Health Personnel in Southern Africa
-----------------------------------
Annotated Bibliography Update 1 June 2003
Summary of information presented in EQUINET newsletters, May 2001 to
June 2003
(The newsletters are archived at the EQUINET website
http://www.equinetafrica.org or at
http://www.lists.kabissa.org/mailman/listinfo/equinet-newsletter )
The bibliography is available at http://www.equinetafrica.org
The first of these updates prepared by the EQUINET secretariat at
TARSC is presented below. It covers the area of Health Personnel.
Overview:
The literature and information on health personnel covered in the
EQUINET Newsletter reveal the challenges facing both health workers
and health systems in southern Africa. Primary among them is the
sheer lack of staff available to adequately provide for the health
needs of the population. Dobson 2003 outlines the daunting lack of
health sector personnel in southern Africa: one in three African
countries has just one medical school for every 10 million people;
nine out of ten countries in Africa have fewer than 50 doctors per
100 000 inhabitants, and a similar density of nurses and midwives ex-
ists in about half the countries in Africa. Absolute personnel short-
falls are exacerbated by other issues. The literature collated from
the newsletters indicate those most commonly raised to be: losses of
public health personnel due to the effects of structural adjustment
on health care systems; the impact of HIV/AIDS on already over-
stretched health sectors; problems in the production and retention of
health care workers; and weak or contested policy intervention by
governments in the region . This overview will briefly look at each
of these issues.
Impact of Structural Adjustment
Economic recession and structural adjustment are reported to have had
a major impact on health sector personnel and their working condi-
tions. Market reforms in health care demanding performance and effi-
ciency targets together with reduced staffing levels are reported to
have put health personnel under high job-related pressure. Perform-
ance and efficiency demands have been made in a context of inadequate
funding for equipment and drugs and real reductions in staff sala-
ries. The transformation of health services under market reforms from
largely regulated public sectors to unregulated markets has not only
led to problems for consumers, but has had an impact on health per-
sonnel. It has left gaps in information systems, monitoring, planning
for and organising human resources in health sectors, placed signifi-
cant demands on planning systems to deal with production and flows of
health personnel in often un-coordinated private and public sectors
and national and international markets and demanded new approaches to
cooperation in health personnel training, incentives and resource
provision at country and international level.
The Impact of HIV/AIDS
Already stretched by economic changes, health sectors have come under
further massive pressure as a result of the HIV/AIDS epidemic.
HIV/AIDS has increased the workload at primary care and hospital ser-
vices. Where patients do not seek formal medical care for HIV/AIDS or
cannot afford it, women, children and community members already vul-
nerable to HIV/AIDS take on health service roles as unpaid caregivers
in ways that are not always clinically effective or equitable. For
overburdened health services and workers, shifting the care burden to
communities has however been one of the ways of accommodating cost
pressures in efficiency driven sectors. Health staff are reported to
be dealing with HIV/AIDS with inadequate drugs and laboratory facili-
ties, inadequate trained personnel and inadequate coordination of
prevention, treatment and care responses, leading to low staff mo-
rale. HIV/AIDS has also affected the occupational risk, health and
losses due to illness of health personnel. This has raised concerns
over workplace safety and support for personnel dealing with
HIV/AIDS.
Production, Retention and professional conditions
Southern Africa, as for other parts of Africa, is experiencing a sig-
nificant outflow of trained health personnel, undermining the returns
on the significant public investments in training for Africa and
leading to savings on training in other parts of the world. One study
estimates that the United States has saved at least US$3 million in
training fees by employing doctors from Nigeria, which has lost
21,000 doctors to the US. Other reports estimate that South Africa is
currently losing over 3000 nurses a year to jobs overseas. This level
of 'brain drain', undermining health care services, is reported to be
exacerbated by public /private sector and international differentials
in wages, in benefits, in working conditions and in quality of care.
Many health workers have nevertheless retained a commitment to public
service and have remained in public service. Downstream of the larger
forces shaping differences in incomes and quality of working life,
these public sector workers, often unionised, are reported to have
engaged in strikes over their conditions, such as the strikes of doc-
tors and nurses in Zimbabwe and Zambia in 2001. However, such action
is has often been 'rearguard' in nature, protecting diminishing pay
and conditions rather than demanding the changes in policy and im-
provements in the public health service that would lead to more sus-
tainable gains.
A WHO Health Information Forum reports that professional information
is often unavailable to health care workers, libraries are under
funded, access to the web is limited and such information as is
available is frequently irrelevant or outdated. Inadequate training
is reported to have undermined the morale of health workers, particu-
larly primary or midlevel health care providers, many of whom are the
only health care provider in some areas. These workers are often the
primary providers of services for poorer communities, for women's re-
productive health and for other areas of primary health care.
Addressing health personnel issues
The literature raises the problems more commonly than the solutions.
Where international economic policies and HIV/AIDS have generated
problems for health personnel, health sector responses appear to have
been inadequate to mitigate these effects and market based health re-
forms to have often worsened them. Such reforms have further weakened
state planning and management capacities and undermined the level of
co-ordination and co-operation needed between public and private sec-
tors and national and international levels. Health workers within the
public sector have not powerfully resisted the reforms undermining
their conditions and those at primary care level have had weak bar-
gaining power. The literature suggests that governments prioritise
training, investing in, protecting and providing professional re-
sources for health personnel. This is needed to adequately deploy
personnel to make use of available service resources and to reap re-
turns on training. It is also needed if health personnel are to feel
sufficiently rewarded to remain committed to their work and to defend
the investments and policies needed to secure both their wellbeing
and that of their clients.
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