Managing a Health Workforce Crisis: Lessons from the Global Context

Maurice Middleberg

“Happy families are all alike,” goes the famous opener to Leo Tolstoy’s Anna Karenina. But are countries with a critical shortage of health workers all alike, in terms of their health outcomes?

While in Nairobi for Kenya’s first national conference on human resources for health, I talked about how we tend to lump the so-called “health workforce crisis” countries together and assume that their health worker shortages correspond to similarly poor health outcomes.

As it turns out, some countries have managed their health workforce shortage more effectively than others.

Surprising variation in health outcomes

There are 57 countries, including Kenya, that are deemed to have a health workforce crisis, meaning fewer than 2.3 doctors, nurses, and midwives per 1,000 people. (All 57 countries are on the low end of that threshold: their average density is actually less than one doctor, nurse, and midwife per 1,000). One might expect that these countries would uniformly exhibit poor health indicators. But there is surprising variation. Under-five mortality ranges from 209 per 1,000 to 17 per 1,000. Contraceptive prevalence varies from 1% to 69%. These figures are not simply outliers; they are the ends of a smooth continuum of health performance.

Countries with similar levels of health professionals have radically different health outcomes.

This variation cannot simply be attributed to differences in the social determinants of health such as income or female education. In the face of similar shortages of health workers, diversity of health outcomes suggests that countries have differed in the choices they have made.

What some countries are doing differently
Some “health workforce crisis” countries have made the best use of scarce resources and compensated for the scarcity of health professionals. Countries that achieve better health outcomes tend to ensure more equitable access to the doctors, nurses, and midwives they do have, and to use them more effectively and efficiently. But what really seems to tip the balance toward better health outcomes, we’re finding, is what these countries do with other cadres of health workers.

Successful countries are making smart use of allied health workers—community health workers, health educators, clinical officers, and other cadres that provide essential health services.

Allied health workers help explain much of the diversity among the crisis countries’ health outcomes. There is wide variation in equitable access to the full array of health workers if one includes both professionals and paraprofessionals.

An encouraging sign
In short, successful countries have deployed and used health professionals more effectively and efficiently. They have also made better use of other health cadres than less successful countries as a way of making essential services widely available. This can be taken as a very encouraging sign. It means that there are creative opportunities to advance access to health workers.

Of course, every country is unique and must chart its own path to ensuring access to qualified health workers. But most countries can take important steps to increase access based on the abundant evidence to guide policy and planning, which can be adapted to the realities of every individual country.

Kenya, for one, has already made great progress in providing its people with access to qualified health workers. The Capacity Kenya project—headed by CapacityPlus lead partner IntraHealth International—is one way the country is helping create stronger health workplaces and systems, and making sure health workers are equipped to succeed.

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Photo courtesy of IntraHealth International.