The health and social sector, with its 234 million workers, is one of the biggest and fastest growing employers in the world, particularly of women. Women comprise seven out of ten health and social care workers and contribute US$ 3 trillion annually to global health, half in the form of unpaid care work. While gender issues have been at the top of the global agenda, few comprehensive studies on gender in the health and social workforce have been conducted at the global level. This brief is based on an analysis of WHO NHWA data5 for 104 countries over the last 18 years. The analysis confirms previous findings that women’s share of employment in the health and social sector is high, with an estimated 67% of the health workforce in the 104 countries analysed being female. Analysis based on median wages from 21 countries showed health workers face gender-related gaps in pay, with female health workers earning, on average, 28% less than males. This is slightly greater than global estimates of gender pay gap data, showing that women are paid approximately 22% less than men. Data from 56 countries showed higher average working hours per week for men than women for most occupations and regions. This likely reflects different type of contracts, with more part-time jobs occupied by women. Women represent around 70% of the health workforce, but earn on average 28% less than men. Occupational segregation (10%) and working hours (7%) can explain most of this gap, but even when considering “equal work” an “equal pay” gap of 11% remains. The authors note that it must be recognized that much of the work in health done by women is unpaid work and that investments in creating decent work in the health sector are needed to support the translation of informal work into formal sector employment.
Human Resources
Produced by the WHO Transforming Health Systems is a training resource for health trainers to use with health managers, policy-makers and others with responsibilities in reproductive health. It offers a training curriculum designed to equip participants with the analytical tools and skills to integrate the promotion of gender equity and reproductive rights into their reproductive health policies, planning and programmes.
In this paper, the authors assess the gender-based distribution of Tanzania’s health workforce cadres. They conducted a secondary analysis of data collected in a cross-sectional health facility survey on health system strengthening, consisting of 815 health workers (HWs) from 88 randomly selected health facilities. Results showed that the mean age of the HWs was 39.7, with 75% women. The proportion of women among maternal and child health aides or medical attendants (MCHA/MA), nurses and midwives was 86%, 86% and 91%, respectively, while their proportion among clinical officers (COs) and medical doctors (MDs) was 28% and 21%, respectively. The authors conclude that the distribution of the Tanzania’s health cadres is dramatically gender skewed, a reflection of gender inequality in health career choices. MCHA/MA, nursing and midwifery cadres are large and female-dominant, whereas COs and MDs are fewer in absolute numbers and male-dominant. While a need for more staff is necessary for an effective delivery of quality health services, the authors call for adequate representation of women in highly trained cadres to enhance responses to some gender-specific roles and needs.
As low- and middle-income countries face continued shortages of human resources for health and the double burden of infectious and chronic diseases, there is renewed international interest in the potential for community health workers to take on a growing role in strengthening health systems. Health surveillance assistants (HSAs) — as the community health cadre in Zomba District, Malawi is known — play a vital role by connecting the community with the formal health care sector. The latest research from the Africa Initiative provides a situational analysis of the HSA cadre and its contribution to the delivery of health services in Malawi. The authors’ findings show that HSAs face numerous challenges related to training, as well as challenges in defining their roles and those of their supervisors. They conclude with recommendations to improve HSA training and policy, with the ultimate goal of improving the effectiveness of this cadre of worker, and improving the health of the population.
According to this profile document, health services and functions in Ghana have been decentralised and budget management centres have been created to improve both access to health services and community involvement in planning and delivery of services. There are about 52,258 individuals currently formally working in the health sector in Ghana. The Ministry of Health employs 42,299 staff, which represents about 81.5% of the total health sector workforce. In addition, about 21,791 people countrywide are registered as engaged in traditional medicine, while 367 people are registered as traditional birth attendants. Current human resources policies and plans emphasise the training of more middle-level cadres, which are cheaper to train and maintain. Distribution of health workers is skewed in favour of the more affluent regions, most of which are in the southern half of the country. Highly skilled professionals are concentrated in Greater Accra region, as well as in Korle Bu and Komfo Anokye Teaching Hospitals. Although training of health professionals has been a shared responsibility between the Ministries of Health and Education, there has not been clearly defined roles and collaboration. There is no comprehensive training policy to clarify roles and address issues.
The Global Health Workforce Alliance (GHWA) strongly welcomes G8 leaders’ commitment, in Hokkaido, Japan, to actively address the critical shortages of health workers across the world. GHWA applauds Japan and the other G8 nations for recognizing that a competent, supported health workforce is fundamental to developing robust health systems and to reaching health and development goals. GHWA also welcomes the G8’s noting of the importance of the Kampala Declaration and Agenda for Global Action to help guide the response to the health workforce crisis. While encouraged by the increased commitment shown by the G8, GHWA urges the leaders follow up with increased and new investment to ensure promises on the health workforce are turned into reality.
Migration has been one of the more important means of greater global integration, and, as the economic crisis has gripped the developed world, many have worried about its impact on such integration, especially falling remittances. A closer examination of the nature of migrant workers' role in the economy suggests more complex outcomes, with somewhat less of an impact than feared. It is true that most of this migration has been driven by economic forces and has given rise to rapidly expanding remittance flows, which have become the most important source of foreign exchange for many developing countries. The International Monetary Fund estimated total remittance flows to developing countries to be nearly US$300 billion in 2009, significantly more than all forms of capital flows put together. In any case, one of the basic pull factors still remains significant: the demographic transition in the North that is increasing the share of the older population that requires more care from younger workers, who must therefore come from abroad. So the current crisis may temporarily slow down the ongoing process of international migration for work, but it is unlikely to reverse it.
Due to a limited health workforce, many health care providers in Africa must take on health leadership roles with minimal formal training in leadership. Hence, the need to equip health care providers with practical skills required to lead high-impact health care programs. In Uganda, the Afya Bora Global Health Leadership Fellowship is implemented through the Makerere University College of Health Sciences (MakCHS) and her partner institutions. Lessons learned from the program, presented in this paper, may guide development of in-service training opportunities to enhance leadership skills of health workers in resource-limited settings. The Afya Bora Consortium, a consortium of four African and four U.S. academic institutions, offers 1-year global health leadership-training opportunities for nurses and doctors. Applications are received and vetted internationally by members of the consortium institutions in Botswana, Kenya, Tanzania, Uganda, and the USA. Fellows have 3 months of didactic modules and 9 months of mentored field attachment with 80% time dedicated to fellowship activities. Fellows’ projects and experiences, documented during weekly mentor-fellow meetings and monthly mentoring team meetings, were compiled and analysed manually using pre-determined themes to assess the effect of the program on fellows’ daily leadership opportunities. Between January 2011 and January 2015, 15 Ugandan fellows (nine doctors and six nurses) participated in the program. Each fellow received 8 weeks of didactic modules held at one of the African partner institutions and three online modules to enhance fellows’ foundation in leadership, communication, monitoring and evaluation, health informatics, research methodology, grant writing, implementation science, and responsible conduct of research. In addition, fellows embarked on innovative projects that covered a wide spectrum of global health challenges including critical analysis of policy formulation and review processes, bottlenecks in implementation of national HIV early infant diagnosis and prevention of mother-to-child HIV-transmission programs, and use of routine laboratory data about antibiotic resistance to guide updates of essential drug lists. In-service leadership training was feasible, with ensured protected time for fellows to generate evidence-based solutions to challenges within their work environment. With structured mentorship, collaborative activities at academic institutions and local health care programs equipped health care providers with leadership skills.
The Global Health Workforce Alliance (GHWA) has welcomed the pledges of commitment expressed at the United Nations High Level Meeting on the Millennium Development Goals and surrounding events that place resolving the health workforce crisis at the centre of ensuring progress on improving maternal and child health and addressing killer diseases such as malaria. Significant financial commitments were made to address the health workforce as part of the drive to move closer to the achievement of Millennium Development Goals 4 and 5 on reducing maternal and child mortality. Commitments included a pledge of £450 million from the UK over the next three years to support national health plans, incorporating training more nurses, midwives and doctors in eight of the poorest countries.
In low- and middle-income countries, scaling essential health interventions to achieve health development targets is constrained by the lack of skilled health professionals to deliver services. The authors project the future health workforce demand based on projected economic growth, demographics and health coverage. They used health workforce data for 1990–2013 for 165 countries from the WHO Global Health Observatory. The demand projections are compared with the projected growth in health worker supply and the health worker “needs” as estimated by WHO to achieve essential health coverage. The model predicts that, by 2030, global demand for health workers will rise to 80 million workers, double the current (2013) stock of health workers, while the supply of health workers is expected to reach 65 million over the same period, resulting in a worldwide net shortage of 15 million health workers. Growth in the demand for health workers will be highest among upper middle-income countries, driven by economic and population growth and ageing. This results in the largest predicted shortages which may fuel global competition for skilled health workers. Middle-income countries will face workforce shortages because their demand will exceed supply. By contrast, low-income countries will face low growth in both demand and supply, both of which are estimated to be far below what will be needed to achieve adequate coverage of essential health services. This may lead to the paradoxical phenomenon of unemployed (“surplus”) health workers in those countries facing acute “needs-based” shortages.