Health labour market policies in support of universal health coverage: a comprehensive analysis in four African countries

Background Progress toward universal health coverage in many low- and middle-income countries is hindered by the lack of an adequate health workforce that can deliver quality services accessible to the entire population. Methods We used a health labour market framework to investigate the key indicators of the dynamics of the health labour market in Cameroon, Kenya, Sudan, and Zambia, and identified the main policies implemented in these countries in the past ten years to address shortages and maldistribution of health workers. Results Despite increased availability of health workers in the four countries, major shortages and maldistribution persist. Several factors aggravate these problems, including migration, an aging workforce, and imbalances in skill mix composition. Conclusions In this paper, we provide new evidence to inform decision-making for health workforce planning and analysis in low- and middle-income countries. Partial health workforce policies are not sufficient to address these issues. It is crucial to perform a comprehensive analysis in order to understand the dynamics of the health labour market and develop effective polices to address health workforce shortages and maldistribution as part of efforts to attain universal health coverage.


Background
Universal health coverage is defined as access of all people to comprehensive health services (including prevention, promotion, treatment, and rehabilitation) at affordable cost and without financial hardship, through protection against catastrophic health expenditures [1]. However, even when financial protection is ensured, access to health services will not be guaranteed without an adequate health workforce. Health workers are a fundamental and instrumental component of service delivery. Unless countries have the appropriate health workforce to deliver quality services, universal health coverage will not be attained. This is a particular challenge for many low-and middle-income countries, which often suffer from severe shortages and maldistribution of health workers [2][3][4].
These problems, however, are not exclusive to low-and middle-income countries; many developed countries are likely to face severe shortages and maldistribution of health workers as a consequence of the latest global economic downturn of 2008/2009. Many wealthy countries are cutting their budgets for social services, including health, which will affect the number of health workers trained and deployed a . In addition, the socioeconomic consequences of the financial crisisincreased unemployment rates, poverty, and social deprivationcoupled with emerging issues, such as aging populations and a higher prevalence of chronic conditions, will increase the demand for public health services in both developed and developing countries [5]. Moreover, the new dynamics of migrationfor example, moving from one developing country to anotherpose a major challenge for global health labour markets [6]. To cope with these challenges and attain universal health coverage, countries will have to do in-depth analyses of their health labour markets in order to understand the driving forces that affect supply and demand both within the country and at a global level [5].
In this paper, we use a health labour market framework to investigate the key indicators of the dynamics of the health labour market in Cameroon, Kenya, Sudan b , and Zambia, and identify the main policies implemented in the past decade to address shortages and maldistribution of health workers in order to highlight the challenges to attaining universal health coverage. These four African countries were chosen because they had reliable and good quality data and the necessary institutional capacity to conduct the analysis, and the Ministry of Health was in each case willing to undertake the analysis c .
The four countries differ in their overall level of economic development and their demographic and epidemiological profiles (Table 1). In each of the countries, there are great inequalities in access to health services and difficulties in attaining universal health coverage. For example, in Cameroon, Kenya, and Zambia, the coverage of skilled birth attendance is less than 20% among the poorest segments of the population, compared with more than 80% for the rich [7] ( Table 2).

The health labour market framework
In many low-and middle-income countries, health workforce policies are frequently formulated on the basis of the number of health workers required to meet the needs of the population (needs-based assessment), and are aimed at training more health workers. However, unless appropriate employment conditions are in place to absorb the newly trained health workers into the labour market, there is a risk of increasing unemployment and brain drain, and wasting resource [17].
The level of employment in a country's health sector is in large part determined by health labour market dynamics, not the population health needs or the worker education capacity alone. The health labour market encompasses a number of dimensions. The combination of needs, demand, supply, training, and governance of health workers determines the wages and allowances, the number of health workers employed, the number of hours they work, their geographic location, their employment setting, their productivity, and their performance [18].
The education and training of health workers is a key determinant of the supply of health labour in a country. The availability of new graduates depends on a number of factors, such as the number of slots available in training programs and the admissions criteria, the location and social orientation of the medical training, and the debt burden. It also depends on individual decisions by potential health workers whether to pursue a health profession and obtain the required education. Those decisions will be based, at least in part, on the attractiveness of the salaries and potential returns for the years of study and financial investment needed (e.g., for tuition fees, books, etc.). The pool of qualified health workers is the number of individuals who have been trained, but the supply is only the number of qualified health workers willing to work at the prevailing wage rate.
The demand for health care workers is determined by the private and public institutions that hire and pay health workers in clinics, hospitals, and other settings. These institutions will compete for workers based on their wage rates, budgets, provider payment practices, benefits packages, working conditions, and other labour regulations and rules. The competitiveness of institutions across all of these factors will influence how attractive they are to health professionals (including new graduates) in comparison with other labour markets or other countries  [19]. Opportunities for self-employment also affect the demand for health workers. In general, the higher the wage, the larger the number of available health workers willing to work in the health sector. However, the wage is not the only determining factor. Good working conditions, safety, availability of supplies and technical support, and career opportunities also play important roles. Taken together, these factors influence whether health professionals decide to work in the country (or migrate), in the health sector (or in another sector), in a public institution (or a private one), on a full-time basis (or part-time), and in an urban area (or a rural one).
In many countries, health worker shortages occur because of labour market mismatches rather than because of an overall lack of workers to fill the jobs in question.

Methods and data
To understand the health labour market dynamics in the four selected countries, we investigated the factors that determine the health workforce supply and demand.
Fourteen key indicators were selected for cross-country comparisons. These were grouped into two categories: stock and density indicators, and shortage indicators ( Table 3). The first group, stock and density indicators, includes measures of the available health workforce, their age, sex, skill mix, geographical location, distribution by sector, presence in the informal economy, and migration. The available health workforce is defined as anyone with the training and ability to do the job, whether they are employed in that position or not. The second group, shortage indicators, reflects the shortages of health workers from different perspectives: (1) The economic shortage, defined by the vacancy rate (the ratio of unfilled vacancies to funded health care posts), to identify the gap between demand and supply; (2) The wage shortage (the ratio of the average health worker wage to the country's per capita GDP) to identify the gap between the wages in the health sector and the country as a whole; and (3) The needs-based shortage (the gap between the available health workforce and the workforce required to meet the health needs of the population), to identify health sector deficiencies in meeting population needs.
The main sources of data were official statistics from the Ministry of Health, the Ministry of Finance, health professional councils, population censuses, and labour force surveys [20][21][22][23]. We additionally used the framework and policy levers proposed by Sousa et al. [5] to identify the major policies that have been implemented in the past ten years in these four countries to address different dimensions of the health labour market.

Health labour market indicators
The available supply of health workers varies from country to country (Table 3). The wealthiest of the four countries, Sudan, has the highest density of total health workers and physicians per 1,000 population, while Kenya and Cameroon, the poorest countries, have the lowest density. In the past ten years, there have been notable increases in the availability of health workers in these four countries, with an average annual growth rate of around 5%.
Although all four countries increased in population over the past decade, with Kenya increasing the most by 33% of its 2004 population, the overall density of health workers decreased in all four countries according to the World Health Statistics. Sudan experienced the smallest health workforce density decrease of 0.19 whereas Zambia's decreased the greatest by 2.39 ( Table 4). As for physician density, Sudan's density significantly surged while Kenya's grew only slightly. On the contrary, Cameroon's physician population decreased by half from 200 to 100 per 1,000 from 2004 to 2011. Zambia also experienced a decrease in physician density but less extreme than Cameroon. Sudan and Zambia both showed contractions in the density of health workers, while the density of physicians and nurses escalated revealing that other health worker positions decreased and that these specific occupation populations surged. Over this period of time, the percent of GDP per country remained relatively stagnant, except in the case of Sudan, which rose 3.5% bringing it to 8.4%.
The health workforces in Kenya and Zambia are mainly composed of nurses and midwives, accounting for 60% and 61% of the total, respectively. However, a large  proportion of nurses in Kenya and of midwives in Zambia are over 45 years old, suggesting that unless strategies are put in place to recruit younger staff, these countries will soon experience a shortage of health workers. In Cameroon, there is a mix of different cadres of health workers with different specialties and training levels; strategies for task shifting have been effective in allowing workers other than physicians and nurses to deliver health services (see Table 5 for a summary of the main policies).
In the four countries, the majority of health workers are women: for example, in Sudan 67% of medical students are women, and in Kenya and Zambia 60% of all health workers are women. This implies that further policies should be oriented to making the working environment friendly for women.
In Cameroon, Sudan, and Zambia, the main employer of health workers is the public sector; however, a large proportion of health workers work in both the public and the private sector. In Sudan, for example, 90% of health workers have a dual practice. However, since there are no policies to regulate it, there are concerns about the availability of health workers in practice and about the quality of services. This suggests that further actions should be oriented to properly regulating and understanding the implications of dual practice employment and its impact on the quality of health services. There is also the need to incorporate informal health workers into the formal economy as in all four countries there is a proportion of the population covered by unregulated health providers such as traditional birth attendants.
In Kenya and Sudan, migrationparticularly of physiciansis a major problem. This suggests that there are a number of qualified physicians who would rather work abroad for better working conditions and higher wages than in their home country with the current working conditions and wages.
Despite efforts to decrease health workforce inequalities between poor and non-poor areas (see Table 5 for a summary of the main policies) major inequalities remain in all four countries. In Kenya and Zambia, the bestserved areas have approximately twice as many health workers as the areas with the lowest density; in Cameroon, the capital city (Yaoundé) has 4.5 times more health workers per 1,000 population than the poorest province (North), which also has the lowest coverage of skilled birth attendants. These data imply that poorer areas have difficulty attracting and retaining health workers, and therefore the population has less access to health services and worse health outcomes than the population in better-off areas. This lack of health workforce capacity to provide health services to the entire population is a major challenge for ensuring equitable access to health services and universal health coverage. Thus, policies should be directed to retaining health workers in underserved and poor areas.
Despite the efforts made to decrease the shortages of health workers (see Table 5 for a summary of the main    policies), such shortages remain a critical constraint for service delivery. The needs-based shortage measure suggests that, in each country, the health sector has less than half of the health workers required to meet the needs of the population. A higher probability of labour shortage is typically associated with a higher vacancy rate. In Zambia, the particularly high rate of unfilled vacancies (62% of physician posts unfilled and 53% of nurse and midwife posts unfilled) suggests that the number of health workers that employers are willing to hire exceeds the number who is willing to work with the proposed working conditions and wages.
Wages are a key component of labour markets. Some governments need to pay higher wages than at present to keep physicians and nurses they are currently training in the health sector and in the country. Between 1990 and 2004, Zambia experienced an exodus of physicians. To discourage more physicians from leaving the country, the government increased the wages of physicians by 16% between 2007 and 2011, to a level 15 times higher than the average income per capita and higher than that of other professions with a similar level of education, such as lawyers. However, despite this increase, the average annual wage of physicians is still only US $21,780.
These findings suggest that there are problems on the demand and the supply side. Unless policies to address health worker shortages and maldistribution are designed with a health labour market perspective, they are unlikely to be effective.

Health labour market policies
We used the framework and policy levers proposed by Sousa et al. [5] to identify the major policies that have been implemented in the past ten years in the four countries and their impact on: 1) the production of new graduates; 2) inflows and outflows of health workers; 3) maldistribution of health workers and inefficiencies; and 4) regulation of the private sector ( Table 5).

Production of new graduates
In the past ten years, major efforts have been undertaken by all four countries to decrease the shortages of health workers. On the production side, the most significant efforts include opening new training institutions, awarding scholarships, providing financial incentives for teaching staff, and training new cadres of health workers. These policies have been highly effective in increasing the number of new graduates in Cameroon and Zambia. However, in Kenya and Sudan, the policies have had limited or negative effects, as they did not take into account the labour market dynamics. In Sudan, for example, there was an increase in unemployment among new graduates, as vacancies and funding were not adjusted to absorb the new graduates into the labour market. The result was a waste of resources and increased brain drain.

Inflows and outflows of health workers
Inflows and outflows refer to the movement of health workers into and out of the country as well as into and out of the overall health workforce. Efforts to address inflows and outflows of health workers have included policies to increase wages and provide extra allowances, improve working conditions, and provide training opportunities. In Zambia, for example, policies targeted at increasing wages and allowances d were effective in reducing migration of nurses but not effective in decreasing the vacancy ratealthough more nurses remained employed, there was still a large pool of unmet needs that increased over time. In Kenya, the introduction of allowances reduced the migration of nurses, but was not sufficient to reduce exits e of medical doctors and community nurses. Kenya also implemented specific policies to increase the retirement age of civil servants, from 55 to 60 years, to tackle the problem of aging nurses and other cadres of health workers. These efforts have changed the age profile of the health workforce; however, they may result in high rates of unemployment and brain drain among new graduates, who will have difficulty finding a job in the health sector, compromising the availability of health workers in the medium and long term and, therefore, the attainment of universal health coverage.

Maldistribution of health workers and inefficiencies
Several policies have been implemented to address maldistribution and inefficiencies of health workers such as training local health workers, providing allowances, and awarding scholarships to increase the supply of health workers in underserved and rural areas. Kenya launched an e-learning programme to train health workers in rural areas, while Zambia trained community health workers to work in underserved areas. These policies have been effective in increasing the number of health workers in rural and underserved areas. However, they have not been sufficient to reduce health worker shortages and increase access to quality services for the entire population. In Zambia, the provision of compensation schemes for health workers serving in rural areas was effective in increasing the number of health workers in the targeted areas. However, it did not lead to a decrease in the overall shortage of health workers. In Sudan, several efforts have been made to increase access in underserved areas, although the efforts were poorly implemented and had very limited effect in decreasing health worker shortages. For example, in 2002, a specific policy was introduced to provide in-service training to physicians working in underserved areas; however, some of the recipient states were not able to provide competent training services and physicians did not abide by the contracts.
To ensure equitable access to quality services for the entire population, there is a need to eliminate health workforce inefficiencies and waste of resources, by improving the productivity and performance of health workers [1,5]. However, Cameroon is the only one of the four countries that has implemented effective strategies to improve the productivity and performance of health workers; for example, a productivity allowance was introduced, comprising 10% of the financial resources generated by the health facility, to motivate staff. As a result, the quality of the health services increased.

Regulation of the private sector
Policies to regulate both the public and private sectors have mainly focused on boosting private sector participation in training health workers. These policies have contributed to the growth in the number of graduates in the four countries over the past decade. However, the lack of government regulation may compromise the quality of training and service delivery. The growth of the private health labour market means that there is a need to develop specific policies to regulate the private sector, to improve the quality of training and service delivery, and to manage dual practice in order to ensure equitable access to quality health services for the entire population.

Conclusions
An understanding of the interactions between the factors that determine demand and supply of the health workforcethe health labour market dynamicsis critical if countries are to develop effective polices to address health workforce shortages and maldistribution and attain universal health coverage. Partial health workforce policies, such as those that focus just on training more health workers, are not sufficient to reduce health worker shortages.
We found that over the past decade, there have been great improvements in the availability of health workers in Cameroon, Kenya, Sudan, and Zambia. However, despite these improvements, there are persistent health workforce shortages and maldistribution. Several factors contribute to and aggravate the shortage of health workers in the four countries, including migration, an aging workforce, and imbalances in the skill mix composition. The lack of health workforce capacity to provide health services to the entire population is a major challenge for ensuring equitable access to health services and for attaining universal health coverage.
In Kenya and Sudan, increasing the production of health workers, particularly physicians, may not be the most appropriate strategy in the short term to reduce health worker shortages, as these countries experience high vacancy and physician migration rates. In Cameroon and Zambia, however, training of new graduates, coupled with recruitment strategies, such as improving working conditions, safety, and wages to attract health workers back to the health sector, could decrease the geographical inequalities and economic shortage of health workers.
For further policies to be effective in reducing health workforce shortages, the countries will need to take into consideration the dynamics of the health labour market. In general, policies should be directed to recruiting and retaining health workers in underserved areas, and should include strategies to improve the retention, productivity, and quality of the current health workforce. In addition, appropriate regulation of the private sector should be implemented, including monitoring of dual practice. Eliminating health workforce inefficiencies by improving productivity and performance will be critical in increasing the supply of services, and, therefore, to some extent mitigating the shortage of health workers [1]. Measures to improve productivity, such as having the optimal workforce mix and providing the appropriate technology and capital, can be important overall strategies. Finally, changes should be made to the skill mix of health workers, by growing and appropriately training and supervising non-professional cadres of health workers, such as community health workers and other health care providers, to perform a variety of health care tasks [24][25][26].
Endnotes a For example, the 2010 UK Coalition Government engaged in retrenchment and restructuring of the public sector [8].
b Sudan in this paper refers to former Sudan, before South Sudan gained independence in 2011. c The country analyses were based on a protocol written by R Scheffler in consultation with WHO, aimed at understanding the health labour dynamics and productivity in low-and middle-income countries [18]. d In Zambia, health workers receive a recruitment and retention allowance of 25% of their basic monthly salary; those in rural areas also receive a 20-25% rural and remote hardship allowance. In addition, health workers serving in rural areas are entitled to top-up allowances under the health worker retention scheme of 30-70% of their basic monthly salary [21]. e Exits are due to attrition, resignation, or internal or external migration. f The analysis of "positive" and "negative" effect is a broad categorization that applies only to the countries in this sample. It is not generalizable to other situations or other countries.