Five Questions With…Dr Juliet Nabyonga-Orem

Africa has less than 30% of its required health workforce, yet at least 700,000 health workers are unemployed. What are the barriers to the recruitment of more health workers?

The restricted wage bill is one of the barriers which does not allow room for recruitment. Ceilings have been imposed in some countries where public service salaries should not exceed a given percentage of the government budget. With such pre-determined budget commitments, recruiting additional health workers is impossible as their salaries cannot be guaranteed. Weaknesses in planning and determining staffing norms pose another constraint. In some countries, staffing norms are either not based on evidence or are outdated and as such do not reflect actual human resource requirements. Indeed, in some of these countries, while vacancy rates are low, inadequacies do exist and justifying additional requirements becomes a challenge.

Weak multi sectoral collaboration in human resource for health (HRH) development is another challenge. Ideally, training institutions should develop training programs that are fit for purpose, in cognizance of skills requirements in the health sector. However, this is rarely the case and indeed qualified health workers have failed to get into the job market because of a mismatch between vacant positions and available qualified health workers.  Relatedly, the civil service defines qualifications for the different positions, and this serves as the guidance to recruitment. Unfortunately, training schools develop new training programs without adequate consultation to ensure that related positions are created in the civil service structure.

In some cases, the health workers are simply not available, especially for countries that do not have in-country training capacity. Once trainees are sent abroad for training some do not return, choosing to take up job opportunities in other countries that offer better remuneration.

As population health needs increase, there has been a stagnancy in health budgets of the member states of the WHO African region. How can this be overcome?

The stagnancy of health budget is of concern with 38 WHO Africa Region member states having a government per capita expenditure on health in current prices of less than US$100.  Several reasons have been advanced and perhaps once addressed, may offer solutions.  Health development aspirations of a country are usually detailed in medium strategic plans which serve as a basis for resource mobilization and allocation.  Ministries of finance have often made reference to the poor prioritisation in these plans, lack of estimated costs (there are countries whose strategies are not costed) as well as unrealistic cost estimates. This is compounded by the weak evidence base to guide the policy dialogue during budget processes and perhaps this explains the misconception that has shrouded health investments, resulting in looking at the health sector as a consumption sector as opposed to one that contributes to economic development.

The Covid-19 pandemic that has impacted all sectors has clearly demonstrated the importance of investing in health and more specifically building resilient health systems. The projected reduction in economic growth as a result of the pandemic notwithstanding the Covid–19 pandemic avails an opportunity that needs to be seized to increase investment in health.

While we make a case for increased investments, we need to address the outstanding concern of inefficiency in resource allocation and expenditure. For example, corruption has been documented in some countries and some of the areas identified include absenteeism of health workers, diversion of patients from the public to the private sector, inappropriate prescribing, informal payments/bribery and theft of drugs and supplies.

In terms of investment, what are the best buys in Health System Strengthening for a future which is uncertain?

Investment in primary health care remains the best buy in and improvements in coverage as evidenced in the case of Ethiopia attest to this. Bringing services close to the people and mobilizing communities to take charge of their health is crucial. In the case of Ethiopia, extensions workers at community level have been instrumental in improving uptake of services but also supporting emergency response efforts.

Strengthening information systems is another area which is very important because it all starts with good planning to inform resource mobilization and implementation as well as monitoring to ensure steady progress and corrective action. Information systems are weak and very few countries in Africa seem to get the population denominators right.  Such data is usually from population-based surveys, but only 16 of the 47 countries of the WHO African Region have well developed capacity for population-based surveys, while only 18 of 54 African countries record and report annual deaths.

What measures can be taken to ensure gender equality and social inclusion (GESI) is implemented more widely as a universal guideline?

Among the measures to be explored is a better understanding of the drivers of inequalities, embracing a wider scope in our approaches and being innovative. Firstly, we need an in-depth understanding of the drivers of inequalities. We have all along known that the level of education, social economic category and residence (urban rural) are major drivers but what we have not yet grasped is how to address these.  Solutions will be context specific and designing these requires contexualised evidence. Does the level of importance of the different drivers differ by intervention? For example, a study conducted in 18 countries in West Africa to assess inequalities in BCG, and DTP3 coverage concluded that a child’s sex and place of residence minimally determined equity gaps. This means that more granular data and intervention specific evidence may offer more insights in improving gender and social inclusion.

Improving gender and social inclusion is much more than what the health sector alone can do but realizing multi sectoral collaboration outside epidemic response has remained elusive in as much as we know it is beneficial. For example, completion of secondary education for women is a major contributor to women empowerment and improving uptake of maternal health services but in African countries, even where education is provided free or is highly subsidized, drop out rates for girls is high. Mainstreaming social science and anthropology disciplines within ministry of health structures including at service delivery levels will facilitate mainstreaming gender considerations in policies and in-service delivery. We also need to appreciate that ensuring GESI is not a quick fix, it takes time and we need to make sustained investments.

What can we learn from previous health challenges, such as HIV or the current COVID-19 pandemic, in terms of leaving no one behind?

When we talk about leaving no one behind, effective community engagement is central to the discussion. The role of communities as major players in planning, implementation as well as uptake of health interventions is crucial. Communities need to be seen as the frontline in response efforts as opposed to merely beneficiaries. Communities trust their own better and are more likely to cooperate and take up interventions when approached by the people they trust. Indeed, they have played a fundamental role not only in disease outbreaks but also in disasters from example in Mozambique during the Cyclone Idai where they provided first aid and took people to safety, Ebola response in West Africa and DRC and the Covid-19 response in several countries in Africa. The HIV and TB programs has made extensive use of community structures and these have been instrumental in improving treatment adherence.