My week with Ann

Corinne  Hinlopen

‘Are you angry enough to make these maternal mortality rates drop to 70 by 2030?!’ Two piercing dark eyes are looking sternly over a pair of glasses at a group of students. They belong to Dr. Ann Phoya, President of the Association of Malawian Midwives (AMAMI). She is trying to instill a sense of urgency into a group of students at the Royal Tropical Institute in Amsterdam. Her powerful call to action hits home, there is awed silence in the room.

Ann is visiting The Netherlands at the invitation of Wemos to acquaint policy makers, politicians and students with the situation in Malawi. Her desire to whip these future global health professionals into action is understandable: her home country faces a maternal mortality rate of an alarming 439 per 100,000 live births, and a newborn mortality rate of 27 per 1,000 live births. To put this into context: the agreed ambitions in the Sustainable Development Agenda (SDG) for low- and middle-income countries are 70 and 12 respectively. The statistics in the other countries where Wemos currently works – Uganda, Zambia, Kenya and Tanzania – are slightly better, but still cause for great concern. And anger. And anger can be a powerful driver for change.

 

Malawi

These high mortality rates are to a large extent due to staffing issues. There are simply not enough doctors, nurses and midwives in countries such as Malawi. A recent study by AMAMI and Wemos shows that the Malawi health system contains 24,678 health staff positions. This is barely one third of the overall agreed SDG target of 4.45 health workers per 1,000 population (calculated at 77,430 health workers for Malawi). To make matters worse, the actual number of health workers employed in Malawi doesn’t even reach 10,000. So there are huge gaps between the supply (no. of health staff available), the demand (positions available) and the need (positions needed for basic health care for all).

 

In terms of budget allocations, this painful lack of health staff is not for lack of trying. Compared to Kenya, Uganda, Tanzania and Zambia, Malawi is performing relatively well when it comes to percentage of government expenditures for health, reaching 11% versus 6 or 7%. Malawi is also top of that class when it comes to the percentage of Gross Domestic Product going to health: 3% versus 1 or 2%. And after Agriculture and Education, the health sector is the biggest receiver of government funding. So it’s not a lack of priority for health: the main problem is that there’s just not enough money in absolute terms.

 

United Kingdom

Surprisingly, there are many similarities between low-income and high-income countries. A recent editorial in The Lancet highlighted how two very different health systems – the UK and Malawi – are facing similar predicaments over health-care resourcing. Admittedly, the UK’s health system is much larger than the Malawian, in absolute and relative terms. But the similarities appear in a number of issues that determine health worker education and employment. In both countries, skilled workers are driven away by poor working conditions. Understaffing means that remaining health-care workers are overworked. In both countries, staff is underpaid. And investments in training are not sufficient to keep up with demographic and epidemiological developments, like the growth of the elderly population in the UK, and the double burden of communicable and non-communicable diseases in Malawi. Also, trained, graduated doctors and nurses often remain unemployed, because there are no decent jobs to be found. So they leave the country in search of greener pastures.

 

The Netherlands

If you work in Dutch health care, these observations should sound familiar, because The Netherlands is also facing a health worker crisis: there are currently approx. 130,000 hard-to-fill vacancies in health, social and home care (on a total workforce of approx. 1,2 million). The consequences of this health workers shortage are notable: pediatric wards are closing due to a lack of pediatricians, general practitioners and community nurses are in increasingly short supply in regions with many elderly, emergency obstetric care is transferred to hospitals further away, waiting lists for youth care and elective surgery are growing, etcetera, etcetera.

 

So why aren’t more people working in health, home and youth care in The Netherlands? In a recent study on the health workforce in The Netherlands, we describe how the Dutch government has been implementing austerity measures in the health, social and home care sector over a number of years. Investments in health and social care staff were driven by macro-economic factors (i.e. the financial crisis) in combination with a dwindling willingness to pay (expenditures for health care were deemed too high), instead of by the actual need for health and social care. There were fewer and fewer jobs, salaries experienced a race to the bottom. But with the economy now booming again, the demand for health and social care workers has been growing steadily since 2017. But health and care workers are nowhere to be found.

 

And it’s not that we weren’t forewarned (our study lists an overview of advisory reports on the Dutch labour market). So how could this happen to us? And what has the Dutch government done to prevent this health worker crisis? Well. It has presented an Action Plan. But it has left the implementation explicitly to the direct stakeholders, including hospitals, nursing homes and other health care institutions, employers’ and employees’ organizations and education institutes to sort it out. It has established supporting programmes to foster ‘innovative, regional, multi-stakeholder collaborations’. It has also recently launched an image campaign to make working in care more attractive.

 

Money or priority?

The latter completely overlooks the fact that many health and care workers have left the sector because of bad working conditions, including the heavy workload, high administrative burden and poor pay. And these are the result of prolonged under-investment in health and social care, and a neglected health workforce. So interestingly, and contrary to what we see in Malawi, the Dutch situation is not so much due to a lack of money in absolute terms: it is a matter of priority. Advisory reports and a longer-term vision on health and social care have not led to commensurate and sustained financial investments to achieve a resilient and well-prepared health workforce.

 

By leaving solutions to the field, and by not taking more directive measures to ensure lasting, future-proof solutions, the Dutch government is shirking away from its responsibility to incrementally ensure the right to health and health care of its population. It lets health staffing levels be determined by a politically very volatile willingness to pay, while it should be the other way around. The health staffing level needed to ensure health for all should determine the amount of funding made available. But the funny thing is: nobody seems to be angry enough to change this situation. And Ann made me realize this.

 

Want to understand what the problem is about? Check out our animation film ‘Finance for a sustainable health workforce’

Read our latest research report on finance for the health workforce in Malawi: ‘Mind the funding gap: who is paying the health workers?’

Read more about the Health Systems Advocacy Partnership and our work on health worker mobility

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