The critical shortage of health care professionals limits the access to care to millions of individuals in resource-limited settings. This situation requires urgent action, such as a profound transformation of the present training approach, as to (i) adapting curricula to local needs, (ii) promoting strategies to retain expert faculty staff, (iii) expose trainees to community needs during training, (iv) promote multisectoral approach to education reforms and (vi) strengthen links between the educational and health care delivery system. Western academic Institutions’ role is to facilitate the process. The possible strategies for assistance must be in constant and balanced partnership
Training Health Personnel in Resource-Limited Settings
by Francesco Castelli* and Marianna Bettinzoli**
* Chair of Infectious Diseases, University of Brescia, Italy
**PhD trainee in “Methodology and Appropriate Techniques for International Development Cooperation”, University of Brescia, Italy
The right of millions of people around the world to have access to care is jeopardized by the shortage of health care personnel. Only in the African continent, the global burden of diseases is estimated to be as high as 27% of the world’s total despite only 12% of the world population live here. The problem is even more critical because the continent only have 3,5% of the total healthcare workforce 1. This shortage is critical, as recognized by Word Health Organization (WHO) in its 2006 annual report requesting urgent interventions. The shortage is even more dramatic if one considers that over 75% of physicians in Sub-Saharan Africa live and work in the urban setting, leaving the rural areas nearly devoid of care providers 2.
The reasons for this shortage of health care professionals where they are more needed are various:
First, in low-income countries, the training of health professionals is quantitatively limited 3. This limited capability is due to scarce funding, poor infrastructure, the highly qualified teachers often search for more remunerative and attractive jobs abroad.
Second, after graduation, a great proportion of health professionals declares its willingness to migrate 4. Among the identified reasons for migration, in decreasing order, are 2: (i) better remuneration, (ii) safer environment, (iii) living conditions, (iv) lack of facilities and (v) the absence of future. Understanding the reasons for migration is crucial in order to define and to put into practice strategies to limit brain drain 5. Other Authors estimate that other factors, apart from financial incentives, including working and living conditions, social and political insecurity could play a even more important role in the migration decision 6. The Global Code of Practice on the International Recruitment of Health Personnel has been recently launched by WHO, requesting all member States to take action to facilitate retention of health personnel in those areas where they are most needed 7.
Third, the social and economic prestige of the health professions is better exploited in the urban setting 8. One possibility to contrast this phenomenon is context-appropriate medical training. In fact, exposing medical students to problem-based learning approach in the rural settings areas may influence their attitude and willingness to work in rural remote areas once graduated 9.
The challenge of health education in resource poor countries
Many strategies have been put forward to combat global health worker shortages, with conflicting results.
Task shifting, the progressive inclusion of tasks, traditionally ascribed to the medical or surgical profession, among the job descriptions of lower level health care professionals, has been advocated by many international Agencies and adopted by many developing countries 10. Training of mid-level personnel has also been implemented in same situations and global standardization of curricula would be desirable to share expertise and compare training experiences 11. Task-shifting and mid-level health professionals are not to be considered a makeshift solution in resource-poor settings but instead as true strategies.
To retain the health professionals in remote areas, offering specific benefits (i.e. housing, etc.) that might elevate their social and economic status might be influence the willingness to migrate 12. On the contrary, the widespread use of per diems for in-job training has motivated health professionals to actively search for continuous training remunerative activities leaving their clinical duties, an attitude referred to as “perdiemitis” 13. Furthermore, reinforcing the social accountability and ethical commitment of medical trainees to engage himself to the underserved community appears crucial.
Finally, the careful planning of training needs for health care professionals (both quantitatively and quantitatively) should involve different sectors at the governmental level and particularly the education and the health sectors 14.
What western education institutes may contribute?
Literature on the medical education needs of resource-poor countries is scanty and, unfortunately, it has been mostly published by Authors working in western institutions. Only quite recently, the academic leaders from the southern countries have raised their voice about the problems and have proposed solutions 15.
When putting in place a training or research partnership between academic institutions from the North and the South, many possible mistakes have to be carefully avoided when partnering for medical education in southern countries. These are: i) curricula are often western-centered, ii) the social and cultural contexts are not considered, iii) tendency to create specialists instead of public health expert without attention to multidisciplinary approach, iv) unbalance between the teaching staff from the north and the south, with little incentives for the latter, v) prolonged training periods of time spent in affluent countries , vi) use of sophisticated training material vii) the local public health system and economic authorities are poorly involved.
The following are among some additional possible solutions to increase quality and quantity of medical education in the south through a possible help by western academic institution.
Long distance internet-based teaching resources. They are attractive and have the advantage to limit travels, vacancies and costs. Positive experiences have been reported 16. The main difficult is the adaptation to the recipients’ settings in terms of social, cultural, legal, economic and, sometimes, religious context. Furthermore, on-line training requires access to electronic facilities and internet competencies 17.
Assistance in quality control procedures, external evaluation and accreditation. The maintenance of high quality of education is essential to gain credibility at the national and international levels 18.
Promoting independent research activity in developing countries. To have a high quality teaching and training, promoting research capability is crucial. The creation of a independent research career path for physicians from resource-limited countries is needed 19.
The critical shortage of health care professionals limits the access to care to millions of individuals, especially where the need is higher. This is mainly caused by poor training capabilities of academic institutions in developing countries, the attitude of health care personnel to migrate to more affluent western countries and the unwillingness of local doctors to work in the most in need rural areas. This situation requires urgent action, such as a profound transformation of the present training approach, as to (i) adapting curricula to local needs, (ii) promoting strategies to retain expert faculty staff, (iii) expose trainees to community needs during training, (iv) promote multisectoral approach to education reforms and (vi) strengthen links between the educational and health care delivery system 19. Western academic Institutions’ role is to facilitate the process. The possible strategies for assistance must be in constant and balanced partnership.
1) WHO. Core Health Indicators 2008, World Health Organization, Geneva, 2008 http://www.who.int/whosis/whostat/EN_WHS08_Full.pdf
2) WHO. World Health Report 2006. Working together for Health. World Health Organization, Geneva, 2006
3) Mullan F, Frehywot S, Omaswa F et al. Medical schools in sub-Saharan Africa. Lancet, 2011 Mar 26;377(9771):1113-21
4) Chen C, Buch E., Wassermann T et al. A survey of Sub-Saharan African medical schools. Human Resources for Health, 2012, 10:4 http://www.human-resources-health.com/content/10/1/4
5) Oyeyemi AY, Oyeyemi AL, Maduagwu SM et al. Professional satisfaction and desire to emigrate among Nigerian physiotherapists. Physiotherapy Canada, 2012; 64: 225-232
6) Vujicic M, Zurn P, Diallo K et al. The role of wages in the migration of health care professionals from developing countries. Human Resources for Health 2004, 2, 3 http://www.human-resources-health.com/content/2/1/3
7) Mills EJ, Kanters S, Hagopian A et al. The financial cost of doctors emicrating from Sub-saharian Africa: human capital analysis. British Medical Journal, 2011; 343:d7031 doi:10.1136/bmjd7031
8) Burch VC, McKinley D, van Wyk J et al. Career intentions of medical students trained in six sub-saharan African countries. Educ Health (Abingdon), 2011; 24: 614
9) Kaye DK, Mwanika A, Sewankambo N. Influence of training experience of Makerere University medical and nursing graduates on willingness and competence to work in rural health facilities. Rural and Remote Health, 2010 http://www.rrh.org.au
10) Nelson R. Combating global health worker shortages: task shifting and sharing may provide one solution. Am J Nurs, 2012; 112: 17-8
11) Brown A, Cometto G, Cumbi A et al. Exchange of the Global Health Workforce Alliance. Rev Peru Med Exp Salud Publica, 2011; 28: 308-15
12) Hagopian A, Ofosu A, Fatusi A et al. The flight of physicians from West Africa: views from African physicians and implication for policy. Social Science and Medicine, 2005; 61: 1750-60
13) Ridde V. Per diems undermine health interventions, systems and research in Africa: burying our heads in the sand. Trop Med Int Health. 2010 Jul 28. doi: 10.1111/j.1365-3156.2010.02607.x
14) Celletti F, Reynolds TA, Wright A et al. Educating a new generation of doctors to improve the health of populations in low- and middle-income countries. PLOS Medicine 2011 http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001108
15) Kiguli-Malwadde, Kijjambu S, Kiguli S et al. Problem Based Learning, curriculum development and change process at Faculty of Medicine, Makerere University, Uganda. African Health Sciences 2006; 6: 127-130
16) Chung MH, Severynen AO, Hals MP et al. Offering an American graduate medical HIC course to health care workers in resource-linited settings via the internet. PLOS One, 2012; 7: e52663. doi:10.1371/journal.pone.0052663
17) Mohammed E, Andargie G, Meseret S, Girma E. Knowledge and utilization of computer among health workers in Addis Ababa Hospitals, Ethiopia: computer literacy in the health sector. BMC Research Notes, 2013; 6: 106 http://www.biomedcentral.com/1756-0500/6/106
18) Galakunde M, Opio K, Nakasujja N et al. Accreditation in a sub-Saharan Medical School: a case study at Makerere University. BMC Medical Education 2013; 13/73 http://www.biomedcentral.com/1472-6920/13/73
19) Manabe YC, Katabira E, Brough R et al. Developing independent investigators for clinical research relevant for Africa. Health Research Policy and Systems, 2011, 9:44 http://www.health-policy-systems.com/content/9/1/44
*Francesco Castelli, MD, FRCP (London), FFTM RCPS (Glasgow), is Professor of Medicine (Infectious Diseases) and Director of the University Division of Infectious and Tropical Medicine at the Università degli Studi di Brescia (Italy). He is also Director of the Specialty School in Infectious Diseases at the same University. He serves as the Vice-President of the Italian Society of Tropical Medicine (SIMET) and is Member of the Board of Directors of the International Society of Travel Medicine (ISTM). He is site Director of the Brescia Geosentinel site and of the WHO Collaborating Center for the implementation of TB/HIV collaborative activities. He is past-President of the Italian NGO Medicus Mundi Italy. His major fields of scientific interest are tropical diseases, migration medicine, travel-related and imported infections and HIV/AIDS both in industrialized and developing Countries. He has published more than 180 papers on peer-reviewed journals and more than 100 chapters of Books and Manuals.
**Marianna Bettinzoli, MD. She is in PhD training in “Metodology and Appropiate Techniques for International Development Coopoeration” at the University of Brescia. Her major fields of scientific interest are global health, migration medicine and public health.