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(HRH) in Ethiopia EDITORIAL Brief overview of the literature relevant to Human Resources for Health (HRH) in Ethiopia Damen Haile Mariam1 Even though modern health services in Ethiopia negative implications on access to health services, were introduced at the beginning of the 20th particularly maternal health services for the poor, century, human resources development activities and is likely contributing to high levels of were started only after the Italian invasion, in the neonatal deaths and maternal mortality ratios (9). mid 1930s (1, 2). During the basic health services period, training was focused on health center Even though the HRH problem is often teams, while the training of physicians and oversimplified as a numerical shortage of community health workers in increased numbers healthcare workers, there are also other was emphasized during the primary health care dimensions of the crisis (management, quality, period (3). Recent reforms leading to location, and performance) that are not usually decentralization have necessitated capacity at being effectively dealt with (10). Past reviews of peripheral levels with the consequence that human resource for health in Ethiopia with resulted in rapid expansion of higher education in respect to challenges of achieving the MDGs the country as well as increased involvement of have also found that there is shortage in number the private sector in training activities (4, 5). In of different groups of professionals, mal- addition, commitment to the Millennium distribution of professional between regions, Development Goals (MDGs) has enhanced urban and rural setting, and governmental and overall efforts in the expansion of primary health non-governmental/private organizations. These care coverage requiring accelerated levels in reviews have also indicated the lack of policy training of health workers (6). specific to human resource development for health as well as proper mechanisms to manage Ethiopia is considered to have one of the lowest the existing health work force (11). A World ratios of doctors to population in the world. In Bank assessment of health worker performance particular, with the recent expansion of health in Ethiopia, based on data from focus group facilities across the country, severe shortages of discussions, has attempted to outline both the health workers for staffing them have been nature of performance problems, as well as the witnessed. Furthermore, even though the possible structural reasons for these problems as threshold density below which high coverage they relate to human resource policies (12). (80%) of essential interventions, (including those Among the performance problems identified in necessary to meet MDGs) is estimated at 2.3 this study were: absenteeism and shirking, salary health workers (the definition of Health workers augmenting practices (moonlighting) pilfering being all people primarily engaged in actions with drugs and materials, informal health care the primary intent of enhancing health) per 1,000 provision, illicit charging, corruption malingering people (7), with a total workforce of 65,744 as well as poor handling of patients. These (physicians, health officers, nurses, midwives and problems are ascribed to causes that are rooted in health extension workers that are deployed within the ongoing transition from a command-and- the public sector) for a population of 81,911,074, control health sector, to a more pluralistic system, there were only 0.80 health workers per 1,000 and the failure of government policies to keep population in Ethiopia at the end of 2003 (EC) pace with the transition toward a mixed model of (8). A more recent (2012) analysis by the World service delivery. Even though public sector Bank has also indicated problems in human salaries weighted against GDP for physicians in resources for health in Ethiopia with regards to the Ethiopian are said to be relatively higher stock, distribution and performance that have when compared to other sub-Saharan African 1School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia 2 Ethiop. J. Health Dev. countries (13), their actual magnitude is very low. because of the general weakness of reporting and In addition to the very high salary gradient health management information system (18). between the public and private/NGO sectors locally, salary levels are excessively low for A review of medical doctors profile in Ethiopia physicians and nurses who have some degree of with regard to production, attrition and retention access to the international labor market. Despite (19) over the hundred years of the country’s such mismatch between performance and medical history has shown high annual attrition remuneration, a survey and experimental study to rate, fast population growth, governmental and assess the development of intrinsic motivation on non-governmental health institution expansion, a sample of newly graduating physicians and low production and increased graduate enrollment nurses in Ethiopia has shown the majority of over the recent years leading to extremely low student physician and nurses as being intrinsically physician-to-population ratio. According to this motivated (14). In addition to economic review, even though the government as well as incentives, such intrinsic motivation is also the private sector has worked much in terms of shown to be among the major factors in health health infrastructure expansion and health workers’ decision to work in rural and public professional training, mechanisms for retention of facilities (15). medical doctors does not appear to have been properly sorted out. As a result, even despite With regard to training of specific categories of salary equivalent top-up payments in some health workers, a study that assessed the first regions, more than 80% of the public hospitals cohort of trainees in the Health Extension outside the capital were under-staffed with Program (HEP) (16) has also found that the physicians implying that the push factors are not training institutions (Technical and Vocational correlated with remuneration alone. Brain drain is Educational Training Institutes (TVETs)) said to be a relatively recent phenomenon in the assessed as lacking adequate facilities to receive Ethiopian health sector workforce. With the the trainees. Teaching and learning conditions advent of an increasing number of push factors, were also constrained with very little practical however, this trend has changed over the past training. The selection of trainees was also found couple of decades. About 50% of Ethiopians who to be flawed, most being from woreda towns as went abroad and completed their studies did not opposed to the rural villages in which they were return home during the past 10-15 years. For supposed to work. Trainees were also found not instance, between 1980 and 1991 only 5,777 to have adequate orientation on their future job students out of a total of 22,700 returned home at recruitment, even though they expressed high (20). Health workers who migrated internally level of commitment to work in rural areas. continue to serve the country’s population, even Similarly, assessment of the access to though those with higher socio-economic status information, continuing education and reference and usually urban residents. On the other hand, materials among 60 Health Extension Workers there also seem to be inefficiencies due to (HEWs) distributed across 50 health posts within inappropriate and underutilization of highly 27 woredas has shown that the HEW training trained health workers by the private sector modules were the only reference materials institutions as well as vertical health programs available at health post levels and that training in (21). curative and delivery related subjects stand out in the future continuing education expectations of Overall, major challenges in relation to human the health extension workers (17). Furthermore, resources in the sector continue to be poor assessment of the working conditions of the first deployment and retention of health professionals, cohort of health extension workers has shown in addition to insufficient number in specific challenges in harmonizing the staffing pattern at cadres of health workers such as midwives. health post levels as there were no clear Health personnel training activities have been guidelines on relationship of HEWs with other expanded more recently as a result of new health workers at community levels as well as initiatives as well with the increased involvement of the private sector. However, there are Ethiop. J. Health Dev. 2013;27(Special Issue 1) Brief overview of the literature relevant to Human Resources for Health (HRH) in Ethiopia 3 concerns over the quality of training. Even workforce, better management systems should be though evidence is scarce on quality of training, established in terms of improving motivation, there is no doubt that the lack of strong quality ensuring adequate and regular pay, improving control mechanism are among the critical issues working conditions and enhancing professional in the face of the fast expansion of private as well values of workers. The country should also as public training institutions. An analysis of the attempt to operationalize in its context the higher education reform efforts in Ethiopia various initiatives and core principles developed indicates that even though enrolment expansion by the World Health Organization. In particular, targets are likely to be met, the dynamics of its future actions in the area of human
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