Case study: Nigeria

A dissertation submitted to the University of Manchester for the degree of Intercalated BSc (Hons) in Global Health, in the Humanitarian and Conflict Response Institute. Word Count: 10,361 Student number: 7546872

The global health workforce crisis: Task shifting as the solution

Ranga Fernando

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Abstract There is no doubt there is a global health workforce crisis. This dissertation examines the factors involved in the global health workforce crisis, explores possible strategy solutions and evaluates the use of task shifting as a possible strategy to help address the growing gap between health worker supply and demand. 57 nations worldwide have critical shortages of health workers which impedes the delivery of essential health services in areas where the burden of disease is highest. However, simply increasing the numbers of workers is not enough. There are wide urban and rural divides in equity of access. Important factors to consider to remedy this situation are the training, management and retention of workers with a special focus on migration. This dissertation examines to what extent task shifting can help solve the aforementioned issues. Evidence suggests that task shifting can markedly improve health worker numbers. In addition, they can ensure greater equitable distribution of access to care. They are cheaper to train than conventional cadres of health workers, can provide equitable if not better standards of primary healthcare to populations and are a category of workers that has proven to be easy to retain in the health service. Currently due to their skillsets task shifted workers such as community health workers are mainly effective in delivering non-specialised primary health care. Further efforts need to be implemented to increase the coverage of specialised health care. This dissertation explores these issues in detail through a case study of Nigeria. The Nigerian case confirms that task shifted workers can increase the supply of health workers and that they are also effective in delivering many essential services and health education programmes. In short, task shifted workers can positively impact in all three key areas of health worker coverage: supply, management and retention. However, it is important to remember that their effectiveness only extends to primary interventions.

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Abstract .......................................................................................................... 2

1. Introduction ................................................................................................ 5 1.1 Global health crisis ......................................................................................................... 5 1.2 HSS lens ........................................................................................................................... 5 1.3 Justification for research ................................................................................................... 6 1.3 Methodology ................................................................................................................... 6 1.5 Chapter overview .............................................................................................................. 7

2. The global health workforce crisis ........................................................... 8 2.1 The global health workforce crisis .................................................................................. 8

2.1.1 What is a health worker? ............................................................................................... 8 2.1.2 How widespread is the issue? ....................................................................................... 9 2.1.3 Why is this important? ................................................................................................. 9 2.1.4 Management of health workers. .................................................................................. 10

2.2 What is causing this crisis? ............................................................................................. 11 2.2.1 Training issues. ........................................................................................................... 11 2.2.2 Management of health workers. .................................................................................. 11 2.2.3 Retention issues .......................................................................................................... 12 2.2.4 Migration issues .......................................................................................................... 13

2.3 Solutions ............................................................................................................................ 13 2.3.1 Training solutions. ...................................................................................................... 14 2.3.2 Management of existing workers. ............................................................................... 16 2.3.3 Retention solutions. .................................................................................................... 17 2.3.4 Migration solutions .................................................................................................... 19

2.4 Task Shifting ..................................................................................................................... 19 2.4.1 What is task shifting? ................................................................................................. 19 2.4.2 Benefits ........................................................................................................................ 21 2.4.3 Drawbacks ................................................................................................................... 22

2.5 Summary ......................................................................... Error! Bookmark not defined.

3. Case Study: Nigeria ................................................................................ 24 3.1 Nigeria overall situation ................................................................................................. 24 3.2 Healthcare ......................................................................................................................... 24

3.2.1 Method of health delivery ............................................................................................ 24 3.2.2 Health workforce ......................................................................................................... 25

3.3 Problems ........................................................................................................................... 26 3.3.1 Training issues ............................................................................................................ 26 3.3.2 Management of existing workers ................................................................................ 27 3.3.3 Retention issues .......................................................................................................... 28 3.3.4 Migration issues .......................................................................................................... 29

3.4 Solutions ............................................................................................................................ 29 3.4.1 Training solutions. ...................................................................................................... 29 3.4.2 Management of existing workers ................................................................................ 30 3.4.3 Retention solutions ..................................................................................................... 30 3.4.4 Migration solutions .................................................................................................... 31

3.5 Task shifting programme ............................................................................................... 31

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3.5.1 Community Health Extension Workers ...................................................................... 31 3.5.2 Progress so far ............................................................................................................. 32

3.6 Summary ......................................................................... Error! Bookmark not defined.

4. Conclusions & recommendations ......................................................... 33 4.1 Original brief .................................................................................................................... 33

5. Glossary of terms ........................................ Error! Bookmark not defined.

6. Bibliography ............................................................................................. 37

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1. Introduction

1.1 Global health crisis Health systems depend on the health workforce to act as the gateway to health. In 2006 the World Health Organisation determined that 2.3 physicians, nurses and midwives per 1000 people is the minimum density needed to sufficiently cover the population with essential health services. 57 priority countries were identified with critical shortages, misdistribution, low motivation and inconsistent performance of health worker (WHO 2006). The workforce crisis is arguably the greatest health system constraint on nations pursuing the 2015 Millennium Development Goals (MDGs). In light of this, the Global Health Workforce Alliance laid out the Kampala Declaration and Agenda for Global Action in 2008 outlining a plan for global, national and local action to remedy the situation. Despite encouraging progress such as the WHO Global Code of Practice on International Recruitment of Health Personnel and commitments from many nations, health workforce shortages continue to hinder a number of health systems from distributing vital services. As of 2010, none of the 57 countries with a human resources for health (HRH) crisis had reached the necessary health worker density ratio (WHO 2006). In tackling these myriad issues, the end goal appears a simple one. Implement sufficient numbers of health service providers, with the correct skills, in the right places, performing the correct tasks. One approach will not work for all, as an effective health plan must be matched to the disease profile of a country. Therefore it is not prescient to create a single blueprint, but an exploration of overarching strategies for when people enter the workforce, their time in the workforce and exit from the workforce.

1.2 HSS lens The recent international focus on health system strengthening has galvanised the impetus to provide health system reform to provide effective, equitable service delivery. One of the most effective methods of strengthening a health system is to ensure adequate supply, support and management of its workforce (Chen 2004).

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1.3 Justification for research Health system effectiveness is dependent on the health workforce. The WHO identified that a minimum worker density of 2.3 per 1000 population is required to delivery essential services consistently. This is doubly relevant today, as the WHO has also identified the health workforce as a key aspect of the current drive for global health system strengthening. Demographic and epidemiological transitions in the coming decades will push changes in population grounded health issues that may exacerbate the crisis. Demand for health providers will increase in all nations in the coming decades. The United Nations estimate the global population peaking around 2050 at 9.1 billion and then stabilise (UN 2012). The wealthier nations face aging populations and low fertility resulting in an accelerating shift in non-communicable diseases (NCDs) such as diabetes and heart disease requiring specialised and continual care demands (WHO 2006). Modern societys waning willingness to care for the elderly will increase basic care needs, resulting in a service gap that will exert pressure on the supply of workers from poorer nations (Spieza 2002). In poorer nations increasingly large numbers of swiftly urbanising youth will join ageing populations to inflict a double burden of infectious disease and emerging incidence of NCDs (Mathers 2006). This will all place stress on already strained and understaffed health systems, underlining the importance of strategies to combat this service gap. A continuum of care is required to deal with the double burden of disease in the 57 crisis countries identified. One of which is Nigeria. It has a disease profile of both developed and developing nations; the double burden of communicable and non-communicable diseases. Immunisation rates are below 70%; maternal mortality rates are approximately 1 in 10 and contraceptive prevalence of 13% (Odusanya 2008). The problems of the health workforce in Nigeria include low salaries; health worker deficits principally in rural areas, skill mix inequities with a curative bias, a negative working environment, the challenge of HIV/AIDS, significant worker migration and insufficient financing. As such, Nigeria can be considered a nation with many of the issues typically exhibited by the 57 countries with an HRH crisis and suitable for a case study, in the context of which to explore the use of task shifting to counter the crisis.

1.3 Methodology

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To identify global health workforce issues and trends this dissertation has made use of numerous sources. Grey literature such as WHO reports, government strategy documents and were utilised to gain a general picture of the current health workforce situation both nationally and internationally. These were mainly accessed online. To explore current theories for the training, management and retention of the health workforce this dissertation used academic research papers accessed through PubMed. PubMed was also utilised for accessing papers on the topics of migration patterns, task shifting examples across the world and task shifting systematic reviews. The above sources were used to identify a global issue; the factors involved and identify possible solutions. Through application of the possible strategies to Nigeria, an evaluation was possible on the effectiveness of task shifting there.

1.5 Chapter overview Chapter 1: Introduces the topic of the global health crisis. It sets the health system strengthening context and details the justification for research and research methodology. Chapter 2: Further explores the global health workforce crisis. It defines what a health worker is and expands on the health system strengthening context. It further investigates the causes of the crisis, the solutions and task shifting as a strategy. Chapter 3: The case study of Nigeria first examines the overall health workforce situation in the nation. It then expands on the method of healthcare delivery and the composition of the health workforce. It then details the problems and solutions using the three lenses of training, management and retention of workers. It evaluates the measures Nigeria has already put in place and then examines the existing use of the task shifting programme. Chapter 4: Drawing on information from both global examples and the Nigeria case study, conclusions and recommendations are given regarding the implementation of task shifting to help solve the health workforce crisis in both Nigeria and the wider global context.

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2. The global health workforce crisis

2.1 The global health workforce crisis This chapter firstly defines the global health workforce crisis before identifying the key causes and solutions. It argues that task shifting is a viable strategy that will have the most effective impact across many sectors using evidence from around the globe.

2.1.1 What is a health worker? When discussing a health workforce crisis, it is important to define who is considered a health worker. One widely used definition is all people engaged in the promotion, protection or improvement of the health of the population (Stillwell 2004). However this can even include family members looking after the ill, vulnerable and disabled. Unpaid caregivers and volunteers are not counted in the global system of health workers due to lack of data and the need to establish boundaries for the health system. Even so, demarcating paid health workers into categories is still a challenge as a classification system that examines the paid actions of the individual or the employer exclusively cannot discern between individuals who work to improve health employed by non-health entities such as a nurse working for a mining company nor those who work in a non health capacity for health entities such as a maintenance worker in a hospital. Therefore, it is important to split the health workforce into health service providers (HSPs) and health management and support workers (HMSWs). There is a conservatively estimated 59.2 million full time health workers globally. Two thirds consist of service providers such as doctors, nurses and midwives. The remaining third is made up of health management and support workers such as technicians, managers and pharmacists (WHO 2006). A truly accurate measure of the global worker pool is difficult because health workers who are employed by non-health entities are omitted in official counts as they are grouped with the industries they work in. An estimated 14-37% of all HSPs in nations with census data come under this category, resulting in an underestimated set of government figures.

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2.1.2 How widespread is the issue? 57 nations lie below this threshold density and are designated as having a critical shortage. 36 of the 57 are located in sub-Saharan Africa and for all these nations to reach target levels of health worker density would require an additional 2.4 million health workers (doctors, nurses and midwives) globally (WHO 2006). It is unclear if this figure is in line with projected population increase or hypothetical immediate expansion. Additionally, if this number of health workers were distributed in current urban/rural patterns there may be still areas of poor coverage. The average ratio of health workers to doctors, nurses and midwives is 1.8 in WHO regions. Multiplied by 2.4 million, the total figure of the health worker deficit may approach 4.3 million. The greatest numerical deficit is in South East Asia, mainly in India, Bangladesh and Indonesia. However, the largest relative deficit is in sub-Saharan Africa where an increase of almost 140% is required to meet the recommended levels of workers. These estimates serve to underscore the need for more human health resources to meet basic coverage levels for essential health services for countries in the greatest need. They cannot replace national sufficiency assessments and must not diminish other important determinants such as income levels, education and gender equality.

2.1.3 Why is this important? It is important to consider the significance of distribution of health workers and to what degree uneven distribution can be considered an issue. Perfectly equitable distribution is not practical and not necessarily appropriate. This raises the issue of health worker sufficiency. There is no absolute manner of assessing how many health workers are enough, but one possible avenue of exploration is essential health needs and their coverage. As a result of estimates of health worker density required to achieve Millennium Development Goals, human health resource deficits have been acknowledged within mainly low-income nations. The WHO health report 2005 projected that 334000 skilled birth attendants need to be trained globally by 2015 to meet 72% coverage of births (WHO 2005). The Joint Learning Initiative (JLI) indicated that generally nations with less than 2.5 health care workers per 1000 people fail to achieve 80% coverage rate for deliveries by skilled birth attendants. A cross country econometric study confirms an inverse correlation between health worker density and mortality outcomes (infant, under 5 and

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maternal mortality) (Anand and Barnighausen, 2004). The effect of health worker density in reducing maternal mortality is larger than reducing child mortality. This possibly due to qualified health workers being better able to address diseases that put mothers at risk.

2.1.4 Management of health workers. The number of health workers is only part of the picture. Where they work and on what financial basis are also significant. Most current data on the mix of global public and private sector workers is based on the primary establishment of employment of the worker. At face value this evidence indicates that the bulk of HSPs in least developed and developing nations are mainly located in the public sector. Over 70% of physicians and 50% of other HSPs appear to work in the public sector but there is evidence that many service providers work mainly in private practice despite being on the payroll in the public sector (WHO 2006). Many nations with principally public sector workers still operate on a private basis through out of pocket fees, moonlighting and prescription fraud. This inequitable distribution skews access to care towards the wealthier in society and out of pocket fees impact the poorest the most. Increasing the efficiency and transparency of health finance is one piece of the puzzle to combat the global workforce crisis. Paradoxically, nations with the highest burden of disease generally have the lowest number of workers. Conversely, while North & South America only shoulder 10% of the global disease burden, 37% of the worlds health workers live in this area and spend more than half of the worldwide fiscal funds for health. The African region has 24% of the global disease burden but only has 3% of health workers and less than 1% of financial resources, including aid grants and loans (WHO 2006). Even within nations there is inequity in health worker density. There are many different factors contributing to the geographical variation. One of the most common patterns involve areas in which teaching hospitals are located and high incomes generally attract health workers most as residents can afford to pay for their health. These attributes are often correlated with urban areas. As such, health worker density is generally higher in urban than rural areas. This trend will only worsen with increasing urbanisation across the globe if unchecked.

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2.2 What is causing this crisis? This section identifies the three key causes of the health workforce crisis. Training, management and retention issues; with a special focus on migration.

2.2.1 Training issues. Globally the numbers of health training institutions are skewed towards doctors and nurses. There are 1691 and 5492 respectively, whereas only 914 schools or pharmacy and only 375 schools of public health (WHO 2006) To be able to respond to shortages or surpluses requires accurate data, foresight and capacity to train different types of workers. The initial investment cost is high to bolster training institutions but is cheaper in the long term than depending on foreign graduates. The classical focus on inpatient and subspecialty acute care has shifted over time to archetypes of care espousing self management, community based care and pre-hospital public health care. (Tollman 1991) This change in thinking requires a shift in the manner of training to prepare health workers for a continuum of care (Kerber 2007). As a result of MDG projects, many in service training programmes have been instituted. The aim of most of these sessions is to prepare workers with skills needed to bestow essential disease specific services. While prepared in good faith, these sessions have severe opportunity costs. There is rarely backup staff to replace those who travel and the sessions rarely link with local training centres. This results in a lack of local training development for long-term use.

2.2.2 Management of health workers. The global profile of health indicates 59 million workers in a state of inequity (WHO 2006). Inequity between nations, geographical inequity within nations and inequity of access to care. There is a dearth of data but more information is needed. A lack of reliable, current data on skill mix, age location and income internationally restricts policy development for sustainable health systems to service disadvantaged populations.

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2.2.3 Retention issues In sub-Saharan Africa is the estimated yearly retirement rate is about 0.6-1% (Kinfu 2006). These rates seem low but when other workforce exit factors and the low supply of workers are taken into account they are more significant. As global demographics begin to grey (skew towards aged populations) retirement rates will increase. This data is no surprise and as such with enough foresight and information, yearly retirement rates can be planned for and policy decisions made accordingly. Employers and the government may offer incentives to retire earlier or later depending on projected labour supply & demand. Another consequence of MDG instituted programmes are salary demands. Well-financed initiatives from non-governmental organisations (NGOs) often pay much more than local wages in the public sector (WHO 2006). As a result, workers performing similar jobs with similar skill sets can be paid at different rates. For one, workers feel undervalued and are a more likely to work for MDG programmes than the public sector. Another effect is skewing of the skill mix toward the better paid positions such as HIV nurses rather than obstetrics. Health worker salaries are one of the key factors affecting the global workforce and factor in many of the issues faced. Remuneration for services can be split into three categories: the amount of pay, frequency of pay, method of pay and other incentives. Underpayment and a sense of unfairness stemming from less than living wages or comparatively less reduce efficiency and performance (Macq 2000). Many public sector workers in low income nations cope with unrealistically low salaries through informal payments, moonlighting (dual employment), non-attendance and migration to labour markets with better conditions. (Macq 2000) Solving these issues are vital to optimising the current health workforce. Simply raising salaries can be costly and convoluted. In many instances salary levels may be set by public service entities, In which case raising pay in one sector alone may have negative consequences in others. For skilled practitioners, the public sector may not be able to compete with private sector pay or overseas pay levels. In addition, many nations have public sector health workers with unpaid salaries. This can trigger absenteeism, moonlighting and overall loss of care coverage (Van Lerberghe et al. 2002). Approaching the global health workforce crisis at the exit point of workers is a strategy that must be considered. Workforce attrition rates increasing lead

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to higher provider costs and in turn less health workers available to provide service coverage. The working lifespan of a typical health worker has morphed over the years due to variations in working configurations, ageing, morbidity & mortality rates and increasing globalisation leading to more migration. A review found that nursing in sub-Saharan Africa was impacted negatively by migration and that the problem is only going to grow over the next 5-10 years (Dovlo 2007). Costs associated with retention problems are indicated as significant financially (Zurn 2005) as well as possible negative effects on quality of care due to disruption of infrastructure, efficiency and loss of experience. Workplace turnover of staff can have positive effects such as providing a chance to match skills to needs efficiently and increase team flexibility (Buchan 2000).

2.2.4 Migration issues Physicians and nurses & midwives trained in sub-Saharan Africa working in OECD nations denote 23% and 5% of current health workforce in the home nations (WHO 2006). The OECD data obscures the precise variation and reasons for migration. Generally, migration occurs from rural to urban areas with nations or from low income to high income nations internationally. Both push and pull factors are significant reasons for migration. Push factors include lack of promotion, poor pay, lack of infrastructure and high levels of violence. Pull factors include better pay, scope for career advancement and a more promising family future. This is all exacerbated by the high demand for health workers caused ageing populations and the actions of recruitment agencies. The impact of health worker migration is mixed. Remittances generate large amounts of income for low-income nations (World Bank 2005) but when substantial numbers of health workers trained at the cost of source nations leave to work in high-income countries, the source nations lose on their investment and provide a paradoxical benefit to the destination country (Mensah 2005).

2.3 Solutions Addressing the worker deficits in sub-Saharan Africa requires a combination of expanding supply through training more workers and diminishing attrition by implementing retention strategies. International cooperation is

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required to remedy excessive worker migration as it is intertwined with the global labour markets. Addressing the crisis will require substantial financial commitments. To fund the required increase in health workers at 2004 prices is $311 million per nation, or by 2015 the salaries of the newly expanded workforce will require a raise of $7.50 per person per year (Verboom 2005). This figure can be interpreted as a minimum cost because additional costs will be necessary to retain the new health workers in the health sector and in the nation. This gap is difficult to estimate, as salaries in deficit nations can be 15 times lower than the most popular migratory destinations for health employment. However, these figures assume current skill mixes and do not take into account the evolving international labour market as globalisation increases and barriers to work fall. This indicates a strong need for international cooperation in addressing the global workforce crisis, in addition to comprehensive cross-sector coordination. The global deficit in human resources requires a concerted and accelerated expansion of the workforce. This requires three main factors: political will, funding and a comprehensive plan that covers both the short and long term. Perhaps as a result of short election cycles and the global financial crisis, public spending on health in recent years has dipped globally. Health investment must be viewed as a long-term benefit rather than a short term cost to be minimised. Funding should cover HSPs and support workers to ensure a cohesively strengthened health system. A combination of short and long term planning would involve meeting current deficits for priority programmes quickly, in addition to galvanising the training centres involved in the production of the workforce.

2.3.1 Training solutions. A controversial development in the issue of the global health workforce crisis is the prolific expansion of private training centres of medical professionals. This reflects a wider trend of increasing proportion of private delivery of vocational education. Between 1980 and 2005 in the WHO Eastern Mediterranean region private training centres increased from 10% to make up almost 60% of all health institutions (WHO 2006). In South America between 1992 and 2000 there was a 60% increase in the number of medical schools. Some are public funded and some require fees from students. Much of the controversy stems from the health workforce diversity issue. Entrance to most programs requires a secondary level education but the nations with low incomes and high educational drop out rates limit the possible candidates

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who can apply to the health workforce. This also reflects a trend in inadequate funding of education in many nations (WHO 2006). As such, this distorts the profile of workers toward the higher social classes in societies and dominant ethnic groups, rarely reflecting the socio-demographic mix of the nation. Additionally, this could cause clustering of lower socio-economic means in less costly training programmes or find career choices limited by student debt. (Pechura 2001) This trend is also true to some extent in wealthier nations too. As such, this context suggests that improved funding of primary and secondary education is key to increasing the supply of health workers. There are no guidelines currently on the recommended amount of investment in the health workforce but as referred to earlier in section 2.2.1, significant funding increases will be needed in nations with human resources for health crises. Redirecting funds spent on in-service training to pre-service training would be both beneficial and much longer lasting. Pre service training programmes often have lower costs for trainers, allow students to gain core competencies to combine with their future practices and avoid diverting personnel time for training days (Naimoli 2006). It is unfeasible for all nations, especially smaller low-income nations to implement comprehensive training programmes. Regionalisation of training health professionals is a possible avenue of international cooperation for mutual benefit. One successful example is the University of the South Pacific. The USP is jointly owned by governments of 12 nations (WHO 2004) and has campuses in all 12 member countries. It utilises comprehensive distance learning programmes and technological innovations to enable effective learning without needing expensive centralised institutions. Recruitment of health workers is a vital area of investigation in the context of the global workforce crisis. The number of recruited workers should represent the disease profile demands, the extent of underemployment and attrition from the workforce. Competencies of the staff should again reflect the disease profile and their background must be compatible with sociocultural profiles of the population to ensure good communication. Labour markets often determine recruitment patterns. Labour supply reflects the outcome of the education system, whereas labour demand is linked to the demand for health services. Market balance is achieved when labour demand is concomitant to the supply, or the outcomes of the health education system can match the demand for health services. However, this does not take into account urban-over supply or inequity of access for parts of the population. Standardised public sector wages limit the ability of the public sector to hire and compete with the private sector employers and non-governmental

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organisations. These pay and condition differences also drive migration rates, causing severe attrition of the workforce in nations where health workers are at a premium (WHO 2006).

2.3.2 Management of existing workers. Given the massive financial costs of meeting the global deficit of health workers at current skill mix densities and efficiencies, it is imperative to optimise the current workforce performance. To improve a workforce, one must define what a parameters a well performing workforce can be judged on and what determines these parameters. An effective workforce must be available to the populace. It needs to be well distributed, with high attendance of workers. Possible indicators to measure this are staff ratios, absence rates and waiting times for patients. The workers must be competent in their skills, knowledge and behaviours matched to the disease profile of their locality. Possible indicators are readmission rates, mortality rates and cross infections. Responsiveness requires the workers to be equitable to all, regardless of who they are and finally health workers must provide the maximum service and outcomes possible with the resources available to them. These two attributes may be measured through patient satisfaction and rates of occupied beds, out patient visits and interventions delivered per worker. (Pongsupap 2006) Measuring performance in itself is a controversial issue, due to its difficulty, possible effects on the workforce and the tendency for employers to manipulate data (Pangu 2000). No single factor affecting performance can be identified, rather a multitude of factors affecting overall health workforce performance. Consequently, major improvements in workforce effectiveness usually stem from a group of linked initiatives rather than single ones. Job related conditions such as clear job descriptions are supported by research in improving achievement of work goals (Dolea 2004). One example of this is in Indonesia where a Clinical Performance Development Management System was developed that clearly identified responsibilities and accountability. Staff reported greater confidence and job satisfaction (Dolea C, 2004) Inefficient use of the worker skill mix can be remedied through matching tasks to skillsets. This may be due to management tasks being carried out by skilled personnel due to lack of other staff or untrained staff executing skilled procedures resulting in unsafe practice. In Ghana the workplace practice of supervision and feedback has strong evidence correlating improved performance outcomes, across the staff spectrum (Dovlo, 1998). It is difficult to put into practice and becomes ever

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more important in busy and resource poor environments, especially in the context of task shifting and redistribution of care. Supervision should be supportive, educational and consistent with the emphasis placed on competency rather than obedience. Given the strong MDG imperatives there was a trend of planning vertical interventions focusing on specific diseases. This manner of planning runs the risk of neglecting the wider basis of the holistic nature of human resources and health service delivery. However, removing existing clinical pathways established in this manner would be inefficient and wasteful. Piggybacking is a term used to describe the method of attaching additional services to previously single-purpose delivery pathways. One example of this is the usage of the community program to prevent river blindness in West Africa to deliver vitamin A supplementation. (Dreesch, 2005)

2.3.3 Retention solutions. Method of payment can influence performance and retention greatly. Fixed budgets can lead to health providers minimising the number of patients seen and service coverage. Performance based incentives can provide incentives to ensure care coverage is maximal but can also encourage redundant and wasteful treatment options (Wouters 1998). Most low-income nations pay health workers with fixed salaries and sometimes allowances unrelated to performance. There are theories espousing the implementation of performance based pay in these nations but measuring the performance of health workers comes with increased administrative costs and complexity, perhaps excluding their use in these resource-poor environments. However, the use of allowances to bolster salaries to increase job palatability is prolific in most nations. Examples include health insurance, access to loans, additional payments while training and financial incentives for working in remote areas (WHO 2006). The effectiveness of these measures depends on design and the other conditions of employment. Mali also very quickly and effectively increased rural coverage and retention in 1986 through a strategy to incentive graduates to work in underserved areas. The ministry instituted a system wherein both public and private sector workers would have different payment methods but the same non-financial benefits. They receive training, accommodation, equipment and transport. By 2004, 80 doctors from Malis total of 529 had signed up. In 2001 a study indicated that the program had increased service coverage in rural facilities (Desplats 2004). Thailand also instituted payment reforms in the 1990s to improve rural coverage. They involved supplements to salary, non-

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private practice compensation and overtime payments. These were combined with non financial incentives as in Mali with a result of improved rural coverage (Nityarumphong 2000). Unpaid salaries present a problem in many HRH nations and can severely impact worker retention as discussed in section 2.23. Financing any initiatives is always an issue in resource poor health systems, especially if they cannot pay their health workers regularly as it is. In Chad, donor funds have been effectively used to strengthen health systems by guaranteeing regular salaries for health workers who previously had experienced severe delays (Zachariah 2001). As referred to in section 2.2.3, a professional working environment is a key factor in worker satisfaction. To impress upon workers the importance of adhering to standards and maintaining a professional work environment the Ugandan government implemented an award system known as the Yellow Star Programme. Health facilities that comply with 35 indicators thought to be representative of effective management receive a plaque, official recognition and publicity. These efforts have engendered better harmonisation between health facilities, administrators and political leaders (Egger 2005). This is another example of non-financial incentives improving performance and bestowing secondary benefits such as improved communication channels. However, this requires a cohesive regulatory and oversight presence of the medical governing body. One issue faced by health workers in low-income countries are lack of infrastructure and supplies. There is scant evidence for performance benefits from improving basic infrastructure but examples such as Kyrgyzstan can demonstrate the risks of insufficiency, especially when increasing health system capacity. Reforms in 1997 changed the budgeting system. Instead of passive fund allocation depending on simple bed and staff numbers, active strategic purchasing depending on demand for service was implemented. However, the reforms required new forms of management and quality control. The message from this is that it is important to be aware of the peripheral infrastructure aside from the main health system delivery service as the whole is essential (Jakab 2004). Many of the costs faced by HRH countries are limited by the rules of public financing. To ensure macroeconomic stability and fiscal endurance international fiscal entities use criteria such as public expenditure to GDP ratio to set debt ceilings and credit ratings. The major relevant consequence of this is the limit on recruitment and non-inflation matched salaries of workers, resulting in a much weaker health system and poor worker

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satisfaction leading to attrition. An international consensus is required to find a way around these regulations, perhaps to make health service the exception to the rule (MOH 2005).

2.3.4 Migration solutions Some measures source countries can consider include instituting training methods that are focused on local conditions such as local languages and skills matched to the disease profile. These measures have evidence of efficacy as indicated by Wibulpolprasert (2001) in reducing migration but can bestow credentials that are not internationally recognised. This is an ethical quandary that rides on the balance between individual health worker rights to an internationally recognised qualification and the needs of the host nation. Some nations such as the Philippines and Cuba pursue health worker export strategies (Choy 2004). As previously mentioned in section 2.2.2, improvements in the conditions in source nations can help stem migration (Denham 2004). Non-financial incentives must be considered carefully before implementation. In Ghana a duty hour allowance allocated to both doctors and nurses was condemned by nurses for perceived or real inequities in benefit. This is thought to have actually increased net nurse migration from the country (Buchan 2004).

2.4 Task Shifting This section will explore task shifting as a concept first. It will then explore the history of its implementation and finish with a discussion of the benefits and drawbacks of the strategy with examples from around the globe relevant to the threes areas of training, management and retention.

2.4.1 What is task shifting? Simplification and delegation of services is another method of improving existing health coverage or when scaling up service. Simplification through reducing task complexity and allowing it to be carried out by less skilled workers can allow more to be achieved with increased reliability. Using technological innovation and strategic planning to reduce task complexity can help consider all available human health resources as executors of health initiatives both inside and outside the health sector. Examples of this include

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the scaling up of oral rehydration therapy in Bangladesh (Chowdry 1997) and the WHO/UNAIDS 3 by 5 initiative (WHO 2003) where patients with HIV/AIDS can make significant contributions to prevention and treatment. There was a decline in interest for CHW programs in the 1980s due to problems such as unrealistic expectations, poor planning and sustainability issues (WHO 1996). Recently, CHW programs have returned globally to address shortages in health workers, especially for HIV/AIDS care. Task delegation, or task shifting is the principle of ensuring tasks that can be carried out as or more effectively by less senior members of staff, are carried out by the lowest safe and effective skill level (WHO 2007). This is especially vital in low resource environments where skilled staffs are at a premium. One example of this is the delegation of malaria diagnosis to volunteer health workers in the Philippines (Bell 2001). Preliminary results show the strategy was reliable, improved outcomes and even raised morale of workers. However, simplification and delegation require careful forethought to ensure the impact is positive and safe. One failed example is the training of thousands of traditional birth attendants (TBAs) in the 1980s to improve maternal mortality rates but there is still no evidence that the initiative has been effective (Sibley 2004). However, the risk-assessed combination of simplification, focusing on patient self-management and community participation can enable tasks in many settings to shift from limited skilled workers to less skilled and more common workers or even the patients themselves. Auxiliary health workers are often known by a number of titles such as health volunteers, community health workers, physicians aides and many more. All auxiliary workers have one attribute in common. They are involved in helping provide health coverage where it is impractical, unfeasible or too costly to provide access with traditional health workers such as doctors or nurses. They carry out many services similar to doctors and nurses such as proving prophylactic medical services such as vaccination, monitoring public health and providing basic curative skills. Auxiliary health workers often provide a link in primary health care between clinical and community care. They can be from the locality in question and be familiar with socio-cultural and language nuances. Progress towards the MDG 4 is slow in sub-Saharan Africa. Approximately 60% of under 5 deaths could be prevented by existing interventions (Jones et al., 2003). With regard to infant mortality, 41-72% of neonatal death can also be prevented with available interventions with high service coverage; with a possible half of those reductions conceivable through community based services (Darmstadt et al., 2005).

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2.4.2 Benefits The key question when it comes to task shifting is whether the alternative cadres of health workers can deliver services comparable to conventional staff. A systematic review of nurse led primary care shows that care assistants achieve health outcomes equal to those of general practitioners with good patient satisfaction (Royal 2006) and comparing nurse led with usual doctor led care outcomes for diabetic patients showed improved glycaemic control, lower mortality and fewer complications. In Kampala, Uganda, a community based antiretroviral therapy program using peer health workers and nurses resulted in good AIDS care and virologic outcomes (Abaasa 2008) equal to or better than care received in hospitals from conventional staff. In free state province, South Africa, the availability of treatment buddies, CHWs and support groups were the most important predictor of treatment success in the first 2 years of treatment (Schneider 2008) suggesting that continuity and access to primary healthcare is the deciding factor in adherence rather than seniority of staff. Lay health workers achieved better outcomes for patients and provided a considerable cost saving compared with clinic based care. Trained CHWs could improve the treatment success rate among TB patients in a health service despite reduction in the range of services available (Clarke 2005). In the Mozambique HAART program, outcomes were similar for doctors and lay workers. Based on pharmacy records patients were more likely to make a quarterly visit if managed by a MLW. Proximity of lay workers to population serves to increase access to healthcare. There were no significant differences in outcome when compared to medical specialists. Surgery by mid level health workers in Mozambique provided the same outcome as doctors whose training cost ten times as much, indicating a strong fiscally positive basis for auxiliary health workers. Junior doctors require more senior medical support for longer periods when sent to rural areas than MLWs (Callaghan 2010). Chung demonstrates that 942 hours of nurse time freed up 737 of physician time which could then be expended on more complex cases in non-HIV fields, increasing the health system capacity. A pilot program in Rwanda transferred several tasks from physicians to nurses trained in HIV management while physicians took on more supervisory and mentoring roles. Improvement in CD4 count, correct prescriptions patient monitoring and overall survival were similar between

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the two groups (Shumbusho 2009). One of the major health indices referred to in section 3.3.2 was infant and under 5 mortality. In Malawi clinical officers conducted 93% of major obstetric operations in government hospitals with no significant differences in post op outcome, wellbeing or neonatal mortality when compared with medical officers (Chilopora 2007). If this is representative of the wider global context, the effects of utilizing task shifting to fill gaps in service coverage could be very positive for specific tasks. A systematic review of 82 randomised controlled trials on the effectiveness of lay health workers in a variety of setting showed that they provide benefits in promoting immunisation, breastfeeding practice, improving TB outcomes and in reducing child morbidity and mortality when compared to usual care (Lewin 2006). In addition to providing a comparable level of care, task shifted workers are more likely to remain in service in comparison to doctors. 7 years after graduation of tecnicos de cirugia in Mozambique, more than 80% were still working in district hospitals (Brown 2011) whereas nearly all-medical doctors posted had left within 3 years.

2.4.3 Drawbacks Another review of 6 large-scale community based worker programs suggest they have succeeded in some objectives but not all. CHWs increase service delivery and equity of access at low costs compared with traditional structures but they do not always provide services likely to have significant impact (Berman et al., 1987). In addition, quality is not always consistent. Conclusions were drawn that many CHW programs have not reached their potential, with further development needed to assure their successes continue and are properly supported. In the pacific region low pay was associated with difficulties in retention. Poor supervision and lack of training opportunities appeared responsible for attrition of the cadre (WHO 2004). However, this may be an issue of implementation rather than principle. One important factor to remember is that task shifting alone may not have as a great an impact on population health, as addressing social determinants of health is essential and often ignored due to the projected return from investment being relatively long term.

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Issues surrounding low utilization do exist. A study in Burkina Faso emphasized the importance severity of disease and perceived effectiveness of treatment were the most significant factors of health seeking behavior. For mild diseases villagers sought their CHW in 8.8% of cases with villagers bypassing the CHWs 96.5% of the time with more serious illnesses (Sauerborn et al., 1989). This may not be representative of an inherent problem with CHWs, but emphasizes the need to pursue an integrated plan of public health education of how to utilize services.

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3. Case Study: Nigeria In section 3, this dissertation will use the key benchmarks and strategies identified in section 2 to assess the effectiveness of Nigerias HRH strategy. In addition, Nigerias suitability for task shifting will be examined.

3.1 Nigeria overall situation Nigeria is one of the WHOs 57 human health resource crisis nations. It is comprised of 36 states and a Federal Capital Territory (FCT). These areas arranged into 6 constitutionally recognised geopolitical regions (North Central, North East, North West, South East, South, and South West).

3.2 Healthcare Advances in essential health indicators have been gradual and Nigeria still ranks as a nation with one of the highest child and maternal mortality rates. In 2004 the under 5 mortality rate was 201 per 1000 live births (DHS 2004) and the maternal mortality ratio was approximated at 800 per 100,000 live births (Ujah 2005). Nigeria is particularly relevant as a case study to explore the global workforce crisis as it exemplifies some of the symptoms of inequity of access to healthcare among various population groups. The health sector is typified by regional inequities in health indicators, health coverage and financing.

3.2.1 Method of health delivery Health care in Nigeria is provided by a combination of public and private sector entities. Public capabilities are governed by the three tiers of government: federal, state and local. There are also private for profit organisations, non-governmental organisations (NGOs), community based organisations and traditional care providers (WHO 2002). Primary level healthcare facilities are the gateway to the health system for the populace. These provide general preventative, curative and referral services and are staffed by nurses and community health workers. These facilities are managed by the local level of government. Further up the health system

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hierarchy, secondary facilities such as general hospitals provide medical services and more specialised care. In addition to these public providers, there is a mostly unregulated private sector delivery primary and secondary care too. Finally, the tertiary level centres are the most specialised providers available. They accept referrals from lower in the system hierarchy. Primary healthcare (PHC) coverage can be a good indicator of the state of the health workforce. The Nigerian government attempted to institute PHC reform with the National Health Policy of 1988 but it failed to implement a comprehensive finance, staffing or care overhaul (Alubo 2001). The policy was revised in 2004 and despite PHC being a designated priority, in action the focus was overly on curative care. Consequently, preventative care was neglected and coverage suffered. This can be inferred from the low immunisation levels for measles, mumps and rubella (Schimmer 2006) of less than 70%. A study exploring factors involved in low utilisation of the PHC system in Nigeria gathered data from 360 mothers of children under 5. The main factors causing a lack of attendance included high out of pocket costs, easy access to traditional healers and transport issues (Katung, 2001). Progress towards MDG 6A is promising but too slow to meet the 2015 target. The prevalence of HIV/AIDS dropped from 5.8% in 2001 to 4% in 2008 and the population access to antiretroviral medication increased to 34.4%. However, the distribution in wealth quintiles is highly inequitable as only the wealthy can afford them and certain states have high prevalence rates (Uzochukwu 2009).

3.2.2 Health workforce In 2007, there were 52,408 doctors and 128918 nurses working in Nigeria (Awofeso 2010), working out at about 35 doctors and 86 nurses per 100,000 population. Compared to the sub-Saharan African average of 15 doctors and 72 nurses per 100,000 population (WHO 2006), Nigeria appears to be performing better than average. However despite containing the largest stockpile of health workers in Africa, it has an average health worker density too low to capably delivery health services (1.95 workers per 1000 population). Compounding the issue, the majority of the workforce is located in urban areas, especially concentrated in the major city of Lagos (DHS 2004). The majority of state health authorities do not have cohesive health workforce plans as staff management resides with the civil service and hospital boards. Consequently, many training centres over or under produce categories of

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health worker for their particular state. Despite other states suffering severe shortages of workers, there is no easy method of matching workers to vacancies.

3.3 Problems

3.3.1 Training issues An encouraging sign of health system vitality is the net supply of graduates to the workforce. The net increase of doctors to the workforce is 16.5%. Compared to the attrition rate of 2.34%, this suggests that the gaps in service coverage are caused more from distribution issues than retention (Dovlo 2005). However, the figures are not as positive for nurses and midwives, laboratory staff, pharmacists and community health extension workers (CHEWs) as demonstrated in figure 2. Again, averages obscure the urban/rural disparity. Rural attrition rates are much higher, either to urban areas or outside of the country (Dovlo 2005). Another significant issue to consider is health workers at primary healthcare level have much higher attrition rates than secondary or tertiary level. Fig. 2

As detailed in section 2.2.1, the location of training of health workers is important. In Nigeria, training is primarily located in the southern parts of the nation with very few in the north. To ensure high standards of care, the nursing and midwifery institutions have limited entry of students to only 50 per year. Despite a critical shortage in workers, there is a lack of intern posts and residencies for physicians.

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There are no public health training institutions in Nigeria. This creates a significant drawback to the national professional workforce and an insufficient capacity to lead public health programmes and systems.

3.3.2 Management of existing workers Fig. 3 Source: NDHS report 2003

Figure 3 emphasises the inequity of staff availability in different areas. Any strategies implemented to ensure increased supply of health workers would have to be mindful of the needs of the deprived areas. National data obscures some information about the different levels of health worker types as doctors and dentists are grouped together, as are nurses and midwives. Not shown in figure 3 are the very low levels of other aspects of the health team such as radiographers. Encouragingly, the ward minimum service package (Osungbade 2008) entails a mandatory minimum laboratory technician per primary health centre but there are no records available on said numbers. The significance of the health worker density inequity between states is apparent with the strong correlation exhibited between low doctor density and the under 5 mortality rates as shown in figure 4. The North East and North West areas have the worst under 5 mortality rates, as well as the lowest doctor density per 100,000. A cross nation econometric study confirms this association, indicating an inverse correlation between health worker density and mortality rates (Anand and Barnighausen, 2004).

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Fig. 4

If the high neonatal mortality rates are to be addressed, the skill mix in most areas need to be rectified. In 2006, it was found that on average there is only one doctor for every 4 PHCs, and only 3 nurses/midwives per PHC (Uneke 2008). As with most of the averaged data collected, it obscures rural disparities. In some of the more rural states it is unusual to even find midwives in PHCs. The under 5 mortality rate in rural areas is as high as 243 per 1000 live births compared to the urban rate of 153 per 1000 live births (ref DHS 2004). The impetus for human resource development should be improved planning and management at both a national and local level for even production, the right staff skill mix and equitable distribution.

3.3.3 Retention issues As referred to in section 2.3.2 the remuneration of staff is a vital factor in retaining and attracting workers. Despite a National Health Service plan, the salaries vary between each state. As a result, health workers tend to be concentrated in federal facilities over government and state payrolls. These inequities are especially apparent for nurses and midwives (Uneke 2008). Exacerbated by salary issues, Nigeria reflects the trend of health workers choosing to work for private providers where they can earn more. This happens to be concentrated in urban centres where patients can afford treatment (Uneke 2008). This causes distinct inequity of access to health workers for those residing in deprived and rural zones. Figure 5 illustrates the distribution of registered Nigerian physicians. Most doctors operate in the private sector. Irrespective of sector, this is an indication of the need for

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cooperation and coordination between the public and private sector to regulate the equitable delivery of service coverage. Fig. 5

3.3.4 Migration issues Nigeria is one of the main staff exporting nations in Africa. Figure 5 emphasises the significant number of Nigerian health workers working abroad. 12% of physicians who qualify in Nigeria are working in OECD (WHO 2006) nations. The cost per doctor to the Nigerian government is US$184,000 (Lal 2007).

3.4 Solutions What path should the government take? The role of the government is to provide policy, arrange financing and manage training. In addition, it must balance the performance of the public sector while ensuring the private sector is not impacting negatively on overall service coverage and equity. This section details possible avenues of action.

3.4.1 Training solutions. The Nigerian government is focusing on capacity building as part of their National Human Resources for Health Strategic Plan (NHRHSP). It will involve training and retraining of primary health care workers. It will also implement compulsory professional development for health workers and

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integrate prevailing health care trends with the curricula. This strategy hinges upon adequate funding being earmarked for human resource planning and initiatives and that all relevant stakeholders continue to prioritise integrated human resources issues.

3.4.2 Management of existing workers To address the rural/urban distribution inequities incentives are provided to workers who choose to reside in rural areas. Some states make rural service compulsory or a requirement for promotions. Recent legislation also requires nurses and midwives to perform one year of national service to ensure their services are available in rural areas. In addition to this, the Nigerian government has initiated a plan to utilise retired midwives and nurses of working age in rural areas. Further efforts as part of the NHRHSP to motivate and retain health workers include a special salary scale and preferential entry points in the public sector. However, these plans depend on all relevant parties agreeing to institutionalise performance management culture at all levels of service provision. Furthermore, involved parties must commit to continuous professional development plans of health workers.

3.4.3 Retention solutions As referred to in section 2.3.3, working conditions are an important variable in health worker retention. Upon investigation, nursing staff in some tertiary hospitals were heavily overworked while others in general hospitals were severely underworked. Both parties reported poor job satisfaction, suggesting the use of workloads to determine levels of staff distribution would be beneficial to maximising efficiency and use of available staff (McCoy 2008). However, the current system of three tier constitutional ownership leads to inflexibility in establishing continuity. To retain health professionals in difficult zones a number of initiatives have been implemented. The Nursing and Midwifery councils one year mandatory midwifery service will help alleviate rural/urban disparities. In addition, there will be an allocated hardship and deprived area allowance for some rural postings. To help build health system capacity in rural areas, a loan scheme is being instituted to encourage the launch of facilities in rural zones.

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Many of the measures designed to retain workers are too focused on financial imperatives instead of effective leadership, supervision and other non-fiscal incentives as referred to in section 2.3.2.

3.4.4 Migration solutions Data on Nigerian doctors emigrating is unreliable as many destination wealthy countries do not allow foreign trained doctors to migrate based on purely their medical skills Nonetheless, hundreds of Nigerian health workers emigrate annually (Awofeso 2008). In 1966 there were 215 Nigerian doctors practicing in the UK. They made up 1.5% of all overseas doctors. This figure grew to 1922 in 2003 and represented 3% of all foreign doctors (GMC 2004). Awofeso (2008) argues that the migration of health workers is not the critical factor in the health workforce crisis in Nigeria, rather the deterioration of the government spending and a lack of a rural and remote health strategy. As such, this dissertation acknowledges migration as an issue that must be addressed but cannot be done unilaterally through the Nigerian government.

3.5 Task shifting programme This section is explore Nigerias current task shifting programme: Community Health Extension Workers, their progress so far and their effectiveness.

3.5.1 Community Health Extension Workers A possible solution to the difficulty in hiring and retaining health workers in rural areas has spurred the increased use of auxiliary health workers or Community Health Extension Workers (CHEWs) in the delivery of primary care for undiagnosed patients with general health problems. A preliminary study done in Nigeria with CHEWs in a private rural health care facility displayed promising results (Ordinioha and Onyenaporo, 2010). CHEWs were chosen through support from their schools and implemented anonymously with clear job descriptions a factor identified as important for worker satisfaction in section 2.3.2. A total of 1028 patients were seen over a 6-month period with the majority of the patients (86.5%) happy with the quality of care delivered. It must be noted that these CHEWs were employed under the supervision of physicians and that the facility was private. Nonetheless, the study supports the contention that auxiliary healthcare workers can positively impact the delivery of primary healthcare, provided there is supervision.

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3.5.2 Progress so far The inhospitable terrain of the Niger delta area of Nigeria makes the delivery of essential services in rural communities a real challenge. A descriptive cross-sectional study by Ordinioha (2010) assessed the provision of primary care in a rural health facility. The results indicated that community health extension workers could provide a good quality of care with good levels of patient satisfaction. This is concurrent with much of the other research globally but against the tide of opinion in Nigeria. However, assessing the representative current performance of CHEWs in Nigeria with regard to increasing equity is difficult due to lack of data. A study examining the inequities involved in using CHEWs to treat malaria found that CHEWs improved overall geographic but not socioeconomic equity of medication (Onwujekwe et al., 2007). This suggests that the CHEWs have been successful in increasing equity in rural regions as hoped but the financial aspect of care must be assessed further to ensure equality.

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4. Conclusions

4.1 Original brief This dissertation examined the factors involved in the global health workforce crisis, explored the possible strategy solutions and evaluated the use of task shifting as a possible method to help address the growing gap between health worker supply and demand. It focussed on Nigeria as a case study to examine one of the 57 human health resource crisis nations and applied key strategies identified through examining examples of good and bad practice of task shift implementation around the globe.

4.2 Overall findings The current global focus on health system strengthening has shed a spotlight on the health workforce. The health workforce crisis can be considered a key obstacle to achieving essential service coverage. The majority of evidence suggests that task shifted workers with the correct funding; support and supervision can provide a consistent, safe and good quality of care to the satisfaction of patients for undifferentiated primary health care. This increases the supply of health workers, increases equity of coverage and is more cost effective than simply training more conventional cadres of worker. Nigeria is one of the WHOs 57 human health resource crisis nations and has a severe health worker shortage problem clearly visible in the inverse correlation between under five mortality rates and health worker density in figure 4 in section 3.3.2. It also suffers from urban rural disparity and health workers preferring to work in higher paying jobs. Reasonable equity of distribution of care is important as low health worker density (below 2.5 per 1000) fails to achieve sufficient service coverage. The three main spheres of interest in ensuring there are enough health workers are their training, management and retention. The key message gained from the theories explored regarding training is that cooperation is key. Resource poor nations cannot afford to run a high standard of training for every cadre of worker needed in the health service. The example of regionalisation to implemented by the University of the South Pacific referred to in section 2.31. is prime for initiatives around the world. However, post graduation equitable distribution would have to be legislated to ensure all partners benefit from the arrangement.

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Most initiatives often cost money. To raise funds, the example of Chad explored in section 2.3.3. Can be applied to almost any other resource poor nation with access to MDG donor funds. Rerouting funds to support health system delivery by paying worker salaries can be effective in regaining service coverage. However, case studies from Mali, Uganda and Kyrgyzstan discussed in section 2.3.3. also emphasise the point that non financial incentives can be as effective, if not more effective than conventional financial incentives in inspiring improved worker performance. By improving the working environment as discussed in section 2.3.2 using grouped interventions, overall service delivery can be improved and health workers can be retained in rural areas. Caution is advised before using any strategy as with the example of Ghana in section 2.3.4 wherein a positive change had unintended consequences resulting in more net migration out of the country. To remedy the private practice inequity of access issue, perhaps Nigeria could follow the examples of Thailand implement payment reforms to ensure that regardless of public or private sector, workers would have the same onus to work in rural and deprived areas. Migration is an important issue in regards to the human health resource crisis as the brain drain from low income to high-income nations paradoxically mirror the inverse burdens of disease resulting in severely inequitable global distribution. International cooperation is vital to rectify this situation, perhaps with stricter regulations on the ethics of wealthy host countries recruiting from nations with staff shortages. However, this multilateral action is outside the remit of this dissertation, which is concentrating on Nigeria, and the use of task shifting. As explored in section 2.4.1, task shifting as an idea has been around since the 1980s but suffered from poor implementation. The context of the present health workforce crisis has reaffirmed the importance of the task shifting strategy. Task shifting is a method of dealing with critical worker shortages as it impacts on all three lenses of inquiry explored in section 2. Training is cheap, cost effective and an investment for the future as community workers do not migrate anywhere near as much as doctors and nurses. The management of workers is still a challenge as previous efforts have failed due to lack of supervision and funding. However, utilising the techniques explored in section 2.3.3 to ensure correct supervision, community health workers can be an effective cadre of the health workforce in Nigeria, and globally.

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It is always vital to remember that task shifting is simply a strategy to optimise health worker distribution, it is important not to lose sight of the social determinants of health, which can have a much needed vital effect on global health. As detailed in 3.5.2, task shifted workers are very effective at addressing geographic inequity of care but cannot remedy financial barriers to healthcare. As detailed in section 2.4.2, the benefits of task shifting far outweigh the drawbacks. Studies examining the effectiveness of task shifted workers in Mozambique, Uganda and Malawi to name a few all confirm the comparable if not better ability of task shifted workers to delivery a cheaper, consistent and effective level of care comparable to conventional cadres of workers. The Burkina Faso study quoted in section 2.4.3 does stress the importance of not only the implementation of task shifted workers, but the peripheral education along with it. CHEWs in Nigeria appear to have made a positive impact as detailed in section 3.5.2 but more monitoring is required to confirm, in wider areas as data is still very scarce. However, with promising results from global implementation of task shifted workers, it is safe to say that Nigeria can also benefit from an expanded task shifted worker program.

4.3 Difficulties conducting research Conducting the research had some shortfalls. There was a distinct lack of data about health workforce migration patterns from low-income nations to high, as general migration data did not specify. Also, when researching the implementation of health workers in rural areas data was comprehensively scarce. However, this may reflect the lack of infrastructure and health support systems that represent the gaps in service coverage that the task shifted workers are aiming to help rectify. Many of the government proposals and strategy documents detailing the national human health resource plan were distinctly lacking in accountability and monitoring frameworks. They often dealt with good ideas and long-term goals but did not express continuity from previous initiatives or monitor progress towards past targets in a sufficient level of detail.

4.4 Recommendations for future research Perhaps future research could utilise raw health workforce data figures direct from the government. Ideally a support infrastructure in the age of connectivity would enable real time readout of health worker distribution.

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Many of the issues causing gaps in service coverage stemmed from not only a lack of supply of health workers, but also a lack of coordination in sync with the health needs of the nation. The reasons behind this are unclear and complex but perhaps a system that compensated workers for employment in less desirable posts commensurate to their possible earnings elsewhere would be very beneficial. As detailed throughout section 2, it is key to implement both financial and non-financial incentives to motivate and retain workers.

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