The global shortage of trained health workers is at crisis level, argues Louise Hill. Just look at the Central African Republic.

As Jonathan’s tiny, cloth-wrapped body is lowered into a hastily dug grave, the monsoon season starts in earnest. The soft hush of 50 or so villagers in unified mourning is drowned out as rain crashes through trees and drums on mud roofs.

Five-year old Jonathan died 50km from here, a journey he and his mother had been forced to make to reach a qualified health worker. Their local clinic boasts a pharmacy stocked with medicine more than capable of curing the routine infections that claim so many children’s lives here. But drugs are not enough if there isn’t a health worker with the skills to diagnose and treat these illnesses in time.

There are two health workers in Jonathan’s village. Neither is qualified. Welcome to life in the Central African Republic (CAR). Few people have heard of CAR yet a quarter of its population – one million people – have been affected by the constant insecurity that’s led to numerous coups in the last 10 years alone.

This reign of conflict has all but destroyed the country’s health system. There are now just 43 midwives in CAR, a country the size of France – 40 of them based in the capital Bangui. More women die in childbirth here than virtually anywhere else on earth – in fact, maternal mortality has more than doubled since 1997. Of the approximately 2,900 health workers on the ground, no one really knows how many are actually qualified.

Merlin, the international medical aid agency, has been working here since 2007. In one remote district where it supports 11 health facilities, nine are staffed by health workers with no formal qualifications. Some filled posts left vacant by health workers forced to flee the fighting, others have years of hands-on experience. The need now is to anchor any knowledge in much needed technical skills. So as well as renovating dilapidated clinics, ensuring drugs are available and educating villagers in basic hygiene and nutrition, the agency ensures health workers are regularly supervised and trained.

Olga Yetikoua is one of five Merlin nurse supervisors working to improve standards and morale. She travels between three rural health clinics every week, training around 30 health workers as she goes. Having spent most of her life working in the capital, she was amazed to discover how little the health workers knew. A year on change is evident: “It’s staggering to see health workers who’ve been doing this for years – decades even – understanding for the first time how to heal people,” she explains.

Africa, which shoulders over 90% of the global neglected disease burden, needs at least one million more health workers to deliver essential care. But it’s fragile nations like CAR, sliding in and out of crises, where urgent attention and action is most needed.

Liberia had approximately 200 doctors before civil war consumed the country for 14 years. Barely half remained when peace was declared in 2003. Five years on, a lack of health workers remains one of its major challenges, starkly demonstrated by the Minister of Health, Dr Gweningale, who sometimes spends his weekends working as a surgeon in the hospital where he trained.

South Sudan, too, is mired in a health worker crisis, played out against 20 years of civil war. Here, there is only one doctor for every 100,000 people. Fragile nations like CAR, DRC, South Sudan and Ethiopia have some of the world’s worst health indicators but the research shows that more people die from disease post-conflict than are actually killed in the fighting. To be truly effective, any emergency response to a health crisis must take a long-term view. Strengthening a health system from the outset with the training, retention and recruitment of health workers must be made a priority by international donors. Long-term funding is also vital.

Last November, 20 doctors qualified in Somalia, the first to graduate for 18 years. But the people of CAR cannot afford to wait for student nurses, midwives and doctors to come through the ranks. Health workers at their posts now must be trained, supported and motivated to give young children like Jonathan a chance of survival.

“We have worked without equipment and support for such a long time,” explains Joel Ngamba, 28, a trainee health worker from CAR. “Now Merlin is training us, we’re more confident of being able to save people’s lives. And for the first time, we don’t feel so alone.” As part of the Hands Up for Health Workers campaign, calling attention to the shortage of four million doctors, nurses and midwives in the developing world, Merlin is hosting a series of photographic exhibitions featuring the work of Africa-based Panos photographer Frédéric Courbet.

More Information

www.handsupforhealthworkers.org
www.merlin.org.uk

“I was really shocked when I first saw the standard of health workers here. Many of them didn’t even know the basics.”

Olga Yetikoua (pictured left), Merlin nurse supervisor, Nana Gribizi district, the Central African Republic 

Everyone likes Olga. It’s impossible not to. Her face is open, friendly and usually creased in a smile; an ideal mask for a driven, no-nonsense trained midwife. She’s a perfect candidate to help improve the standard of health workers in Merlinsupported clinics in the remote district of Nana Gribizi. But even she didn’t expect to be met with such a profound picture of neglect.

“I’ve spent most of my professional life in the capital. Coming here, I realised for the first time that my country doesn’t even have the minimum level of healthcare anymore. “When we arrived, the health posts had pretty much been abandoned by the health workers, the government, the community – everyone. I turned up at one health post and no one was there. Not even the head of the clinic.

All the staff I spoke to were demotivated: they hadn’t been paid for months. The ones who’ve been trained – even a little – hadn’t put any of their knowledge into practice for years. How could they? They had no drugs, no equipment. So even basic things, they’d forgotten. We literally had to start from zero.” Olga’s job is to look after three of the 11 health facilities Merlin supports in Nana Gribizi. In total, she oversees the training of around 30 health workers.

In six short months, the difference she’s helped bring about is enormous. “Our posts are seeing maybe 240-300 patients every month now. Before we’d be lucky to see 20. Every facility has drugs, which are free to patients. There are medical cards, equipment, newly built clinics – it’s unrecognisable.

The difference in the health workers is inspiring. They understand what they’re doing so much better. It’s staggering to see health workers who’ve been doing this for years – decades even – understanding for the first time how to heal people.” While progress is being made, there is still a tremendous amount to do in the Central African Republic. Training rural health workers is key.