Public Health

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Africa suffers about one-quarter of the world’s burden of disease yet has barely three percent of its health workers. By complementing standard medical doctors with less intensively—though professionally—trained local health officers who serve their home communities, African countries could dramatically improve access to health care. Several practical lessons emerged from our research.

  • Successful programs hire local women as health officers whenever possible. Rural women are perceived as more trusted (and trustworthy) than men by other rural women, and women are already the focal point of many health initiatives, including reproductive ones. While an ideal candidate would be well educated, health officers need only be literate, with a primary education. Countries that have tried to relocate more skilled urbanites to rural areas have struggled both to hire and retain them.
  • Training will vary according to the specifics of a country’s program but should include about 9 to 12 months of formal instruction (classroom and field work) paired with practical apprenticeships to build comprehension, confidence, and independent work habits. Supplemental training is essential. In Bangladesh, for instance, BRAC5 complements its basic training with monthly refresher courses to keep health workers current on best practices in treatment and prevention, as well as to teach new skills.
  • Health workers should have manageable territories—roughly one health officer for every 1,000 to 1,500 people. This ratio ensures that workers can visit patients regularly to monitor them, check compliance, and follow up over time. Bigger territories jeopardize a worker’s ability to serve and build trust with patients.
  • Local health officers must be paid, with compensation ranging from perhaps one-sixth of an average nurse’s salary to 125 percent of the country’s average salary. Volunteer models suffer retention problems and are unlikely to be sustainable. Indeed, Ethiopia’s decision to pay its health extension workers (after initially treating them as volunteers) helped it add 30,000 of them in just five years.
  • Health services should be focused enough to be manageable and affordable yet broad enough to cover a range of essential needs. These will include first aid, basic preventive and diagnostic services, the distribution of materials (say, nutritional supplements or condoms), and essential curative care—as well as the monitoring and, occasionally, treatment of chronic conditions. If the services provided are too narrow, patients will ultimately disregard them. Furthermore, services must be offered at low cost. Small out-of-pocket costs for drugs appear to be bearable, but charging higher sums for services, drugs, and other supplies appears to be impossible on a large scale, at least today.
  • Programs should aspire to an eight-to-one ratio of health workers to supervisors. At these levels, a supervisor can accommodate often lengthy travel times yet still meet with workers at least two to four times a month. In our experience, this level of contact gives health workers enough time to sharpen their skills and even to start viewing their positions as promising careers. (Our work in Tanzania suggests that career development can be more important than financial considerations to health officers.) Best-practice programs will focus on supervision and performance management—using checklists and other simple tools to keep guidance fair and thorough—while striving to create opportunities for professional growth.

By applying these best practices and employing groups of local health officers, African countries could address the bulk of the most important clinical conditions they face. Furthermore, meeting this goal would require just a single local health officer per every 1,000 to 1,500 people, at a cost of about $1 a year per capita. This staffing level would give patients more than three meaningful interactions a year with trained medical personnel—a dramatic improvement over the status quo.