Nurses and midwives are the backbone of health systems globally. Of the world's 43.5 million healthcare professionals, more than 20 million are nurses and midwives. They play a critical role, particularly in sub-Saharan Africa, as quite often they are the first and only healthcare professionals people will see.
Because nurses and midwives respond to the needs of people in all settings, they are critical to the achievement of global health goals. The World Health Organisation (WHO) recognises the vital role they play in promoting universal health coverage and sustainable development.
The WHO says the world needs 9 million more nurses and midwives to reach the global Sustainable Development Goal on health by 2030. It recommends a ratio of 83 nurses per 10,000 people. But – even with variations noted across the region – most countries in sub-Saharan Africa have fewer than 20 nurses for 10,000 people. The region is home to 1.07 billion people, about 15% of the global population . But it carries 24% of the global burden of disease and has only 3% of the world's health workforce.
One of the reasons the small health workforce is a problem is that nurses and midwives can make a significant impact in managing and preventing the leading causes of death in the region. These are infectious diseases, conditions affecting newborn babies and mothers, and nutritional conditions. Nurses provide primary and community care, and participate in disease prevention and health promotion programmes.
Adequate numbers of healthy and motivated health professionals are also critical to governments' effective responses to public health emergencies such as COVID-19.
Addressing the shortage
The goal of good health and well-being for all the world's people by 2030 is feasible, but it might not be attained. It won't be easy to address the shortage of healthcare professionals, especially in regions like sub-Saharan Africa.
It will take greater efforts to make nursing an attractive career, starting with appropriate training, then working conditions and pay, and retention of staff where they are most needed.
Nursing, like other caring professions, is highly demanding; even more so in developing countries, where demands on staff are often greater than the support offered.
This support should start with equipping people properly for the job. The Global Health Workforce Alliance and the Lancet Commission highlight a mismatch between current healthcare challenges and professional education. For instance, the population structure in the region is changing, with more people living longer, but training in the health aspects of ageing is not common in Africa.
Professional training in sub-Saharan Africa is largely limited to a technical focus on clinical care with little attention to health promotion and disease prevention at the community level. A focus on medical care limits the understanding of the broader context that affects people's health. This is particularly important for vulnerable populations whose health and well-being are closely related to factors such as environment, housing, income level and education. Healthcare professionals, especially nurses and midwives, need to understand these social determinants of health so as to provide more holistic, comprehensive care.
In the past few years countries have instituted reforms to nursing and midwifery education, shifting from content-driven curricula to competence-based programmes that are responsive to the primary healthcare needs. Digital technologies have been successfully used to support the learning of healthcare professionals globally and progressively in sub-Saharan Africa.
But many challenges remain . These include inadequate preparation of mentors and educators, lack of resources to implement the changes and limited involvement of key stakeholders. In sum, these limit the number of appropriately trained nurses.
Another way that nurses and midwives could be supported is by giving greater value to their work. This might encourage greater numbers of people to join the profession. The health workforce in sub-Saharan Africa suffers from persistent gender stratification of professional status – women dominate at the level of service delivery while men dominate decision-making. Remuneration is low and working conditions are often poor.
The conditions vary across the region, so the shortage is felt more acutely in some areas than in others. Most nurses and midwives prefer to live and work in urban areas, for better opportunities, but 60% of the population resides in rural areas. In urban areas, though a majority of the population resides in informal settlements, trained health professionals prefer to work in the more developed areas. As a result, people living in urban informal settlements have poorer health than people in rural areas and other urban areas.
Support for nurses and midwives could start with curriculum reforms that equip them better for the work they will do.
Innovative teaching strategies are also needed, responding to the career stages of the different healthcare professionals and accommodating those in training and in practice. Technology could allow them to benefit from mentors and educators who are physically distant while giving them flexibility to create learning goals in their preferred locations. For instance nurses in East Africa have benefited from mobile and e-learning platforms developed by different digital health service providers .
There is also potential for greater collaboration between regions and countries, and between public and private sectors, to share best practices.
Health care managers need to make work environments conducive to doing the job better. They should ensure that all nurses and midwives have the resources they need, such as working equipment, protective gear and social support from colleagues and significant others. Occupational health and safety measures through adequate infection prevention and control are paramount.
With strong leadership and political commitment, matched with more domestic funding for the health sector, it's possible to build a stronger workforce and achieve the 2030 goals on health.
Pauline Bakibinga receives funding from Comic Relief (UK), the Gates Foundation, the Medical Research Council UK and National Institute for Health Research UK. The funding agencies did not have a decision in the writing and publication of this opinion piece.
By Pauline Bakibinga, Associate Research Scientist, African Population and Health Research Center