32804 Africa Region Human Development Working Paper Series The State of the Health Workforce in Sub-Saharan Africa: Evidence of Crisis and Analysis of Contributing Factors Bernhard Liese The World Bank/Georgetown University Gilles Dussault The World Bank Africa Region The World Bank Washington, D.C. Copyright © September 2004 Human Development Sector Africa Region The World Bank The findings, interpretations, and conclusions expressed herein are entirely those of the authors They do not necessarily represent the views of the World Bank Group, its Executive Directors, or the countries that they represent and should not be attributed to them. Cover design by Word Express Typography by Word Design, Inc. Cover photo: ii Table of Contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 II. Country Estimates of the Health Sector Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 III. Trends in the Health Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 IV. Geographical Imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 V. Impact of Economic Reform Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 VI. International Migration of Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Factors Contributing to Emigration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 VII. Impact of HIV/AIDS on the Health Sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 VIII. Achieving the Millennium Development Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 IX. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Annex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 Figures Figure 1: Average Health Workforce Availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Figure 2: Trend of Africa's Physician to Population Ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Figure 3: Trend of Africa's Nurses to Population Ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Figure 4: Niger Health Personnel Distribution by Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Figure 5: Health Personnel from Zambia and Zimbabwe Registered in the UK . . . . . . . . . . . . .13 Figure 6: Health Personnel in South Africa 1996 vs. 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Figure 7: Proportion of Health Workers Who Intend to Migrate . . . . . . . . . . . . . . . . . . . . . . . .15 iii Figure 8: Distribution of Increased Labor Costs due to HIV/AIDS in Zimbabwe . . . . . . . . . . . .18 Figure 9: Projected Health Workers with AIDS in Botswana . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Figure 10: Estimates of Shortages of Health Workers in SSA . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Boxes Box 1: Malawi Faces Grave Health Personnel Shortage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Box 2: The Impact of Structural Adjustment Programs in Cameroon and Ghana . . . . . . . . . . . .11 Box 3: Ghana's Loss of Health Sector Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Box 4: Impact of HIV/AIDS on Kenya's Health Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Tables Table 1: Classification of Sub-Saharan Countries by HRH Ratios and Languages . . . . . . . . . . . .5 Table 2: Projection of the Cost of the Health Personnel Brain Drain for Ghana . . . . . . . . . . . . .16 Table 3: WHO Estimates of Health Personnel per 100,000 Population for SSA . . . . . . . . . . . . .24 Table 4: WHO Estimates of Health Personnel per 100,000 Population, Averages . . . . . . . . . . .26 Table 5: Trends in Physicians 1960-1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Table 6: Trends in Nurses 1960-1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Table 7: Health Personnel Statistical Database . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Table 8: Brain loss in 9 SSA countries, by profession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 iv Foreword T he declaration and acceptance of the This report is an attempt to systematically Millennium Development Goals her- document and evaluate the state of the health alded renewed commitment by coun- workforce in Africa. It draws on academic tries and the international community published literature (which is limited), the to work towards the achievement of a better WHO statistical database (which is incomplete quality of life for all the people of the develop- and only sporadically updated), studies of ing world. At least 4 of the 8 goals are health bilateral donors , national documents, and related and provide the impetus for govern- newspaper articles. The report shows clearly ments, bilateral and multilateral development that for more than a decade HR issues have agencies working in the health sector to devel- received very little attention. Ministries of op effective strategies to attain these goals. Finance often consider HR as a recurrent Yet, for many African countries, it will be expenditure and a drain on the budget rather hard, if not impossible to achieve the goals than a critical investment and input to the by 2015. The key obstacle is now recognized attainment of positive health outcomes. Demo- as the lack of a stable human resource base in tivation of the health workforce has reached the health sector. Absolute shortages, internal alarming levels and resulted in their migration and external migration, inadequate remuner- to the developed world. Increasing nursing ation and incentive mechanisms, maldistribu- shortages in many high income countries such tion and training and education issues of as the UK, USA, France, and Canada have led health workers, as well as macroeconomic to a dramatic increase in emigration of highly policy constraints (often highlighted by the skilled health personnel particularly from Bank, the Fund and other international Anglophone and now from Francophone financial institutions) are identified as root countries in Africa. causes for the present situation. The realiza- The situation has been compounded by the tion that there are health work-force issues of HIV/Aids epidemic which has put additional such serious dimensions has led the usage of strains on the health care sector. The disease the phrase "The African health workforce burden has escalated, productivity of health crisis". workers has diminished and a great number of v health workers have succumbed to the epidem- needs of national markets. Our hope is that the ic, thus aggravating the crisis. report will stimulate further work on this The report shows that Africa faces a crisis important issue. and offers recommendations for action. It sug- gests the need to recognize the importance to align health sector, civil service and macroeco- Ok Pannenborg nomic policies; it stresses that countries must Senior Health Advisor and Sector Leader offer internally competitive wages and nonfi- for Health, Nutrition and Population nancial incentives; and proposes to invest into Human Development training that is specifically oriented to the Africa Region vi Acknowledgement We would like to thank our colleagues, Christoph Kurowski and Demissie Habte, for shar- ing their data and experience and their guidance. We would also like to thank Ying Zhou, who provided superb research support, and Elsie Lauretta Maka, who has overseen the pub- lication of this report. vii CHAPTER 1 Introduction I n 2000, all 189 United Nations mem- essential health services and for bringing down ber states endorsed the Millennium the disease burden to the level of the MDGs Development Goals (MDGs). This rep- (WHO CMH, 2001). resented an unprecedented agreement This paper examines some of the issues of within the development community about key human resources in the health sector, focusing development outcomes (OECD, 2002). The on the situation in Africa in view of its partic- MDGs are a set of 8 goals, 18 targets and 48 ularly critical state. First, we examine the cur- performance indicators relating to poverty rent state of the health sector workforce, reduction by 2015. Of these goals, four are including the latest statistics and trends. Sec- directly related to better health outcomes: two- ond, we analyze the economic factors that third reduction of infant and under five mor- influence the availability of human resources. tality, three-fourth reduction of maternal mor- Next, we take a close look at the brain loss tality, halt and reverse HIV/AIDS, tuberculosis, phenomenon, or exodus of trained health care and malaria epidemics, and halve the propor- professionals from the country or from the sec- tion of people suffering from hunger. By some tor. Then, a discussion of the impact of the estimates, US$46 billion per year is required to HIV/AIDS epidemic on the workforce itself scale up health services in low-income coun- and working conditions follows. Last, we con- tries (WHO CMH, 2001). The majority of clude with some issues that governments and these funds would be used to expand the development partners need to tackle to address capacity of human resources in health,1 as this the growing human resources crisis in the is a prerequisite for increasing the access to African health sector. 1 CHAPTER 2 Country Estimates of the Health Sector Workforce U p-to-date reliable statistics on human are country specific, as well as the method resources for health (HRH) in Africa used to count the number of such persons in are scant, and when available they each occupations (such as the distinction remain difficult to standardize and between headcount data and full-time equiva- compare internationally.2 Despite this data lent data) (Diallo et al., 2003). Further, the challenge, published figures of health person- actual roles and scope of practice of health nel to unit population ratios from the 1960s care workers also vary, making them difficult through the mid-to-late 1990s--and some to compare. Finally, this indicator depends on more recent figures--clearly indicate that a the accurate measurement of the denominator, serious crisis in human resources exists. The e.g. total population. In many low-income severe shortage and imbalanced distribution of countries, and especially in Africa, census data trained health personnel poses a serious obsta- do not exist and when they do are often unre- cle to the achievement of the MDGs and to the liable. improvement of the overall health of the poor. Health care-related occupations are mainly Here is a quantitative overview of the extent of categorized under two groups according to the this crisis. International Standard Classification of Occu- pations: Latest WHO Statistics 1. "professionals" (physicians, nurses and midwifes, and other health professionals, There are a range of indicators that measure such as dentists and pharmacists); and the level of human resources employed in a country's health services. The principal indica- 2. "technicians and associate professionals" tor is the stock of health personnel, typically (medical assistants, dental assistants, measured as the proportion of health workers physiotherapists, opticians, sanitarians, among the total population. Though this indi- nursing and midwifery associate profes- cator is theoretically simple, there are a num- sionals and traditional medicine practi- ber of practical difficulties when comparing it tioners) (Diallo et al., 2003). across countries. Occupational classifications 2 Country Estimates of the Health Sector Workforce 3 Box 1: Malawi Faces Grave Health Personnel Shortage The World Bank sponsored a Health, Nutrition, and Population Project in Malawi from 1991­2000. The Implementation Completion Report (ICR) found that under-staffed and under-supplied facilities have become increasingly common, with adverse effects on quality of care. A survey conducted by KPMG in 1999 showed that many district hospitals do not have physicians, that lower-level staff were performing higher-skill functions, and that even in terti- ary facilities patients rarely see a physician. Among SSA countries, Malawi has consistently had one of the worst health worker to pop- ulation ratios, with 2.22 physicians per 100,000 people, compared to 4.55 in Kenya and 9.09 in Zambia (Picazo, 2002). Currently 50% of the available nursing posts are unfilled. Malawi has struggled with low numbers of health professionals in the past, but the situation has become more acute due to: 1) low pay and poor staff benefits of government workers; 2) an exodus of government workers to the private sector, which offers better salaries and benefits; and 3) the increasing demand for skilled nurses in neighboring countries and in Europe. The Malawi Nursing and Midwifery Council has also insisted they should produce higher skilled registered nurses (mainly hospital-based, with a longer and more expensive training period) rather than the lower skilled, but more cost-effective community health nurses. In addi- tion, a lack of nursing tutors, severe scarcity of secondary school graduates, limited science education, and increasing death and morbidity from the AIDS epidemic all continue to con- tribute to the Malawi nursing shortage. Without improvements in training and remuneration of health professionals, Malawi will continue to lose valuable human resources. Figure 1: Average Health Workforce Availability (1995­2002) 800 700 600 100,000 500 per 400 Population 300 Personel 200 100 Health 0 Sub-Saharan North Africa Emerging Industrialized Africa Countries Countries Physicians Nurses Source: WHO Statistical Information Service. Figures are from one year between 1994-1998, with the except of Nigeria for which figures are from 1992. May be accessed at http://www3.who.int/whosis. 4 The State of the Health Workforce in Sub-Saharan Africa Although health personnel to population compared to Egypt with 218 physicians and ratios are somewhat problematic for the vari- 284 nurses per 100,000 people. However, ous reasons listed above, they do provide the some other SSA countries are faring a little bet- clearest starting point in recognizing the extent ter: Botswana has 28.7 physicians and 241.0 of the crisis. nurses per 100,000 people, while Congo has The World Health Organization (WHO) 25.1 physicians and 185.1 nurses per 100,000 Statistical Information Service lists such ratios people. While pharmacists play a key role in for most countries. Tables 3 and 4 in the people's access to medicines, very little data Annex list the data for physicians, nurses, mid- has been collected on their numbers. As can be wives, and pharmacists for all available seen from the Table 3 in the Annex, only a African countries and selected others for com- handful of countries report data. This data parison. The figures for Africa are appallingly problem is not specific to SSA but applies to low, especially when compared to other emerg- other middle or high income countries as well. ing and developed countries (Figure 1 and see Based on the ratio of physicians and nurses Box 1 for the case of Malawi). The average to population, we divided the SSA countries ratio of physicians per 100,000 people in sub- into four groups. We use a physician to Saharan Africa (SSA) was a meager 15.5, com- 100,000 population ratio of 10 and a nurse to pared to an average of 311.0 in nine selected population ratio of 20, respectively, as the industrialized countries. For nurses, the same threshold to categorize each country into either comparison was 73.4 in SSA and 737.5 in a top or bottom group (Table 1). Thirty three industrialized countries. On average, African out of 43 analyzed countries (about 78%) have countries had about 20 times fewer physicians more than 20 nurses per 100,000 population, and 10 times fewer nurses than developed and only 18 out of the 43 countries (about countries. Even compared to other emerging 42%) have more than 10 physicians per countries, SSA numbers are strikingly low. For 100,000 population. A total of ten countries India, Korea, Singapore, and Vietnam, the have less than 10 physicians and less than 20 average number of physicians per 100,000 nurses per 100,000 population. There are no people was 106.3; for nurses it was 220.4.. countries with 10 or more physicians per Out of 48 African countries, thirteen3 had 100,000 population and less than 20 nurses. fewer than five physicians per 100,000 people, A majority of Lusophone and Arabic speak- and, except for Burkina Faso, Mozambique, ing countries have more than 10 physicians per and Tanzania, those same countries had fewer 100,000 population, and all of their nurses to than 20 nurses per 100,000 people (Table 3 in population ratios are above 20. In contrast, the Annex). Further, there is significant indi- more than half of the Anglophone countries vidual variation among countries throughout and almost two third of the Francophone the continent. For example, Burkina Faso has 4 countries have less than 10 physicians per physicians and 26 nurses per 100,000 people 100,000 population. Country Estimates of the Health Sector Workforce 5 Table 1: Classification of Sub-Saharan Countries by HRH Ratios and Languages More than 20 Nurses Less than 20 Nurses More than Anglophone: Botswana, Kenya, Namibia, 10 Physicians Nigeria, South Africa, Sudan, Swaziland Francophone: Benin, Congo, Guinea, Mauritius, Senegal, Seychelles Lusophone: Cape Verde, Guinea Bissau, Anglophone: Gambia, Liberia, Uganda Sao Tome and Principe Francophone: Burundi, CAR, Chad, Arabic: Djibouti, Mauritania Madagascar, Mali, Togo Less than Anglophone: Ghana, Lesotho, Sierra Leone, Other: Ethiopia 10 Physicians Tanzania, Zambia, Zimbabwe Francophone: Burkina Faso, Cameroon, Cote d'Ivoire, DR Congo, Niger, Lusophone: Angola, Mozambique Arabic: Somalia, Other: Eritrea Source: Annual statistics from the World Bank and WHO. See: World Bank. 1978 and 1980. World Development Report: World Development Indicators; World Bank. 1993. World Development Report: Investing in Health. p. 208; and WHO. 1998. WHOSIS database. Available at http://www3.who.int/whosis. CHAPTER 3 Trends in the Health Workforce T he production or supply of health sec- workplace conditions further compound the tor workers does not even come close current crisis. to keeping pace with the rate of popu- Figures 2 and 3 compare the trends in physi- lation growth.4 Although these statis- cian and nurse to population ratios since 1960 tics paint a discouraging picture, they provide of eight sub-Saharan countries for which the only part of a larger picture. Issues of health data was available with Morocco and India. worker distribution within a country and The following are a few key observations Figure 2: Trend of Afruca's Physician to Population Ratio (1960­2002) 60 50 40 Population 30 100,000 20 per 10 Physicians 0 1960 1975-77 1988-92 1992-98 2002 India Morocco Sub-Sahara Africa Source: Annual statistics from the World Bank and WHO. See: World Bank. 1978 and 1980. World Development Report: World Development Indicators; World Bank. 1993. World Development Report: Investing in Health. p. 208; and WHO. 1998. WHOSIS database. Available at http://www3.who.int/whosis. 6 Trends in the Health Workforce 7 Figure 3: Trend of Africa's Nurses to Population Ratio (1960­2002) 120 100 80 Population 60 100,000 40 per 20 Nurses 0 1960 1975-77 1988-92 1992-98 2002 India Morocco Sub-Sahara Africa Source: Annual statistics from the World Bank and WHO. See: World Bank. 1978 and 1980. World Development Report: World Development Indicators; World Bank. 1993. World Development Report: Investing in Health. p. 208; and WHO. 1998. WHOSIS database. Available at http://www3.who.int/whosis. based on country data reported in Tables 5 and In addition to these figures, confirmation 6 in the Annex: that the crisis continues and may be worsening When compared to figures from either the was presented at a recent Consultation of 17 1970s or 1980s, 7 out of the 8 SSA countries5 African countries organized by the World Bank experienced a decline in physicians per and WHO. Background papers documented 100,000 population in the 1990s. Five of the the following: African countries6 experienced the same trend for nurses. By 2002 the situation had slightly · In 1998, medical physician vacancy rates improved in three countries but deteriorated in in the public sector were reported at 43% Madagascar. in Ghana and 36% in Malawi. The physician to population ratio has stag- nated or declined in nearly every SSA country, · In 1998, the public sector nurse vacancy since 1960. Meanwhile, India has made con- rate was reported at 48% in Lesotho. siderable progress--increasing its physician to population ratio from 17.2 per 100,000 popu- · Fifty percent of physicians in public serv- lation in 1960 to 51.2 by 2002, and improving ices in Namibia are reported to be expa- its nurse to population ratio from 10.4 per triates. 100,000 population to 62.9 over the same period. Morocco also experienced improve- · Cameroon has had no recruitment of ment in the health personnel ratio during this health personnel in the public sector for time period. 15 years. These figures indicate that ameliorating the human resources for health situation in SSA is · Data from Ghana, Zambia, and Zimbab- an enormous challenge that must be surmount- we suggest that annual losses from public ed to adequately serve poor populations. The sector health employment continue at experience of India shows that it can be done. rates of 15% to 40% (WHO/WB, 2002). CHAPTER 4 Geographical Imbalances B eyond national-level shortages of ple, but that ratio ranged from 18.7 in the cap- health personnel, imbalances in geo- ital region (Bamako) to a mere 1.9 in the graphic distribution--especially be- Koulikoro region (Ministère de Santé, Mali, tween rural and urban areas--exacer- 2002). bate the health workforce crisis (Dussault and In Niger, recent data on the regional distri- Franceschini, 2003). In Ghana, Guinea, and bution of health personnel show that most Senegal, more than 50% of physicians are con- health professionals concentrate in urban areas centrated in the capital city where less than (Figure 4). In the capital, Niamey, the physi- 20% of the population lives (Ghana MoH, cians to population ratio is about 24 times 2002). In many countries, a similar situation higher than in the Tillaberi region; the nurses exists for nurses, pharmacists, and medical and the midwives to population ratios are 7 technicians. For example, 55% of pharmacists and 17 times, respectively, higher than in the in Ghana work in the Greater Accra region, Maradi region (World Bank, 2002b). which has 16% of the total population; only Studies on the health workforce in Tunisia 2% of Ghanaian pharmacists work in the (which has much more adequate nation-wide Northern Region, with 10% of the population ratios), Angola, and South Africa equally (Ghana MoH, 2002). show geographical imbalances, implying that Other recent reports describe this urban- the urban-rural split is likely to be found con- rural split dramatically. In Chad, for example, tinent-wide (Bchir and de Brouwere, 2000; the capital region of N'Djaména was reported Fresta, Fresta, & Ferrinho, 2000). This indi- to have 71 physicians per 100,000 population, cates that rural populations have much less whereas the rural Chari-Baguirmi region had access to health care services than do urban only 2 physicians per 100,000 (Wyss et al., dwellers, and are often forced to travel signif- 2002; Wyss et al., in press, cited in Kurowski, icant distances to find any health care, even 2003). A report from Mali shows a similar for their most basic needs. This adds to the imbalance. Nationwide, Mali was reported to costs of services and can even be a deterrent to have about 5.15 physicians per 100,000 peo- use services. 8 Geographical Imbalances 9 Figure 4: Niger Health Personnel Distribution by Region (2000) 45.0 40.0 35.0 population 30.0 100,000 25.0 per 20.0 15.0 personnel 10.0 5.0 Health 0.0 Tillaberi Dosso Maradi Zinder Tahoua Diffa Agadez Niamey Nger Physicians Nurses Midwives Source: World Bank, 2002b. CHAPTER 5 Impact of Economic Reform Processes T he crisis in the African health work- structural adjustment programs (SAP) of the force has been emerging over several World Bank and International Monetary Fund decades. Starting from very low levels (IMF). A central tenet of these reforms includ- in the 1960s, many countries' work- ed better control of public wages, reduction of forces progressed somewhat in the 1970s and public expenditures, privatization of public early 1980s, but stagnated or even declined in enterprises, elimination of subsidies, liberaliza- the late 1980s and the 1990s following the tion of the economy, and devaluation of the well-known wave of economic crises that hit currency in order to achieve sustained growth. the continent. Macroeconomic constraints dis- Results of these measures on public servants, couraged the expansion of personnel and serv- particularly on health personnel, were not dra- ices; thus, the international community and matically different from one country to anoth- low-income country governments have given er. The impact is a lasting one, largely deter- little attention to health-workforce issues in mining the attitudes of health providers and the past two decades. The health workforce the actual availability of health personnel. In was seen as a drain on the budget rather than most countries, the SAP reforms went along an asset for poverty reduction, and unemploy- with public service reform and decentralization ment of health professionals even appeared in of the health sector. Case studies for Cameroon countries where needs were enormous.7 Some and Ghana, where detailed research is avail- countries even enacted complete freezes on able including interview surveys with health recruitment of certain health personnel (Ngu- personnel, are illustrative of the impacts (See for, 1999; WHO/WB, 2002).8 Box 2). The consequences of a series of reform Between 1981 and 1991, the Bank conduct- processes, starting in the mid-1980s, has large- ed 55 civil service reform operations in Africa. ly determined the present situation. When More than half of these operations were struc- many African countries were confronted with tural adjustment loans. But the functional a dramatic fall in public revenue from exports reviews failed to mention the impact on the of commodities, a series of important econom- health and education sector. A review of the ic reforms were introduced. In many of the World Bank's operations on macroeconomics countries, the reforms were executed through in Africa between 1995 and 2002 found that 10 Impact of Economic Reform Processes 11 Box 2: The Impact of Structural Adjustment Programs in Cameroon and Ghana In Cameroon, government reform was initiated in the early 1980s as part of their Structural Adjustment Program (SAP) administered by the World Bank and International Monetary Fund (IMF). Measures affecting the health sector resulted in suspending recruitment, strict imple- mentation of retirement at 50 or 55, limiting employment to 30 years, suspension of any finan- cial promotion, reduction of additional benefits (housing, travel expenses, etc.), and two salary reductions--totaling 50%--and a currency devaluation resulting in an effective income loss of 70% over 15 years. In addition, paramedical training for nurses and laboratory technicians was suspended for several years and schools closed. The overall effect was dramatic. In 1999, the health sector budget had shrunk to 2.4% of the national budget, from 4.8% in 1993. These adjustments occurred while in the private sec- tor (40% of service provision--mostly denominational) wages substantially increased, adjust- ing again for the effects of the devaluation. Thus, the spread between public and private health worker income is large. Not surprisingly, in 1999, jobs in the public sector were about 80% unfilled, and Cameroon had a truly de-motivated national health workforce. Notwithstanding the efforts of many health workers to provide services, in general, a lais- sez faire attitude prevails--with under the table payments, absenteeism and a lack of attention to quality. The perception of punishment inflicted by the IMF and the World Bank is still com- mon. On the positive side, however, budgets have been decentralized and are now available locally, and the private sector has been strengthened. The serious shortage of health workers, though, has lead to the direct recruitment of qualified personnel by communities and hospi- tals, which have the financial resources. In Ghana, the reform process focused on national democratization, decentralization, and the creation of the Ghana health services. While the civil service lost 32,000 jobs between 1987- 1989, the health sector remained somewhat a priority and faired better than other sectors. There was also meaningful sector reform with emphasis on the quality of services. Health workers have received some benefits--such as first priority housing in rural areas and increased salaries in urban areas. Despite the well-documented severe shortage of health work- ers and significant brain drain, the motivation of the health workforce remains good in Ghana (Wiskow, 1999). while half of the operations discussed the ly were associated with changes in the wage impact of changes in public expenditure on bill for public sector health employees, only health, the impact on the health workforce was 10% of the operations mentioned the implica- not mentioned in any of the documents. tions to the health workforce (Elmendorf, Although one third of the operations apparent- 2003). CHAPTER 6 International Migration of Health Professionals E migration of highly skilled persons fications, and competencies" (Lowell and Find- from developing to developed countries lay, 2001) is depleting human capital in many has increased in the last decade (Lowell developing countries and further reducing the and Findlay, 2001). Growing concerns possibility for strong economic growth.11 Sim- among many rich countries about actual or ply put, the emigration of an individual is a future shortages9 has initiated large-scale loss because s/he is an investment loss to her recruitment of foreign-trained health workers. country, since s/he will not apply the education Foreign-trained health professionals are esti- gained in-country. The UN Commission for mated to represent more than a quarter of the Trade and Development estimated that each medical and nursing workforces of Australia, migrating African professional represents a Canada, the UK, and the US (OECD, 2002), loss of US$184,000 to Africa. Paradoxically, and the needs are rapidly growing. This trend Africa spends US$4 billion a year on the is expected to increase, with health profession- salaries of 100,000 foreign experts (Seepe, als being increasingly recruited from SSA. The 2001). number of overseas trained nurses and mid- In Ghana, for example, a continuous flow of wives registering with the United Kingdom Co- physicians, nurses, midwives, and pharmacists operative Council from SSA10 increased from have left the country directly after receiving 905 in 1998/99 to 2133 in 2000/01 (Mar- their degrees (See Box 3). According to its tineau et al., 2002). Figure 5 illustrates this Health Minister, Kenya has only retained 600 accelerating trend with a depiction of Zambia's of 6,000 physicians trained in public hospitals. and Zimbabwe's loss of nurses and midwives This number rose to 1200 after increasing to the U.K. It has been estimated that 15,000 compensation for physicians, which is still foreign nurses were recruited in the U.K. in below the requirement. Similarly, 4,000 2001 and that 35,000 more are needed by Kenyan nurses have left for the UK and the US 2008 (USAID SARA, 2003). (BBC, 2003). In Zimbabwe, only 360 of 1,200 The permanent departure of skilled labor, or physicians trained during the 1990s were prac- "the emigration or flight of skilled human cap- ticing in their country in 2000; half of those ital from one country to the other in search of trained in Ethiopia and Zambia have also emi- better returns to one's knowledge, skills, quali- grated (Frommel, 2002). Table 8 in the Annex 12 International Migration of Health Professionals 13 Figure 5: Health Personnel from Zambia and Zimbabwe Registered in the UK 1200 1086 1000 Midwives 800 and 600 Nurses of 400 221 200 52 Number 83 40 0 15 1999 2000 2001 Zambia Zimbabwe Source: Loewenson and Thomson, 2002. summarizes earlier studies of the sub-Saharan sub-Saharan countries not able to pay compet- brain drain. itive salaries and, therefore, not able to attract A pattern has emerged where physicians and health personnel from abroad the situation is nurses are continually moving to countries even more critical. with a perceived higher standard of living, cre- This brain loss is a particular problem in ating what has been referred to as a "carousel" Africa where the challenge of developing and of movement (Martineau, Decker, and Bun- retaining human resources is extremely diffi- dred, 2002). Canada for instance recruits pri- cult and fundamental for development mary care physicians from South Africa to (Wadda, 2000). Worsening economic condi- work in remote areas, leaving South Africa to tions and severely declining or stagnant fill vacancies by recruiting from Zimbabwe, salaries and benefits contribute to the loss of Botswana, Malawi, and other African coun- health personnel. Although data on this phe- tries. More than 600 South African physicians nomenon is sketchy, the International Office are registered in New Zealand, at a cost to for Migration estimates that 300,000 African South African taxpayers of roughly US$37 mil- professionals live and work in the West (Shinn, lion, reports the University of Western Cape, 2002). South Africa. As of 1999, 78% of rural physi- The brain drain will remain a relevant force cians in South Africa were from abroad, most- for the foreseeable future and entails signifi- ly from Cuba (OECD, 2002). South Africa cant costs to sub-Saharan Africa. As summa- presents a rare case because it is one of the few rized in Figure 7, a study of migration issues in developing countries that pays comparatively six African countries found that 68% of health higher salaries and is, thus, able to compensate workers in Zimbabwe intend to migrate, 49% for emigration. Yet WHO data, summarized in in Cameroon, and about 60% in Ghana and Figure 6, show that the country still experi- South Africa (Awases, Gbary, and Chatora, enced a strong net loss of health personnel. The 2003). A study by the Ministry of Health in ratios of physicians and nurses per 100,000 Ghana (2002) projects that the costs will population dropped by 55% and 70%, respec- amount to US $55 million between 2001 and tively, between 1996 and 2001. For the many 2006 (Table 2). The largest fractions of these 14 The State of the Health Workforce in Sub-Saharan Africa Box 3: Ghana's Loss of Health Sector Workers The State of Ghanaian Economy Report 2002 shows that 31% of trained health personnel, including physicians, nurses, midwives, and pharmacists, left the country between 1993 and 2002 (Safo, 2003). Table 1 below shows trends in employment of human resources in health by the government of Ghana between 1996 to 2002 based on a government report. While both reports signify the extensive degree of brain loss in Ghana, it is questionable whether any of the currently existing records demonstrate accuracy, consistency, and reliability, since varia- tions occur from report to report. As seen in Table 2 below, the University of Ghana Medical School, the School of Medical Sciences of KNUST, and the UDS Medical School train only approximately 150 medical officers annually. However, 50% of every graduating class leaves the country within the second year, while 80% have left by the fifth year (Safo, 2003). This exodus of medical officers is mirrored in other health sector professions. Out of 944 pharmacists trained between 1995 and 2002, a total of 410 were presumed to have left the country by the end of 2002. The number of nurses and midwives immigrating to foreign coun- tries is greatest compared to all other categories; of the 10,145 trained between that same peri- od, 1,996 were deemed to have left Ghana by the end of 2002 (Safo, 2003). Table 1: Public Sector Health Staff, Ghana CATEGORY 1996 1998 2000 2002 Physicians 1,154 1,132 1,015 964 Nurses (including auxiliaries) 14,932 15,046 13,742 11,325 Pharmacists 230 200 Source: Ghana MoH. (2002). Human Resources Projections from Internal Report. Table 2: Annual Output of Trained Public Sector Health Staff, Ghana CATEGORY Annual Production Physicians 150* Professional Nurses 500 Midwives 200 Community Health Nurses 200 Source: Ghana MoH. (2002). Human Resources Projections, Internal Report. *Safo, A. (2003). 604 physicians abandon Ghana. Public Agenda costs are the lost investment in physicians' and tion to emigrate, nor the reasons why they do pharmacists' training. so; they simply vacate their posts, resign, or ask for leave without pay for an indefinite peri- od of time (Awases, Gbary, and Chatora, Factors Contributing to Emigration 2003). The causes and extent of emigration vary from one country to another, but lack of To exactly define the factors contributing to job opportunities, low wages, and a poor emigration is a difficult task because most working environment are the most commonly health professionals do not report their inten- cited causes. Negative side effects of SAPs, International Migration of Health Professionals 15 Figure 6: Health Personnel in South Africa 1996 vs. 2001 472 500 400 300 Population 140 Personnel 200 56 25 Health 100,000 100 per 0 Physicians Nurses 1996 2001 Source: WHO, 2003. with their associated measures to eliminate or tunities for continuing education and training, reduce budget deficits and public expenditure, mediocre quality of training, and inadequate downsizing or retreat of government from eco- day care facilities for their children. nomic activity, and the liquidation or privati- Political instability, lack of security and an zation of enterprises, have also led to the emi- environment of abject poverty have also been gration of professionals (Mato, 2002). Awases, cited as factors contributing to out-migration. Gbary, and Chatora (2003) report that other Today, health professionals in SSA work in de-motivating factors include a lack of oppor- extraordinary circumstances. The pressure of Figure 7: Proportion of Health Workers Who Intend to Migrate 70 68 60 62 58 50 49 40 38 30 Percentage 26 20 10 0 Cameroon Ghana Senegal South Africa Uganda Zimbabwe Source: Awases, Gbary, and Chatora, 2003. 16 The State of the Health Workforce in Sub-Saharan Africa Table 2: Projection of the Cost of the Health Personnel Brain Drain for Ghana (in millions of US$) 2001 2002 2003 2004 2005 2006 Total Physicians 3.60 3.84 4.02 4.14 4.38 4.50 24.48 Pharmacists 3.82 4.14 3.58 3.15 2.77 2.51 19.97 LabTechnician 0.11 0.15 0.10 0.08 0.07 0.06 0.57 GenNurses 1.31 1.31 1.32 1.33 1.33 1.33 7.93 Midwives 0.36 0.36 0.36 0.37 0.37 0.37 2.19 C.H. Nurses 0.06 0.06 0.07 0.07 0.08 0.08 0.42 Total 9.26 9.87 9.45 9.14 8.99 8.86 55.57 Source: Ghana Ministry of Health Report, 2002. having too many patients increases daily stress tors, including active recruitment strategies by levels and leads to poor quality of care. Poor agencies from rich countries. While the many working conditions are reported to seriously aforementioned factors may de-motivate and undermine health systems performance by discourage health care workers, other studies thwarting staff morale and motivation, and have found that most individuals who do stay directly contributing to problems in recruit- in the health sector, work hard and receive ment and retention (WHO, 1996). These recognition and status from colleagues and "push" factors are compounded by "pull" fac- family (Stillwell, 2001). CHAPTER 7 Impact of HIV/AIDS on the Health Sector W hile we have touched upon some contributes to worker absenteeism. Studies in of the issues affecting the number, Zimbabwe indicate that almost 60% of distribution, and performance of increased labor costs are attributed to workers in the health sector, the HIV/AIDS absenteeism (Whiteside and Sunter, enormous impact of the HIV/AIDS epidemic 2001). For a distribution of these costs see Fig- merits its own discussion. The epidemic has ure 8. impacted health sector workforce in two ways: Caring for AIDS patients has made the work 1) direct costs--labor loss, disability and death environment more complex, difficult and benefits, and increasing medical aid costs; and stressful as well as a chilling place to work-- 2) indirect costs--increased absenteeism, with the fear of infection and also with a con- reduced productivity, and stressed workforce stant observance of patients dying. One study from additional staff recruitment and training of Zairian nurses indicated that they had to of personnel (Kinoti, 2001). See Box 4 for the "work significantly more, sometimes at double case of Kenya. effort, to care for AIDS patients" (Lombela, With a generalized epidemic of HIV/AIDS in 1996; cited in Kinoti, 2002). many African countries, health care workers The HIV/AIDS epidemic has placed addi- themselves are being infected, as they are part tional strain on the health care sector and con- of the adult, sexually active population. The tributed to the human resource crisis. But the impact of HIV/AIDS is serious and is estimat- extent of the impact of HIV/AIDS on the ed to be the cause of between 19-53% of all health care sector is not fully known. More deaths of government health employees in comprehensive country-level assessments of African countries today (Tawfik and Kinoti, the impact are needed. 2001). This results in personnel attrition due to In 2000, ABT Associates undertook a health death and absenteeism due to sickness. For sector assessment in Botswana (using a 25% example, by some estimates a person living prevalence rate as baseline) which projected with AIDS may be away from work for up to HIV-related morbidity and mortality among half the time of their final year of life (Tawfik health workers (Figure 9). The model takes and Kinoti, 2001). Caring for ill family mem- into consideration the demographic profiles of bers or dependents and attending funerals also health workers, leading to two estimations, 17 18 The State of the Health Workforce in Sub-Saharan Africa Figure 8: Distribution of Increased Labor Costs due to HIV/AIDS in Zimbabwe 7% 5% HIV Absenteeism 6% AIDS Absenteeism 40% Burial 9% Recruitment Funeral Health Care 17% 16% Training Source: Whiteside and Sunter, XXXX. non-age adjusted and age adjusted. The non- ing with HIV/AIDS by 2010. The Abt health age adjusted estimation assumes that health sector assessment also showed that the project- workers have the same HIV/AIDS prevalence ed cumulative AIDS deaths in Botswana as the general 20-64 age group population. among health workers will increase from 5% As illustrated by Figure 9, 2% to 3% of of current health workforce in 2000 to about health workers had AIDS in 2001. Assuming 17% by 2005 and 40% of current health no interventions are taken to reverse the epi- workforce by 2010. demic, 6% to 9% of health workers will be liv- Figure 9: Projected Health Workers with AIDS in Botswana (2000 to 2010) 10 9 8 7 6 5 4 Percent 3 2 1 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Not age adjusted Age adjusted Source: ABT Associates, 2000. Impact of HIV/AIDS on the Health Sector 19 Box 4: Impact of HIV/AIDS on Kenya's Health Workforce Since the first HIV/AIDS case was reported in Kenya in 1984, a total of 1.75 million adults have been infected. The current prevalence rate of HIV/AIDS is at 9.4%. Assuming a similar infection rate, 3,500 health workers in Kenya are infected by HIV. The disease caused about 55,000 deaths, mainly among young people, including health workers. A recent study of the impact of HIV/AIDS on the health workforce in Kenya collected data from 6 sampled hospitals between 1996 to 2002. The study shows that HIV/AIDS caused an increased demand for health services. Between 1996 and 2002 there has been a 40% increase in total admissions due to HIV/AIDS. Bed occupancy by HIV related illness is high and is asso- ciated with long stays and frequent re-admissions. Overall, fifty percent of the Medical wards' patients are admitted with HIV/AIDS related illness. Kenya recently introduced VCT and PMTCT and rapidly scaled up these interventions using the existing health workforce. There are strong indicators of overload among the service providers. Ideally a counselor is expected to have an average of 160 clients per month. The study showed that, among the sampled hospitals, each VCT provider had 349 clients, while each PMTCT provider had 560 clients per month. Current staffing levels are not adequate to cope with the workload for HIV/AIDS and other services. Among the sampled facilities, there is a trend toward death becoming the primary reason for health personnel attrition (Figure 1). Of the 170 deaths with record of cause, 45% are due to AIDS related illnesses (pneumonia, tuberculosis, chronic diarrhea and immunosuppression). Further, these deaths occur predominantly among relatively young people (age 15 to 49). Figure 1: Cause of Health Personnel Attrition 35 30 31.4 25 27.7 20 20.2 15 Percentage 10 13.7 5 6.3 0 Death Voluntary/ Resignation Dismissal Others Retrechment Source: Cheluget, Ngare, Wahiu, et al, 2003. CHAPTER 8 Achieving the Millennium Development Goals I n 2003, Kurowski et al. undertook case ately increased by 50%, the 2015 workforce studies of Tanzania and Chad to look would constitute only 45% and 25% of total at the `role and importance' of human human resource requirements. In Figure 14, resources for scaling up health services Kurowski et al. estimate the shortage of health in low-income countries. This study examined workers for all low and lower-middle income the size, structure, and compositions of the countries in SSA. health workforces; and estimated future The study also identified four priority issues human resource availability and requirements for scaling up, which merit further research: 1) for scaling up priority interventions, as recom- geographical imbalances must be better under- mended by the Commission on Macroeconom- stood and overcome; 2) more needs to be ics and Health. known about health staff attrition rates--espe- The study indicates that future staff avail- cially due to emigration--which has implica- ability is grossly insufficient for the scaling up tions for training; 3) how can staff productivi- of priority interventions, accounting for only ty (estimated at approximately 50% to 65%) 40% and 20% of requirements in Tanzania be improved through better staff management; and Chad, respectively, by 2015. Shortages are and 4) alternative service delivery mechanisms likely to be greater than indicated, since the need to be developed. Finally, the authors total health workforce would not be available urged decades-long international commitment for the provision of priority interventions. to scaling up, to ensure that the efforts made Even if training capacities would be immedi- are not wasted. 20 Achieving the Millennium Development Goals 21 Figure 10: Estimates of Shortages of Health Workers in SSA 1,200,000 1,000,000 800,000 Health of 600,000 Personnel 400,000 Numbers 200,000 0 Physicians Nurses HR Availability HR Requirements Source: Kurowski, 2003. CHAPTER 9 Conclusion G iven the crisis of human resources in wage, and do not have to seek outside the health sector of sub-Saharan employment or under-the-table payments Africa outlined in this paper, the for services to survive. health-related MDGs are arguably difficult targets for most African countries to · Investing into training capacities, in par- attain. However, MDGs are useful in high- ticular training that is specifically orient- lighting underlying problems or constraints ed to the needs of national markets to hindering their attainment. stem brain drain. Some of the key issues that African govern- ments and development partners should focus · Improving training and knowledge on, to address this human resource crisis, regarding HIV/AIDS to decrease risk for include: workers, address fears and misconcep- tions, and improve patient care.12 · Instituting a consultative process in which all stakeholders collectively develop · Investing into HIV/AIDS prevention and strategies to address the crisis facing the care to mitigate the impact of the epidem- health workforce. ic on the demand for health services and to prevent any further depletion of the · Recognizing the importance to align workforce. health sector, civil service and macroeco- nomic policies and their objectives to · Exploiting alternative service delivery improve the health workforce (and health mechanisms (community based, syn- sector) performance. dromic approaches) to reduce the work- load of health personnel. · Acknowledging that African countries must offer internally competitive wages · Improving the non-monetary incentive and benefit packages to retain highly framework faced by health personnel (e.g. trained staff; this includes increasing com- continuous training, supervision, appro- pensation so that workers receive a living priate equipment) to improve motivation 22 Conclusion 23 and thus the productivity and quality of pace of scaling-up services and to limit the the health workforce. capacity to absorb additional financial resources. More importantly, it is likely to be The limited availability of human resources the most significant impediment towards the in Africa is likely to singularly determine the attainment of the health related MDGs. Annex Table 3: WHO Estimates of Health Personnel per 100,000 Population for SSA Country Physicians1 Nurses1 Midwives2 Pharmacists2 Algeria 85.0 300.0 NA NA Angola 5.0 114.0 4.3 NA Benin 10.0 20.0 7.9 NA Botswana 28.7 241.0 0.0 NA Burkina Faso 4.0 26.0 3.4 NA Burundi 0.5 1.0 NA NA Cameroon 7.4 36.7 0.5 NA Cape Verde 17.1 55.8 NA NA CAR 3.5 8.8 4.9 NA Chad 2.5 15.0 2.3 NA Congo 25.1 185.1 24.9 NA Côte d'Ivoire 6.8 44.1 15.0 NA DR Congo 9.0 31.2 NA NA Djibouti 13.0 64.0 NA 2.0 Egypt 218.0 284.0 NA 56.0 Eritrea 5.1 21.0 2.2 NA Ethiopia 3.0 6.0 NA NA Gambia 3.5 12.5 8.2 NA Ghana 9.0 64.0 53.2 NA Guinea 13.0 55.7 5.2 NA Guinea-Bissau 16.6 109.3 12.7 NA Kenya 14.1 108.0 NA NA Lesotho 7.0 33.0 47.0 NA Liberia 2.3 5.8 4.3 NA Libya 120.0 360.0 NA 23.0 Madagascar 8.7 18.8 10.7 NA Mali 4.4 12.6 3.0 NA Mauritania 13.8 62.4 10.1 NA Mauritius 85.0 232.9 NA NA 24 Annex 25 Country Physicians1 Nurses1 Midwives2 Pharmacists2 Morocco 49.0 101.0 NA 11.0 Mozambique 2.4 20.5 NA NA Namibia 29.1 165.8 116.5 NA Niger 3.3 23.1 5.5 NA Nigeria 26.9 66.2 52.4 NA Sao Tome and Principe 46.7 127.4 29.6 NA Senegal 10.0 50.0 6.6 NA Seychelles 132.4 467.6 394.6 NA Sierra Leone 8.8 90.7 4.7 NA Somalia 4.0 20.0 NA 0.1 South Africa 25.1 140.0 NA NA Sudan 16.0 86.0 NA 1.1 Swaziland 15.1 40.0 NA NA Tanzania 4.1 85.2 44.8 NA Togo 5.6 16.7 10.4 NA Tunisia 70.0 286.0 NA 17.0 Uganda 4.7 5.6 13.6 NA Zambia 6.9 113.1 NA NA Zimbabwe 5.7 54.1 28.1 NA Africa Region Average 25.1 93.5 30.9 NA 1Source: WHO 2003 2Source: WHO Statistical Information Service. Figures are from one year between 1994-1998, with the exception of Nigeria for which figures are from 1992. May be accessed at http://www3.who.int/whosis. 26 The State of the Health Workforce in Sub-Saharan Africa Table 4: WHO Estimates of Health Personnel per 100,000 Population, Averages Country Physicians1 Nurses1 Midwives2 Pharmacists2 Sub-Saharan Africa Average 15.5 73.4 30.9 1.1 SSA without South Africa Average 15.2 71.8 30.9 1.1 North African Average3 108.4 266.2 NA 26.8 Four Emerging Countries: India 51.2 62.9 NA NA Korea 180.0 341.0 NA NA Singapore 140.0 421.1 NA NA Viet Nam 53.8 56.6 17.6 NA Four Emerging Countries' Average 106.3 220.4 NA NA Industrialized Countries: Australia 247.4 769.5 40.0 NA Canada 187.0 748.0 NA NA France 329.7 668.6 21.7 100.0 Germany 363.2 954.8 11.3 57.7 Italy 606.5 446.5 29.2 102.0 Japan 201.5 821.3 18.9 NA Russia 420.4 793.0 62.5 6.2 UK 164.0 497.0 43.3 58.2 USA 279.0 939.0 NA NA Industrialized Countries' Average 311.0 737.5 32.4 64.8 1 Source: WHO 2003 2 Source: WHO Statistical Information Service. Figures are from one year between 1994 and 1998, with the exception of India for which figures are from 1992. May be accessed at http://www3.who.int/whosis. 3 Algeria, Egypt, Libya, Morocco, and Tunisia Table 5: Trends in Physicians 1960-19981,2 Country 1960 1975/77 1988/92 1992/98 2002 Burkina Faso 1.7 1.8 3.0 3.4 4.0 Cameroon 2.5 6.1 8.0 7.4 7.4 CAR 2.8 5.7 4.0 3.5 3.5 Ghana 8.2 10.0 4.0 6.2 9.0 India 17.2 27.6 41.0 48.0 51.2 Kenya 9.5 8.4 14.0 13.2 14.1 Madagascar 10.4 9.8 12.0 10.7 8.7 Morocco 10.6 9.9 21.0 46.0 49.0 Tanzania 4.8 6.5 3.0 4.1 4.1 Tunisia 10.0 20.8 53.0 70.0 70.0 Zambia 8.3 9.8 9.0 6.9 6.9 1Measured as physicians per 100,000 population. Figures are from an individual year within the given period. 2Annual statistics from the World Bank and WHO. See: World Bank. 1978 and 1980. World Development Report: World Development Indicators; World Bank. 1993. World Development Report: Investing in Health. p. 208; and WHO. 1998. WHOSIS database. Available at http://www3.who.int/whosis. Annex 27 Table 6: Trends in Nurses 1960-19981,2 Country 1960 1975/77 1988/92 1992/98 2002 Burkina Faso 1.7 1.8 3.0 3.4 4.0 Cameroon 2.5 6.1 8.0 7.4 7.4 CAR 2.8 5.7 4.0 3.5 3.5 Ghana 8.2 10.0 4.0 6.2 9.0 India 17.2 27.6 41.0 48.0 51.2 Kenya 9.5 8.4 14.0 13.2 14.1 Madagascar 10.4 9.8 12.0 10.7 8.7 Morocco 10.6 9.9 21.0 46.0 49.0 Tanzania 4.8 6.5 3.0 4.1 4.1 Tunisia 10.0 20.8 53.0 70.0 70.0 Zambia 8.3 9.8 9.0 6.9 6.9 1Measured as nurses per 100,000 population. Figures are from an individual year within the given period. 2Annual statistics from the World Bank and WHO. See: World Bank. 1978 and 1980. World Development Report: World Development Indicators; World Bank. 1993. World Development Report: Investing in Health. p. 208; and WHO. 1998. WHOSIS database. Available at http://www3.who.int/whosis. 28 The State of the Health Workforce in Sub-Saharan Africa earY ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1997 1994 1998 1998 1997 1998 1997 1998 1998 1998 1998 2 ... ... ... ... 3.8 ... ... 20 ... ... 11 40.6 89.1 52.8 33.1 30.7 145 ... ... ... ... ... ... ... ... ... 18.5 100,000 per (1995-1999) Pharmacists earY ... ... ... 1997 1996 1995 1998 1997 1996 1997 1998 1998 1998 1998 1996 1997 1993 1998 1998 1996 1995 1997 1998 1994 1996 1996 1998 1995 1 0 9 40 ... 0.3 ... 19 2.2 0.3 ... 31.5 28.2 53.1 18.2 66.2 27.6 47.2 27.1 25.4 16.1 40.6 68.2 10.6 21.1 85.1 12.8 58.6 Dentists 100,000 per (1995-1999) earY ... ... ... ... ... ... ... ... ... ... ... 1994 1998 1997 1998 1998 1997 1998 1998 1996 1995 1995 1991 1994 1998 1995 0 ... 9.4 4.3 ... ... 40 65 56 59.1 48.1 18.6 137 ... ... ... ... 7.9 ... ... ... 3.4 ... 67.6 35.8 70.6 100,000 Midwives per (1995-1999) earY ... 1997 1998 1995 1998 1997 1996 1994 1998 1998 1998 1998 1996 1997 1997 1993 1998 1996 1996 1995 1995 1997 1998 1994 1996 1996 1998 1995 18 11 82 39 380 283 76.8 481 830 532 767 283 20.4 69.4 452 41.3 713 ... 297.8 114.5 330.3 229.7 330.3 1182 1075 19.6 219.1 401.5 Nurses 100,000 per (1995-1999) earY ... 1997 1998 1995 1998 1997 1996 1992 1998 1998 1998 1998 1996 1997 1997 1993 1998 1998 1996 1995 1995 1997 1998 1994 1996 1996 1998 1995 11 20 16 129 84.6 253 7.7 316 240 302 360 100 443 395 5.7 54.8 143 23.8 84.8 345 3.4 ... 113.6 268.4 151.8 125.4 129.9 127.2 100,000 Physicians per (1995-1999) 6 6 5 5 6 23 39 12 16 31 77 13 13 51 12 17 34 94 74 60 15 80 31 14 IMR 165 154 104 114 2000- 2002 0 0 0 0 8 8 8 0 0 37 42 25 50 84 24 15 96 14 18 39 87 18 45 50 10 15 IMR 167 166 111 118 114 1990 (2002) 70,000 70,000 68,890 90,000 60,000 313,990 671,970 269,380 253,330 850,820 350,630 3,195,100 3,072,000 8,140,900 8,184,300 9,930,800 6,603,400 8,697,100 4,120,600 1,711,800 7,868,000 7,071,000 Population 27,963,000 31,320,000 13,896,000 37,928,000 19,581,000 10,320,000 11,831,000 135,680,000 174,490,000 2 3 4 5 4 1 6 6 4 6 2 4 4 6 5 3 6 4 4 6 1 6 3 6 4 1 6 2 4 1 1 Database Region 1 1 2 2 5 1 5 3 2 5 4 4 1 5 5 1 5 2 4 3 1 5 1 2 2 3 2 5 2 1 1 Statistical level Income GDP $598 $505 $396 $435 $580 $947 $258 $143 (2002) $1,071 $1,657 $9,204 $6,579 $1,495 $8,610 $1,579 $3,227 $1,671 $4,233 $4,644 $1,733 Personnel $24,801 $33,480 $13,836 $11,070 $31,333 $17,650 Health Samoa Barbuda 7: & & Faso ableT Herzegovina Afghanistan Albania Algeria American Andorra Angola Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Brazil Brunei Bulgaria Burkina Burundi Annex 29 earY ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1998 1995 1998 1994 1996 1996 1998 page)) 2 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 56 next 45.5 104 ... ... ... ... ... ... 44.3 18.2 53.5 100,000 non per (1995-1999) Pharmacists earY ... ... ... (continued 1998 1996 1997 1996 1995 1994 1996 1994 1997 1996 1997 1997 1998 1997 1995 1998 1995 1996 1996 1997 1997 1996 1997 1996 1996 1998 1 1.8 0.4 1.5 0.2 0.2 ... 14 1.1 ... 90 ... 65 62 1.7 5.6 25 0.1 58.6 41.5 40.3 39.4 65.7 84.5 88.6 23.4 63.9 35.6 67.9 Dentists 100,000 per (1995-1999) earY ... ... ... ... ... ... ... ... ... ... ... 1998 1996 1995 1994 1998 1997 1995 1997 1996 1998 1998 1997 1996 1996 1998 0.5 ... ... 4.9 2.3 ... 3.9 ... 14 ... 30 ... 15 33 ... ... ... ... ... 2.2 2.2 28.8 24.9 44.7 21.1 37.4 100,000 Midwives per (1995-1999) earY 1998 1996 1996 1996 1995 1994 1996 1998 1994 1997 1996 1995 1997 1997 1996 1998 1997 1996 1998 1994 1996 1996 1997 1997 1996 1997 1996 1996 1998 8.8 74 16 73.8 36.7 55.6 14.7 47.2 98.6 48.3 34.1 44.2 200 31.2 474 447 886 722 29.9 70.1 233 34.9 39.5 625 897.1 185.1 109.1 677.6 415.5 Nurses 100,000 per (1995-1999) earY 1998 1996 1995 1996 1995 1994 1994 1998 1997 1997 1996 1995 1997 1997 1996 1998 1997 1996 1998 1994 1996 1996 1997 1997 1996 1997 1996 1996 1998 9 3 7.4 3.5 3.3 90 14 29.7 17.1 116 7.4 6.9 25.1 229 255 303 290 49.3 202 24.6 297 229.1 110.3 161.7 141.1 530.4 215.6 169.6 107.1 100,000 Physicians per (1995-1999) 5 6 0 7 7 5 4 4 97 96 29 10 31 19 59 81 14 41 24 35 33 72 11 IMR 115 117 129 129 102 100 101 2000- 2002 7 0 7 8 80 85 45 16 38 29 88 83 15 11 11 11 11 19 53 43 76 46 92 12 IMR 115 118 128 128 100 119 122 1990 0 (2002) 35,000 71,800 458,030 149,000 585,940 764,970 656,510 481,420 3,828,000 8,144,400 3,941,800 4,376,900 5,373,300 8,634,700 6,523,900 4,308,800 1,358,000 Population 12,487,000 15,523,000 31,414,000 15,579,000 43,745,000 53,797,000 53,797,000 16,775,000 11,263,000 10,210,000 13,112,000 66,372,000 1,281,000,000 2 2 1 6 1 6 1 1 4 6 2 6 1 1 1 6 1 4 6 4 4 4 5 6 6 6 5 6 1 1 4 Region 1 1 1 4 2 5 1 1 5 3 2 2 1 1 1 3 1 3 2 5 3 4 2 3 2 2 2 2 1 1 3 level Income $0 $87 $87 GDP $325 $711 $348 $248 $942 $436 $712 $775 $166 (2002) $1,571 $5,436 $2,274 $3,927 $5,549 $5,691 $3,157 $2,129 $1,250 $1,763 $1,541 $5,000 $23,590 $14,800 $39,211 $17,046 Rep. Republic Rep. Guinea Islands erdeV African Islands Dem. Rep Islands Rica Republic Arab d'Ivoire Salvador Republic Cambodia Cameroon Canada Cape Cayman Central Chad Channel Chile China Colombia Comoros Congo, Congo, Cook Costa Côte Croatia Cuba Cyprus Czech Denmark Djibouti Dominica Dominican Ecuador Egypt, El Equatorial Eritrea Estonia 30 The State of the Health Workforce in Sub-Saharan Africa earY ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1998 1997 1998 1998 1988 1998 1997 1996 1998 1998 1998 1996 ... ... 145 100 ... ... 9.2 ... ... ... ... ... ... ... ... ... ... 11 57.7 69.2 47.3 83.1 11.8 77.8 60.5 102 100,000 per (1995-1999) Pharmacists earY ... ... ... ... ... 1997 1998 1996 1997 1998 1998 1996 1995 1997 1997 1996 1997 1992 1997 1998 1997 1996 1998 1998 1998 1997 ... 4.3 ... 0.5 0.2 13 16 93.7 67.8 35.3 75.9 102 8.6 ... 0.9 3.8 1.2 16.8 42.4 105 ... ... 5.7 46.2 116 64.4 Dentists 100,000 per (1995-1999) earY ... ... ... ... ... ... ... ... ... 1998 1996 1997 1998 1997 1996 1993 1995 1996 1998 1998 1994 1998 1998 1982 ... ... 78 ... 8.2 ... ... 5.2 ... ... ... ... 26 21.7 31.1 11.3 53.2 18.5 12.7 18.6 85.9 411 18.6 29.2 100,000 Midwives per (1995-1999) earY ... ... 1997 1998 1996 1997 1998 1998 1996 1992 1997 1997 1995 1996 1997 1997 1997 1998 1998 1992 1994 1996 1995 1998 1998 1989 ... 497 ... 72 27 45 50 474 957 257 385 865 259 236 613 296 195.1 2162 12.5 55.7 84.2 10.7 25.5 367.7 109.4 1593 Nurses 100,000 per (1995-1999) earY ... ... 1997 1998 1997 1997 1998 1998 1996 1995 1997 1997 1995 1996 1997 1992 1997 1998 1997 1992 1994 1996 1998 1998 1998 1997 ... 13 48 16 85 55 47.6 299 303 ... 3.5 436 350 6.2 392 8.4 49.5 93.3 16.6 18.1 83.2 357 326 219 385 554 100,000 Physicians per (1995-1999) 4 4 4 5 6 8 3 6 6 4 18 10 60 91 24 57 20 43 54 79 31 67 33 35 IMR 116 109 130 107 2000- 2002 0 6 7 7 9 6 8 8 25 18 60 24 74 10 30 60 65 47 15 80 60 54 40 10 IMR 128 103 145 153 102 1990 (2002) 50,000 823,300 239,800 101,710 159,350 771,970 283,990 5,199,000 1,290,600 1,375,700 5,177,000 7,744,400 1,252,700 8,286,500 6,755,100 3,877,600 6,494,200 Population 67,335,000 59,442,000 82,495,000 20,071,000 10,631,000 11,992,000 10,166,000 65,540,000 24,256,000 57,919,000 211,720,000 1,048,300,000 2 1 4 2 4 4 2 1 1 4 4 1 4 6 2 6 1 1 6 6 6 4 4 3 2 5 5 4 5 4 Region 1 1 5 2 4 4 5 3 1 1 4 1 4 3 5 2 1 1 2 1 2 3 4 1 1 2 2 4 5 4 level Income GDP $124 $370 $537 $432 $628 $193 $938 $344 $711 $494 (2002) $2,910 $4,405 $3,516 $1,545 $5,735 $1,060 $1,787 $32,575 $30,667 $19,895 $32,807 $14,157 $31,835 $30,157 $17,067 $21,233 Rep. (continued) 7 The Islands Polynesia Islamic ableT Ethiopia Faeroe Fiji Finland France French Gabon Gambia, Georgia Germany Ghana Greece Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran, Iraq Ireland Israel Italy Annex 31 earY ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1997 1994 1996 1998 1997 1996 1998 1998 1998 1998 page) ... ... 77 ... ... ... ... 35 6.7 ... ... 50 ... ... 23 next ... ... ... ... ... ... ... ... ... ... 65.7 57.8 69.4 14.9 49.3 on 100,000 per (1995-1999) Pharmacists (continued earY ... ... ... 1994 1996 1997 1998 1995 1998 1997 1997 1998 1996 1998 1997 1995 1997 1996 1998 1998 1998 1996 1997 1994 1998 1996 1995 1995 1990 1999 9 1 2 49 2.2 4.9 ... 26 4.3 80 0.5 0.1 13 61 ... 8.6 ... 0.1 5.1 68.6 25.1 33.4 27.4 43.5 65.8 51.9 35.8 13.5 65.9 12.2 Dentists 100,000 per (1995-1999) earY ... ... ... ... ... ... ... ... 1996 1998 1995 1998 1998 1995 1997 1998 1998 1998 1996 1997 1995 1994 1993 1996 1995 1999 3 ... ... ... 60 ... ... 47 4.3 ... 18.9 56.1 72.8 33.2 43.5 21.9 66.6 10.7 27.1 185 ... ... 0.8 77.1 10.1 10.1 100,000 Midwives per (1995-1999) earY ... 1996 1996 1997 1998 1995 1998 1995 1997 1997 1998 1996 1998 1997 1995 1997 1996 1998 1998 1998 1996 1997 1995 1994 1993 1996 1995 1995 1995 1999 64.5 296 649 90.1 180 475 750 549 100 5.9 60.1 360 884 782 488 ... 21.6 113 13.1 279 744.9 235.8 291.2 107.7 113.3 1100 62.4 86.5 148.8 232.9 Nurses 100,000 per (1995-1999) earY ... 1996 1996 1997 1998 1995 1998 1995 1997 1997 1998 1996 1998 1997 1995 1997 1997 1998 1998 1998 1996 1997 1995 1994 1998 1996 1995 1995 1990 1999 40 85 166 353 13.2 29.6 297 189 301 24.3 282 210 5.4 2.3 128 395 272 204 ... 4.7 10.7 65.8 261 42.2 13.8 57.3 140.1 193.2 136.1 186.4 100,000 Physicians per (1995-1999) 3 5 9 9 8 5 8 5 17 27 81 78 51 42 87 17 28 91 16 22 84 58 54 17 24 24 IMR 157 114 141 120 2000- 2002 5 8 7 9 17 35 42 63 65 26 14 14 14 32 34 10 32 16 80 63 21 37 37 IMR 120 102 157 103 146 152 120 1990 (2002) 94,700 53,200 443,500 286,680 397,000 2,612,900 5,171,300 2,103,900 2,103,900 5,530,100 2,335,000 4,441,200 2,086,700 3,295,100 5,533,900 3,476,000 2,038,000 2,828,000 1,212,400 Population 14,795,000 31,345,000 22,519,000 47,640,000 16,437,000 10,743,000 24,305,000 11,346,000 127,140,000 100,920,000 100,920,000 2 6 4 5 4 1 2 2 2 5 4 2 4 5 1 1 5 4 4 4 1 1 2 3 1 5 2 1 1 6 2 Region 1 2 4 2 2 1 2 1 4 5 1 1 3 3 1 1 3 3 4 2 1 1 3 2 1 5 2 1 3 3 2 level Income GDP $325 $575 $477 $577 $199 $217 $162 $313 $513 (2002) $2,174 $1,661 $1,893 $3,100 $2,868 $2,659 $2,418 $4,811 $1,990 $1,554 $4,537 $3,713 $3,713 $44,108 $14,280 $13,345 $13,345 $56,513 $10,098 Rep. FYR Islands Dem. Rep. Rep. Sts. PDR Fed. Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Korea, Kuwait Kyrgyz Lao, Latvia Lebanon Lesotho Liberia Libya Lithuania Luxembourg Macedonia, Madagascar Malawi Malaysia Maldives Mali Malta Marshall Mauritania Mauritius Mexico Micronesia 32 The State of the Health Workforce in Sub-Saharan Africa earY ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1994 1995 1996 1997 1998 1998 1996 1997 1998 1996 1998 1998 11 19 34 51 67.5 218 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 7.3 6.2 17.4 57.1 53.5 75.3 100,000 per (1995-1999) Pharmacists earY ... ... ... 1998 1995 1998 1997 1999 1997 1996 1997 1997 1997 1992 1996 1998 1998 1997 1998 1997 1998 1997 1997 1996 1997 1998 1996 1998 1998 4 4 9 39 87 11 52 21 41.2 121 ... 2.1 ... ... 0.2 2.6 13.5 47.1 18.6 118 2.3 2.7 83.8 22.8 39.6 45.6 33.3 23.9 32.2 Dentists 100,000 per (1995-1999) earY ... ... ... ... ... ... ... ... 1998 1995 1999 1997 1995 1997 1997 1997 1992 1996 1998 1998 1996 1997 1984 1998 1998 ... ... ... 7.4 9.1 ... 5.5 87 5.6 ... ... ... ... 87.1 35.7 22.1 56.2 52.4 59.1 163 8.3 64.3 39.6 62.5 116.5 100,000 Midwives per (1995-1999) earY ... 1998 1995 1998 1997 1999 1997 1995 1995 1991 1997 1997 1997 1992 1996 1998 1998 1996 1998 1997 1998 1997 1997 1996 1990 1998 1996 1998 1998 5 874 105 ... 34 67 1621 26.1 168 588 902 771 91.9 22.9 66.1 325 144 418 527 379 289 409 821 307.3 478.3 1840 23.9 144.1 115.2 Nurses 100,000 per (1995-1999) earY ... 1998 1995 1998 1997 1999 1997 1995 1995 1990 1997 1997 1997 1992 1996 1998 1998 1997 1998 1995 1998 1997 1997 1996 1997 1998 1996 1998 1998 4 46 350 664 ... 57 29.7 29.5 157 251 3.5 85.6 18.5 413 133 7.3 93.2 123 236 312 126 184 421 243.3 217.5 130.4 110.4 166.8 109.8 100,000 Physicians per (1995-1999) 0 0 5 6 4 8 5 27 61 39 77 55 55 36 12 84 24 19 70 26 30 29 11 19 18 IMR 125 156 110 110 2000- 2002 0 7 8 7 0 30 77 66 91 65 65 52 25 96 27 79 30 58 45 19 11 19 27 17 IMR 143 100 191 114 114 1990 0 0 (2002) 30,000 19,900 610,490 4,255,000 2,448,500 1,823,200 3,869,600 5,334,900 4,538,700 2,539,400 2,940,400 5,373,300 5,510,000 Population 29,641,000 18,438,000 48,895,000 24,122,000 16,144,000 11,542,000 26,749,000 79,944,000 38,626,000 10,032,000 22,355,000 132,780,000 144,900,000 144,070,000 2 4 4 2 5 1 2 1 3 4 4 6 1 1 4 5 3 2 6 2 6 6 2 4 4 5 4 4 Region 1 1 5 1 1 1 1 2 1 4 4 1 1 1 4 3 1 3 2 1 2 2 2 3 4 5 2 2 level Income $0 $0 GDP $729 $440 $229 $241 $437 $207 $248 $527 $856 (2002) $1,476 $2,412 $6,277 $5,435 $3,839 $1,703 $2,404 $1,195 $3,762 $1,611 $2,734 $31,160 $19,024 $38,843 $13,151 Guinea (continued) Rep. 7 Federation New Zealand ableT Moldova, Monaco Mongolia Morocco Mozambique Myanmar Namibia Nauru3 Nepal Netherlands New Nicaragua Niger Nigeria Niue3 Norway Oman Pakistan Palau Panama Papua Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Annex 33 earY ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1990 1997 1998 1998 1997 1997 1999 1996 1998 1998 1998 1998 page) ... ... ... 21 ... ... ... ... ... 0.1 ... 4.5 ... ... ... 1.1 ... ... 53 12 next 52.1 33.8 36.3 113 ... ... ... 67.3 61.5 on 100,000 per (1995-1999) Pharmacists (continued earY ... ... ... 1996 1984 1996 1997 1995 1996 1996 1998 1998 1998 1995 1997 1996 1997 1999 1997 1997 1997 1996 1996 1997 1997 1998 1998 1995 1995 4 7 ... 5.2 16 1.2 0.4 0.2 2.5 6.2 5.3 0.7 0.9 ... 74 36.4 12.2 28.9 48.2 60.8 17.8 38.5 19.5 152 0.7 ... 0.7 48.8 18.4 Dentists 100,000 per (1995-1999) earY ... ... ... ... ... ... ... ... ... ... 1996 1990 1996 1995 1996 1996 1995 1990 1988 1999 1991 1990 1998 1995 1995 ... 36 26 6.6 4.7 ... ... ... ... ... ... ... ... ... 29.6 39.3 32.7 16.2 41.9 71.8 26.5 65.4 44.8 10.4 394.6 100,000 Midwives per (1995-1999) earY ... ... 1996 1990 1996 1997 1995 1996 1996 1998 1995 1998 1995 1997 1996 1997 1999 1997 1997 1997 1996 1996 1997 1990 1998 1998 1995 1995 1995 ... 33 20 58 87 155 508 330 22.1 708 681 119 458 263 ... 821 779 189 484 85.2 29.7 127.4 467.6 492.1 471.8 102.7 497.6 238.6 156.3 Nurses 100,000 per (1995-1999) earY ... 1996 1990 1996 1997 1995 1996 1996 1998 1998 1998 1995 1997 1996 1997 1999 1997 1997 1997 1996 1996 1996 1997 1998 1998 1998 1995 1995 1995 4 9 ... 14 24 34.4 252 46.7 166 7.5 7.3 353 228 56.3 424 36.5 47.3 87.7 25.2 15.1 311 323 144 201 4.1 7.6 132.4 162.7 117.1 100,000 Physicians per (1995-1999) 4 3 3 4 4 3 5 0 96 20 57 23 79 13 20 56 17 20 17 22 65 26 23 24 85 79 IMR 182 133 106 104 2000- 2002 0 7 7 8 8 6 7 0 33 69 34 90 17 29 45 19 30 19 21 75 35 77 37 98 34 88 IMR 107 185 133 102 1990 (2002) 30,000 83,590 45,980 176,200 154,210 443,300 158,520 116,720 422,570 753,000 8,163,000 5,235,500 4,164,000 4,164,000 1,992,000 9,390,800 1,088,200 8,924,000 7,227,500 6,315,700 4,766,600 Population 22,116,000 10,007,000 43,580,000 41,180,000 18,968,000 32,365,000 17,005,000 35,181,000 61,613,000 2 1 2 4 1 5 1 1 1 2 4 4 2 1 1 4 3 6 6 6 1 6 1 4 4 5 4 1 2 1 Region 1 1 2 5 1 3 1 3 1 5 3 5 1 1 2 4 2 3 3 2 1 2 2 4 4 2 1 1 2 1 level Income GDP $295 $347 $628 $165 $527 $891 $356 $801 $453 $204 $324 (2002) $1,491 $6,614 $5,715 $4,183 $6,125 $3,709 $2,471 $1,057 $1,528 $2,986 $27,254 $27,254 $12,326 $17,885 $32,117 $46,993 Nevis & Rep. Islands Arabia Leone Rep. & Arab Marino omeT Africa Principe Lanka Kitts Lucia incentV Grenadines -Leste & the Rwanda Samoa San Sao Saudi Senegal Seychelles Sierra Singapore Slovak Slovenia Solomon Somalia South Spain Sri St. St. St. Sudan Suriname Swaziland Sweden Switzerland Syrian ajikistanT anzaniaT Thailand imorT ogoT 34 The State of the Health Workforce in Sub-Saharan Africa earY ... ... ... ... ... ... ... ... ... ... ... 1997 1998 1997 1997 1996 1992 1998 1996 4 ... ... 17 ... ... 81 ... ... 3.1 ... ... ... ... ... . 33.6 33.5 46.7 58.2 100,000 per (1995-1999) Pharmacists respectively earY ... ... ... 1997 1997 1997 1998 1997 1999 1996 1998 1996 1992 1996 1996 1998 1997 1996 1995 countries, 9.2 8.4 13 21 10 0.2 39 26 ... ... 1.6 ... 1.3 21.6 39.8 59.8 24.4 57.1 126.3 Dentists 100,000 per (1995-1999) non-OECD earY ... ... ... ... ... ... 1997 1998 1997 1999 1996 1998 1989 1998 1998 1995 income high 31 ... 90 ... ... ... ... ... 64.4 78.4 13.6 58.7 43.3 67.5 17.6 28.1 and 100,000 Midwives per (1995-1999) OECD, ome earY 1997 1994 1997 1998 1997 1999 1996 1998 1996 1989 1996 1996 1998 1997 1997 1998 1995 1995 1995 inc high 70 56 51 286 109 587 300 18.7 736 341 497 972 260 315.1 286.8 1011 64.4 113.1 128.7 Nurses 100,000 income, . per (1995-1999) middle earY ... 1997 1994 1997 1998 1997 1999 1998 1997 1993 1995 1996 1998 1997 1997 1998 1996 1995 1995 upper respectively 44 70 30 12 48 23 78.8 121 300 ... 299 181 164 279 309 6.9 13.9 370.3 236.3 income, 100,000 countries, Physicians per (1995-1999) middle MENA 8 6 7 17 17 21 36 69 69 79 17 14 52 34 19 19 79 76 IMR 112 2000- 2002 lower and ECA, 8 9 25 21 37 61 80 80 18 12 20 53 52 23 23 98 53 IMR 100 108 income, 1990 SA,, 0 low EAP to (2002) 101,160 205,570 SSA, 1,318,300 9,788,300 5,545,400 3,049,200 3,381,000 to Population 69,626,000 23,395,000 48,717,000 58,858,000 25,391,000 25,093,000 25,093,000 18,601,000 10,461,000 12,967,000 288,370,000 2 2 6 5 4 4 1 4 5 4 4 6 4 2 6 2 5 1 1 corresponds 5 Region and corresponds 4, 5 1 2 3 2 2 2 1 2 5 4 4 3 1 2 3 1 1 1 1 3, 2, and level 1, 4, Kurowski Income 3, 2, $0 level, 1, GDP $367 $525 $314 $410 $522 (2002) $1,750 $5,466 $2,580 $2,942 $1,787 $1,038 $5,463 $1,176 $2,978 $2,978 $15,590 $23,015 $31,977 Christopher income region, of for for (continued) obagoT RB data. 7 & Arab Kingdom States Rep. Courtesy measure measure Nam WDI ableT ongaT inidad nezuela, Tr unisiaT urkeyT urkmenistanT uvalu3T Emirates Uganda Ukraine United United United Uruguay Uzbekistan anuatuV Ve ietV emen,Y The The No Zambia Zimbabwe 1 2 3 Source: Annex 35 Table 8: Brain loss in 9 SSA countries, by profession Country Physicians Nurses and Others Cameroon 49% of health workers have intention to emigrate (p.47) (Awases, Gbary, and Chatora, 2003). Ghana 600 Ghanaian medical practitioners are Ghana has lost about 2,500 nurses to Europe practicing in New York. 62% of health workers from 1999 to 2002 according to the president of have intention to emigrate (p.47) (Frimpong, 2002). the nurse association of Ghana (Awases, Gbary, and Chatora, 2003). 604 (70%) out of 604 out of the 871 (70%) medical officers trained between 1993-2002 left the Ghana lost 328 nurses in 1999 which was country (Safo, 2003). equivalent of its annual output (Loewenson and Thomson, 2002). UNDP notes that in Africa, the loss of physicians has been the most striking. At least 60% of physicians trained in Ghana during the 1980s have left the country (Mutume, 2003). In 1999, 40 of Ghana's 43 final year medical students planned to leave immediately after graduation, while 70% of its 1995 graduates had already emigrated by 1999 (Loewenson and Thomson, 2002). Kenya Kenya estimated that only 600 physicians work in public hospitals out of more than 5000 registered. The rest have moved abroad or are working in private sector (Pang, Lansang, and Haines, 2002) Malawi In 2001, the School of Medicine stated that: Out of a group of 35 RN graduates, some went to work with NGOs and 4 went directly overseas. Four of their teachers also went to work over- seas (p.30) (Martineau et al, 2001). The Nursing Association reports that in 2001, 100 nurses applied for references application to work abroad and 80 have made similar request up to September 2002 (Hornby, Kathyola, and Martineau, 2002). Nurses and midwives registering with the UK CC (Loewenson and Thomson, 2002): 1998/1999: 1 1999/2000: 15 2000/2001: 45 Senegal 38% of health workers have intention to emigrate (p.47) (Awases, Gbary, and Chatora, 2003). (continued on next page) 36 The State of the Health Workforce in Sub-Saharan Africa Table 8 (continued) Country Physicians Nurses and Others South Africa 58% of health workers have intention to More than 300 South African specialist nurses emigrate (p.47) (Awases, Gbary, and Chatora, are thought to leave the country every month 2003). (Tettey, 2003). In the past four years(1998-2002), South Africa has 600 of its medical graduates (trained at a Nurses and midwives from South Africa cost of US$ 37 million) registered in New registering with the UK CC (Loewenson and Zealand (Lancet, 2002). Thomson, 2002): 1998/1999: 599 10% of Canada's hospital-based physicians are 1999/2000: 1460 South African graduates (Loewenson and 2000/2001: 1086 Thomson, 2002). South Africa medical school suggest that a third to a half of its graduates emigrate to the developed world (Pang, Lansang, and Haines, 2002). Uganda Uganda produces 150 physicians per annum, Uganda produces 200 registered nurses/ estimated migration is 30% for physicians midwives per year, more than 10% of these (Omaswa, 2003). professionals are estimated to migrate (Omaswa, 2003). Many Ugandan physicians left for more affluent countries. One of South Africa's medical schools has several senior faculty from Uganda (Bundred and Levitt, 2000). 26% of health workers have intention to emigrate (p.47) (Awases, Gbary, and Chatora, 2003). Zambia Zambia's medical school in Lusaka has trained Nurses and midwives from Zambia registering over 600 Zambian medical graduates in its 23 with the UK CC (Loewenson and Thomson, 2002): years, but only 50 work in the Zambia public 1998/1999: 15 sector health service now (Bundred and Levitt, 1999/2000: 40 2000). 2000/2001: 83 The Zambian public health system has retained The principal reason for staff losses is salary, only about 50 of more than 600 physicians with a large number of nurses and midwives trained in the country since independence leaving Zambia for jobs in the UK and the US. (Loewenson and Thomson, 2002). The Zambian government recently increased the salaries of nurses and midwives, but complaints that the salaries remain insufficient even after the increase are widespread. Therefore, it is not clear that this recent salary increase will influence staff loss rates (Huddart, Lyons, and Furth, 2003). (conbtinued on next page) Annex 37 Country Physicians Nurses and Others Zimbabwe 68% of health workers have intention to 18,000 Zimbabwean nurses work abroad emigrate (p.47) (Awases, Gbary, and Chatora, (Mangwende, 2002). 2003). Nurses and midwives from Zimbabwe registering About 200 physicians left Zimbabwe for with the UK CC (Loewenson and Thomson, 2002): Botswana and South Africa in 1992. Of 1200 1998/1999: 52 Physicians trained in Zimbabwe during the 1999/2000: 221 1990s, only 360 were still practicing in the 2000/2001: 1086 country in 2001. (= 840 went abroad) (Loewenson and Thomson, 2002). Non-specific UN Commission for Trade and Development estimated that each migrating African professional rep- resents a loss of US$184,000 to Africa. Paradoxically, Africa spends US$4bn a year on the salaries of 100,000 foreign experts (Seepe, 2001). Notes 1. In many countries, up to three quarters of more services, a smaller pool of recruits for the recurrent health expenditures are used on health professions), social and cultural factors staffing costs and wages. (more career options available to young peo- 2. At the time of writing, the most current ple, particularly to women), work related fac- and comprehensive data available is compiled tors (lower attractiveness of health occupations by the WHO, using a variety of national health perceived as demanding and not well reward- surveys. More information on this topic can be ed). found in Diallo et al. (2003). 10. Statistics available for South Africa, 3. Burkina Faso, Burundi, Central African Zimbabwe, Nigeria, Ghana, Zambia, Kenya, Republic, Chad, Ethiopia, Gambia, Liberia, and Malawi. Mali, Mozambique, Niger, Somalia, Tanzania, 11. This is often described as "brain drain", and Uganda. an expression traditionally used to describe the 4. As of 2002, SSA had an estimated popu- permanent emigration of qualified persons. lation of 693 million, which is expected to The notion of "brain loss" is more compre- increase to 1081 million by 2025, (Population hensive, as it also encompasses losses due to Reference Bureau, World Population Data people leaving the health sector to take other Sheet, 2002). jobs which reward them better. 5. Cameroon, CAR, Ghana, Kenya, Mada- 12. An example of an interesting and poten- gascar, Tanzania, and Zambia. tially effective measure is the International 6. Burkina Faso, Cameroon, CAR, Ghana, Council of Nurses supported Zambian Nurses and Madagascar. Association partnership with the Zambian 7. CREDESS, Paris, 1999 data for Ivory Ministry of Health in the administration of a Coast, unpublished. program to provide free testing and treatment 8. See, for example, the case of Cameroon, for pregnant nurses and other health workers Congo, and Cote d'Ivoire. (see ICN, http://www.icn.ch/PR26_03.htm). 9. 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