Health Workforce Planning

This report addresses the health workforce crisis in Ethiopia, focusing on issues such as migration, inequities, and skill distribution. It provides recommendations and strategies for improvement based on the World Health Organization's guidelines.

Running head: HEALTH WORKFORCE PLANNING
HEALTH WORKFORCE PLANNING
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Executive Summary
An optimum healthcare workforce, is essential for a nation to maintain universal health
coverage, ensure achievement of positive health outcomes and overall development of a healthy
nation. According to the World Health Organization, Ethiopia has been estimated to suffer from
a health worker crisis, with a dearth of maternity coverage, physician services and diagnostic
technologies. The major areas of crisis include: excessive migration, rural and urban inequities,
lack of equal skill mix and concentration of credible workers in private sectors. The following
report aims to address these issues using the recommendations outlined by the World Health
Organization.

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Table of Contents
Introduction..........................................................................................................................2
Brief Overview: Ethiopia.................................................................................................2
Environmental Scan.............................................................................................................3
Data Profile..........................................................................................................................5
Critical Issues and Possible Strategies.................................................................................8
Framework Strategies........................................................................................................11
Conclusion.........................................................................................................................13
References..........................................................................................................................14

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Introduction
Brief Overview: Ethiopia
According to the World Health Statistics 2015 report, Ethiopia has been placed by the
World Health Organization in the grouping of low income nations. Further statistics reported by
the WHO in the nation’s achievement of a the Millennium Developmental Goals (MDGs),
Ethiopia scores poorly in terms of provision of maternal healthcare services, with only a reported
10% of births occurring in the presence of qualified health workers, coupled with only 34% of
maternal health coverage as compared to the targets of 90 % and 100 % respectively – hence
depicting a severe shortage of skilled health workforce availability for expectant mothers. The
nation was further reported to project high rates of mortality in 2013, due to communicable
diseases (559), non-communicable diseases (476) and injuries (94) (World Health Organization,
2015). Such high rates of mortality across disease based causative factors may be an indirect
indicator of an inadequacy in terms of staff skilled with deliverance of services pertaining to
disease prevention and management (Reich et al., 2016). Additionally, increments in the
percentages of mortality of infants within the age group of 5 years, from 10 to 15% due to
intrapartum related complications, further emphasizes the inadequate maternal health workforce
of the nation. While the rate of maternal mortality has reduced commendably from 1400 per 100,
000 live births at 1990 to 990 in 2000, the rate continues to remain considerably high in the year
2013, estimated to be 420 (World Health Organization, 2015). While such alarming health
statistics clearly project the need to improve present health workforce in the nation, Ethiopia has
also been attributed to possess a severe crisis in terms of a healthcare staff shortage, which has
been estimated to be only 0.7 per 1000 population - a value considerably low in comparison to

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the WHO’S recommendation of 2.3 per 1000 population. Despite attempts by the country to
correct these shortages resulting in significant strides of improvements, the health workforce of
Ethiopia continues to be plagued with issues pertaining to workforce retention and skill
distribution (World Health Organization, 2019). Hence the following report will seek to address
the critical issues pertaining to its health workforce coupled with provision of strategies for
possible improvements as per WHO’s recommendations.
Environmental Scan
As a response to the estimated shortages in healthcare workforce, as well as the inequities
observed in the human resources for health (HRH), in terms of distribution, the Ethiopian
government has attempted to mitigate these issues, with the aid of comprehensive staff
improvement policies and change frameworks, since 1998. This has resulted in the government
of Ethiopia to undertake heavy investments in the sector of healthcare, leading to considerable
enhancements in the overall health status of the nation and reduction in diseases World Bank
Group, 2019). Such improvements due to governmental efforts resulted in achievement of MDG
goals of a 67% reduction in rates of mortality of infants aged below 5 years, followed by
increments in life expectancy at birth from 45 to 64, across 1990 to 2014 (Abay et al., 2018).
Further, the additional healthcare framework implemented by the nation, that is, the Health
Extension Programme, formed the crux of improvement of Ethiopia’s healthcare sector resulting
in increased accessibility to the citizens, specifically children and mothers, towards
comprehensive healthcare packages and services (Gesesew et al., 2016). The program has further
improved clinical governance and leadership across the healthcare workforce projected in the
form of enhanced community as well as political participation at every platform of healthcare

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deliverance. The programme also resulted in improvements in sanitation and hygiene coupled
with establishment of a team of healthcare extension workers to ensure door-to-door healthcare
deliverance (Derbew, Laytin & Dicker, 2016).
However, as a response to the continuing issues associated with prevalence of high
mortality rates due to communicable and non communicable diseases as well as injuries, the
nation’s government established and implemented the Health Sector Transformation Plan
(HSTP), to ensure improvements in healthcare equity and quality, dissemination of healthcare
coverage which is universal and transformation of existing healthcare services (World Bank
Group, 2019). Based on the same, the HSTP was formulated considering four strategies aimed at
ensuring excellent deliverance of healthcare, excellent improvements in terms of assurance and
quality, excellent clinical governance and leadership and excellence in the capacity of the health
system (Teklehaimanot et al., 2016). The aim of the HSTP in Ethiopia is to ensure by 2020, the
reduction of rates of maternal mortality to 199 per 100, 000 live births and rates of under five,
infant and neonatal mortality per 1000 live births respectively. In addition to targeted reductions
in deaths caused due to tuberculosis and malaria, the HSTP also aims to reduce mortalities
caused due to road traffic injuries and accidents (Hanlon et al., 2019). To ensure targeted health
workforce improvements, the policy frameworks of HSTP has undertaken key strategies in the
form of: improved healthcare regulation, evidence based research, technological innovations,
improvements in infrastructure, increased leadership, community healthcare representation,
establishing coordinative healthcare at multiple sectors, formulation of an Emergency Operations
Center and the creation of comprehensive national healthcare workforce, with a equal
distribution of a multiple mix of skills World Bank Group, 2019).

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Data Profile
Table 1: Health Workforce Density of Ethiopia (per 10, 000) (World Health Organization,
2015)
Physician Nursing and
Midwifery
Pharmaceutical Dentistry Psychiatrists
0.3 2.5 0.3 - -
The health workforce of Ethiopia has been presented by the World Health Organization
in the World Health Statistics report of 2015. In terms of density of the health workforce per 10,
000 population, physicians in Ethiopia has been estimated to be 0.3, followed by personnel for
nursing and midwifery estimated to be 2.5, pharmaceutical workforce as 0.3 and a lack of
information on the density across dentistry and psychiatrists sectors. Further alarming values
have been reflected in the density of hospitals estimated to be 0.2 per 100, 000 and a relative
absence of psychiatric beds (World Health Organization, 2015) (See Table 1).
Table 2: Diagnostic Units of Ethiopia (per 10, 000) (World Health Organization, 2015)
Computer Tomography Radiology Mammography
0.4 <0.05 -
Additionally, a significant inadequacy in terms of diagnostic resources has been indicated
in the report, with an estimated 0.4 units of computer tomography, less than 0.05 units of
radiology and absence of mammography units – hence reflecting a serious possibility of
inadequate clinical assessments and diagnosis (World Health Organization, 2015) (See Table 2).

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2000 2012
0
10
20
30
40
50
60
70
Figure 1: Financial Resources for Healthcare
Government Expenditure
External Resources
Ironically, though, perhaps as a result of the proactive response by governmental bodies
since the last two decades, there has been a projected rise in the allocation of monetary resources
across healthcare organizations from 2000 to 2012, in terms of general government expenditure
on health from 54.6 to 60.6%, and external resources of health from 16.0 to 40.9% (World
Health Organization, 2015) (See Figure 1).

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Rural Urban
0
10
20
30
40
50
60
Figure 2: Health Worker Inequities: Rural-
Urban
Antenatal Care Coverage
Births Attended by Skilled
Personnel
Severe inequities in terms of health has been estimated in terms of coverage of antenatal
care, across places of residence (rural: 14%, urban: 46%), wealth quintile (lowest: 9, highest: 49)
and educational level of women (none: 12, secondary or higher: 65). Huge disparities in health
workforce in terms of births being attended by personnel who are skilled occur across places of
residence (rural: 5%, urban: 52%), wealth quintile (lowest: 2, highest: 46) and educational level
of women (none: 5, secondary of highest: 74) (World Health Organization, 2015) (See Figure 2).
The World Health Organization further denotes key statistics of the health workforce of
Ethiopia, by denoting the existence of a crisis considering its overall health workforce to be 0.7
per 100, 000 population, which is significantly deficiently comparing with the recommendations
of 2.3 per 100, 000 population. The highest rates of inadequacies in the health workforce has
been observed in terms of physicians, whose densities have been predicted to be one of the least
in the Sub African region, that is, 1: 42, 706 population (World Health Organization, 2019).

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Despite such detrimental numbers, the nation’s governmental body has attempted to
improvise upon the same. With the implementation of several healthcare policies and
frameworks as discussed previously, the last 5 years have observed increments in populations of
health professionals such as health extension workers, nurses, health officers and midwives.
Such nationwide attempts have resulted in the country to achieve the recommended nursing
personnel density of 1 per 5000 population. To further mitigate and ensure long term
improvements as a response to the decreasing healthcare crisis, the government of Ethiopia
further implemented a post graduation healthcare education framework of 3 years across 5
academic institutions, coupled with the expansion of enrollment across schools of midwifery
(World Health Organization, 2019).
Critical Issues and Possible Strategies
1. One of the first strategies which must be implemented for health workforce improvement
of Ethiopia, is to ensure an equitable distribution of health workforce across both rural
and urban areas, which can perhaps be done, by governmental establishment of increased
rural healthcare organizations or innovative provision of incentive packages to motivate
health worker migration to remote, Indigenous or rural areas (Assefa et al., 2017). This is
due to fact that, in addition to the prevalent crisis in terms of health workforce, a number
of critical issues can also be identified across the healthcare staff communities of
Ethiopia. Along with the gross deficiency across the workforce of physicians, one of the
most critical issues plaguing the health workforce of Ethiopia is the stark inequities in
distribution of the same across rural and urban places of population residences. A
shortage of health workers have been estimated to be prevalent across 83% of

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communities residing in rural and remote areas of the nation (World Health Organization,
2019).
2. The next key strategy which is further required to be implemented is the equitable
distribution of health workers across private and public health organizations. This can be
done possibly by collaborative functioning of both private and public sectors in working
of healthcare organizations to ensure equitable working conditions across both fields.
Further, provision of financial benefits for workers opting to work for public health
organizations can also be considered as a key strategy (Sidibé & Campbell, 2015). The
reason for the same, is due to the fact that, another key critical issue which is required to
be addressed is the inequitable distribution of skilled and credible healthcare workers
across publicly and privately owned organizations. This can be observed in the total
population of physicians estimated to be 1806 in number in the years 2006 and 2007, of
which 38% of health practitioners and 56% of specialists were found to be employed in
privately owned healthcare organizations (World Health Organization, 2019).
3. Thirdly, a key strategy aimed at improvement of health workforce is the rapid migration
of the concerned staff from Ethiopia. A major issue which is of concern and is a key
contributor to the decreased healthcare workforce is the high rate of emigration of staff to
work at organizations away from the nation. It was estimated that in the year 2002, 30%
of doctors and 17% of nurses migrated from the country (World Health Organization,
2019). To address the same, the government of Ethiopia has worked actively with the
administration of several organizational strategies aimed at retention and flooding of
health workers. Despite the implementation of extensive workforce flooding innovations,
Ethiopian strategies have been criticized to focus merely on increasing the numbers of

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healthcare staff, without paying adequate attention to enhancing areas of professional
development and improvement such as healthcare education and training (Olu et al.,
2018). Academic institutions, despite implementation of masters educational programs,
have been observed to lack in adequate infrastructure and human resources for teaching.
Further, there has been an observed lack of established standards in ensuring the quality
or regulating the proficiency across staff who are receiving training and education from
academic or healthcare institutions (Araujo, Evans & Maeda, 2016). Lack of conducive
work conditions continue to prevail across healthcare organizations, with the government
providing little attention and instead has implemented counterproductive strategies in
which the certificates and diploma degrees of the health professionals are kept on hold
until they attend the workplace organized to them. While the same may seem to be
effective, such stringent policies may discourage existing health workers resulting in their
emigration (Kibwana et al., 2016). Hence, considering all the above, not only must the
government seek to implement strategies aimed at providing motivating and conducive
environments but must also seek to implement quality or accreditation standards of
healthcare professional improvement, redirect financial resources for implementation of
technological implementations especially in terms of diagnostics as well as establish
reward programs for workers wishing to stay back to the nation or undergo completion of
educational and professional certification policies (Kols et al., 2018).

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Framework Strategies
Hence, the following can be considered as possible strategies for the improvement of the
health workforce of Ethiopia, using the 10 recommendations of healthcare transformation
outlined by the World Health Organization (World Health Organization, 2016).
1. Creation of Jobs: Considering the crisis in terms of physician, nursing and midwifery
workforce, evident in Ethiopia, the government must seek to invest and redirect financial
resources towards the creation of novel health worker positions. To further ensure
optimum allocation of jobs as per the Ethiopian scenario, the government can follow
WHO recommendations and invest in jobs for youth and women across rural areas in
physician and maternal healthcare coverage sectors (Teklehaimanot et al., 2016).
2. Gender and Rights of Women: Organizations must not only implement gender
equitable organizational polices coupled with ensuring empowerment across women.
Hence, considering the dearth of educated women in the Ethiopian maternal coverage
workforce, the government can reserve specific positions for female candidates in clinical
leadership designations. Further strategies include implementation of financial benefits
for female workers with higher educational degrees, as well as establishment of sexual
harassment strategies and flexible working environments to encourage women to work
(Kälvemark Sporrong et al., 2016).
3. Education, training and skills: Considering the lack of educational infrastructure, the
Ethiopian government must implement innovative healthcare curriculum, with not just
evidence based theory but also practical based learned based on accreditation standards to
ensure enthusiasm to learn as well as achievement of competencies. To prevent

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inequities, such curriculum must be open to all, irrespective of religious or cultural
differences (Miller et al., 2016).
4. Delivery and Organization of Health Service: Considering differences in private as
well as public sectors, the Ethiopian government must aim to implement healthcare
policies which dictates and necessitates both public as well as private organizations
across both remote and urban areas to practice person centered, evidence based
interventions aimed not just primary care but also prevention of diseases for overall
national healthcare improvement (Argaw et al., 2019).
5. Technology: To address hastened healthcare delivery especially across rural areas, the
government must implement cost effective technological innovations such as triage or
telehealth services or door-to-door services further ensuring greater health worker
participation and healthcare deliverance (Ruducha et al., 2017).
6. Humanitarian settings and Crisis: To motivate health workers, instill security and
prevent attrition, healthcare organizations must seek to implement policies of employee
protection or counseling services to further ensure optimum functional capacity among
the same (Jigssa et al., 2018).
7. Fiscal Space and Financing: Along with supplementing governmental funding, the
Ethiopian government can out source funds from international as well as non
governmental bodies to implement new jobs, improve existing infrastructure and work
environments in healthcare organizations (Desta, 2017).
8. Cooperation and Partnership: In equities in the Ethiopian workforce have been
observed across rural and urban, as well as across public and private organizations.
Hence, to mitigate the same, the government must seek to implement collaborative,

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partnership based policies where both public as well as private, rural as well as urban can
work together to establish equitable working conditions across all sectors (Lunsford et al.,
2015).
9. International Migration: To prevent excessive international migration, the Ethiopian
government can implement awards and recognition policies for workers wishing to stay
back or work collaboratively with partnership nations to internationally accredit workers
who are migrating for a limited time period to return and contribute to the nation
(Assefa et al., 2016).
10. Data, accountability and Information: The government must implement routine
monitoring of health worker analytics, population distribution, attrition and recruitment
rates, to identify key worker trends and changes. This can be used to implement evidence
based change practice policies to further improve healthcare working conditions and
prevent crisis (Kibwana et al., 2016).
Conclusion
Hence, it can be observed that Ethiopia continues to be affected due to a heath worker
crisis, characterized by a dearth of maternal healthcare personnel, emigration, physicians, nurses
and inequitable distribution across both public, private, rural and urban sectors. Hence, in
conclusion, to address the same, the Ethiopian government must work beyond merely ‘flooding’
and seek to implement new educational policies, gender friendly benefits, employee security,
reward programs and multi-sectoral partnerships.

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