Africa's health worker shortage is projected to reach more than six million by 2030, and the weaker the systems, the more likely health workers will leave due to poor working conditions and low morale.
Nonprofit organization Seed Global Health is working to address this shortage by investing in long-term training and support for health workers in four countries: Malawi, Sierra Leone, Uganda and Zambia, in partnership with Ministries of Health.
For Seed, long-term means “as long as our partners accept us,” says CEO Dr Vanessa Kelly, who is also a World Health Organization special envoy for climate change.
Seed released its 2030 strategic plan last week, an ambitious program that requires the organization to raise at least $100 million in funding.
“The 2030 Strategy reflects a critical need in the world today, which is to prepare the health workforce of the future and make that workforce a global priority,” Secretary Kerry said in an interview with Health Policy Watch.
“Whether it's managing the existing disease burden, preparing for a pandemic or responding to climate change, the workforce is at the frontline of every response.”
She stressed that Seed is not “looking at some new flashy moment” but rather “doing more of what we've always done – focusing on education, practice and policy to ensure we have a skilled workforce that can deliver reliable care to those who need it.”
“The mission is simple: a just, equitable and healthy world. The mission is to expand access to quality health care and improve health outcomes for all. We do this through training health care workers, and we really believe that can be transformative across sectors.”
It's not a “fly in, fly out” model.
Seed sends educators “on the road” with their partners for at least a year to build trust, understand the context, learn from their peers, and apply their skillsets to problem-solve.
“A lot of people will be creating curriculum, teaching over Zoom, or feeling like they just come, teach, and go,” Kelly says.
“We're not a fly-in, fly-out model. Our mission is to be embedded in the community and serve the priorities of our partners.”
The challenge is enormous: all four partner countries are on the World Health Organization's (WHO) list of countries with severe health worker shortages.
A woman giving birth in Malawi is 28 times more likely to die than one in the UK, a newborn in Zambia is 24 times more likely to die than one in Norway, and there are four doctors per 100,000 people in Uganda compared to 440 in Switzerland.
Sierra Leone has the highest maternal mortality rate (MMR) in the world, Malawi also has a high MMR, Uganda suffers from high injury rates, mainly from road traffic accidents, and Zambia is trying to move towards universal health coverage but lacks staff trained in home health care.
All four countries are experiencing the impacts of a rapidly changing climate, including floods, droughts and migration.
Seed realized the best way to support healthcare workers was by providing daily instruction at patients' bedsides.
“I’m a doctor, and medicine, nursing and midwifery require apprenticeship and learning – you can’t just memorise the hypertension algorithm and expect to be able to walk into a patient’s room and care for them in the right way.
“Each patient has a different background, a different disease pattern, and a different combination of diseases.”
Choose your country
Kerry founded SEED in 2011, and through the Peace Corps' Global Health Services Partnership (GHSP), it deploys U.S. medical professionals overseas, including to Malawi and Uganda, to train others.
But when the GHSP ended after more than a decade, “we weren't done,” Kelly said.
Both Malawi and Uganda hoped that Seed would continue to help train health workers and address their health challenges.
Malawi's maternal mortality ratio (MMR) is 349 per 100,000 live births. The country aims to reduce this to 70 per 100,000 by 2030.
The leading causes of death and illness in Uganda are acute childhood illnesses, injuries (due to road traffic accidents) and maternal health conditions. Non-communicable diseases account for 40% of the disease burden.
Then, in 2018, Zambia requested support to launch a family health programme as a core part of its primary health care system.
In 2019, the government of Sierra Leone called Secretary of State Kerry to ask for help in addressing the MMR problem, which is causing 717 deaths of women per 100,000 live births, the highest in the world.
Chief operating officer Andrew Musoke said Seed supports the Ministry of Health's training objectives rather than the ministry developing its own plan.
Some of their results have been astonishing: for example, since they began working in Sierra Leone in 2020, maternal mortality rates in the area have fallen by 60%.
Human rights issues
Postpartum haemorrhage is a leading cause of maternal deaths in Uganda and Malawi and is sometimes caused by unlicensed abortions, which are illegal in both countries.
Prior to becoming Seed’s chief operating officer, Musoke served as country director for the Clinton Health Access Initiative (CHAI) in Uganda, where she acknowledged that “we have seen a lot of increases in teen pregnancy and abortion mortality, especially during the COVID-19 pandemic.”
Women and girls often arrived at health facilities with severe bleeding and at a much later stage in their treatment, making it difficult for health workers to manage them.
“In our efforts to improve emergency medical services, we recognised there were some gaps in our problem-solving capabilities as well as in our referral pathways,” Musoke says.
Faster referrals and more skilled healthcare workers have helped reduce deaths from bleeding.
A year ago, Uganda passed a draconian anti-gay law that imposed severe penalties on same-sex sexual activity, prompting many civil society groups to call on international programs to stop funding from flowing through the Ugandan Ministry of Health.
Kelly acknowledged that human rights issues pose challenges for Seed in a “very complex world with very complex politics.”
“I can look at my own country, I can look at the United States, I can look at Uganda. Every country is struggling to figure out their values and how to move forward politically in this world. When you look at the human rights issues in each country, it's very difficult.
“But at the end of the day, we're a healthcare organization. I'm a physician. We're committed to caring for our patients with dignity and respect and making sure they receive services.”
She added that Seed's partners all recognize that patient care needs to be based on science.
“We're really focused on raising awareness about how anti-gay policies, for example, can actually have a negative impact on progress in the HIV response and in primary care, and really helping to raise that awareness and provide education.”
Climate resilience
Another element of Seed's training is helping health workers deal with the everyday effects of climate change, Kelly said.
“No matter what aspect of disease you look at, people are being affected by climate change,” she added.
Zambia is in the midst of a drought that has led to a major cholera outbreak; Malawi is experiencing cholera outbreaks following Cyclone Freddy; coastal Sierra Leone is facing rising sea levels as water sources become more saline; and Uganda is facing changing weather patterns that are adversely affecting livelihoods, especially agriculture and fishing.
A recent study found that for every degree increase in temperature above 23.9°C, infant mortality increases by 22%. If midwives know this, they can advise women with high-risk pregnancies on how to stay cool in extreme heat and prevent infant mortality.
Indirect impacts of climate change include migration, predicted to affect up to 1.2 billion people over the next decade, and women in some countries who have to walk longer distances to find water are more likely to be sexually assaulted.
“The focus on building a strong and resilient health care workforce is a key part of our response,” Kelly said.
Rich countries poaching health workers
One of the risks the partners face is that health workers are recruited by wealthy countries.
While Kelly says mobility for health care workers is a human right, Seed seeks to address the “push” factors associated with job satisfaction.
“Healthcare workers may want to stay in their country, their community, their environment and their family, but at the same time they don't want to be discouraged by seeing someone die every day because there is no blood for transfusions, for example,” she says.
“So the extent to which we can support systems change by developing advocates and changing health outcomes can go a long way in helping retention. And we've seen it work, with emergency medicine graduates that we train staying in Uganda. When morale changes, it helps retention.”
South Africa, through the African Union COVID-19 Committee led by President Cyril Ramaphosa, is leading efforts to develop a health worker agreement that will allow health workers to take part in training exchange programmes abroad.
“What this agreement does is create the economic case and the roadmap for countries to understand their own health workforce needs and training and think about how to train enough health workers to serve not just their own countries but the world.”
“This creates jobs and remittances. It builds an economy around health workers, solving multiple problems at once. Africa has a growing population and a workforce that can contribute to the world, so we're trying to think very ambitiously about how we solve these problems.”
Image credit: Seed Global Health.
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