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Despite health being a global right, available data show that in many countries, this right is not yet realised. This is starkly illustrated in the health statistics from around the world. For example, figures show that life expectancy in Liberia for a woman is only 44 years (compared with 81 years for a woman in the UK), and that the maternal mortality ratio in Afghanistan is a staggering 1600/100 000 live births (compared with 11/100 000 live births in the UK). Malaria still kills more than 1 million people annually, most of them children under 5 years of age, and contributes to an under-5 mortality rate in some African countries of over 200 deaths per 1000 live births (or roughly one in five). Up to 45 million people worldwide are living with HIV, two-thirds of them in sub-Saharan Africa.1
At the start of the millennium, the world's leaders united in a global commitment to reduce poverty, health and other inequalities through the Millennium Development Goals. These goals call for countries to work collectively to make changes in current practice and to commit the necessary resources to eradicate extreme poverty and hunger, reduce child mortality, improve maternal health, and combat HIV and AIDS, malaria, and other diseases by the year 2015. Achieving the Millennium Development Goals is a central tenet of the UK's current development assistance. To date some progress has been made towards reaching the targets set, but in many countries, particularly in sub-Saharan Africa, the gains are either patchy or non-existent.2 According to current projections the targets will not be met in many countries, highlighting the need for an urgent and considerably enhanced effort from the global community.
One of the greatest challenges to strengthening the health sector in many countries, and delivering on the health Millennium Development Goals, is the availability of trained health staff to support the health system. In 2006 the World Health Organization (WHO) published its annual report highlighting the serious shortage in human resources for health. It was estimated that 57 countries have critical shortages in health staff, equivalent to a global shortage of some 2.4 million doctors, nurses, and midwives, or 4 million health workers if managers and other public health workers are included. This shortage is felt most acutely in low income countries with a combination of factors leading to the current situation, including under-investment in the health system; the impact of AIDS on life expectancy of health staff; and the loss of trained staff to other countries, including the UK. The 2006 WHO report marked the launch of a 10-year Global Plan of Action to tackle the issue.3
In recognition of the importance of human resources in meeting the health Millennium Development Goals and also the potential role of the UK, Tony Blair invited the former NHS Chief Executive, Lord Crisp, to review how the UK's expertise and experience in health could be used to support the global effort. The result is Lord Crisp's report Global Health Partnerships: the UK contribution to health in developing countries, published March 2007.4
The report combines information from visits by Lord Crisp to a number of countries, and includes feedback from discussions with service users, health workers, and planners in these countries as well as concerned parties in the UK and elsewhere. The report provides a picture of the current situation and makes recommendations for future support aimed at enhancing the UK's efforts.
Lord Crisp's report recognises that the UK has shown leadership in the area of human resources in the past, but that there is still more that can be done. The report calls for stronger global health partnerships, which could have benefits not only for developing countries, but also for the UK health system through broadening the skills of UK health staff.
The report notes that UK institutions, both developmental and academic, have a long history of involvement in healthcare delivery and systems strengthening in developing countries, but that this support has often failed to promote the necessary strong base of qualified health staff in these countries. In part, this has been due to the nature of the support provided, which in some cases has focused on capital investments, such as hospital buildings and equipment, at the expense of recurrent costs to cover salaries for health staff. While capital investment is important, it has been recognised that without the staff to deliver health interventions, the returns on these investments are limited.
Lord Crisp highlights three important areas where changes to current support could be improved and progress towards the Millennium Development Goals strengthened. The first of these is an improved and more comprehensive approach to the development of policy and the delivery of aid. The report recommends more support for country-led approaches across development agencies, following the lead of the UK and other like-minded countries to place an emphasis on longer-term support and greater ownership by government ministries in the countries concerned.
The second change is for a more powerful and coordinated response to the staffing crisis in developing countries, in particular sub-Saharan Africa.
Among other suggestions, the report recommends that new partnership arrangements with volunteer organisations should be established to support staff from the UK who wish to volunteer abroad. At the same time the UK should support international efforts to manage migration from countries with critical health staff shortages.
The third area of change involves improved sharing of good practice and learning between development projects, agencies, and countries to capitalise on collective experiences. Lord Crisp recommends that the UK should assist international efforts to identify and share good practice and help countries develop systems that can support health workers' and the public's access to knowledge.
Merlin is a UK agency specialising in support to health care in some of the most difficult environments in the world. It was able to contribute to the Crisp report through its own learning (J Roberts, unpublished data, 2007). Merlin's experience highlights the impact of acute health staff shortages on the availability of basic health care in many of the countries in which it works. In Liberia, where Merlin has been working for 10 years, the acute shortage of doctors means that there is currently only one doctor for every 21 000 people (compared with 1 per 434 in the UK). Merlin's experience in Liberia and other chronic crisis contexts has shown the importance of making a long-term commitment to local health staff development, as well as providing shorter-term support through the placement of international health staff. This longer-term support, which includes training and mentoring of local staff as well as the payment of salary incentives, is aimed at building a stronger and more effective work force for the future.
Lord Crisp calls for a dramatic increase in training, education, and employment of health staff in developing countries, which can only be welcomed. Merlin's experience indicates the need to ensure that, once trained, local health staff receive a living wage accompanied by better working conditions, performance management, and professional development if they are to be encouraged to remain in country rather than seek employment elsewhere.
Lord Crisp's report has lent much needed attention to the critical issue of human resources for health and, in highlighting the UK contribution, has shown how one country can contribute to this critical area of health development. Lord Crisp's call for a global health partnership is key to improvement. Action is needed not only in the UK, but also in the countries concerned if this Global Health Partnership is to lead to the goal of high performing workforces, able to respond to current and emerging challenges by the end of the decade.
Merlin staff for their input.
The author has stated that there are none