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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000423494.77404.42
AJN Reports

Combating Global Health Worker Shortages

Nelson, Roxanne BSN, RN

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Task shifting and sharing may provide one solution.

Health care workers are in short supply around the globe, particularly in developing nations. According to data from the World Health Organization (WHO), 57 nations, primarily in sub-Saharan Africa, are facing a crisis. To combat the problem, a set of strategies known as task sharing and task shifting are increasingly being used to boost access to health care.

Figure. Health worke...
Figure. Health worke...
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Although these two terms are sometimes used interchangeably, they're not necessarily the same thing. Task sharing is a strategy in which health care workers take on additional duties. Task shifting, as defined by the WHO, is when “specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of available resources for health.”

“I prefer the term task sharing, which to me suggests sufficient training and supervision,” said Marilyn A. DeLuca, PhD, RN, cochairwoman of the October 2011 Strengthening 21st Century Global Health Systems summit, Investing Strategically in the Health Care Workforce. “In a number of settings there are growing examples of very positive outcomes using community health workers in this manner.” But she added a caveat: “We need to be cautious as task shifting expands. Without adequate training and supervision, it can lead to unsafe clinical practice and compromised, discouraged health workers.”

The ideal, of course, would be to train more physicians and nurses, increasing the numbers of highly skilled workers, but even though some progress has been made, it's an uphill battle. Educating nurses and physicians is an expensive and lengthy process, and low-income nations generally lack the necessary resources and infrastructure. Retention also becomes a problem when low pay, poor working conditions, political instability, and foreign recruiters induce nurses and physicians to seek employment abroad.

Targeting disease: a double-edged sword. Although there is funding for health workforce development, “it's inadequate and difficult to track,” said DeLuca, who's also an adjunct associate professor at the New York University College of Nursing. Public and private funders of global health care have typically not targeted workforce development as part of the strategy to strengthen health care systems. This reluctance stems in large part from the complex issues related to human resources for health care. “Historically,” she said, “the majority of aid from public and private funders has been directed toward specific diseases.”

Although the focus on specific diseases, such as HIV and tuberculosis, has yielded many benefits and great progress has been made, good programs can sometimes have unintended consequences, DeLuca noted. Disease-specific programs, she said, “often segment care and can pull health care workers away from government jobs.”

If a nongovernmental organization is implementing a project, for example, it may offer nurses better pay and working conditions than they have with their government job. This in turn strains the government-funded health system.

The issue is further complicated in low- and middle-income countries, not only because of cost but by restrictions arising from the International Monetary Fund and World Bank, said DeLuca. These types of expenditure restrictions have limited governments in creating new positions.

The recognition of the need is there, she said, but what will accelerate the development and retention of health workers isn't only more private funding from foundations but commitments from individual countries to build their health care workforce. “Country ownership is key,” she said. “Funders need to work within the country's strategic plan, in partnerships with its government officials and local stakeholders. It takes time to increase the workforce; ideally, a foundation provides support until the country can sustain it. You really can't make strides with a two-year grant.”

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The 2006 WHO report Working Together for Health concluded that, although there are over 59 million health care workers in the world, their distribution is uneven, both between nations and among regions within individual countries. Overall, the report estimated the shortage of health care workers globally to be in the range of 4.3 million.

The WHO has set the acceptable minimum ratio of high-level health care workers—nurses, midwives, and physicians—at 2.3 workers per 1,000 population, according to Judith A. Oulton, MEd, RN, former chief executive officer of the International Council of Nurses. Most of the 57 “crisis countries” fall below that mark, as low as 1.1 per 1,000 workers. In Malawi, for example, according to the WHO's Global Health Observatory, the situation is so critical that there are fewer than two physicians for every 100,000 people.

In its 2008 recommendations on task shifting, the WHO writes that nonphysician clinicians “can safely and effectively undertake a majority of clinical tasks” and that “nurses and midwives can safely and effectively undertake a range of HIV clinical services.” Task shifting then also encourages the use of nurses to their full potential, which in many cases involves taking over duties typically performed by physicians. For example, in Mozambique, according to the Global Health Workforce Alliance (GHWA), experienced nurses have been successfully trained as surgical–obstetric officers and can even perform cesarean sections when no physician is present.

A recent paper by Fairall and colleagues, published in the September 8 issue of the Lancet, found that in South Africa the task of initiating and prescribing antiretroviral therapy was able to be safely shifted from physicians to primary care nurses. This in turn allowed physicians to focus on patients who were seriously ill.

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Global efforts to step up training of health care professionals are also under way. One example is the Nursing Education Partnership Initiative (NEPI), which is part of the President's Emergency Plan for AIDS Relief, to train at least 140,000 new health care professionals and paraprofessionals in sub-Saharan Africa, Oulton told AJN. The goal of NEPI is to give funding to nursing schools in each of the target countries, prioritize interventions that strengthen nursing and midwifery programs, and ramp up innovative approaches to both nursing and midwifery education. The program initially began in Zambia, Malawi, and Lesotho and will expand to three more countries.

However, the average attrition rate of students in the health professions in the African region is 30%, and graduates have an emigration rate of about 19%, according to the GHWA.

Although the causes of the health care worker shortage are multifactorial, the basic underlying problem is that an insufficient number of high-level workers—namely nurses, midwives, and physicians—are being trained. The reality is that because of the enormous costs involved, this situation isn't likely to change anytime soon. According to Oulton, approximately $26.4 billion is needed to educate and train the extra 1.5 million health workers the WHO estimates are needed to provide a minimum standard of service to the African region. And the annual cost of spreading out that training over a 10-year period would increase the total cost to more than $29 billion.

Of course, the target of 2.3 high-level workers per 1,000 people may not be realistically attainable, at least not in the near future, because it would require some countries to devote an unrealistic proportion of their gross domestic product to training health care workers. The expansion of alternatives, then, must be a priority. Such alternatives include community workers and midlevel providers, defined as women or men with two to three years of post–secondary school health care training who perform duties typically performed by physicians and nurses.

The GHWA calls the immediate investment in community and midlevel health workers one of several initiatives that are urgently needed. But the training, supervision, pay, and working conditions of such workers vary widely, said Oulton, and there's little information on how such variations affect health, access, and cost-effectiveness.

Similarly, evidence supporting the use of midlevel workers is uneven, even though it appears that when their training is adequate and they're supported and supervised, they are able to safely and competently deliver essential health services.—Roxanne Nelson, BSN, RN

© 2012 Lippincott Williams & Wilkins, Inc.


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