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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. 1
INTRODUCTION This Policy Brief is a response to the theme of the 15 th 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 1
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 2
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 3
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. 4
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, deployment, motivation and retention. 5
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 6
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 7
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. 8
Table 1 Host Institution, Consortium University, Specialist Field and Progress So Far Country and Host Country and Specialist field Progress So Far Institution Consortium University Kenya South Africa, Maternal and Child Situational analysis completed. Moi University University of Health Students have registered. Project up (Eldoret) Pretoria and running. University of East Africa South Africa, Community Health Situational analysis completed. (Barraton) North West Students have registered. Project up University and running. 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). 9
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. 10
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 11
support and leadership from the Ministries of Health and Education in all the African Union Member States we certainly can achieve this milestone soonest. 12
COMMENTS / NOTES......... 13
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: 14