Spotlight Interview

With Eric Buch
Conducted January 2008
Eric Buch is Professor of Health Policy and Management in the School of Health Systems and Public Health at the University of Pretoria and is Health Adviser to the New Partnership for Africa's Development (NEPAD). He is a member of the ICHRN Strategic Advisory Group and currently sits on the board of the Global Health Workforce Alliance.

ICHRN: As a member of the Board of the Global Health Workforce Alliance (GHWA), what do you see as the most pressing challenge confronting health human resource policy makers in the African region?

Eric Buch: The work of the GHWA has shown that it is not possible to single out one challenge. Rather, the goal is to emerge with a package of policies that will work together to overcome the multiple interlinked causes that drive the health workforce crisis in Africa. Although one could list one line policy answers such as “reduce migration”, “improve salaries and incentives”, “scale up training” etc., the real challenge is to find policies and strategies that will actually successfully do this. So, as decided by Africa's Heads of State at the Fourth Assembly of the African Union, countries need to “Prepare inter-ministerial costed development and deployment plans to address the Human Resources for Health crisis”. This will require a set of policies and strategies by Ministries of Health to:
  • Convince their own countries, in particular their Finance and Planning Ministries, to invest more resources in health and not to reduce the country's own expenditure as development aid increases. This will not only allow for employment of more health workers, but also improve the health system in which they work by providing the drugs, equipment, facilities and working referral systems they need _ the lack of which undermines the morale of even the most committed health workers.

  • Agree with Ministries of Education on how to scale up education of health workers to achieve the numbers required at the quality desired. This will require forward funding of establishments to reach the needed training capacity.
  • Gain support from Ministries of Public Service / Public Service Commissions for faster processing of appointments and better packages and incentives for health workers. There should be special incentives for those working in disadvantaged areas to help the drive towards equity. There is also a need for more flexible employment policies, such as 3-5 year contracts that can be renewed on the availability of further funding (as opposed to permanent employment only). This would overcome the argument that one cannot employ more health workers because funding is not permanently guaranteed.

  • Come up with different scenarios and show what can be delivered with different levels of staffing. One of the mistakes that we have made as Africans is to continue to commit to achieving goals that are unrealistic against the resources available. Then, when we don't meet these expectations the perception is reinforced that Africa doesn't deliver on its promises or that Ministries of Health are not effective. We need to be bold enough to say what can be achieved with the health workforce we have, even if this means saying we will not achieve the Health Millennium Development Goals or Universal Access to anti-retrovirals (ARVs) with the resources available, and then show what it will take to get there.

  • Determine the categories of professional, auxiliary (mid-level) and community health workers that will provide an appropriate human resource mix for their needs. Neither a policy that is loaded to overly rely on professionals nor one that “throws” thousands of community / village health workers into the mix with inadequate training, supervision and support is the answer.

Finally, this answer cannot be complete without stressing the need to seek policies to ensure universal access to ARV care and prevention measures for nurses. They cannot care if they are not cared for. No need to say more.

ICHRN: What is the GHWA doing to address this key set of challenges?

Eric Buch: A wide range of actions is being accelerated – too many to detail here. Successful advocacy about the human resources for health crisis and its implications is moving this to the top of the health development agenda and realising a number of changes, both in Africa and globally. The GHWA has established international task forces on scaling up education, migration and financing, all with a strong focus on Africa. There has also been work on the skill mix and how to develop effective community health worker programmes. The GHWA Forum in March in Kampala, Uganda will be a unique opportunity to share experiences and learn from one another. It was rewarding and exciting to listen to Africa's health ministers briefly sharing their challenges, initiatives, innovations and ideas of what not to do at the AU Health Ministers Conference early in 2007. The GHWA and its African Platform offer to deepen this shared learning. An inter-ministerial meeting, hosted by WHO, brought together high level officials in health, education, public service and finance. The range of proposals which emerged on how to deal with the full extent of the intersectoral challenges was well received by Africa's Health Ministers. The African Union and WHO Regional Office for Africa are committed to taking this agenda forward.

The GHWA has provided funding to a number of African countries to work as pathfinders in the process of developing effective national HRH strategies and plans and has developed tools to assist in this regard. African HRH consultation and strategy meetings at the Regional Economic Community level have been supported, some of which brought HRH directors and other stakeholders together for the first time.

ICHRN: How do you see the ICHRN, as part of ICN, working with GHWA?

Eric Buch: It's simple. Nursing is the backbone of Africa's health system and the ICHRN, or where appropriate the International Council of Nurses (ICN) and its regional structures should be deeply involved in every aspect of the GHWA effort. ICHRN has unique insights to bring and should be on all the task forces of the GHWA. It should also bring its depth of understanding and strategic sense to advocacy, policy and leadership. It is a mutually beneficial relationship. If you don't get your nursing right, you don't get your health system right.

ICHRN: The migration of nurses from South Africa to countries such as Australia, USA, Canada, Saudi Arabia and within the African continent has been described as being significant in recent years. There is also an increasing number of nurses moving from the public to the private sector in South Africa. What has been the impact of this on health system coverage in South Africa?


Eric Buch: The answer to this must be seen in the context of nurses being the backbone of our public health system, the absence of clinical assistants in South Africa and the South African commitment to not poach health professionals from other African countries. So, nurses lost are not easily replaced.

The private sector in South Africa absorbs about 60% of total health spending for about 20% of the population and has a voracious appetite for nurses. Although urban public hospitals are affected, public district and rural hospitals and clinics suffer most. The number of consultations may be maintained, but as nurse workload grows, quality of patient care and morale are the big losers. This leads to more resignations creating a vicious cycle.

Responses to migration are growing and the country is on the verge of further significant improvement in conditions of service for health professionals in the public sector, but there is still much to do. Certainly, the onus, is on the recipient countries to make a better effort and not to simply suck nurses out of Africa as a low cost solution _ they haven't invested in the nurses' primary, secondary or tertiary education and other social services. And, the cost to the country goes beyond these direct costs. We know that health contributes to social and economic development, so the increased health burden from an undermined health system impedes economic growth. The calculations that I have seen have failed to take this latter factor into account. It would be interesting to determine if the full cost of the loss of health professionals exceeds that of development aid in health! Africa's Health Ministers', understandably, are passionate about the issue of migration and it will be interesting to track the responses that are emerging from rich countries to their calls for a comprehensive solution. Unless Africa can stop the profuse bleeding of its health professionals, the prognosis for its health systems is poor.

ICHRN: In what ways is South Africa harnessing the Diaspora for health workforce development?

Eric Buch: It is not clear if you mean the Diaspora generally, or the South African Diaspora specifically. Either way, the answer is not very much. In some ways South Africa is quite self-sufficient. In other ways, a clearly thought through Diaspora programme could add enormous value. For example, a programme that could ensure a regular flow of specialized nurses (e.g. theatre, orthopaedic, paediatric) to hospitals that find it hard to recruit and retain them could play an invaluable role in imparting essential skills to local staff and enhancing standards. South Africa does have some government to government arrangements. However, if it is to tap the Diaspora more effectively, it will have to create wider networks for this, market them better and streamline the professional registration and administrative processes.


ICHRN: Some countries in Africa report unemployed or underemployed nurses. What are the causes of this and what can be done to enable them to use their skills?

Eric Buch: This is a real tragedy – at every meeting of Africa's Health Ministers we hear about another country where this is happening – and these nurses don't wait in their country for long before they are lost. I outlined some of the key causes in my answer to the first question – inadequate funds, too little flexibility and too few posts. It is important that posts be set at the number needed to deliver and not simply at what the budget has available. The number of unfunded posts will then show the gap between what the budget can pay for, and what the country actually needs. This will also help in lobbying for funds and change the artificial perception that some countries have a surplus of nurses simply because there are more nurses than posts, when in fact there is an absolute shortage of nurses against any empirical calculation.

The roots of the problem of unemployed nurses extend beyond the country. Most countries in Africa do not have the fiscal space to fund the posts they need and have budget caps on increases in social spending – often encouraged by international funders. So, development aid is and will remain a real feature in Africa's health budgets for the foreseeable future. This is where some important changes can be made, as the architecture of development aid has been wanting. Donor funding has too often been short term and not dependable, disease based rather than health system based and has often excluded human resources costs. It took the Global Fund to Fight AIDS, TB and Malaria too long to realise that it doesn't help to pay for medicines if you haven't got nurses in the system to deliver the care. There are important changes emerging in donor approaches and it will be interesting to track the application of these promises. But, still too much funding is going into creating parallel systems that entice nurses out of general clinics – and then there are complaints that the health system is not functional. At the same time African countries need to show that they are truly committed to health by allocating more of their own funds to health and preferentially allocating funds mobilised by debt relief to more posts.

What is needed on this score is a massive advocacy campaign in Africa and across the globe. ICN and the GHWA should mobilise a “No unemployed nurse in Africa” campaign. I think this could really take hold. At least one country has already adopted this policy.

ICHRN: Can you briefly describe for our readers what NEPAD s current policies and activities are in the area of nursing human resources?

Eric Buch: The core action to express the NEPAD developmental vision is based on country action and through Regional Economic Communities. The small NEPAD secretariat is not itself an implementation agency. Its role is to facilitate, mobilise, enable, leverage and generate commitment, both on the continent and beyond. NEPAD recognized the importance of addressing health workforce challenges in the Health Strategy adopted by Africa's Heads of State in 2002. Then, as global interest emerged, NEPAD made a strategic decision to invest energy in helping to build the Global Health Workforce Alliance and in particular to bring an African perspective to the Board. It has also played a role in establishing the African Platform on Human Resources for Health and has been active in African Union and other efforts on HRH. There have also been engagements by NEPAD on HRH with the G8, the Blair Africa Commission and in other forums, as well as on the architecture of development aid, lobbying to balance in support for health systems and HRH. The NEPAD position on AIDS has always called for access to ARVs with the health system and human resources investments needed to do so. We have emphasized that human resources – the shortage of trained and motivated doctors, nurses and other health workers – is the key rate limiting factor in achieving progress in scaling up disease programmes.

One of the critical obstacles to effective health systems performance is weak mid-level management capacity. NEPAD has initiated a course for district health managers from Southern African Development Community (SADC) countries. The goal remains to develop such courses for the rest of Africa as well.

As you can see from my answer, NEPAD, as a small secretariat, has not worked specifically on issues affecting any specific health profession, including nursing, rather it works generically. Nonetheless, nursing examples and issues are at the forefront of any HRH agenda – they have to be!

NEPAD is a programme of the African Union, which needs to continue to take on a continental policy and strategy role, supported by the likes of the GHWA, the World Health Organization Regional Office for Africa and of course organisations like yours – the ICN. This should facilitate countries working together on actions that need continental solidarity and leadership. One of these is undoubtedly migration, where engagement with developed countries is clearly a priority.

ICHRN: Recently there has been a lot of debate about “scaling up" the workforce in Africa. What do you think will be the most effective and sustainable strategies for scaling up the health workforce in South Africa in particular and on the continent more broadly?

Eric Buch: Scaling up has three elements: better retention, more posts and more training. I think we have addressed the former two already.

South Africa needs to better retain the professionals it trains and fully mobilise its nurse training capacity. The private sector has embarked on nursing training and this has been a positive development. Nurse training in the public sector was curtailed in the mid 90s in line with the fiscal restrictions of the time. The country can comfortably afford to reverse this.

Under apartheid, policies were built on what served white interests best and this led to neglect of the role of mid level / auxiliary workers, who fill a critical niche in bringing good standard care to all South Africans. South Africa has had the introduction of mid-level workers in its health plans for almost a decade now, but progress has been slow. Clinical officer training will start soon and is being very actively stewarded by the Ministry of Health, but there needs to be a much bigger push to fund training for all categories of mid-level workers and to create posts for them.

Although there were various initiatives, community health worker (CHW) programmes had been poorly supported in South Africa until the emergence of AIDS Home Based Carers. Government has actively stewarded this development and provided substantial funds for this, including their reimbursement. There have been challenges, but this has been a positive development. It is my view that not only for South Africa, but for Africa as a whole we need to move to consolidate this level of worker. We need to integrate the different vertical categories, which are not sustainable or cost-effective, into a collective of CHWs, who are suitably recruited, trained, supported and remunerated and work full or major time. I think we should have four categories: family health workers, chronic care workers, environmental health workers and rehabilitation workers. I think the former two should be categories of nursing.

At the continental and global level, the GHWA Task Force on Scaling Up Education will provide its comprehensive report soon. I will make just one or two points. Africa is producing excellent nurses without much of the infrastructure that is taken for granted elsewhere. Scaling up is not that difficult if the resources to do so are made available – more teachers, being the most critical. At the same time we do need a better understanding of what the shortfalls in current staff and facilities are for the students in training, let alone what is needed to reach full potential. Certainly many colleges are not training large enough groups to achieve economies of scale and this seems a good place to start upscaling because the framework is there.

ICHRN: Is there anything further you would like to communicate to our readers interested in health human resource issues?

Eric Buch: You have posed quite searching questions so there has been a lot for me to digest – and I guess for your readers too. A last word: the changes in the past few years in recognising the value of the health workforce, and nurses in particular, are really gratifying. We need to use this space and energy effectively to make sure this is not just a passing window of opportunity. It must be a sustained, comprehensive effort to overcome the crisis. We owe it to our poorest people and to our dedicated health workers.