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EXECUTIVE SUMMARY
The availability of appropriately trained, well-deployed and motivated human
resources is critical for an efficiently functioning, sustainable health system.
Health workers with the potential to deliver health interventions to their
populations are key to improving health outcomes (Anand & Barnighausen,
2004). Thirty-six countries in sub-Saharan Africa have severe shortages of
health workers. At least 2.3 trained health care providers are needed per
1,000 people to reach 80 percent of the population with skilled care at birth
and child immunization coverage.
According to a report published in 2004 by the International Council of
Nurses (ICN), “The scarcity of qualified health personnel, including nurses, is
being highlighted as one of the biggest obstacles to achieving the
Millennium Development Goals (MDGs) for improving the health and well
being of the global population... Nurses are the “front line” staff in most
health systems, and their contribution is recognized as essential to meeting
these development goals and delivering safe and effective care.”
The shortage of Nurses and Midwives is especially acute in certain countries
in Africa – particularly sub-Saharan Africa where AIDS has impacted
dramatically on the nursing and midwifery workforce. The ICN estimates a
shortfall of more than 600,000 Nurses in the sub-Saharan countries just to
meet the MDGs. There is a need to scale up production of health workers
particularly Nurses and Midwives. The need to review approaches to
medical and nursing education is of relevance to current health reform
efforts in many countries. The sheer scale of the challenge in many low- and
middle-income countries in Africa demands immediate attention and
investment.
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INTRODUCTION
This Policy Brief is a response to the theme of the 15th
Ordinary Session of the Summit of the African Union (19 – 27
July 2010), held in Kampala, Uganda. The title of the theme
was, Maternal, Infant and Child Health and Development in
Africa. This Brief is also a response to the goals of the New
Partnership for Africa’s Development (NEPAD)(2001) stated as
follows:
· To reduce infant and child mortality ratios by two-thirds
between 1990 and 2015;
· To reduce maternal mortality ratios by three-quarters
between 1990 and 2015;
· To provide access for all who need reproductive health
services by 2015 (p.14).
There is no doubt that Nurses form the backbone of health
service delivery in Africa, and that the quality of care is often
dependent on the quality of Nurses and Midwives working in
single-discipline
clinics
and
other
services.
This
was
acknowledged by the resolution WHA54.12 of the World Health
Organization (WHO) assembly, which lead to the adoption of
five Key Result Areas (KRA) by the WHO in 2002 to strengthen
Nursing and Midwifery services. KRA 4 refers to developing “…
a sufficient supply of educators and trainers” and “…
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appropriate skills required to practice within different health
service delivery contexts” (p.25). This document (KRA) goes
further to identify South-South collaboration to develop
educational institution capacity as one of the strategies to
achieve these aims.
In the Commission for Africa report (2005) the health worker
crisis in Africa and the need to build health professional
capacity on the continent was again highlighted. In his
analysis, Bryant (2002) pointed out that in addressing human
resource issues in Africa, attention has mainly been focused
on medical education, with little attention to nursing and other
health professionals (p.8).
It, therefore, seems eminently reasonable to develop this
category of health workers optimally so as to increase the
quality of health care in Africa.
THE CHALLENGE
The shortage of Nurses and Midwives are reflected in the
following indicators of a Nursing and Midwifery workforce that
is not meeting the needs:
· Countries train too few Nurses and Midwives with
appropriate competencies to deliver quality care at all
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levels of the health service; for instance there is an
abundance of non-professional, semi-skilled health
workers, and an inadequate number of professional
nurses and midwives.
· The training is not appropriate for the health settings in
which Nurses and Midwives have to work after training,
for instance, they are not trained at Primary Health Care
(PHC) level, but have to function at that level.
· There is inadequate provision for development of
leadership in the profession, which will enable nurses to
create positive work environments that will promote
quality care and retention of Nurses and Midwives in
public services.
While lack of sufficient investment in Nursing and Midwifery
education is an underlying problem, lack of sufficient planning
information is also an issue. For instance, few countries have
done thorough studies about the actual numerical and
qualitative needs of the Nursing and Midwifery workforce.
Another
issue
is
an
over-dependence
on
traditional
educational approaches and technologies. For instance, the
use of decentralized, part-time and blended education is still
very limited, compared with traditional centralized, face-toface, full-time professional educational programmes. While
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this might have been appropriate decades ago when these
technologies were new and untested, it now unnecessarily
limits access to education and even hampers the quality of
education.
POLICY RECOMMENDATIONS FOR MINISTRIES OF HEALTH
WHO AFRO, in collaboration with the International Council of
Nurses and Pepfar, has embarked on developing a plan for
upscaling Nursing and Midwifery education systematically and
dramatically. The overall objective is to have available a well
motivated and competent Nursing and Midwifery workforce in
the right numbers, at the right time and in the right place and
responsive to the dynamic health needs in each country
through providing access to quality health care to diverse
population groups in Africa.
Supported by a range of strategies to be implemented in the
next ten years, it aims at achieving three main goals for all
Member States:
1. Meet human resources for Nursing and Midwifery
requirements in line with the national health and human
resources for health development – have enough Nurses
and Midwives.
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2. Provide quality and relevant Nursing and Midwifery basic
and post-basic education and training programmes.
3. Improve Nursing and Midwifery leadership and positive
workplace environment including regulation at all levels of
service delivery.
While many of the strategies are in the hands of Nurses and
Midwives themselves, there are particular strategies which are
heavily dependent on the relevant Ministries.
To Reach Goal 1 (Enough Nurses and Midwives)
1. The primary strategy to achieve this goal is that, based on
the national Health and Human Resources for Health
policies and plans, each country should develop a National
Operational
Plan/Nursing/Strategy
for
Nursing
and
Midwifery workforce which clearly provides details on:
a. Planning the numbers and skill mixes of Nursing and
Midwifery workforce;
b. Planning the education and training of such required
numbers at both pre and post – basic levels of
education and
c. Developing strategies for their effective management
including
regulation,
recruitment,
motivation and retention.
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deployment,
In order to prepare an intervention that is appropriate,
scientific and credible, it is recommended that Ministries of
Health work with National Nursing Associations, Nursing
Education Institutions and Regulatory Bodies to conduct a
comprehensive situation analysis on Nursing and Midwifery
workforce to determine:
a. the actual numbers of existing categories and skill mixes of
Nursing and Midwifery personnel and the actual gaps;
b. the education and training programmes for the Nursing and
Midwifery workforce at both pre- service and post – basic
levels;
c. the management of the Nursing and Midwifery workforce:
their regulation, recruitment system, deployment policies,
motivation and retention strategies in order to effectively
contribute to the national health development agenda.
Based on this situation analysis, it will then be possible to
develop a national Nursing and Midwifery strategy/action plan
based on this analysis and within the context of the broader
health and human resource development policy orientations.
This will lead directly to the preparation of a detailed, costed
up scaling training plan for different categories of Nursing and
Midwifery personnel through an inclusive consultative process,
which can be processed within the government and perhaps
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be marketed to development partners for additional resources.
To Reach Goal 2 (Quality Basic and Post-basic Nursing and
Midwifery Education)
Another area in which the Professions need the active
engagement of the Ministries of Health, is to stimulate and
support the establishment of post – basic clinical specialist
programmes in Nursing and Midwifery to improve skill mixes
and advanced knowledge to accelerate achievement of the
Millenium Development Goals (MDGs) (4. Reduce child
mortality, 5. Improve maternal health and 6. Combat HIV/AIDS,
malaria and other diseases). While it has long been recognized
in the medical profession that specialization is essential for
practice development in certain areas, the recognition that the
same is true for Nursing and Midwifery has been slow to
develop. The result is that in many Member States in Africa
limited or no specialist educational programmes exist for
Nursing and Midwifery. This leaves a vacuum in terms of
service development, service evaluation, capacity building and
quality improvement.
Ministries of Health and Ministries of Education should,
therefore, collaborate with Higher Education Institutions and
their own Nursing Regulatory Bodies to conduct an inventory of
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the structure and scope of nationally and regionally (RECs)
recognized specialist development programmes for Nurses
and Midwives working in academic and clinical settings in the
country and determine priority specialist areas of focus to
meet their national health priority needs. To develop specialist
training, which is absent, collaboration with countries in the
region which offers such specialist training can support the
development of local training programmes.
Example: A NEPAD Project
Over the last four years, a consortium of Southern African universities
assisted four countries to establish advanced training programmes in
Community Health Nursing, Maternal and Child Health, Psychiatric/Mental
Health Nursing and Critical Care and Trauma Nursing. Based on this
programme Kenya, Tanzania, Rwanda and the Democratic Republic of the
Congo now each has at least one such specialist programme. In
Mozambique the first two programmes are awaiting selection of students by
the Ministry of Health.
In Kenya specialists in Community Health Nursing and Maternal and Child
Nursing are now being trained. In Tanzania specialists in Psychiatric Nursing
and Critical Care and Trauma are being trained. In the DRC the specialist
training is focused on Maternal and Child Nursing and in Rwanda on Critical
Care and Trauma. This not only provides specialist practitioners, but also
researchers in these fields, and people who can train others. Table 1
indicates the progress so far.
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Table 1
Host Institution, Consortium University, Specialist Field and
Progress So Far
Country and Host
Country and
Institution
Consortium
Specialist field
Progress So Far
University
Kenya
South Africa,
Maternal and Child
Situational analysis completed.
Moi University
University of
Health
Students have registered. Project up
(Eldoret)
Pretoria
University of East Africa
South Africa,
(Barraton)
North West
Students have registered. Project up
University
and running.
and running.
Community Health
Situational analysis completed.
Tanzania
South Africa,
1.Critical care and
8 students have graduated. A New
Muhimbili University
University of
Trauma
intake is taking place.
(Dar-es-Salaam)
KwaZulu-Natal
2. Mental Health
Democratic Republic of
South Africa,
Maternal and Child
Situational analysis completed.
the Congo (DRC)
University of the
Health
Students have registered. Project up
Institut Superieur des
Free State
and running.
Techniques Medicales de
Lubumbashi
Rwanda
Botswana,
Critical care and
Situational analysis completed.
Kigali Health Institute
University of
Trauma
Students have registered.
Botswana
Mozambique
South Africa,
1.Critical care and
Situational analysis completed.
Academic Department at
Witwatersrand
Trauma
Students are in the process of
the Instituto Superior de
University
2. Maternal and
registering.
Ciências de Saúde
Child Health
(ISCISA).
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To Reach Goal 3 (Leadership and a Positive Workplace
Environment)
Essential for reaching this goal is that each member state
ensures the establishment of a statutory Professional
Regulatory Framework for Nurses and Midwives to ensure
quality of Nursing and Midwifery education and practice in the
Africa. Some countries in the region have well-developed
regulatory bodies and such countries may be willing to partner
with countries in which such regulatory bodies do not exist, in
order for such developments to take place. The Regulatory
Body will then be responsible for:
· Establishing of educational standards for pre-service
Nursing and Midwifery training programmes;
· Strengthening pre-service Nursing and Midwifery curricula
and
· Developing professional ethical guidelines and manage
professional discipline.
Example
Botswana and Malawi have well functioning Nursing Councils that provide
leadership in nursing education development, human resource planning
and monitoring of quality of Nursing education and practice.
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CONCLUSION
The project on the training of Nurses and Midwives adds value
to one of NEPAD’s objectives, “To build and retain within the
continent critical human capacities for Africa’s development”
(p.30).
The lack of adequately prepared health professionals in
sufficient numbers to deal with the health needs of the people
demands urgent attention especially within the context of the
huge burden of preventable disease and death in Africa. In
response to these demands, educational responses in the
past have often been ad hoc, outside of the formal
qualification framework of the countries and of limited scope
and depth. This has lead to a lack of health professionals
trained at sufficient breadth and depth to deal creatively,
constructively and based on appropriate evidence, with the
health challenges of the continent.
The three major strategies outlined above are central to the
plan and it will go a long way to addressing the challenges in
the immediate future if Member States can commence with
these activities. The Nursing and Midwifery professions stand
ready to play their part in restructuring these professions in
order to reach the Millenium Development Goals. With the
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support and leadership from the Ministries of Health and
Education in all the African Union Member States we certainly
can achieve this milestone soonest.
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COMMENTS / NOTES
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For more information on the Human Resource Development in Africa: Education and Training of
Nurses and Midwives Project, contact: Prof. Mzobz Mboya, Advisor: Education And Training,
NEPAD Planning and Coordinating Agency, P.O. Box 1234, Halfway House, 1685,
Johannesburg, South Africa, Tel: +27-11 256 3624, Fax: +27-11 206 3392, Email:
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