How Can Ethiopia Mitigate the Health Workforce Gap to Meet Universal Health Coverage?

Availability of adequate number and skill-mix of health workforce is critical to the achievement of any population level health goal. Besides the number and skill-mix, their distribution and quality also matter. However, nations at all levels of socioeconomic development face difficulties, to varying degrees in production, placement, retention and proper utilization of their health workforce.

The core for Sustainable Development Goals (SDGs) health target is Universal Health Coverage (UHC), which is well-established and agreed by member counties, but its implications for the health workforce have only lately started receiving thoughtfulness. Countries working towards UHC need to keep track of the size, distribution and composition of their health workforce and to anticipate future need for human resources for health (HRH) (1). This can be strategically informed by valid and reliable workforce data (2); without these information, decision-makers are less likely to plan strategically or anticipate future needs (3).

Achieving universal health coverage by 2030 requires lessons from the Millennium Development Goals. The most important lesson is that the HRH underpins every function of the health system and is the rate-limiting step. The three dimensions that continue to limit the success of the development agenda are availability, distribution and performance of health workers. Similarly, the Sustainable Development Goals cannot be achieved without addressing all the above three. Hence, the traditional response of scaling up supply is inadequate; a paradigm shift is required in the design of systems that can properly identify, train, allocate and retain health workers.

Despite the efforts made in the past two decades to increase the number and skill mix of health work forces, Ethiopia is one of the countries with very low health workforce (Medical Doctors, Health Officers, Nurses and Midwives) density which is 0.96/1000 population. This is much far below the African density of health workers (2.2/1000 population and five times less than the minimum threshold of 4.45 per 1000 population set by the World Health Organization to meet the SDG health targets (4). Another way of stating it is, taking the current population of 100 million, Ethiopia is supposed to have over 220,000 health work forces to level with the African health workforce density, and 445,000 to meet the minimum threshold to ensure UHC, while the available number is less than 100,000. This means, with the ever-increasing population, the country needs to produce over 30,000 health workers (Medical Doctors, Health Officers, Nurses and Midwives) every year for the coming 12 years to achieve universal health coverage by 2030. Nonetheless, the current production capacity from all health professionals training institutions for doctors, health officers, nurses and midwives is not more than 10,000 per annum.

Envisioning for HRH fundamentally is needed to indicate direction and provide guidance for what is needed to be done to develop the valuable resource of health workforce. A strategic plan will also lay the foundation and framework for HRH plans that should be developed at all levels of the health system. However, strategic planning for HRH is mostly overlooked at all levels. Even when human resource planning is attempted, it usually addresses the projection of staff numbers leaving uncovered important areas like HRH policies and management systems. Harmonization of HRH planning with the overall health planning process is another problematic area and, in many occasions, dichotomies between the two processes are the norm.

Likewise, in 2016, the Federal democratic Republic of Ethiopia Ministry of Health developed 10 years National Human Resource for Health Strategic Plan for the years 2016–2025 (5). Although this document appeared all-inclusive, it has several limitations. Particularly, the facility scale-up, the projection of health workforce and the costing set for the upcoming years are far below what the country will require to achieve UHC as per the World Health Organizations guidelines. If we take the health work force alone, there is close to 100,000 shortfalls between what is projected in the strategic document (207,138) and what it should be (306,000). Such deficit holds true for health facility and costing projections as well. Therefore, if not late, it is time to revise the National HRH strategic plan to allay the discrepancy and inform major stakeholders so that implementation is commenced accordingly.

In conclusion, the major challenges in the current and future health system pertaining health workforce are related to number, quality, skill-mix, distribution, attrition and career path. To mitigate these key issues, FMOH, FMOE and other stakeholders need to:

1. Transform the health professionals' education system where the curricula, model of schooling, trainee recruitment, instructors' mix & quality and their benefit scheme needs to be revisited in line with the international standard and the capability of the country.

2. Include health officers and level four health extension workers in the service provider package in the Ethiopian context unlike the other countries where these health workers are non-existent.

3. Improve the in-service trainings to continually improve the knowledge and skill of practitioners and also lesson the dissatisfaction by the community and the provider.

4. Create conducive career path for all, working environment, remuneration scheme as well as considerate management and leadership system.

The current issue of the journal, the third regular issue for the year 2018, contains an editorial, thirteen original articles, a review and a letter to the editor focusing on various topics. All the issues presented, in one way or another, require availability of adequate number and skill mix of health workforce.

I invite readers to read through these articles and appreciate or utilize the contents. I also encourage readers to forward comments and suggestions to the editor or the corresponding authors.