Achieving the Health Millennium Development Goals (WHO) in Africa will require substantial investments in training a dynamic and skilled health workforce. Most countries in Africa are experiencing significant underfunding of the health sector which co-exists with critical health workforce shortages, maldistribution and inadequate performance. Health sectors in Africa are facing serious challenges in producing, employing, incentivizing, motivating and managing results based performance.

Globally, Africa ranks the lowest in the availability of health personnel. Out of the 57 countries identified by World Health Organization (WHO) in 2006 as having critical shortages in health workers per population, 36 were in Sub-Saharan Africa. With 12% of the world population and 25% of the world's burden of diseases, Africa has only 3% of the world health workforce. The problem is more acute in rural areas that fail to attract and retain the minimum numbers of motivated and skilled health workforce. In 2006, WHO estimated that approximately 1.5 million additional health workers are required in Africa to meet the minimum density of 2.28 health workers per 1,000 population to provide essential care. 36 countries in Africa do not meet that requirement.

The stewardship of Ministers of Health and Finance is critical in this endeavor.

The African Development Bank works towards allying partners behind the Human Resources for Health agenda. On July 4-5, 2012, the African Development Bank in collaboration with Harmonization for Health in Africa (HHA) partners organized a high level dialogue between Ministers of Finance and Health on "Value for Money, Sustainability and Accountability". The conference gathered Ministers of Finance and Health and/or their representatives from 54 African countries, African parliamentarians as well as over 400 participants from the public and private sectors, academia, civil society and media globally. His Excellency Hamadi Jebali, Prime Minister of Tunisia, Dr. Donald Kaberuka, President of the African Development Bank, and Dr. Margaret Chan, Executive Director of the World Health Organisation delivered the opening remarks.

Distinguished guests such as Dr. Michel Sidibe, Executive Director of UNAIDS, Dr. Babatunde Osotimehim, Executive Director for UNFPA, Mr. Gabriel Jaramillo, General Manager of the Global Fund to Fight AIDS, Tuberculosis and Malaria and Mr. Seth Berkeley, CEO of the Global Alliance for Vaccines and Immunizations (GAVI) delivered keynote speeches.

High-profile speakers like Julio Frenk, Dean of the School of Public Health, Harvard University and Hans Rosling, Chairman of Gapminder Foundation also delivered keynote speeches during the conference.

This conference emphasized the urgent need for greater domestic accountability, reduced dependence on foreign aid and value for money in the delivery of health services in Africa. It gathered the expertise from all over Africa as well as globally featuring speakers from India, China, Brazil, Vietnam and Kyrgyzstan. This high level dialogue culminated in a Tunis Declaration endorsing, among other things, taking advantage of Africa's demographic transition to invest in human capital and provide equitable access to skilled health workers and the introduce measures such as results based financing to enhance transparency, performance and reduce wastage in order to deliver better health services in Africa.

What can be done?

Salary is perceived as the most important factor for retention of health workers in Africa. Increasing wages was associated with decreases in annual attrition from public health workforce by 1.5% among younger workers in Ghana.

Tasks shifting--having lower skilled cadres or even non-professional workers undertaking tasks previously performed by more skilled colleagues --can reduce the production cost of health services.

However this strategy needs to be adopted with care. Changing the ratios of doctors to nurse/midwives can achieve productive efficiency when the appropriate mix is reached within a budget constraint. The strategy proved to be successful for example in reducing clinic operation cost in Uganda and South Africa, increasing access to HIV services in Botswana and Zambia, and improving health outcomes in Zambia, Uganda, South Africa, Mozambique, Uganda and Malawi. Evidence from Tanzania and Mozambique about producing and deploying non-physician surgery technicians shows improved access to emergency obstetric care and cost effectiveness. Also, according to 2010 study by the Global Health Workforce Alliance, the services offered by Community Health Workers have helped in the decline of maternal and child mortality rates (Bangladesh, Ghana, Brazil) and have also assisted in decreasing the burden and costs of TB (Ethiopia, South Africa) and Malaria (Uganda, Cameroon).

Country experience suggests that health workers with a rural background are more likely to work in rural settings as observed in Ethiopia and Rwanda. Targeted admission policies in health professional schools to increase the selection of students with a rural background are a successful strategy.

Similarly, locating schools outside of capital cities is facilitating rural deployment in Mozambique and the Democratic Republic of Congo.

Use of information and communication technology (ICT) to support distance learning has proven to have a positive impact not only on education but also on the motivation and retention of rural health workers in Tanzania. In May 2012 the African Development Bank (AfDB) announced the launch of its eHealth award, which recognizes the best Authentic African ICT solutions in health.

What is being done?

Malawi, has implemented an emergency innovative HRH program including skills substitution to enhance training, deployment and retention of health workers. This initiative is credited with saving 13 000 lives, largely through increased coverage of reproductive, maternal, newborn and child health interventions. Linking pay to performance is introduced in some African countries in order to deliver more value for the money available (Result based financing in Rwanda) to improve outputs, service quality and outcomes.

Under the Harmonization for Health in Africa (HHA), the Human Resources for Health (HRH) Community of Practice (COP) the African Development Bank is assisting African Countries in dealing with the HRH issues.

The African Development Bank is a member of the Global Health Workforce Alliance (GHWA) as well as HHA contributing to the resolution of the HRH problems.

The Bank has been actively bringing private investments to the East African region in a public private partnership to establish regional centres of excellence in medical education, bio-medical engineering and social sciences postgraduate education and research

The Bank is taking a lead role in coordinating Health Development Partners in Africa through the HHA mechanism and various communities of practice (HRH, Health Financing, etc.)