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Health Care Workers; Health Workers; Africa; Shortage; Possible Solutions

Sub-Saharan Africa (SSA) is a region characterised by a wealth of natural resources, political instability, poverty, low levels of human development and adverse health conditions of all kinds: from the health care itself, to the lack of available resources, budget, government policies, other social determinants and human resources. All the above factors are modulated by governments of different countries with little opportunity for community participation. All contribute to the inaccessibility of health care and difficulties in transporting of patients, directly affecting access and coverage to the disadvantage of those residing in rural communities. These are regarded as social injustices that produce health inequity due to the unfair distribution of goods, services and privileges across populations. The shortage of health workers (HW) and their reluctance to work in rural areas in preference for big cities contribute to the obvious dearth of manpower. Not only has it considerably constrained achieving health-related development goals, but has also impeded progress towards Universal Health Coverage (UHC).

Shortage of professionals and cancer

The WHO estimates an undersupply in SSA of almost 4.3 million doctors, midwives, nurses and other healthcare professionals [1]. Highincome countries have an average of almost 90 nurses and midwives per 10,000 people, as compared with some low-income countries that have fewer than 2 per 10,000 people [2].

This imbalance results in North America and Europe gaining 65% of healthcare workers, yet bearing only 20% of global disease. Africa, in contrast, bears 24% of the health burden with only 3% of the global health workforce [3, 4]. Africa has a severe shortage of doctors, nurses and other health specialists and there is an urgent need to provide universal access to health, education and other basic services for all. As of 2015, this region had an average of 1.3 health care workers (HCW) per 1,000, far below the 4.5 per 1,000 required for Sustainable Development Goals (SDGs); yet, health systems are designed more for urban elites, with little coverage when it comes to the needs of rural women and children. In Africa, there is one doctor for every 10,000 people, while the global average is 13.9/10,000 (in Europe and the US >25), and 0.8 dentists and pharmacists/10,000. In 2016, there were 0.002 doctors/10,000 in Liberia, 0.005/10,000 in Burkina Faso, 0.005/10,000 in Sierra Leone, 0.002/10,000 in Mauritania, 0.013/10,000 in Nigeria, 0.037/10,000 in Senegal, 0.007/10,000 in Niger and 0.002/10,000 in Cameroon, with the majority of doctors practicing in urban areas [5, 6].

The low number of HCW, particularly doctors and nurses, per 1,000 children is a key determinant of variation in maternal, infant and under-five mortality rates. There are too many inequities in the distribution of HCW between countries and within countries. The same is true for other specialists. In Africa, there is one oncologist for every two million people (in the USA, one for every 26,418) and, in 2014, there were only four oncologists and a few pathologists in Cameroon, practicing in Yaoundé, which means a several months-delay in obtaining a pathological evaluation until diagnosis, and a consequent delay in treatment. Nigeria has 90 oncologists for 213 million inhabitants (1 to over 1,100 cancer patients) and Ethiopia has four for 100 million. It is of the utmost importance to promote the training of oncologists, radiotherapists and pharmacists and to retain them in the country [7- 9]. These elements constitute a major barrier to timely access to quality medicine, in addition to malnutrition, poor hygiene, environmental and water pollution and many endemic infectious diseases that affect the vulnerable and poor, particularly the migrants [9].

As we know, the early diagnosis of breast and cervical cancer is essential. The former is evaluated with mammography, requiring diagnostic personnel and, for the latter, cytology and anatomicpathologists are required. These personnel are essential in the diagnosis of the disease and confirmation of the extent of the tumour [8-10]. In Africa and most low- and middle-income countries (LMCIs), the problems range from lack of manpower, such as surgeons and anaesthesiologists, hospitals equipped with operating theatres and, primarily, the patients' inability to access and pay for surgical services [11]. Jamison, et al. estimate that 6-7% of annual deaths in LMCIs would be averted if a range of health services for the most basic surgeries were guaranteed [12]. Many surgical services are almost entirely concentrated in the cities and are accessed largely by those who can pay for the care and, oftentimes, the cost of transportation.

It is essential to re-evaluate the importance of surgical services in poor countries and to prioritise support, resources, training and manpower development. There is a great need to increase supplementary training for general surgeons to treat surgical oncology cases [12-15]. A World Bank Group study [16] estimates that about 1.5 million deaths per year would be prevented if the 44 most basic surgical interventions in developed countries were available in LMICs. These are places where minor surgical ailments often develop through time and inattention to lethal conditions, and anomalies such as cleft palate can remain untreated for life [13, 14]. Eleven percent of premature deaths or disabilities - according to the 22nd Edition of the Disease Priority Control in Developing Countries (DCP, 2006) - could be avoided by appropriate surgical services to trauma, cancer and congenital deformities [15-18]. Surprisingly, more people die each year due to the inability to access surgical care than from AIDS, tuberculosis and malaria, combined [12-15]. The establishment of a 'surgery fund' would be an important step to improve global public health [16, 17].

The lack of radiotherapy (RT) facilities in poor countries is an issue that must be addressed in order to improve the care of cancer patients [19, 20]. In Africa, 29 out of 52 countries (totalling 198 million inhabitants) have no RT facilities at all. Only 23 countries in this continent have access to teletherapy and brachytherapy. Africa holds two percent of all RT machines worldwide (277), but would need 703 and no linear accelerators [1]. RT requires other expert staff, not just oncologists, but physicists and specialised technicians, as well. In high-income countries, one radiotherapy machine is available for every 120,000 people, and in middle-income countries, one machine serves over one million people. Conversely, in low-income countries, an average of at least five million rely upon a single radiotherapy machine; this is the reality for many other African countries, including Nigeria, Ethiopia and the Democratic Republic of Congo [20]. Most cancer patients require RT, but with cobalt-60 machines (which are often broken down), it is almost impossible to implement standard RT protocols in the primary or metastatic phase, as is the norm in rich countries. Only three African countries (South Africa, Egypt and Algeria) are close to the recommended standards for RT access.

The treatment of cancer can be cost-effective for all income levels. There is an Essential Medicines List of 51 drugs - chemotherapy, antimicrobials and supportive care medications-that are key to paediatric cancers, but to achieve this, these medicines must be efficacious, free of contaminants and not counterfeited [21]. The shortage or non-availability of safe blood products (which, in Africa, is worsened by the high seroprevalence of HIV and hepatitis Bbetween 10-25% of donors) with little or no provision of PC services to children. This problem is compounded by the shortage of trained health professionals and the lack of efficient multidisciplinary teams, consisting of oncologists, surgeons, nurses, pathologists, radiologists, radiotherapists and support staff.

Challenges and solutions to the shortage of health care workers

Health systems can only function with health care workers (HCW); improving health service coverage is dependent on their availability, accessibility, acceptability and quality [1, 4, 22-26]. Out of the estimated shortage of global health workforce (14.5 million) required for Universal Health Coverage and sustainable development goals (SDGS), the African Region has the most severe health workforce shortage, estimated to reach 6.1 million by 2030. This is against the backdrop of a vision to ensure that, by 2030, all communities should have universal access to health workers. Potential solutions to these deficits include models that would strengthen and build infrastructure and training staff along a multidisciplinary team-approach by the year 2030. Therefore, it is necessary to identify and strategise feasible solutions, especially in primary care and rural areas, towards addressing these multiple complex factors. As the WHO points out, as countries in the region aspire to attain SGDS, health workforce shortages and imbalances could be the Achilles heel that can derail the attainment of these goals (See Table 1) [4].

Table 1: Estimated health worker demand (in millions) in 165 countries, by region.

a) The need to strengthen health services and develop tailored training plans for specialists and multidisciplinary teams

The causes of health care-related human resource shortages are many and complex. Effective mitigating strategies should, therefore, be comprehensive and context-specific, derived from an adequate understanding of the context [1, 4, 22-26]. The "Framework for the implementation of the global strategy on human resources for health (health workforce 2030) in the African region" (Brazzaville, DRC, 2017) [4], proposes a range of actions that must be implemented by African countries by 2022 and 2030:

• Ensure effective use of available resources. For example, in 2014, only Liberia, Rwanda, Swaziland and Zambia met the Abuja Declaration target of allocating 15 % of their annual budget for health. Some states cannot afford to absorb all the available HCWs, leading to the paradox of HCW unemployment amidst shortages in the health system [4].

• Countries should prioritise building the capacity of national human resources for health (HRH plans) and to develop HRH plans that quantify the health workforce needs, demands and supply for the various cadres of health, although their implementation has been a challenge. This will help to make better decisions regarding the production, recruitment and retention of sufficient numbers of health workers [4].

• African countries are urged to train more HCWs and improve the effectiveness of Community HCW programs; moreover, there are cases where some health institutions are not being accredited, which implies that the quality of education is in question. Trained health care professionals must be equitably and sufficiently allocated to all healthcare facilities. They should be empowered with knowledge, skills and positive attitudes; the same is true for both formal and informal caregivers. There are only 168 medical schools in the region - 24 SSA countries have only one medical school, and 11 SSA countries have no medical school at all.

b) Emigration

HWC workers in SSA often face challenges of job satisfaction, they drift with economy and some find opportunities for employment abroad, and this has contributed majorly to the migration of workers from low-income countries to higher income countries [1, 22-26]. 65.000 African –born physicians and 70.000 African born professional nurses are currently working overseas in HICS [25-28]. Their migration has major effects on the SSA countries from which workers migrate from, and the receiving developed countries greatly benefit. This dearth of health workers on the African continent can literally create life-endangering situations for communities where the health services simply disappear due to the emigration of qualified health personnel.

The SSA countries experience negative effects, such as shortages in health service capacity, financial loss of the investment in training and educating the health care workers. The loss of income taxes paid to governments, lack of adequate motivation, decline in morale and commitment among remaining workers, loss of expert knowledge in academic centers, and loss of role models for young students [26]. Nigeria in recent times and other SSA countries ultimately suffer most from the brain drain [4]. Nigeria and other West African countries have been experiencing a massive drove of doctors and nurses to UK and Saudi Arabia as a result of low wages and poor living conditions.

Among the possible solutions include a good leadership, solid economy, good wages and security may reverse the trend. It can not be over-emphasised that the LMICS not only lose manpower in the health sector, but also effectively lose out on their financial investments into training and education. Its is necessary to provide better incentives to retain staff and also attract overseas workers from the diaspora with better renumeration, good working and living conditions and rural infrastructure should also be improved for most HWC. The low wages for primary care physicians is also another barrier that is flawed and there is need to improve the situation [22-26].

c) Education

The healthcare workforce shortage can be improved with some creative thinking and a change of the prevailing educational mode. Recently, at a Senate hearing in the US, Dr. James Herbert, president of the University of New England, said that the healthcare workforce shortage can be improved with some creative thinking. "We must fundamentally change the prevailing educational model". Rather than having trainees work in specialized silos, "a new educational model has emerged in which students from diverse disciplines are explicitly trained to work together across traditional boundaries in multidisciplinary teams... and this model has been shown to improve clinical outcomes, to reduce medical errors, to increase patient satisfaction, and to decrease provider burnout [27]." It is also relevant to incorporate the use of ICT tools such as e-learning, electronic health records and telemedicine that can improve education and efficiency of health service delivery, the COVID-19 challenges has created opportunities to promote more and better global communication through telemedicine [28].

Tele-oncology, the oncology application in medical telecommunications, that includes pathology, radiology and other related disciplines, has the potential to facilitate access to and improve the quality of clinical care is also capable of fostering the education and training of professionals. Clinicians no longer need to attend conferences in far distant countries and can easily acquire knowledge at the click of a button on the Internet. Virtual platform groups, such as WhatsApp, have also emerged, facilitating basic dialogues that will continue beyond the pandemic [28-29]. Thus, with Telemedicine the systematic and effective communication between advanced cancer centres and centres in resource-poor countries can improve care and promote opportunities for continuing education [4]. Cell phones have facilitated patient navigation and cancer screening, as well as retention in treatment [28-29]. Nigeria has about 2 % of the world´s population but accounts for 10 % of the world´s maternal deaths. Providing pregnant women with cell phones, for instance, as part of the Safe Motherhood Project, improved their attendance at health clinics and overall health care services to pregnant women and decreased maternal mortality rates in 10 participating health facilities [4].

The WHO launched the Global Initiative for Children's Cancer in 2018, [30] to coerce governments to develop and organize high-quality children's cancer programmes with the goal of achieving 60% five-year survival by 2030. This initiative is greatly needed in AAS, where health systems are weak and the population of children is expected to grow from 320 million in 2015 to more than 720 million in 2050. (See Figure 1) [31-33]. A good way to do this is to help train paediatric oncologists as https://worldchildcancer.org.

Figure 1: Six common, tracer cancers for the Global Initiative.

The education of health professionals can help to change the current situation, which is why various NGOs, such as Paliativos Sin Fronteras (Palliative without Borders) and Cirugía Solidaria, (Cooperative surgery) [11, 14] have carried out on-site training of local professionals with procedures and means that have promoted the creation of palliative care, oncology and surgery units and teams in SSA. They have sent aid workers and surgeons on short-term missions, providing various interim teaching services as a temporary measure or as a recurrent but intermittent service, with 38 internships in Spanish hospitals for training in oncology, pain relief and PC [11, 14]. In situ missions provide great benefits to a target population within a short time, are economically more feasible, viable and facilitate immediate teaching opportunities for HCW; they also prevent large displacements of local populations, making them more socially sustainable, as they avoid family breakdown [34-36].

In recent years, cooperative surgery, missions providing these services of temporary transfers of resources, has changed; either complemented with, or replaced by, long-term partnerships aimed at building local capacity and developing a newer model of surgical training programmes for local doctors in low- and medium-resource countries to care for their own people, in their own country [34-37]. This has proven to be an excellent model for young doctors who are much more culturally aware, communicate in local dialects and identify better with their people, without suffering the frequent psychological stresses that expatriates experience. Thus, the Pan-African Academy of Christian Surgeons, which began training surgeons in 1996, has trained 43 residents in six countries and is accredited by South African universities and the West African College of Surgeons [34].

Faced with the problem of up to 22% of sub-Saharan medical school graduates migrating out of the continent due to lack of postgraduate training and economic considerations in some nations [37], a partnership was created in 2010 between the National University of Rwanda and the Centre for Global Surgery at McGill University in Canada. This targeted intervention was based on local needs with multidisciplinary approaches in various specialties, with surgery, anaesthesia, obstetrics and nursing at the forefront of such efforts, rather than Western models and expectations, using educational programmes aimed at local health professionals in the early stages of their careers. It is essential to move from a passive to an active intervention. International cooperation among SSA countries can alleviate suffering, increase survival, improve quality of life, counteract poverty and the loss of human life that impede development in poor and middle-income countries [38].

Summary

The shortage of health care personnel has a clear impact on the poor quality of care in SSA, which is most noticeable especially in the delivery of oncological services in that region. Besides, the 'brain drain' phenomenon with attendant high turnover rates of HCWs is hampering effective delivery of quality health care services. This scenario may be a continuum and may adversely affect the training of the young professionals judging from the recurrent loss of experienced hands to the diaspora. There is an urgent need to reverse this ugly trend and motivate the HCWs by providing good wages, better social conditions, security and ensuring job-satisfaction to prevent the recurrent brain drain and loss of manpower to the developed countries. Concerted efforts among the countries should be geared towards fostering international cooperation and partnerships especially in the area of education and encourage evidenced-based multidisciplinary team care approach.

The authors declare no conflict of interest.

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