As discussed in Chapter 1, current resource constraints in donor nations and the growing HIV-related needs and demand for treatment in Africa are at odds. Lacking well-functioning health systems,2 African nations are ill prepared to confront the looming HIV/AIDS burden of 2020 to 2025. Accordingly, the international community must focus on enabling them to muster the necessary internal resources. A major requirement to this end is to strengthen health care systems, in particular by building institutional and human resource capacity.

The Health Workforce Crisis

Health workforces play a crucial role in achieving the United Nations’ Millennium Development Goals (MDGs). For example, the supply of health workers impacts the health of women and children. Yet only 5 of 49 low-income countries have the minimum 23 doctors per 10,000 inhabitants, recommended by the World Health Organization (WHO) (WHO, 2010a). Three major forces challenge the health workforce in Africa. First is the devastation of HIV/AIDS, increasing workloads, exposing workers to infection, and trying their morale. Second is accelerating labor migration, causing losses of nurses and doctors from countries that can least afford the “brain drain.” Third is the legacy of chronic underinvestment in human resources; frozen recruitment and salaries; and restricted public budgets, depleting work environments of basic supplies, drugs, and facilities (JLI, 2004). Continued underinvestment in the health care workforce is detrimental to staff morale and the ethos of care.

In addition to health workers being compensated insufficiently and asked to work under harsh conditions with few supplies and little support, an extreme imbalance exists in the distribution of credentialed health professionals among regions and countries (and by geographic location within the same country). The problem of insufficient human resources for health care is particularly acute in Africa, which bears 25 percent of the world’s burden of disease but is home to only 1.3 percent of the world’s health workforce (Commission for Africa, 2005; High-Level Forum on the Health MDGs, 2004). Currently, an estimated 750,000 health workers serve the 682 million people of sub-Saharan Africa, representing an extremely low health care provider-to-population ratio; by comparison, the ratio is 10 to 15 times higher in Organisation for Economic Co-operation and Development (OECD) countries (see Figure 5-1) (High-Level Forum on the Health MDGs, 2004).


As defined by WHO, a functioning health system should include access to adequate financing; essential medical products, vaccines, and technologies; a well-performing health workforce; reliable and timely health information; and strategic policy frameworks to provide effective analysis, oversight, and governance (WHO, 2007a).

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