Helping hands for health workers in fragile states

Nowhere is the global health worker crisis more acute than in fragile states – those countries where the government cannot or will not deliver core functions to the majority of its people. Since the civil war, Liberia has an absolute shortage of health workers. Merlin is working with the government to help train health workers and rebuild the shattered health system.

Midwife Sarah Shaffa teaches at the Merlin/Ministry of Health Midwifery School in Liberia, remote south eastern region

Amy Waddell tells the story.

In 2007, fragile states received only 38.4 per cent of Overseas Development Aid. Fifty per cent of that benefited just five countries, with the rest divided up among the remaining 41 states. Yet fragile states carry a disproportionate level of the global health burden: one third of women who die in childbirth and half of all children who die before their fifth birthday live in fragile states.

Sustained investment in health, especially health workers, in fragile states is vital to save lives and to meet the Millennium Development Goals.


Before the civil war, Liberia boasted 237 doctors providing health care for a population of two million people. By 2005, an evaluation estimated there were less than 20 doctors left in the country. Fourteen years of government coups and rebel clashes had shattered the health system and caused the death or emigration of many qualified health workers.

With the commitment of President Ellen Johnson Sirleaf, the Ministry of Health and Social Welfare (MoH&SW) is tackling the huge challenge of rebuilding Liberia’s health infrastructure including the health workforce – yet with minimal resources.

Since 1997, Merlin has been supporting the MoH&SW. Initially running mobile clinics for people displaced by fighting, the organisation has expanded its role to support the delivery of a third of the country’s health care. Merlin’s key focus is the training and supervision of health workers; helping to implement Liberia’s ambitious National Health Plan, which highlights the need to strengthen human resources.
In Liberia the shortage of health workers is most acute in rural areas, such as the isolated south eastern region. Until June 2009, there had not been a permanent doctor in a county of 185,000 people for almost six months.

Reaching the south east can take a 20 hour drive on dirt roads that are barely passable during the rainy season, from March to October. Health workers sent by the MoH&SW make their own way to take up their remote roles, often only to resign and return to the capital, Monrovia, months later.

With inadequate housing and few schools, there is little to encourage health workers to stay. Leaving their families in Monrovia, Liberia’s health workers struggle both to support their main family home and feed themselves; a bag of rice in the south east costs $45 instead of the usual $30, because of transport costs. Health workers receive no added incentives to live and work in this remote region.

Investing in Health Workers

An example of one project addressing just such issues is the Midwifery Training School, based in Grand Gedeh.

Supported by Merlin, this MoH&SW school re-opened in December 2008 after a forced closure of almost 20 years. Returning to pre-war ideals, a two year full-time course, accommodation, uniforms and materials are provided free of charge to all students.

In a bid to retain health workers in the south east, the school only advertises across the region’s six counties – encouraging men and women, aged 18 to 45, to apply for the 40 places that are offered, on average, each year. The sole condition for the Midwifery School’s free training: that students sign a bond to work in their communities for at least three years after graduation.

By recruiting future health workers from their home counties, areas where health workers are most sparse, the Merlin-supported MoH&SW school offers a sustainable solution to Liberia’s health worker crisis.

For now, it is a small step towards equipping Liberia with the estimated 1000 midwives it needs; by 2010, over forty students will be providing pregnant women in isolated communities with rare access to a trained health worker.

Merlin believes investing in health systems and health workers is the most effective use of funding to the sector. Investment, especially in fragile states, is vital – without it, the world has little chance of reaching the Millennium Development Goals for health by 2015.
With this in mind, Merlin’s international campaign, Hands Up For Health Workers, is calling for urgent and sustained investment in health workers in fragile states. Central to this are health workforce plans which cover the equitable distribution of health workers and the incentives required to keep them where theyare most needed.

Campaign for change now at
Amy Waddell, Merlin

Addressing the health workforce challenges of the 21st century

Lack of appropriate health workers is a major reason why health services are not reaching poor people in low income countries. Fifty seven countries – mostly in sub-Saharan Africa – do not have the minimum health workforce numbers proposed by the World Health Organization (WHO). In the least developed countries only 35 per cent of pregnant women have access to skilled birth attendance.

How did things get so bad?

Reasons include expanding demand for health services, failing economics leading to reduced public services, piecemeal approaches to addressing health workforce problems and, in general, a lack of appreciation of the changing and globalising labour market in health.

The health workforce was low on the agenda for ministries of health and donors alike, partly because the problems seemed unsolvable. The good news is this is changing. The recognition of the impact of migration and the massive funding increases for HIV and AIDS, tuberculosis and malaria programmes highlights the imperative to address health workforce problems.

Advocacy through the Joint Learning Initiative, the World Health Report 2006 and, as featured in an article here, the Global Health Workforce Alliance, has finally given the health workforce its rightful place on the wider health agenda. Donors are now much more open to funding workforce-strengthening initiatives and even topping up salaries. This issue of Health Exchange provides an excellent range of examples of what can be done when there is a will to address health workforce challenges.

The shortage of health workers – particularly in remote rural areas – is a high profile problem. In some countries, like Malawi, the problem starts with lack of suitably qualified (particularly in science subjects) school leavers to train to be health professionals. Even if there are enough applicants, the lack of training facilities may cause a bottleneck. The buildings may be there, but as the article on pharmacy schools in Africa shows, the teachers may not.
Low training output of new health professionals is supplemented by many countries – not just in the North – by international recruitment – often of volunteers. The Director of the Royal College of Nursing in the UK explains how nurses from the North are working in low income countries with health workforce shortages.

In a rapidly changing labour market, health workers now make choices about what work they want to do, for whom and where. This is why it is so important to understand the job preferences of young graduates, as described in the article on research being carried out in Thailand, Kenya and South Africa. The report from Liberia highlights the challenge of attracting health workers to rural areas.

Faith-based organisations make a major contribution to health service provision – particularly in Africa. The article from the National Catholic Health Service in Ghana explains how they commissioned a study and have developed their retention strategies, which include bonding for training, improving job security and financial allowances, to address the findings. The article from Lesotho’s Christian Health Association (online only) reports on similar experience.

Increased workload, related to both staff shortages and treatment of highly infectious diseases, is having a serious impact on the health of remaining staff, leading to sickness and often to resignation. The International Council of Nurses explains why carers need to be cared for and the dramatic impact this can have on staff retention.

Many health workers decide to take their skills to another country where working conditions and pay are better. Such losses to the country of origin have a serious impact on health services and a raft of strategies to manage migration has been introduced. The most notable is the WHO Code of Practice on the International Recruitment of Health Personnel, still in draft. Earlier drafts and similar codes have stressed that in addition to curbing indiscriminate international recruitment, countries should do more to retain their health workers. The article about managing migration of pharmacists (an interesting group, as we usually only hear about doctors and nurses and often assume the private sector is covering the issue) describes the need for a comprehensive package of retention strategies.

Developing strategies to retain health workers or plan for appropriate numbers requires both human resource planning and management expertise, and appropriate tools. A number of workforce planning tools have been developed, but the Workforce Indicators of Staffing Need (WISN) –developed over a decade ago is a tool that promotes a bottom-up planning process.

Re-thinking who does what is an important part of workforce planning. Recently there has been much emphasis on task-shifting and using non-formal health workers to improve access to health care, as explained in the paper on the role of lay health workers.
Information about what works or does not work, need to be communicated. The PAHO observatory is an excellent example of a process to monitor and share knowledge, to help managers develop more appropriate strategies to meet the workforce challenges.

Shortages of health workers are indeed a problem, but the importance of helping health workers to provide quality services efficiently cannot be over-emphasised. It is notable that the first decade of the 21st century has seen recognition of the need to address health workforce problems seriously. The following pages will provide the reader with some examples of what is actually being done.

Tim Martineau
Senior Lecturer in Human Resource Management, Liverpool School of Tropical Medicine, UK

Pharmacy schools

Seven African countries share solutions

Access to essential medicines and medicines expertise is a basic health service requirement. The way that medicines are selected, procured, delivered, prescribed, administered and reviewed is the key to optimising medicines therapy for patient care. To ensure adequate medicines management there is a need for high quality education to prepare an appropriately-trained pharmaceutical workforce for all countries.

Heads of pharmacy schools in Africa, as with all global regions, are facing educational challenges to meet local medicines needs. These challenges are many, ranging from the physical infrastructure and laboratory teaching equipment to the world-wide shortage in academic capacity to fill teaching positions. Seven Heads of pharmacy schools in Africa met recently to discuss how to tackle this situation in order to provide solutions from which the global educational infrastructure can learn.

Sarah Whitmarsh of the Pharmacy Education Taskforce tells the story.

In August 2009, Deans or Heads of schools of pharmacy from Ethiopia, Ghana, Kenya, Malawi, Tanzania, Uganda, and Zambia, held a three-day workshop in Nairobi with the World Health Organization (WHO), United Nations Educational, Scientific and Cultural Organisation (UNESCO), and the International Pharmaceutical Federation (FIP) Pharmacy Education Taskforce. They discussed the challenges of educating pharmacists in resource-limited settings in sub-Saharan Africa and developed an action plan to address those challenges.

There are global issues in operation, which the seven leaders identified as being most pertinent in facing the local challenges. Getting qualified and experienced academics to fill teaching positions is a key issue, as is setting up independent quality assurance procedures within institutions. However, the leaders identified ways to tackle this; a recent pilot project conducted in Zambia and Ghana illustrated that cross-border cooperation (in quality assurance processes) can contribute significantly to educational quality and can be cost effective.

Professor Mahama Duwiejua said the FIP Global Framework for Quality Assurance of Pharmacy Education, a document which can be used by governments or institutions to establish or further develop quality assurance systems, was a useful tool to aid the assessment of quality at the Kwame Nkrumah University of Science and Technology in Ghana. Prof. Duwiejua said, in Ghana, quality assurance systems exist at three levels: the National Accreditation Board, a Quality Assurance (QA) Unit in the university, and the Pharmacy Council. Prof. Duwiejua said the use of the QA tool revealed weaknesses among the institutions, such as lack of transparency and accreditation criteria.

The African leaders also shared strategies they used to address problems at their institutions. For example, Dr Lungwani Muungo, Head of the Pharmacy Department at the University of Zambia has implemented a new staff development tutor programme. The tutor programme addresses academic capacity on two fronts: it offers teaching experience for young academics and also helps better manage available resources in the department’s faculty.

Although the needs within their countries are still significant, the African leaders said they were seeing improvement. For example, they reported an expanded intake of students at their institutions and an increase in employment of pharmacists in the clinical field, especially in private hospitals. Within the last several years, for example, Kenya has focused on increasing the number of well-trained technicians to augment the workforce, and optimising the current skill-mix. Zambian pharmacy schools have placed a stronger emphasis on clinical training and medicines-related public health issues, strategies which are increasingly being adopted by university curricula across the globe.

Encompassing the various strategies shared by the leaders, in addition to evidence-based literature gathered by the Taskforce, small group discussions and roundtable consensus consultations led to a work plan to address these challenges.

The leaders saw potential for further development and collaboration with partner organisations like the Taskforce in four key areas: academic capacity, quality assurance, strategic partnerships, and advocacy and communication. They especially focused on partnerships as the way forward in overcoming challenges due to limited resources. One prominent idea was to reach out to the diaspora and alumni and engaging stakeholders within the community and industry. Forming a regional network of pharmacy educators in Africa was seen as a key activity for the action plan. The leaders said that educating the community and government about the role of pharmacists would help empower pharmacists at all levels. All the leaders agreed that advocacy and better communication were key mechanisms to mobilising workforce and resources.

The proposed three-year work plan will include activities such as establishing an African regional database of pharmacy courses and setting up a team of African quality assurance experts.

Pharmacy education development is a key strategy for the Taskforce in the effort to redress critical shortages of pharmacists and pharmacy technicians, particularly in sub-Saharan Africa where some of these needs are most acute. Scaling up of the pharmacy workforce is necessary to ensure improved access to and rational use of medicines. The Taskforce, and the African leaders’ forum, advocate for needs-based pharmacy education development, meaning education that is determined by evaluating the services required nationally and the competencies needed to provide such services.

Sarah Whitmarsh, Communications Liaison
Pharmacy Education Taskforce

Managing pharmacist migration

The migration of health workers and pharmacists in particular is seen as a problem with no easy solution. It is not simply a matter of difference in salary, but also in training and career progression opportunities and a conducive practice environment. A comprehensive package which offers a range of incentives is the best way forward.

2006 World Health Day in Zambia

Tana Wuliji reports.

The migration of health workers has many catchy labels – some call it brain drain, others call it brain gain or even brain circulation, but for Ruth* – a final year pharmacy student from Zimbabwe – migrating abroad is a life changing decision which is not taken lightly. Over the past ten years, the migration of pharmacists to countries such as the UK, Australia and Ireland has increased. Half of all final year pharmacy students like Ruth, surveyed across nine countries worldwide including Nepal, Bangladesh and Zimbabwe, planned to migrate within five years. More than half of these planned to remain abroad long term.

Such figures are perhaps not surprising, but may be a cause for concern for any country which invests in the development of its own health workforce. In order for policies to be effective in maximising the gains and minimising the risks from migration, there is a need to take the underlying factors influencing migration intentions into account. In the case of pharmacists, it seems to be as much a reflection of the individual’s perception of the home environment as it is of the perception of opportunities abroad.

It is tempting to simplify the problem of migration to a matter of differences in salaries between countries. However, retaining health workers requires a more holistic understanding of the factors that influence migration intentions.

Ruth’s perception of opportunities to develop her career and financial situation abroad are just one set of factors she will take into consideration. The issue of salaries cannot be separated from professional development and both need to be addressed. For example in Australia, the rural workforce recruitment and retention programme offers packages to offset disincentives for working in remote and rural areas, like offering allowances and supporting continuing education. As a result, over the last six years, the number of pharmacists in the rural community has grown by 12 per cent.

However, salary and career are not the only considerations. Ruth’s attitudes towards the local practice and professional environment, and social and political environment will also shape her migration intentions. The latter may be outside the health sector’s zone of influence.

Those who plan to migrate long term also have negative perceptions of the professional status and practice environment within their home countries compared to those that do not plan to migrate. To ensure job satisfaction, Ruth needs to feel that her services are valued by her colleagues, members of other health care professions and patients. The work environment should also be felt to be conducive for her performance, with policies that support the services that she will provide.

Interestingly, an average of 20 per cent of final year pharmacy students plan to migrate on a short term basis. There is no difference in the attitudes of these students compared to those that do not wish to migrate at all; both view the home environment positively, in contrast to those planning long term migration. This means that it is very important to know the difference between those who plan to migrate on a short term basis and those planning to migrate on a long term basis as these groups have completely different attitudes and perspectives. Short term migrants are more likely to return home, hold positive perceptions about their home environment and facilitate mutual gains from migration abroad. Those planning long term migration will be the most difficult group to retain and least likely to return from abroad.

In packing away the labels for migration which oversimplify a complex issue, strategies that aim to retain pharmacists like Ruth are more likely to be successful with a comprehensive package of interventions that satisfy her needs. In addressing the underlying factors that influence migration, retention across the health system can be improved; the very same factors not only shape the movement of health workers between countries, but within as well.

Tana Wuliji, Editor of the 2009 International Pharmaceutical Federation (FIP) Global Pharmacy Workforce Report (

Revitalising primary health care

The role of lay health workers

Lay or community workers can be a valuable resource in response to the human resource crisis in many low- and middle-income countries. Successful interventions by lay health workers have led to improvements in maternal and child health, including reductions in mortality and morbidity from common childhood illnesses, and effective support to people receiving treatment for tuberculosis.

Simon Lewin and Claire Glenton of the LAYVAC (Lay health workers for vaccination) Project Group give more of the story.

Thirty years after the Alma-Ata Declaration, the World Health Organization (WHO) and a wide range of other agencies are calling for the revitalisation and reinvigoration of the primary health care approach. A key component of primary health care as envisaged at Alma-Ata is the lay or community health worker (LHW). The 1970s saw the rapid expansion of many LHW programmes in low- and middle-income settings. For example, the Auxiliares de Medicina Simplificada (Simplified Medicine Auxiliaries) programme in Venezuela trained thousands of LHWs, or “little doctors” as they are known locally, to provide health services to indigenous groups and isolated communities across the country. Recruited from the communities they serve, and skilled in primary health care, this cadre are still respected locally for their medical proficiency.

In Nepal, the Female Community Health Volunteer (FCHV) Programme, established by the government in 1988, now has more than 48,000 trained women who spend on average five to six hours a week on activities tied primarily to maternal and child health. The FCHVs are trained to deliver a number of key interventions, including the distribution of vitamin A supplements and oral rehydration salts; antenatal care; participation in vaccination campaigns; and, in some cases, the diagnosis and treatment of childhood pneumonia. The programme is generally seen as a key contributor to the decrease that Nepal has achieved in childhood mortality and morbidity over the last two decades.

Across a wide range of settings in both the North and the South, LHWs perform diverse functions related to health care delivery. The term ‘lay health worker’ is broad in scope and includes, for example, community health workers, village health workers, health promoters, treatment supporters and birth attendants. While LHWs are usually provided with informal job-related training, they have no formal professional or para-professional tertiary education and can be involved in either paid work, as in the Venezuelan programme, or voluntary care, as in the Nepalese FCHV system.

The renewed interest in LHWs has been prompted by a number of factors. These include the human resource crisis in the health care systems of many low- and middle-income countries; the AIDS epidemic; the resurgence of other infectious diseases such as tuberculosis (TB); and the difficulties faced by the formal health system in providing adequate care for people with chronic illnesses. An increasing emphasis on partnership with community-based organisations and consumer involvement in health care has also contributed to this renewed interest in some settings.

It has been suggested widely that LHWs may play an important role in extending services to ‘hard to reach’ groups and in substituting for health professionals in a range of tasks, thereby helping to achieve the Millennium Development Goals for health.

This interest in LHW programmes has also revived questions regarding the effectiveness and cost of such programmes. Before scaling up these interventions, policy makers need evidence that they do more good than harm.

Evidence on the effectiveness of LHW interventions is developing rapidly. A global review of best evidence in this area, undertaken as part of a Norwegian Research Council funded study of LHW programmes (see, identified a number of important messages. The review shows that the use of LHWs in maternal and child health programmes can have promising benefits across a range of outcomes, compared to usual care or no intervention. These benefits include increasing the uptake of immunisation in children and promoting breastfeeding, particularly in settings where breastfeeding rates are low. The review also concludes that LHWs can be effective in reducing mortality and morbidity from common childhood illnesses, including acute respiratory infections (ARI), malaria, diarrhoea, malnutrition and other illnesses during the neonatal period. The tasks undertaken by the LHWs in these studies were wide. They included educating mothers in their homes and in the community about ARI, malaria, and immunisation; distribution of de-worming tablets and vaccines; first line treatment of cases, for example with anti-malarials or antibiotics; and referral of severe cases to health facilities.

The review also suggests that LHWs can successfully support people receiving treatment for TB and achieve treatment outcomes equivalent to support delivered by professional providers. In addition to supervising and supporting TB treatment, tasks undertaken by the LHWs in these studies included the follow up of patients who had failed to adhere to treatment and referral of patients with TB-like symptoms. Other studies in the review, focusing on chronic diseases such as hypertension, suggest that here also LHWs can provide supportive care effectively.

A key question for policy-makers in low and middle income country settings is the extent to which this research evidence is applicable to their setting. Factors that need to be considered in assessing whether the effects of LHW programmes, as outlined above, are likely to be transferable to other settings include:

  • Whether the studies from which the evidence was drawn were conducted in similar settings to that in which the implementation decision is being taken.
  • Whether there are important differences in on-the-ground realities and constraints that might substantially alter the feasibility and acceptability of a LHW programme, compared to the sites in which the studies were done. For example, whether there is financial and political support for LHW programmes, including support from health professional organisations.
  • Whether there are important differences in health system arrangements that may mean that a LHW programme could not work in the same way as in the sites in which the studies were conducted. For example, if there is no mechanism for employing LHWs within the public health system in the implementation setting.
  • Whether there are there important differences in the baseline conditions between where the studies were done and the implementation setting. For example, if the incidence of TB is much lower than in the study settings, perhaps making it less cost-effective to employ LHWs to support TB patients.
  • The availability of routine data on who might benefit from the intervention (e.g. children whose immunisation is not up-to-date). Such data are needed to target these programmes towards the areas of greatest need.
  • Whether there are sufficient resources to provide ongoing clinical and managerial support for LHWs and to ensure the availability of supplies and equipment, such drugs and vaccines.

Improving access to primary health care since Alma-Ata has faltered in many countries. LHWs are one of a number of promising health systems strategies to improve the delivery and performance of primary health care in low- and middle-income settings. These programmes need to be tailored to local circumstances and health systems and, where the evidence base is weak, implemented in the context of rigorous evaluation.

Simon Lewin, Health Systems Research Unit, Medical Research Council of South Africa and Norwegian Knowledge Centre for the Health Services, Norway

Claire Glenton, SINTEF Health Research, Norway for the LAYVAC (Lay health workers for vaccination) Project Group