African countries are in need of an agile and skilled health workforce that can make optimum use of scarce resources, especially in rural areas. Three East African nations—Rwanda, Tanzania and Malawi—are looking to innovative partnerships to build sustainable healthcare ecosystems.
Students graduate from University of Global Health Equity’s Butaro Campus in Rwanda.
Photo: 64 Waves for UGHE/Partners In Health
The difficulty in training and retaining skilled health workers is one of the principle obstacles to improving healthcare access and outcomes in sub-Saharan Africa.
African healthcare systems face many key challenges, including the growing double burden of infectious and non-communicable diseases (NCDs) and a health infrastructure that remains underdeveloped compared to those in high-income countries (HICs). African countries have higher percentages of population living in rural areas; about 58% of the population in sub-Saharan Africa lived in rural or underserved areas in 2021, according to the World Bank.
In 2022, the continent had 3.6 million health workers across 47 countries—that is, 1.55 physicians, nurses and midwives per 1,000 population, according to a 2022 study published in BMJ Global Health. Only four countries in the survey had 4.45 physicians, nurses and midwives per 1,000 population—the threshold seen necessary for universal health coverage.
At 37%, nurses and midwives make up the largest share of healthcare workers in Africa, according to the BMJ study, while just 9% are medical doctors, 10% are laboratory personnel, 14% community health workers, 14% other health workers, and 12% administrative and support staff.
The chronic shortage of skilled health workers reflects a number of broader problems that need to be addressed, regional experts say. A lack of professional mentors, networks and continuing career development, alongside poor working conditions can make it difficult to retain staff, especially in rural areas.
African ministries of health often are still reliant on donor funding from non-governmental organisations (NGOs) or foreign governments to deal with priority disease areas or preventive care. With expenditure focused on vertical, or stand-alone programmes, interventions are often focused on specific disease areas with separate funding and administration that can be difficult to integrate with the wider health system.
“You can’t get money for primary health—it’s not vertical enough,” says Dr Corrado Cancedda, a strategic advisor for academic partnerships at the Center for Global Health at the University of Pennsylvania Perelman School of Medicine. “There’s no CDC [US Centers for Disease Control and Prevention] grant you can apply [for] to train a bunch of practitioners in Africa.”
There are labour shortages among both primary care and speciality physicians, nurses and community health workers, as well as support staff. Although there have been some experiments with task-shifting , in which lay health workers provide care for diseases such as HIV/AIDS and chronic conditions to bridge the shortage of healthcare personnel, governments will need to remain flexible and ensure that less qualified healthcare providers can continue to gain credentials on the job.
There are signs that some donors are recognising the gaps in support. In May 2022, the Biden administration announced the launch of the Global Health Worker Initiative (GHWI) and committed investing US$1.33 billion annually in health workforce development in the African region from 2022 to 2024, including recruitment and training of clinicians, community health and care workers, and public health professionals.
Meanwhile, a handful of East African nations—Rwanda, Tanzania and Malawi—have used innovative partnerships to build capacity in the health professions in a sustainable way.
Rwanda: Evolution of a regional leader
Rwanda was one of the earliest in the African continent to commit to universal health insurance in 2000. Along with several regional neighbours, Rwanda has recorded significant progress between 2000 and 2019, according to the World Health Organization (WHO). The country introduced Community-Based Health Insurance as early as 1999, the WHO says, and was “not far off UHC [universal health coverage]” by 2011, although its insurance system has faced financial constraints since. More recently, it has been the site of two projects designed to help develop infrastructure for training a new generation of health workers.
The Human Resources for Health (HRH) project, which ran for seven years between 2012 and 2019, connected the National University of Rwanda with a consortium of more than 20 US academic institutions. Designed in conjunction with Rwanda’s Ministry of Health—and with a budget from the US government and the Global Fund—the programme aimed to address the shortage of skilled health workers and improve the quality of health worker education, the educational infrastructure and the management of health facilities.
“What we did there was extraordinary. Over 4,000 health professionals graduated, including a few hundred specialists, over 3,000 nurses, and a few hundred dentists and managers.”
In addition to offering advanced degrees for physicians and nurses, and undergraduate programmes in dentistry, HRH offers advanced diplomas and bachelor’s degree programmes for nurses and midwives, and master’s degrees in global health delivery and hospital administration. For the duration of the programme, North American partner institutions sent faculty members from medical, dentistry, nursing and health management programmes to schools of medicine, nursing and hospitals throughout Rwanda.
The programme was unique in the scale of its ambition, says Cancedda, who managed the contribution of seven Harvard-affiliated institutions to the HRH programme while working as an associate professor at Harvard Medical School. The financial scale of the HRH programme and the depth of partners was matched by the level and diversity of professionals it produced, he adds. The extended length of the programme also enabled faculty in Rwanda to develop continuing professional relationships with their counterparts in US universities.
“A lot of projects will be splintered into US$2 million to US$3 million across four years; this one was US$150 million over seven years,” he says. “What we did there was extraordinary. Over 4,000 health professionals graduated, including a few hundred specialists, over 3,000 nurses, and a few hundred dentists and managers.”
HRH was also distinctive due to the Rwandan government’s ownership of it; programme funds went directly to Rwanda instead of to partner institutions, or via NGOs.
University of Global Health Equity’s Dr Ornella Masimbi teaches medical school students with the assistance of state-of-the-art mannequins.
Photo: O’Rule/Partners In Health
“It was truly transformational,” Cancedda adds, observing the way in which the project was managed and funding channelled. “It required all the major brokers to do things in ways that were substantially different than what they were used to.”
Sustainability has been a key goal: the pairing of visiting and Rwandan faculty was designed to maintain support for health education, and the programme included measures for continuing education of health professionals. In addition, the government required the freshly minted graduates to commit to working in the country’s public sector for a few years, in an attempt to aid retention.
While HRH centred around teaching institutions in Rwanda’s capital city, Kigali, another project has focused on training in rural areas, where much of the need for healthcare remains.
Launched in 2015 by Rwanda’s government with funding from the Bill & Melinda Gates Foundation and Cummings Foundation, the University of Global Health Equity (UGHE) is a private institution located in Burera district, around 129 km north of Kigali. Focused on equity and social determinants of health, UGHE combines education in human rights and social justice with community-based medical training.
Judy Khanyola, a registered nurse and chair of UGHE’s Center for Nursing and Midwifery, emphasises the importance of viewing training more broadly. The programme is training nurses to treat patients holistically, rather than viewing them solely through the prism of their illness.
Nurses in the region, struggling to deal with overwhelming workplace demands, still need to learn how to be compassionate, alongside technical competencies, she says. “We forget that people come from a social environment and a social ecosystem.”
UGHE is training nurses across specialities, from oncology to family practice, she says, and the students come from Rwanda and neighbouring countries such as Botswana, Malawi, Kenya and Ethiopia, as well as Nepal, Bangladesh and the US, putting it on the path to becoming a centre of regional and national excellence.
“We are changing the way we are teaching, and we are also collaborating, to harness the strengths of global health institutions around the world,” she adds, noting that UGHE has partnered with nursing and midwifery programmes in both the global north and global south.
While UGHE’s first students have worked toward a Master of Science degree in global health delivery, with 23 students from 12 African countries graduating in 2021, the university launched a full medical degree programme in 2019, welcoming 30 local students, of which two-thirds are women. It also offers students the opportunity to “upgrade” their skills.
The nearby Butaro District Hospital, supported by the US health charity Partners in Health (PIH), will serve as the teaching hospital for the course, and the three districts that PIH serves in Rwanda will have research and training opportunities for students. Because the university is funded by private donors, it is able to provide training for free.
“It is still a work in process,” Khanyola says. “But to me, the important change UGHE has brought is in mindset.”
Tanzania: Building from the bottom up
At the most fundamental level, capacity-building in the health workforce relies on a qualified and sustainable middle cadre of professionals who can fill the primary health needs of rural communities.
Tanzania is pursuing efforts to develop, support and mentor health workers with the aid of both NGOs and the Benjamin Mkapa Foundation, a health charity named after Tanzania’s third president.
The Mkapa Foundation operates two-week training modules on basic primary care, including hygiene promotion, nutrition and reproductive healthcare for community health workers, using guidelines set by the Ministry of Health. The foundation also offers scholarships to enable graduates from local communities to upgrade their training through two-year certificate and three-year diploma courses in maternal and newborn health, according to Hendry Samky, head of the Mkapa Foundation’s health systems training unit.
The development of a specialised cadre of biomedical engineers is a crucial part of a sustainable health workforce.
Although the foundation is helping build a broad base of health workers, Tanzania faces a number of continuing challenges, Samky says, notably the need to beef up ancillary facilities for training.
“If you look at public health training institutions, they have a lot of candidates, with limited resources to support training,” he adds. “Libraries and classes that can help institutions deliver training are important. Another challenge is [the requirement for] qualified trainers, because professional development for trainers is not given priority.”
Samky flags another widely shared concern: the absence of professionals with technical skills who can support technology and innovation in healthcare delivery, as well as laboratory scientists and specialists such as anaesthetists.
“In the past five years, we have invested a lot in innovation and improvement of primary healthcare in Tanzania in various health facilities; most of the existing healthcare workers in those facilities, like radiology and laboratories, aren’t equipped with the skills and knowledge for using those machines,” he says. The development of a specialised cadre of biomedical engineers is a crucial part of a sustainable health workforce, he adds.
Malawi: A focus on integration and support structures
In Malawi, policymakers focusing on health workforce development are championing the integration of existing programmes in an effort to conserve existing skills and resources. They are also developing mentoring programmes to provide extra support to health workers, especially in rural areas.
With a growing double burden of infectious diseases and NCDs, Malawi’s 2023-2030 strategic health plan, launched in early January, is focused on how to use staff resources more efficiently.
“We are looking at the whole spectrum of health workforce needs; the government has been pretty good at developing mapping and policies around that, but even today 50% of positions have not been filled,” says Dr Luckson Dullie, a family physician who is the executive director of Partners in Health (PIH) in Malawi.
"There are a lot of vertical programmes, such as HIV treatment, which receive Global Fund money, but if we integrate better, we can be more efficient with the resources we have."
The organisation works in the rural region of Neno, where there are just 90 nurses and four physicians for a population of 160,000; the region’s 14 clinics offer decentralised treatment for illnesses ranging from HIV/AIDS to NCDs. A key aim of PIH’s programme in the region is to help integrate care so that patients attending an HIV clinic, for instance, are screened for chronic conditions as well. As part of this focus, PIH opened Malawi’s first specialised NCD clinic at Neno District Hospital and Lisungwi Community Hospital in 2018, adding secondary-level care to the primary care clinic.
Nurse John Paul (left) and Dr George Talama (right) check on a recently diagnosed 27-year-old HIV patient who has severe depression at Neno District Hospital in Malawi.
Photo: Zack DeClerck/Partners In Health
“There are a lot of vertical programmes, such as HIV [treatment], which receive Global Fund money, but if we integrate better, we can be more efficient with the resources we have,” Dullie says.
Given the challenge of retaining health workers in rural areas such as Neno, PIH Malawi has also set up a mentorship programme for nurses in the region.
“We have 14 facilities—two hospitals and 12 healthcare centres—serving 10,000 to 15,000 people each; there are mostly two nurses per facility,” he says. “In these settings, it is easy to feel very isolated and not supported, so nurses with advanced skills work alongside these nurses to help them acquire the different skills they need and improve best practices.”
The programme identifies nurses within the Ministry of Health system who already have advanced skills and trains them to become mentors, creating a more sustainable system of professional support that can complement opportunities to upgrade skills and credentials.
Building skilled workforces at a policy level
To ensure African countries develop the agile and skilled health workforces that will allow them to make the best use of scarce resources, governments across the continent need to take a fresh look at how health systems are run.
Khanyola in Rwanda argues that a certain degree of flexibility is needed at the national level to allow practices to change. This involves both greater acceptance of task-shifting, such as permitting non-specialist nurses to fill in at operating theatres, as well as allowing professionals to receive additional training while continuing to work at the same time. “The scope of practice needs to be widened,” she says.
Health policymakers can revisit guidelines and work to integrate health delivery where possible, including helping professionals upgrade skills and acquire new ones. African training programmes also need to look beyond health workers directly involved with patients and commit to educating new professionals—from administrators and managers to laboratory technicians and biotechnology engineers. Meeting these goals will help the continent manage its multiple health burdens sustainably.