs. There is rarely backup
staff to replace those who travel and the sessions rarely link with local
training centres. This results in a lack of local training development for long-
term use.

2.2.2 Management of health workers.

The global profile of health indicates 59 million workers in a state of inequity
(WHO 2006). Inequity between nations, geographical inequity within nations
and inequity of access to care. There is a dearth of data but more information
is needed. A lack of reliable, current data on skill mix, age location and
income internationally restricts policy development for sustainable health
systems to service disadvantaged populations.

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2.2.3 Retention issues

In sub-Saharan Africa is the estimated yearly retirement rate is about 0.6-1%

(Kinfu 2006). These rates seem low but when other workforce exit factors and
the low supply of workers are taken into account they are more significant.
As global demographics begin to grey (skew towards aged populations)
retirement rates will increase. This data is no surprise and as such with
enough foresight and information, yearly retirement rates can be planned for
and policy decisions made accordingly. Employers and the government may
offer incentives to retire earlier or later depending on projected labour supply
& demand.

Another consequence of MDG instituted programmes are salary demands.
Well-financed initiatives from non-governmental organisations (NGOs) often
pay much more than local wages in the public sector (WHO 2006). As a
result, workers performing similar jobs with similar skill sets can be paid at
different rates. For one, workers feel undervalued and are a more likely to
work for MDG programmes than the public sector. Another effect is skewing
of the skill mix toward the better paid positions such as HIV nurses rather
than obstetrics.

Health worker salaries are one of the key factors affecting the global
workforce and factor in many of the issues faced. Remuneration for services
can be split into three categories: the amount of pay, frequency of pay,
method of pay and other incentives. Underpayment and a sense of unfairness
stemming from less than living wages or comparatively less reduce efficiency
and performance (Macq 2000). Many public sector workers in low income
nations cope with unrealistically low salaries through informal payments,
moonlighting (dual employment), non-attendance and migration to labour
markets with better conditions. (Macq 2000) Solving these issues are vital to
optimising the current health workforce. Simply raising salaries can be costly
and convoluted. In many instances salary levels may be set by public service
entities, In which case raising pay in one sector alone may have negative
consequences in others. For skilled practitioners, the public sector may not be
able to compete with private sector pay or overseas pay levels. In addition,
many nations have public sector health workers with unpaid salaries. This
can trigger absenteeism, moonlighting and overall loss of care coverage (Van
Lerberghe et al. 2002).

Approaching the global health workforce crisis at the exit point of workers is
a strategy that must be considered. Workforce attrition rates increasing lead

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to higher provider costs and in turn less health workers available to provide
service coverage. The working lifespan of a typical health worker has
morphed over the years due to variations in working configurations, ageing,
morbidity & mortality rates and increasing globalisation leading to more
migration. A review found that nursing in sub-Saharan Africa was impacted
negatively by migration and that the problem is only going to grow over the
next 5-10 years (Dovlo 2007). Costs associated with retention problems are
indicated as significant financially (Zurn 2005) as well as possible negative
effects on quality of care due to disruption of infrastructure, efficiency and
loss of experience. Workplace turnover of staff can have positive effects such
as providing a chance to match skills to needs efficiently and increase team
flexibility (Buchan 2000).


2.2.4 Migration issues

Physicians and nurses & midwives trained in sub-Saharan Africa working in
OECD nations denote 23% and 5% of current health workforce in the home
nations (WHO 2006). The OECD data obscures the precise variation and
reasons for migration. Generally, migration occurs from rural to urban areas
with nations or from low income to high income nations internationally. Both
push and pull factors are significant reasons for migration. Push factors
include lack of promotion, poor pay, lack of infrastructure and high levels of
violence. Pull factors include better pay, scope for career advancement and a
more promising family future. This is all exacerbated by the high demand for
health workers caused ageing populations and the actions of recruitment
agencies.

The impact of health worker migration is mixed. Remittances generate large
amounts of income for low-income nations (World Bank 2005) but when
substantial numbers of health workers trained at the cost of source nations
leave to work in high-income countries, the source nations lose on their
investment and provide a paradoxical benefit to the destination country
(Mensah 2005).

2.3 Solutions

Addressing the worker deficits in sub-Saharan Africa requires a combination
of expanding supply through training more workers and diminishing
attrition by implementing retention strategies. International cooperation is

13

required to remedy excessive worker migration as it is intertwined with the

global labour markets.

Addressing the crisis will require substantial financial commitments. To fund
the required increase in health workers at 2004 prices is $311 million per
nation, or by 2015 the salaries of the newly expanded workforce will require a
raise of $7.50 per person per year (Verboom 2005). This figure can be
interpreted as a minimum cost because additional costs will be necessary to
retain the new health workers in the health sector and in the nation. This gap
is difficult to estimate, as salaries in deficit nations can be 15 times lower than
the most popular migratory destinations for health employment. However,
these figures assume current skill mixes and do not take into account the
evolving international labour market as globalisation increases and barriers to
work fall. This indicates a strong need for international cooperation in
addressing the global workforce crisis, in addition to comprehensive cross-
sector coordination.

The global deficit in human resources requires a concerted and accelerated
expansion of the workforce. This requires three main factors: political will,
funding and a comprehensive plan that covers both the short and long term.
Perhaps as a result of short election cycles and the global financial crisis,
public spending on health in recent years has dipped globally. Health
investment must be viewed as a long-term benefit rather than a short term
cost to be minimised. Funding should cover HSPs and support workers to
ensure a cohesively strengthened health system. A combination of short and
long term planning would involve meeting current deficits for priority
programmes quickly, in addition to galvanising the training centres involved
in the production of the workforce.

2.3.1 Training solutions.

A controversial development in the issue of the global health workforce crisis

is the prolific expansion of private training centres of medical professionals.
This reflects a wider trend of increasing proportion of private delivery of
vocational education. Between 1980 and 2005 in the WHO Eastern
Mediterranean region private training centres increased from 10% to make up
almost 60% of all health institutions (WHO 2006). In South America between
1992 and 2000 there was a 60% increase in the number of medical schools.
Some are public funded and some require fees from students. Much of the
controversy stems from the health workforce diversity issue. Entrance to
most programs requires a secondary level education but the nations with low
incomes and high educational drop out rates limit the possible candidates

14

who can apply to the health workforce. This also reflects a trend in
inadequate funding of education in many nations (WHO 2006). As such, this
distorts the profile of workers toward the higher social classes in societies and
dominant ethnic groups, rarely reflecting the socio-demographic mix of the
nation. Additionally, this could cause clustering of lower socio-economic
means in less costly training programmes or find career choices limited by
student debt. (Pechura 2001) This trend is also true to some extent in
wealthier nations too. As such, this context suggests that improved funding of
primary and secondary education is key to increasing the supply of health
workers.

There are no guidelines currently on the recommended amount of investment
in the health workforce but as referred to earlier in section 2.2.1, significant
funding increases will be needed in nations with human resources for health
crises. Redirecting funds spent on in-service training to pre-service training
would be both beneficial and much longer lasting. Pre service training
programmes often have lower costs for trainers, allow students to gain core
competencies to combine with their future practices and avoid diverting
personnel time for training days (Naimoli 2006).

It is unfeasible for all nations, especially smaller low-income nations to
implement comprehensive training programmes. Regionalisation of training
health professionals is a possible avenue of international cooperation for
mutual benefit. One successful example is the University of the South Pacific.
The USP is jointly owned by governments of 12 nations (WHO 2004) and has
campuses in all 12 member countries. It utilises comprehensive distance
learning programmes and technological innovations to enable effective
learning without needing expensive centralised institutions.
Recruitment of health workers is a vital area of investigation in the context of
the global workforce crisis. The number of recruited workers should
represent the disease profile demands, the extent of underemployment and
attrition from the workforce. Competencies of the staff should again reflect
the disease profile and their background must be compatible with
sociocultural profiles of the population to ensure good communication.

Labour markets often determine recruitment patterns. Labour supply reflects
the outcome of the education system, whereas labour demand is linked to the
demand for health services. Market balance is achieved when labour demand
is concomitant to the supply, or the outcomes of the health education system
can match the demand for health services. However, this does not take into
account urban-over supply or inequity of access for parts of the population.
Standardised public sector wages limit the ability of the public sector to hire
and compete with the private sector employers and non-governmental

15

organisations. These pay and condition differences also drive migration rates,
causing severe attrition of the workforce in nations where health workers are
at a premium (WHO 2006).

2.3.2 Management of existing workers.

Given the massive financial costs of meeting the global deficit of health
workers at current skill mix densities and efficiencies, it is imperative to
optimise the current workforce performance. To improve a workforce, one
must define what a parameters a well performing workforce can be judged on
and what determines these parameters. An effective workforce must be
available to the populace. It needs to be well distributed, with high
attendance of workers. Possible indicators to measure this are staff ratios,
absence rates and waiting times for patients. The workers must be competent
in their skills, knowledge and behaviours matched to the disease profile of
their locality. Possible indicators are readmission rates, mortality rates and
cross infections. Responsiveness requires the workers to be equitable to all,
regardless of who they are and finally health workers must provide the
maximum service and outcomes possible with the resources available to
them. These two attributes may be measured through patient satisfaction and
rates of occupied beds, out patient visits and interventions delivered per
worker. (Pongsupap 2006) Measuring performance in itself is a controversial
issue, due to its difficulty, possible effects on the workforce and the tendency
for employers to manipulate data (Pangu 2000).

No single factor affecting performance can be identified, rather a multitude of
factors affecting overall health workforce performance. Consequently, major
improvements in workforce effectiveness usually stem from a group of linked
initiatives rather than single ones. Job related conditions such as clear job
descriptions are supported by research in improving achievement of work
goals (Dolea 2004). One example of this is in Indonesia where a Clinical
Performance Development Management System was developed that clearly
identified responsibilities and accountability. Staff reported greater
confidence and job satisfaction (Dolea C, 2004) Inefficient use of the worker
skill mix can be remedied through matching tasks to skillsets. This may be
due to management tasks being carried out by skilled personnel due to lack of
other staff or untrained staff executing skilled procedures resulting in unsafe
practice.

In Ghana the workplace practice of supervision and feedback has strong
evidence correlating improved performance outcomes, across the staff
spectrum (Dovlo, 1998). It is difficult to put into practice and becomes ever

16

more important in busy and resource poor environments, especially in the

context of task shifting and redistribution of care. Supervision should be
supportive, educational and consistent with the emphasis placed on
competency rather than obedience.

Given the strong MDG imperatives there was a trend of planning vertical
interventions focusing on specific diseases. This manner of planning runs the
risk of neglecting the wider basis of the holistic nature of human resources
and health service delivery. However, removing existing clinical pathways
established in this manner would be inefficient and wasteful. Piggybacking
is a term used to describe the method of attaching additional services to
previously single-purpose delivery pathways. One example of this is the
usage of the community program to prevent river blindness in West Africa to
deliver vitamin A supplementation. (Dreesch, 2005)

2.3.3 Retention solutions.

Method of payment can influence performance and retention greatly. Fixed
budgets can lead to health providers minimising the number of patients seen
and service coverage. Performance based incentives can provide incentives to
ensure care coverage is maximal but can also encourage redundant and
wasteful treatment options (Wouters 1998). Most low-income nations pay
health workers with fixed salaries and sometimes allowances unrelated to
performance. There are theories espousing the implementation of
performance based pay in these nations but measuring the performance of
health workers comes with increased administrative costs and complexity,
perhaps excluding their use in these resource-poor environments. However,
the use of allowances to bolster salaries to increase job palatability is prolific
in most nations. Examples include health insurance, access to loans,
additional payments while training and financial incentives for working in
remote areas (WHO 2006). The effectiveness of these measures depends on
design and the other conditions of employment.

Mali also very quickly and effectively increased rural coverage and retention
in 1986 through a strategy to incentive graduates to work in underserved
areas. The ministry instituted a system wherein both public and private
sector workers would have different payment methods but the same non-
financial benefits. They receive training, accommodation, equipment and
transport. By 2004, 80 doctors from Malis total of 529 had signed up. In 2001
a study indicated that the program had increased service coverage in rural
facilities (Desplats 2004). Thailand also instituted payment reforms in the
1990s to improve rural coverage. They involved supplements to salary, non-

17

private practice compensation and overtime payments. These were combined

with non financial incentives as in Mali with a result of improved rural
coverage (Nityarumphong 2000).

Unpaid salaries present a problem in many HRH nations and can severely
impact worker retention as discussed in section 2.23. Financing any
initiatives is always an issue in resource poor health systems, especially if
they cannot pay their health workers regularly as it is. In Chad, donor funds
have been effectively used to strengthen health systems by guaranteeing
regular salaries for health workers who previously had experienced severe
delays (Zachariah 2001).

As referred to in section 2.2.3, a professional working environment is a key
factor in worker satisfaction. To impress upon workers the importance of
adhering to standards and maintaining a professional work environment the
Ugandan government implemented an award system known as the Yellow
Star Programme. Health facilities that comply with 35 indicators thought to
be representative of effective management receive a plaque, official
recognition and publicity. These efforts have engendered better
harmonisation between health facilities, administrators and political leaders
(Egger 2005). This is another example of non-financial incentives improving
performance and bestowing secondary benefits such as improved
communication channels. However, this requires a cohesive regulatory and
oversight presence of the medical governing body.

One issue faced by health workers in low-income countries are lack of
infrastructure and supplies. There is scant evidence for performance benefits
from improving basic infrastructure but examples such as Kyrgyzstan can
demonstrate the risks of insufficiency, especially when increasing health
system capacity. Reforms in 1997 changed the budgeting system. Instead of
passive fund allocation depending on simple bed and staff numbers, active
strategic purchasing depending on demand for service was implemented.
However, the reforms required new forms of management and quality
control. The message from this is that it is important to be aware of the
peripheral infrastructure aside from the main health system delivery service
as the whole is essential (Jakab 2004).

Many of the costs faced by HRH countries are limited by the rules of public
financing. To ensure macroeconomic stability and fiscal endurance
international fiscal entities use criteria such as public expenditure to GDP
ratio to set debt ceilings and credit ratings. The major relevant consequence
of this is the limit on recruitment and non-inflation matched salaries of
workers, resulting in a much weaker health system and poor worker

18

satisfaction leading to attrition. An international consensus is required to find

a way around these regulations, perhaps to make health service the exception
to the rule (MOH 2005).

2.3.4 Migration solutions

Some measures source countries can consider include instituting training
methods that are focused on local conditions such as local languages and
skills matched to the disease profile. These measures have evidence of
efficacy as indicated by Wibulpolprasert (2001) in reducing migration but can
bestow credentials that are not internationally recognised. This is an ethical
quandary that rides on the balance between individual health worker rights
to an internationally recognised qualification and the needs of the host nation.
Some nations such as the Philippines and Cuba pursue health worker export
strategies (Choy 2004). As previously mentioned in section 2.2.2,
improvements in the conditions in source nations can help stem migration
(Denham 2004).

Non-financial incentives must be considered carefully before implementation.
In Ghana a duty hour allowance allocated to both doctors and nurses was
condemned by nurses for perceived or real inequities in benefit. This is
thought to have actually increased net nurse migration from the country
(Buchan 2004).

2.4 Task Shifting

This section will explore task shifting as a concept first. It will then explore
the history of its implementation and finish with a discussion of the benefits
and drawbacks of the strategy with examples from around the globe relevant
to the threes areas of training, management and retention.

2.4.1 What is task shifting?

Simplification and delegation of services is another method of improving

existing health coverage or when scaling up service. Simplification through
reducing task complexity and allowing it to be carried out by less skilled
workers can allow more to be achieved with increased reliability. Using
technological innovation and strategic planning to reduce task complexity can
help consider all available human health resources as executors of health
initiatives both inside and outside the health sector. Examples of this include

19

the scaling up of oral rehydration therapy in Bangladesh (Chowdry 1997) and

the WHO/UNAIDS 3 by 5 initiative (WHO 2003) where patients with
HIV/AIDS can make significant contributions to prevention and treatment.
There was a decline in interest for CHW programs in the 1980s due to
problems such as unrealistic expectations, poor planning and sustainability
issues (WHO 1996). Recently, CHW programs have returned globally to
address shortages in health workers, especially for HIV/AIDS care.

Task delegation, or task shifting is the principle of ensuring tasks that can be
carried out as or more effectively by less senior members of staff, are carried
out by the lowest safe and effective skill level (WHO 2007). This is especially
vital in low resource environments where skilled staffs are at a premium.
One example of this is the delegation of malaria diagnosis to volunteer health
workers in the Philippines (Bell 2001). Preliminary results show the strategy
was reliable, improved outcomes and even raised morale of workers.
However, simplification and delegation require careful forethought to ensure
the impact is positive and safe. One failed example is the training of
thousands of traditional birth attendants (TBAs) in the 1980s to improve
maternal mortality rates but there is still no evidence that the initiative has
been effective (Sibley 2004). However, the risk-assessed combination of
simplification, focusing on patient self-management and community
participation can enable tasks in many settings to shift from limited skilled
workers to less skilled and more common workers or even the patients
themselves.

Auxiliary health workers are often known by a number of titles such as health
volunteers, community health workers, physicians aides and many more.
All auxiliary workers have one attribute in common. They are involved in
helping provide health coverage where it is impractical, unfeasible or too
costly to provide access with traditional health workers such as doctors or
nurses. They carry out many services similar to doctors and nurses such as
proving prophylactic medical services such as vaccination, monitoring public
health and providing basic curative skills. Auxiliary health workers often
provide a link in primary health care between clinical and community care.
They can be from the locality in question and be familiar with socio-cultural
and language nuances.

Progress towards the MDG 4 is slow in sub-Saharan Africa. Approximately
60% of under 5 deaths could be prevented by existing interventions (Jones et
al., 2003). With regard to infant mortality, 41-72% of neonatal death can also
be prevented with available interventions with high service coverage; with a
possible half of those reductions conceivable through community based
services (Darmstadt et al., 2005).

20

2.4.2 Benefits

The key question when it comes to task shifting is whether the alternative
cadres of health workers can deliver services comparable to conventional
staff. A systematic review of nurse led primary care shows that care assistants
achieve health outcomes equal to those of general practitioners with good
patient satisfaction (Royal 2006) and comparing nurse led with usual doctor
led care outcomes for diabetic patients showed improved glycaemic control,
lower mortality and fewer complications.

In Kampala, Uganda, a community based antiretroviral therapy program
using peer health workers and nurses resulted in good AIDS care and
virologic outcomes (Abaasa 2008) equal to or better than care received in
hospitals from conventional staff. In free state province, South Africa, the
availability of treatment buddies, CHWs and support groups were the most
important predictor of treatment success in the first 2 years of treatment
(Schneider 2008) suggesting that continuity and access to primary healthcare
is the deciding factor in adherence rather than seniority of staff.

Lay health workers achieved better outcomes for patients and provided a
considerable cost saving compared with clinic based care. Trained CHWs
could improve the treatment success rate among TB patients in a health
service despite reduction in the range of services available (Clarke 2005).

In the Mozambique HAART program, outcomes were similar for doctors and
lay workers. Based on pharmacy records patients were more likely to make a
quarterly visit if managed by a MLW. Proximity of lay workers to population
serves to increase access to healthcare. There were no significant differences
in outcome when compared to medical specialists. Surgery by mid level
health workers in Mozambique provided the same outcome as doctors whose
training cost ten times as much, indicating a strong fiscally positive basis for
auxiliary health workers. Junior doctors require more senior medical support
for longer periods when sent to rural areas than MLWs (Callaghan 2010).
Chung demonstrates that 942 hours of nurse time freed up 737 of physician
time which could then be expended on more complex cases in non-HIV fields,
increasing the health system capacity.

A pilot program in Rwanda transferred several tasks from physicians to
nurses trained in HIV management while physicians took on more
supervisory and mentoring roles. Improvement in CD4 count, correct
prescriptions patient monitoring and overall survival were similar between

21

the two groups (Shumbusho 2009).

One of the major health indices referred to in section 3.3.2 was infant and
under 5 mortality. In Malawi clinical officers conducted 93% of major
obstetric operations in government hospitals with no significant differences in
post op outcome, wellbeing or neonatal mortality when compared with
medical officers (Chilopora 2007). If this is representative of the wider global
context, the effects of utilizing task shifting to fill gaps in service coverage
could be very positive for specific tasks.

A systematic review of 82 randomised controlled trials on the effectiveness of
lay health workers in a variety of setting showed that they provide benefits in
promoting immunisation, breastfeeding practice, improving TB outcomes and
in reducing child morbidity and mortality when compared to usual care
(Lewin 2006).

In addition to providing a comparable level of care, task shifted workers are
more likely to remain in service in comparison to doctors. 7 years after
graduation of tecnicos de cirugia in Mozambique, more than 80% were still
working in district hospitals (Brown 2011) whereas nearly all-medical doctors
posted had left within 3 years.

2.4.3 Drawbacks

Another review of 6 large-scale community based worker programs suggest
they have succeeded in some objectives but not all. CHWs increase service
delivery and equity of access at low costs compared with traditional
structures but they do not always provide services likely to have significant
impact (Berman et al., 1987). In addition, quality is not always consistent.
Conclusions were drawn that many CHW programs have not reached their
potential, with further development needed to assure their successes continue
and are properly supported.

In the pacific region low pay was associated with difficulties in retention.
Poor supervision and lack of training opportunities appeared responsible for
attrition of the cadre (WHO 2004). However, this may be an issue of
implementation rather than principle.

One important factor to remember is that task shifting alone may not have as
a great an impact on population health, as addressing social determinants of
health is essential and often ignored due to the projected return from
investment being relatively long term.

22


Issues surrounding low utilization do exist. A study in Burkina Faso
emphasized the importance severity of disease and perceived effectiveness of
treatment were the most significant factors of health seeking behavior. For
mild diseases villagers sought their CHW in 8.8% of cases with villagers
bypassing the CHWs 96.5% of the time with more serious illnesses (Sauerborn
et al., 1989). This may not be representative of an inherent problem with
CHWs, but emphasizes the need to pursue an integrated plan of public health
education of how to utilize services.

23

3. Case Study: Nigeria

In section 3, this dissertation will use the key benchmarks and strategies
identified in section 2 to assess the effectiveness of Nigerias HRH strategy. In
addition, Nigerias suitability for task shifting will be examined.

3.1 Nigeria overall situation

Nigeria is one of the WHOs 57 human health resource crisis nations. It is
comprised of 36 states and a Federal Capital Territory (FCT). These areas
arranged into 6 constitutionally recognised geopolitical regions (North
Central, North East, North West, South East, South, and South West).

3.2 Healthcare

Advances in essential health indicators have been gradual and Nigeria still
ranks as a nation with one of the highest child and maternal mortality rates.
In 2004 the under 5 mortality rate was 201 per 1000 live births (DHS 2004) and
the maternal mortality ratio was approximated at 800 per 100,000 live births
(Ujah 2005). Nigeria is particularly relevant as a case study to explore the
global workforce crisis as it exemplifies some of the symptoms of inequity of
access to healthcare among various population groups. The health sector is
typified by regional inequities in health indicators, health coverage and
financing.


3.2.1 Method of health delivery

Health care in Nigeria is provided by a combination of public and private
sector entities. Public capabilities are governed by the three tiers of
government: federal, state and local. There are also private for profit
organisations, non-governmental organisations (NGOs), community based
organisations and traditional care providers (WHO 2002).

Primary level healthcare facilities are the gateway to the health system for the
populace. These provide general preventative, curative and referral services
and are staffed by nurses and community health workers. These facilities are
managed by the local level of government. Further up the health system

24

hierarchy, secondary facilities such as general hospitals provide medical

services and more specialised care. In addition to these public providers,
there is a mostly unregulated private sector delivery primary and secondary
care too. Finally, the tertiary level centres are the most specialised providers
available. They accept referrals from lower in the system hierarchy.

Primary healthcare (PHC) coverage can be a good indicator of the state of the
health workforce. The Nigerian government attempted to institute PHC
reform with the National Health Policy of 1988 but it failed to implement a
comprehensive finance, staffing or care overhaul (Alubo 2001). The policy
was revised in 2004 and despite PHC being a designated priority, in action
the focus was overly on curative care. Consequently, preventative care was
neglected and coverage suffered. This can be inferred from the low
immunisation levels for measles, mumps and rubella (Schimmer 2006) of less
than 70%.

A study exploring factors involved in low utilisation of the PHC system in
Nigeria gathered data from 360 mothers of children under 5. The main
factors causing a lack of attendance included high out of pocket costs, easy
access to traditional healers and transport issues (Katung, 2001).

Progress towards MDG 6A is promising but too slow to meet the 2015 target.
The prevalence of HIV/AIDS dropped from 5.8% in 2001 to 4% in 2008 and
the population access to antiretroviral medication increased to 34.4%.
However, the distribution in wealth quintiles is highly inequitable as only the
wealthy can afford them and certain states have high prevalence rates
(Uzochukwu 2009).

3.2.2 Health workforce

In 2007, there were 52,408 doctors and 128918 nurses working in Nigeria
(Awofeso 2010), working out at about 35 doctors and 86 nurses per 100,000
population. Compared to the sub-Saharan African average of 15 doctors and
72 nurses per 100,000 population (WHO 2006), Nigeria appears to be
performing better than average. However despite containing the largest
stockpile of health workers in Africa, it has an average health worker density
too low to capably delivery health services (1.95 workers per 1000
population). Compounding the issue, the majority of the workforce is located
in urban areas, especially concentrated in the major city of Lagos (DHS 2004).
The majority of state health authorities do not have cohesive health workforce
plans as staff management resides with the civil service and hospital boards.
Consequently, many training centres over or under produce categories of

25

health worker for their particular state. Despite other states suffering severe
shortages of workers, there is no easy method of matching workers to
vacancies.

3.3 Problems

3.3.1 Training issues

An encouraging sign of health system vitality is the net supply of graduates
to the workforce. The net increase of doctors to the workforce is 16.5%.
Compared to the attrition rate of 2.34%, this suggests that the gaps in service
coverage are caused more from distribution issues than retention (Dovlo
2005). However, the figures are not as positive for nurses and midwives,
laboratory staff, pharmacists and community health extension workers
(CHEWs) as demonstrated in figure 2. Again, averages obscure the
urban/rural disparity. Rural attrition rates are much higher, either to urban
areas or outside of the country (Dovlo 2005). Another significant issue to
consider is health workers at primary healthcare level have much higher
attrition rates than secondary or tertiary level.


Fig. 2

As detailed in section 2.2.1, the location of training of health workers is
important. In Nigeria, training is primarily located in the southern parts of
the nation with very few in the north. To ensure high standards of care, the
nursing and midwifery institutions have limited entry of students to only 50
per year.

Despite a critical shortage in workers, there is a lack of intern posts and
residencies for physicians.

26

There are no public health training institutions in Nigeria. This creates a

significant drawback to the national professional workforce and an
insufficient capacity to lead public health programmes and systems.

3.3.2 Management of existing workers

Fig. 3 Source: NDHS report 2003

Figure 3 emphasises the inequity of staff availability in different areas. Any
strategies implemented to ensure increased supply of health workers would
have to be mindful of the needs of the deprived areas. National data obscures
some information about the different levels of health worker types as doctors
and dentists are grouped together, as are nurses and midwives. Not shown in
figure 3 are the very low levels of other aspects of the health team such as
radiographers. Encouragingly, the ward minimum service package
(Osungbade 2008) entails a mandatory minimum laboratory technician per
primary health centre but there are no records available on said numbers.

The significance of the health worker density inequity between states is
apparent with the strong correlation exhibited between low doctor density
and the under 5 mortality rates as shown in figure 4. The North East and
North West areas have the worst under 5 mortality rates, as well as the lowest
doctor density per 100,000. A cross nation econometric study confirms this
association, indicating an inverse correlation between health worker density
and mortality rates (Anand and Barnighausen, 2004).

27

Fig. 4

If the high neonatal mortality rates are to be addressed, the skill mix in most
areas need to be rectified. In 2006, it was found that on average there is only
one doctor for every 4 PHCs, and only 3 nurses/midwives per PHC (Uneke
2008). As with most of the averaged data collected, it obscures rural
disparities. In some of the more rural states it is unusual to even find
midwives in PHCs. The under 5 mortality rate in rural areas is as high as 243
per 1000 live births compared to the urban rate of 153 per 1000 live births (ref
DHS 2004). The impetus for human resource development should be
improved planning and management at both a national and local level for
even production, the right staff skill mix and equitable distribution.

3.3.3 Retention issues

As referred to in section 2.3.2 the remuneration of staff is a vital factor in
retaining and attracting workers. Despite a National Health Service plan, the
salaries vary between each state. As a result, health workers tend to be
concentrated in federal facilities over government and state payrolls. These
inequities are especially apparent for nurses and midwives (Uneke 2008).

Exacerbated by salary issues, Nigeria reflects the trend of health workers
choosing to work for private providers where they can earn more. This
happens to be concentrated in urban centres where patients can afford
treatment (Uneke 2008). This causes distinct inequity of access to health
workers for those residing in deprived and rural zones. Figure 5 illustrates the
distribution of registered Nigerian physicians. Most doctors operate in the
private sector. Irrespective of sector, this is an indication of the need for

28

cooperation and coordination between the public and private sector to

regulate the equitable delivery of service coverage.

Fig. 5

3.3.4 Migration issues

Nigeria is one of the main staff exporting nations in Africa. Figure 5
emphasises the significant number of Nigerian health workers working
abroad. 12% of physicians who qualify in Nigeria are working in OECD
(WHO 2006) nations. The cost per doctor to the Nigerian government is
US$184,000 (Lal 2007).

3.4 Solutions

What path should the government take? The role of the government is to
provide policy, arrange financing and manage training. In addition, it must
balance the performance of the public sector while ensuring the private sector
is not impacting negatively on overall service coverage and equity. This
section details possible avenues of action.

3.4.1 Training solutions.

The Nigerian government is focusing on capacity building as part of their
National Human Resources for Health Strategic Plan (NHRHSP). It will
involve training and retraining of primary health care workers. It will also
implement compulsory professional development for health workers and

29

integrate prevailing health care trends with the curricula. This strategy
hinges upon adequate funding being earmarked for human resource planning
and initiatives and that all relevant stakeholders continue to prioritise
integrated human resources issues.
3.4.2 Management of existing workers

To address the rural/urban distribution inequities incentives are provided to
workers who choose to reside in rural areas. Some states make rural service
compulsory or a requirement for promotions. Recent legislation also requires
nurses and midwives to perform one year of national service to ensure their
services are available in rural areas. In addition to this, the Nigerian
government has initiated a plan to utilise retired midwives and nurses of
working age in rural areas.

Further efforts as part of the NHRHSP to motivate and retain health workers
include a special salary scale and preferential entry points in the public sector.
However, these plans depend on all relevant parties agreeing to
institutionalise performance management culture at all levels of service
provision. Furthermore, involved parties must commit to continuous
professional development plans of health workers.

3.4.3 Retention solutions

As referred to in section 2.3.3, working conditions are an important variable
in health worker retention. Upon investigation, nursing staff in some tertiary
hospitals were heavily overworked while others in general hospitals were
severely underworked. Both parties reported poor job satisfaction,
suggesting the use of workloads to determine levels of staff distribution
would be beneficial to maximising efficiency and use of available staff
(McCoy 2008). However, the current system of three tier constitutional
ownership leads to inflexibility in establishing continuity.

To retain health professionals in difficult zones a number of initiatives have
been implemented. The Nursing and Midwifery councils one year
mandatory midwifery service will help alleviate rural/urban disparities. In
addition, there will be an allocated hardship and deprived area allowance for
some rural postings. To help build health system capacity in rural areas, a
loan scheme is being instituted to encourage the launch of facilities in rural
zones.

30

Many of the measures designed to retain workers are too focused on financial
imperatives instead of effective leadership, supervision and other non-fiscal
incentives as referred to in section 2.3.2.

3.4.4 Migration solutions

Data on Nigerian doctors emigrating is unreliable as many destination
wealthy countries do not allow foreign trained doctors to migrate based on
purely their medical skills Nonetheless, hundreds of Nigerian health workers
emigrate annually (Awofeso 2008). In 1966 there were 215 Nigerian doctors
practicing in the UK. They made up 1.5% of all overseas doctors. This figure
grew to 1922 in 2003 and represented 3% of all foreign doctors (GMC 2004).
Awofeso (2008) argues that the migration of health workers is not the critical
factor in the health workforce crisis in Nigeria, rather the deterioration of the
government spending and a lack of a rural and remote health strategy. As
such, this dissertation acknowledges migration as an issue that must be
addressed but cannot be done unilaterally through the Nigerian government.

3.5 Task shifting programme

This section is explore Nigerias current task shifting programme:
Community Health Extension Workers, their progress so far and their
effectiveness.
3.5.1 Community Health Extension Workers

A possible solution to the difficulty in hiring and retaining health workers in
rural areas has spurred the increased use of auxiliary health workers or
Community Health Extension Workers (CHEWs) in the delivery of primary
care for undiagnosed patients with general health problems. A preliminary
study done in Nigeria with CHEWs in a private rural health care facility
displayed promising results (Ordinioha and Onyenaporo, 2010). CHEWs
were chosen through support from their schools and implemented
anonymously with clear job descriptions a factor identified as important for
worker satisfaction in section 2.3.2. A total of 1028 patients were seen over a
6-month period with the majority of the patients (86.5%) happy with the
quality of care delivered. It must be noted that these CHEWs were employed
under the supervision of physicians and that the facility was private.
Nonetheless, the study supports the contention that auxiliary healthcare
workers can positively impact the delivery of primary healthcare, provided
there is supervision.

31

3.5.2 Progress so far

The inhospitable terrain of the Niger delta area of Nigeria makes the delivery
of essential services in rural communities a real challenge. A descriptive
cross-sectional study by Ordinioha (2010) assessed the provision of primary
care in a rural health facility. The results indicated that community health
extension workers could provide a good quality of care with good levels of
patient satisfaction. This is concurrent with much of the other research
globally but against the tide of opinion in Nigeria. However, assessing the
representative current performance of CHEWs in Nigeria with regard to
increasing equity is difficult due to lack of data. A study examining the
inequities involved in using CHEWs to treat malaria found that CHEWs
improved overall geographic but not socioeconomic equity of medication
(Onwujekwe et al., 2007). This suggests that the CHEWs have been successful
in increasing equity in rural regions as hoped but the financial aspect of care
must be assessed further to ensure equality.

32

4. Conclusions

4.1 Original brief

This dissertation examined the factors involved in the global health workforce
crisis, explored the possible strategy solutions and evaluated the use of task
shifting as a possible method to help address the growing gap between health
worker supply and demand. It focussed on Nigeria as a case study to
examine one of the 57 human health resource crisis nations and applied key
strategies identified through examining examples of good and bad practice of
task shift implementation around the globe.

4.2 Overall findings

The current global focus on health system strengthening has shed a spotlight
on the health workforce. The health workforce crisis can be considered a key
obstacle to achieving essential service coverage. The majority of evidence
suggests that task shifted workers with the correct funding; support and
supervision can provide a consistent, safe and good quality of care to the
satisfaction of patients for undifferentiated primary health care. This
increases the supply of health workers, increases equity of coverage and is
more cost effective than simply training more conventional cadres of worker.

Nigeria is one of the WHOs 57 human health resource crisis nations and has
a severe health worker shortage problem clearly visible in the inverse
correlation between under five mortality rates and health worker density in
figure 4 in section 3.3.2. It also suffers from urban rural disparity and health
workers preferring to work in higher paying jobs.

Reasonable equity of distribution of care is important as low health worker
density (below 2.5 per 1000) fails to achieve sufficient service coverage. The
three main spheres of interest in ensuring there are enough health workers
are their training, management and retention. The key message gained from
the theories explored regarding training is that cooperation is key. Resource
poor nations cannot afford to run a high standard of training for every cadre
of worker needed in the health service. The example of regionalisation to
implemented by the University of the South Pacific referred to in section 2.31.
is prime for initiatives around the world. However, post graduation equitable
distribution would have to be legislated to ensure all partners benefit from
the arrangement.

33

Most initiatives often cost money. To raise funds, the example of Chad
explored in section 2.3.3. Can be applied to almost any other resource poor
nation with access to MDG donor funds. Rerouting funds to support health
system delivery by paying worker salaries can be effective in regaining
service coverage.

However, case studies from Mali, Uganda and Kyrgyzstan discussed in
section 2.3.3. also emphasise the point that non financial incentives can be as
effective, if not more effective than conventional financial incentives in
inspiring improved worker performance. By improving the working
environment as discussed in section 2.3.2 using grouped interventions,
overall service delivery can be improved and health workers can be retained
in rural areas. Caution is advised before using any strategy as with the
example of Ghana in section 2.3.4 wherein a positive change had unintended
consequences resulting in more net migration out of the country.

To remedy the private practice inequity of access issue, perhaps Nigeria could
follow the examples of Thailand implement payment reforms to ensure that
regardless of public or private sector, workers would have the same onus to
work in rural and deprived areas.

Migration is an important issue in regards to the human health resource crisis
as the brain drain from low income to high-income nations paradoxically
mirror the inverse burdens of disease resulting in severely inequitable global
distribution. International cooperation is vital to rectify this situation,
perhaps with stricter regulations on the ethics of wealthy host countries
recruiting from nations with staff shortages. However, this multilateral action
is outside the remit of this dissertation, which is concentrating on Nigeria,
and the use of task shifting.

As explored in section 2.4.1, task shifting as an idea has been around since the
1980s but suffered from poor implementation. The context of the present
health workforce crisis has reaffirmed the importance of the task shifting
strategy.

Task shifting is a method of dealing with critical worker shortages as it
impacts on all three lenses of inquiry explored in section 2. Training is cheap,
cost effective and an investment for the future as community workers do not
migrate anywhere near as much as doctors and nurses. The management of
workers is still a challenge as previous efforts have failed due to lack of
supervision and funding. However, utilising the techniques explored in
section 2.3.3 to ensure correct supervision, community health workers can be
an effective cadre of the health workforce in Nigeria, and globally.

34


It is always vital to remember that task shifting is simply a strategy to
optimise health worker distribution, it is important not to lose sight of the
social determinants of health, which can have a much needed vital effect on
global health. As detailed in 3.5.2, task shifted workers are very effective at
addressing geographic inequity of care but cannot remedy financial barriers
to healthcare.

As detailed in section 2.4.2, the benefits of task shifting far outweigh the
drawbacks. Studies examining the effectiveness of task shifted workers in
Mozambique, Uganda and Malawi to name a few all confirm the comparable
if not better ability of task shifted workers to delivery a cheaper, consistent
and effective level of care comparable to conventional cadres of workers. The
Burkina Faso study quoted in section 2.4.3 does stress the importance of not
only the implementation of task shifted workers, but the peripheral education
along with it. CHEWs in Nigeria appear to have made a positive impact as
detailed in section 3.5.2 but more monitoring is required to confirm, in wider
areas as data is still very scarce. However, with promising results from global
implementation of task shifted workers, it is safe to say that Nigeria can also
benefit from an expanded task shifted worker program.

4.3 Difficulties conducting research

Conducting the research had some shortfalls. There was a distinct lack of
data about health workforce migration patterns from low-income nations to
high, as general migration data did not specify. Also, when researching the
implementation of health workers in rural areas data was comprehensively
scarce. However, this may reflect the lack of infrastructure and health
support systems that represent the gaps in service coverage that the task
shifted workers are aiming to help rectify. Many of the government
proposals and strategy documents detailing the national human health
resource plan were distinctly lacking in accountability and monitoring
frameworks. They often dealt with good ideas and long-term goals but did
not express continuity from previous initiatives or monitor progress towards
past targets in a sufficient level of detail.

4.4 Recommendations for future research

Perhaps future research could utilise raw health workforce data figures direct
from the government. Ideally a support infrastructure in the age of
connectivity would enable real time readout of health worker distribution.

35

Many of the issues causing gaps in service coverage stemmed from not only a
lack of supply of health workers, but also a lack of coordination in sync with
the health needs of the nation.

The reasons behind this are unclear and complex but perhaps a system that
compensated workers for employment in less desirable posts commensurate
to their possible earnings elsewhere would be very beneficial. As detailed
throughout section 2, it is key to implement both financial and non-financial
incentives to motivate and retain workers.

36

6. Bibliography

Abaasa, Andrew M., et al. "Good adherence to HAART and improved

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