Community health worker distributing medications
A community health worker distributes medications in Haiti

For years, Partners In Health has advocated for accompaniment – medical, social and economic support provided by paid community health workers – as the key to delivering quality health care in poor communities. For much of that time we encountered skepticism from global health experts and policymakers accustomed to relying on universiity-educated consultants and doctors rather than on locally trained villagers. Now the tide has turned. Confronted with the double-barreled crisis of pandemic disease and a catastrophic shortage of trained health personnel, the international aid community has embraced “task-shifting” to community health workers and other paraprofessionals as the only way to meet the challenge, particularly in Africa. PIH and our Haitian partner organization, Zanmi Lasante, have taken a leading role in developing international guidelines for task-shifting and the role of community health workers.

The World Health Organization (WHO) was the first agency to raise the alarm about the worldwide health worker shortage. In 2003, when the agency began to roll out its 3 x 5 AIDS treatment program (with a goal of treating 3 million people infected with HIV/AIDS with antiretroviral therapy by 2005), it was confronted with a dramatic absence of health infrastructure in the areas the programs was designed to serve. Antiretroviral therapy could not be administered without a network of nurses, doctors, community workers, and lab technicians. But in most African countries, these medical personnel were nowhere to be found, especially outside the capital cities.

It is now widely recognized that the world is experiencing a chronic shortage of trained health workers—one felt most acutely in those countries that are experiencing the greatest public health threats. In fact, the shortage of human resources has replaced finance issues as the most serious obstacle to implementing national treatment plans. WHO estimates that more than 4 million health workers are needed around the world to fill the gap between what is there and what is needed.  Sub-Saharan Africa alone faces a shortage of more than 800,000 doctors, nurses, and midwives, and an overall shortage of 1.5 million healthcare workers.

The causes of the shortage of health workers are complex, as noted in a recent PIH Action Alert. The HIV pandemic itself has been a major factor, both because it has greatly increased the need for health care and because it has decimated Africa’s healthcare workforce. In South Africa, it is conservatively estimated that 16 percent of healthcare staff are HIV-positive. In Malawi, the government expects to lose three percent of its already understaffed and underfunded health workforce to the disease each year.

There are many other reasons to account for the critical shortage of health workers, including: a lack of sufficient and relevant training capacity to produce the number of health workers required; an inability to retain health workers due to poor working conditions and meager salaries, often caused by restrictions on public sector spending imposed by international donors and financial institutions; and, lastly, "brain drain" – the large-scale emigration of health care workers seeking better paying and more satisfying jobs in countries with greater resources, such as the United States, England, and Canada. To cite one striking example, there are more Malawian doctors practicing medicine in Manchester, England, than in all of Malawi.

WHO has acted to address this barrier to universal access to care. In May 2006, a new global partnership – the Global Health Workforce Alliance (GHWA), hosted by WHO – was formed to address the worldwide shortage of nurses, doctors, midwives, and other health workers. Its stated goal was to increase the number of qualified health workers rapidly in countries experiencing shortages. Last August, the agency announced a new global strategy – Treat, Train, Retain (TTR). This broad, multifaceted AIDS health workforce plan is being undertaken under the umbrella of the Global Health Workforce Alliance and has been designed to involve the key stakeholders in human resources for health.

One of the primary working groups set up by the GHWA under this strategy was an 11-member task force – the Joint WHO/OGAC Technical Consultation on Task Shifting – made up of representatives from HIV programs and human resources departments from Ministries of Health, professional associations, academic institutions, and others. This task force has been charged with promoting increased investment in educating and training health workers in developing countries and boosting international support for practical strategies to address the shortage. Initially it will deal with the key elements of a regulatory framework to support in-country implementation of task-shifting. The task force will also focus on the need and scope for financial and technical support worldwide; the links between training institutions and universities in developed and developing countries; and innovative use of technology for distance education.

 Dr. Wesler Lambert
Dr. Wesler Lambert

PIH is represented on this task force by Dr. Wesler Lambert, HIV/AIDS and Maternal and Child Health Program Advisor for Zanmi Lansante in Haiti. The task force met for the first time in February 2007 in Geneva to discuss the need for a draft regulatory framework for task-shifting that can be validated at the country level before being recommended to countries and to agree on a series of steps towards the development and the implementation of certification and credentialing mechanisms to support task-shifting for HIV service delivery in affected countries.  The task force will meet again in June, in Rwanda, and is scheduled to present its initial recommendations to GHWA in the fall of 2007.

[published April 2007]