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Training Health Workers: We Need Practical and Long-Term Solutions

This month’s Health Affairs issue “Lessons from Around the World” highlights some of the most pressing issues in health systems strengthening and human resources for health. The popular press quickly picked up the findings that the quality of care offered by foreign-born doctors trained abroad is on par with American doctors trained in the States. This doesn’t surprise me. Many of the health workers who migrate here are among the brightest and most ambitious. The article reminded me that nearly a quarter of physicians practicing in the United States were born and trained elsewhere. What does this mean for the health systems and communities they left behind?

We talk too little about how the unmet demand for doctors and especially nurses in developed countries contributes to the drain of desperately-needed health workers from developing countries. A recent report from the World Health Organization documents the common migration pattern among health workers in developing countries from rural areas to small and then larger cities and then abroad to wealthier countries, which is leaving as many as a billion people without access to health services. The report also highlights the increasing rates of migration among health workers—both in developed and developing countries. It is a trend we cannot afford to ignore. One article in Health Affairs addresses this issue, in part, by examining the types of incentives that Ethiopian doctors and nurses say would encourage them to practice in rural areas, although it doesn’t address how to entice them to stay in Ethiopia.

Health Affairs also presents data from a recent study in the United States that shows nurse anesthetists can safely administer anesthesia without physician oversight. Recently, the Lancet published a study from South Africa showing that nurses can monitor patients on antiretroviral treatment just as well as doctors. Increasingly, we are seeing this focus on task-shifting, which is the delegation of specific tasks, where appropriate, to less specialized health workers. When done right, it offers a viable solution to provide more people with health care by using the limited health workers we have more efficiently.

My view on task-shifting is that we have to be very practical. It should not be a question of “strategies for the poor,” and task-shifting should not be seen as a replacement for other long-term solutions. We need creative solutions now, though, to provide high-quality care to more people. We have seen some controversial and ambitious examples of this work in places like Mozambique where, in the aftermath of the war, the government enacted a policy to train a new cadre of non-physician technical surgeons to offer obstetric surgeries.  This is one very bold approach.

Other countries such as Senegal are taking a more conservative tack by introducing a policy to train   physicians/generalists in surgery. This is a step in the right direction, but we have to recognize that even if every doctor in Senegal could offer basic surgery, it would not be enough to meet the need. Task-shifting programs with the greatest reach will be those that involve community health workers. In Ethiopia, the government has developed an ambitious health extension worker program, which has already trained 30,000 health workers and aims to train 30,000 more to go into communities and do outreach, health education, and  referral. IntraHealth is working with Ethiopian community health workers and with mothers support groups led by women living with HIV to improve local health care and the connections between health centers and communities.

 In Mali, IntraHealth has spearheaded a USAID pilot program to train local auxiliary midwives, known as matrones, in active management of the third stage of labor. After training, the matrones scored equally with skilled birth attendants in how to recognize and handle delivery complications. These are promising results for women in Mali, who face a 1 in 15 lifetime risk of dying in childbirth. While in some places such task-shifting strategies are new, in others they are long-standing, proven approaches. Many countries such as Indonesia, India, and Bangladesh have made tremendous progress in areas like family planning by using community health workers.

Task-shifting is only a part of the solution for some of today’s shortages, but it is an important one. Focusing on task-shifting does not allow us to skirt the tougher questions about long-term solutions for making health care accessible to all. Particularly in Africa, this means questioning whether the medical education systems many countries inherited from colonial times still serve them well. Training our health workers in systems modeled on the French or British systems may encourage migration. These systems also make it both lengthy and costly to train health workers and were never designed with public health in mind. Any sustainable solution to the pressing health worker shortage will have to include using the health workers we have more efficiently but also going back to the drawing board of how we produce health workers in the first place. We need to find real, sustainable solutions in countries like Ghana that lose more health workers than it is able to produce, every year.