Health workers must be heard in high-level health system improvement meetings, says Priya Shetty.
Recognition that global health will only improve by strengthening the health systems of poor nations has been put on the agenda at an important conference this week, adding to recent but belated international funding and support for a key issue.
More than 2,000 delegates have attended the First Global Symposium on Health Systems Research, in Montreux, Switzerland this week (16–19 November), organised by the WHO and partners. Speakers include many international experts at the forefront of public health.
Such high-level academic and policy debates about health systems are vital. But meetings where top researchers exchange ideas with policymakers run the risk of being elitist and overly academic, and contributions from social scientists are often a lower priority than research into drugs or vaccines.
Improving health systems is not an exact, theoretical science. So much is highly practical, such as the state of transport systems. The November conference must, therefore, not ignore a key group in developing countries — health workers themselves.
These workers are struggling on a daily basis to provide the best care they can while battling with poor transport and infrastructure, lack of medicines, and drugs that are too expensive for their patients. In addition they must endure difficult working conditions such as grossly overcrowded hospitals or power shortages.
Their recommendations and feedback on the shortfalls in health systems is the practical input that is desperately needed, yet not often sought.
Workforce and feedback crisis
Health professionals are the backbone of any health system — but a major reason for crumbling health systems in developing nations is a shortage of workers. Lack of healthcare personnel could also hinder progress towards the Millennium Development Goals (MDGs), an issue discussed on the fringes of the UN MDG Summit in September.
The WHO says 57 countries face a severe workforce crisis — defined as a healthcare system with fewer than 2.3 health professionals per 1,000 of population. Many developing countries must manage with levels well below this. Cameroon, for example, has just four health workers for every 10,000 people.
'Fragile states' have an average of just 0.6 health workers per 1,000 population, confirmed Carolyn Miller, chief executive of Merlin, a UK medical aid agency, speaking at a side-event at the MDG Summit, co-hosted by the Global Health Workforce Alliance and other partners.
It seems obvious that improving a healthcare system requires the input of health workers. For instance, a Mumbai-based cancer surgeon, who works in both the UK and India (and who preferred to remain anonymous), told SciDev.Net that one of the "main challenges in healthcare systems in India relates to the regulation and coordination of services".
A vast number of healthcare providers in India are barely regulated, which "results in huge variations of the quality of healthcare being provided". Furthermore, poor levels of education among healthcare consumers and the high regard with which the medical community is held in India mean that reported cases of medical malpractice are rare, which exacerbates the problem, the surgeon said.
However, according to the Alliance, healthcare workers are rarely consulted when evidence is gathered for improving health systems or identifying research needs.
"Health workers are the practitioners on the ground, taking the pulse of the health system on a daily basis in their face-to-face interactions with patients," said Dr Mubashar Sheikh, Executive Director of the Alliance, "They have first-hand knowledge of the needs and challenges they face in delivering the best possible care. It is vital to seek their individual perspective on what works, what does not work and what could be done differently".
Old solutions, new thinking
Insight that needs to come directly from health workers includes issues such as why they emigrate — as this exacerbates the severe shortage of personnel — and what incentives might make them stay.
Health workers in any country tend to concentrate in cities, but in developing countries the needs can be much greater in rural areas, and effective incentives could include bonuses for health professionals working outside of urban centres.
In developing countries, health workers also risk contracting disease; in South Africa, for example, many have HIV. Understanding their health could also help retain higher numbers within the workforce.
Another solution to the shortage of health professionals has been to recruit less-skilled workers to liaise between the health system and the community. The WHO is currently trying to promote the delegation of basic tasks from doctors and nurses to community health workers, using the term 'task shifting'.
But doctors and nurses in developing countries are concerned: can this be managed so that community health workers are not asked to undertake roles requiring a high level of medical knowledge? Feedback from health professionals is clearly vital to implementing new policies on task shifting.
The symposium this week will be retreading some old ground — these problems were identified as far back as 2004 at a meeting in Mexico to discuss the improvement of health systems. This time the meeting must ensure that high-level discussion leads to action and to real change in understanding and policies.
And if academics and policymakers hope to improve health systems, they also need the input of local doctors and nurses.