Marjolijn Paauwe and Lisanne Denneman

 

Worldwide there is a severe shortage of health workers. The numbers are impressive: many countries have a physician density of <0.1 per 1 000 inhabitants and millions of people don’t have access to essential care. At this moment 57 countries face a severe health workforce crisis and without action the shortage will worsen. The greatest shortage, in absolute terms, is faced in South-East Asia (Indonesia, Bangladesh and India). The largest shortage, relatively, is faced in sub-Saharan Africa where an increase of 140% is necessary to fill the gap. In fact the existing health workforce of 59 million should be complemented with more than four million health workers to fill the gap.

The health workforce

The health workforce is the backbone of each health system. Health workers are people with the job to protect and improve the health of their communities. They include health service providers, such as doctors, nurses, pharmacists and laboratory technicians, health management and support workers such as financial officers, drivers and cleaners. All together they make up the global health workforce; according to the World Health Organization (WHO) the size of the global health workforce is now around 59 million workers.  Furthermore, health workers are unequally distributed across the globe. The highest number of workers is found in countries with the lowest relative need, while a much smaller workforce is found in countries with the highest burden of disease.

Also the distribution within countries differs. In general, health worker density is highest in urban areas and the private sector, where teaching hospitals and high wages are more common. The density of health workers is directly correlated with positive health outcomes. Higher health worker density improves population-based health and human survival. For example, a 10% increase in the size of the health workforce correlates to a decrease in maternal mortality of approximately 5%.

Health care system in Brazil

The Brazilian health care system and the solutions that it brought to the human resource crisis can be seen as an example to the rest of the world.

Important changes of the Brazilian health care system, Sistema Único de Saúde (SUS), were brought into force in 1988, when the military dictatorship ended and the World Bank implemented its neoliberal recipe for reforming health care systems. Health was acknowledged as a fundamental social right in the new constitution of Brazil and the government was responsible for providing health care for every citizen.

The main primary health care strategy of the SUS is the Family Health Program (FHP), launched in 1994. By 2004, the programme had been implemented in 82% of Brazil’s 5 561 municipalities, covering 40% of the total national population. The FHP centres on a family and community approach in which diverse teams (including physicians, nurses, community health workers, and oral health professionals) work together to provide care. These family teams are linked to the nearest health care facility and are supervised and trained by a doctor, using IT and other new technologies. Each FHP team is responsible for the health care of a certain number of families in a circumscribed area. The most important activities within the FHP are prevention (e.g. immunization campaigns), maternal care and childcare and the management of infectious diseases. It is very cost effective: almost 95% of the rural areas in Brazil has health coverage now and the health outcomes are very positive.

 

Guilherme Sella, medical student, Ribeirão Preto, Brazil:

"Here, in general the health system works in this way. However the theory is not always like the reality. Recent figures show that 25% of population has a private health care system, showing that SUS is not as good as it seems. For a country that did not have a public health care system twenty years ago, SUS is a dream, but still many things need to change." 

Health outcomes

Large scale implementation of FHPs in Brazil provides perfect circumstances to study the effectiveness of primary health care strategies. It was showed that when FHP coverage increased to nearly 60%, mortality rates drastically decreased. The infant mortality rate and post-neonatal mortality rate decreased with 13% and 16%, respectively. Moreover, access to basic health services improved, such as basic medical consultations, vaccines and educational activities.

About the author

Marjolijn Paauwe and Lisanne Denneman are medical students from Amsterdam. Last year they were enrolled in a course on International Development Studies.

Further reading

• Anvangwe SC & Mtonga C. ‘Inequities in the global health workforce: the greatest impediment to health in sub-Saharan Africa.’ International Journal of Environmental Research and Public Health. 2007 June; 4(2):93-100.
• Elzinga G, Dieleman M, Dussault G, Chowdurhy M. ‘Workers for priorities in health’. Amsterdam: KIT Publishers.
• Barreto ML & Aquino R. ‘Recent positive developments in the Brazilian health system.’ American Journal of Public Health. January 2009, vol. 99, no. 1.