Huge cost of scaling up entire health system in Sub-Saharan Africa

Hiring the nearly 800,000 workers needed to eliminate the staggering shortage of health care professionals in sub-Saharan Africa by 2015 will cost $2.6 billion a year, or 2.5 times the annual funds currently allocated for health worker wages in the region, according to a new study by researchers at the University of California, Berkeley, and collaborators from the World Health Organization (WHO) and The World Bank.

"To say that generating the funds needed to alleviate the shortage will be difficult is a gross understatement," said lead author Richard Scheffler, professor of health economics and public policy at UC Berkeley's School of Public Health and director of the school's Global Center for Health Economics and Policy Research.

"We project that sub-Saharan Africa will only have one-third of the health care workers they need by 2015," he said. "Specifically, 240,000 more doctors and 551,000 more nurses and midwives are needed to fill the gap. The numbers we are providing are a first step in helping policymakers make decisions about where to put their resources."

In addition, the cost of scaling up the entire health system in the region is projected to be $19 billion per year, which exceeds the annual aid for health worldwide by $2 billion, noted co-author Brent Fulton, a health services researcher at the Global Center.

The paper, to be published Aug. 6 in the journal Health Affairs, is the first attempt to quantify and forecast the shortage of doctors, nurses and midwives in 31 sub-Saharan African countries in the context of government spending on wages there, the authors said.

While global aid is necessary, it will not be enough to fill the enormous gap in need, the researchers said. To buffer the effects of the shortage, the researchers recommend that government leaders in sub-Saharan Africa take the following steps:

• Change the skill mix to allow utilization of health workers with less training, such as mid-level and community health workers, for certain tasks
• Provide worker incentives to improve motivation and morale
• Increase the capacity, quality and efficiency of training for health care workers, perhaps through creative partnerships with established schools in developed countries

Changing the workforce mix is a particularly promising avenue to reducing labor costs, the researchers said.

"If we take the tasks physicians do that don't really require physician training - such as giving vaccinations or conducting health interviews - and shift them to nurses or community health workers, we can then free up doctors to do more complex tasks," said co-author Chris Brown Mahoney, who conducted the research while she was a post-doctoral scholar at the Global Center. "We see this concept of task shifting in the United States, where patients are increasingly seen by nurse practitioners. Here, it's happening primarily for money reasons. In Africa, there are so few physicians, it would be more efficient for them to focus on more serious health needs."

"A large increase in the number of mid-level and community health workers is a more cost-effective policy," added study co-author Mario Dal Poz, coordinator of human resources for health at the WHO. "This is especially true when you consider that they require less training and are more likely to stay in their own countries, and practice in traditionally underserved rural communities."

The consequences of insufficient health resources are dire. Every year, 500,000 women die from complications related to pregnancy and childbirth, 3 million babies are stillborn and 2.9 million people die from HIV/AIDS, according to figures from WHO.

"Without intervention, many African countries will take until 2030 to reach the health-related (United Nations) Millennium Development Goal targets," said co-author Alexander Preker, head of health investment policy and lead economist at The World Bank. "Billions of dollars currently spent on global public health priorities would be wasted if the human resources crisis is not given a higher priority on the development agenda."

The study was supported by WHO and the Global Center. The National Institute of Mental Health provided funding for Mahoney's post-doctoral research.

The study in Health Affairs is online at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.5.w849.