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Health Workers Needed: Poor Left Without Care in Africa’s Rural Areas

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February 26, 2008 -- Despite billions of dollars invested into health in Africa, the shortage of appropriate health workers particularly in rural areas in many countries is a major barrier to health service coverage for the poor.

‘‘I was assigned to a very remote area some 38 km from the local town and 18 km off the main road but I did not go,” according to one physician from a provincial town in Ethiopia. “Two years later, there was a new graduate who was sent there. He served for one month and could not collect his salary unless he traveled 18 km by horse. After two months he packed his belongings, managed to collect his salary, and then left straight for Washington, DC [1].”

Despite major investments in health in Africa, populations -- particularly those in poorer parts of many countries in Sub-Saharan Africa (SSA) -- continue to lose out in terms of health service coverage.

“To a great extent, the problem lies with a shortage of appropriate, well-performing health workers, particularly in remote and poorer parts of many countries,” says Ok Pannenborg, senior health advisor for the World Bank Africa Region. “The poor cannot benefit from new health investments and programs without the appropriate workforce to translate them into health services.”

Urban Areas Are Better off

Mother and child with doctor in Ethiopia 
A young mother and child visit a doctor at a health center in Ethiopia.
© World Bank/Michael Tsegaye
In  most if not all countries in SSA, urban and more prosperous areas are disproportionately home to the countries’ skilled workforce. In Zambia, there are 20 times more doctors and over five times more nurses and midwives in urban than rural areas. In Malawi, despite 87 percent of its population living in areas considered rural, 96.6 percent of doctors are found in urban health facilities. In Burkina Faso, there is one midwife for approximately 8,000 inhabitants in the richer zones, against one for nearly 430,000 inhabitants in the poorest zone. Many remote regions and districts do not have a single doctor, nurse or midwife to provide assistance to those that need it most.

Christopher H. Herbst, a public health analyst, working on health workforce issues in the Africa Region at the World Bank, says that there are good reasons why many health workers prefer urban postings, or postings outside of SSA altogether.

“Health workers often earn more, can specialize, and enjoy a higher quality of professional and private life in urban areas.”

Inadequate management, equipment and supplies, as well as the absence of quality schooling and lack of opportunities to earn additional income are all reasons that keep health workers away from rural areas.

A Combined Effort to Find Solutions

HRH Birth Attendant 

A traditional birth attendant in Uganda. Photo courtesy of Africa Vox 2007

In 2006, the World Bank, with funding from the Gates Foundation and NORAD, started a program to assist governments in Sub-Saharan Africa design and implement country-specific solutions to the Human Resources for Health (HRH) problem in the region.

“Innovative and pro-poor policies that focus on improving management and education capacity, as well as interventions that motivate health workers and those that address HIV/AIDS are all key to ensuring health service coverage for the poor in Africa,” according to Agnes Soucat, lead economist and team leader of the Bank’s Africa Human Resources for Health Program. “The aim is not only to shift the rural/urban balance of health workers in many countries, but also to ensure that health workers made available to the poor are accessible and responsive to the needs of the poor.”

The HRH program closely coordinates efforts with other multilateral and bilateral organizations as well as both local and international NGOs. It is supporting governments to obtain and interpret the necessary country-specific evidence and baseline information required for targeted policy and program development on HRH.

Health Extension Workers 

Health extension workers in Ethiopia. Photo courtesy of Columbia University

In some countries in SSA, the combined effort to address the shortage of appropriate heath workers in rural areas is showing early results. In Ethiopia for example:

“All roads today lead to health extension workers,” says the country’s Federal Minister of Health, Dr. Tedros Adhanom.

Ethiopia has trained and deployed more than 27,000 female health workers in remote areas. They were chosen from amongst communities to provide basic curative and preventative services in almost every community throughout the country.

"We make house calls three times a week," explains Fantaye, a health extension worker in Thero Boro kebele, Mulo district. "Sometimes we have to walk up to two hours, but we are not discouraged by this [2].”

It is programs like these that may be necessary to accelerate Africa’s path towards development.

“Unless we all work together and come up with innovative strategies to ensure that the billions of dollars invested into health in Africa reach those that need it most, the Millennium Development Goals are unlikely to be achieved,” noted Pannenborg, referring to goals set by the United Nations to end poverty by 2015.

[ 1] Magnus Lindelow, Pieter Serneels: The performance of health workers in Ethiopia: Results from qualitative research, Social Science and Medicine  (62) 2006

[ 2] DFID Case Study

Contributed by the Africa Region's Human Development Department.

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