Leadership in Health Services

ISSN: 1751-1879

Article publication date: 3 October 2008



Bowerman, J. (2008), "Editorial", Leadership in Health Services, Vol. 21 No. 4. https://doi.org/10.1108/lhs.2008.21121daa.001



Emerald Group Publishing Limited

Copyright © 2008, Emerald Group Publishing Limited


Article Type: Editorial From: Leadership in Health Services, Volume 21, Issue 4

This special issue, jointly sponsored by the World Health Organization and Leadership in Health Services, includes an interview and articles submitted by authors from around the world who are working in or studying health care issues from a global perspective. Recognizing the critical need for a skilled and sustainable workforce in the developing world, the papers describe the impact of the global situation, and address ways to meet the global shortage specifically through training and education initiatives designed to empower people to deal with the health and medical issues threatening to overwhelm them. Without enough workers and systems that facilitate the delivery of drugs vaccines, advice and care, all the money in the world cannot improve the health and well-being of the world’s population

The facts on the global inequality of health services and workers are stark. The WHO fact sheet dated April 2006 tells us the following:

  • A total of 57 countries, most of them in Africa and Asia face a severe health workforce crisis- the estimate are that 4.3 million health service providers and management support workers are required.

  • Not only are there severe imbalances between developing and developed countries, but also within countries. Rural areas in particular face shortages of qualified workers compared with urban areas.

  • Sub-Saharan Africa faces the greatest challenges. While it has 11 percent of the world’s population and 24 percent of the global burden of disease, it has only 3 percent of the world’s health workers.

  • There is a direct relationship between the ratio of health workers to population and survival of women during childbirth and children in early infancy. As the number of health workers declines, survival declines proportionately.

The crisis demands that we create more training and education for would be health care workers on the ground – where the need exists. In addition, transporting a western model of health care to these developing regions does not address the cultural values that exist in such places. It is essential to build the appropriate model around people’s natural patterns of interaction – in alignment with their community practices. Other factors cited include poor working conditions for health workers and inadequate pay, the disparity between rural and urban conditions, and the ongoing migration of trained workers from developing to developed nations.

Alistair Craven of Emerald Insight has provided us with a brilliant interview with Dr Faith Mwanga-Powell – Executive Director of the African Palliative Care Association. Palliative Care is defined as holistic care incorporating the entire life span from birth to end. What makes Dr Mwanga-Powell’s work so remarkable is that it is occurring on a huge continent where human resources, leadership, strategic vision, drugs to ease pain, caring governments, and conditions that sustain life are sorely lacking. Her words paint a picture of the sheer complexity and misery of the problem, but they are also inspiring – leaving us with hope that strong leadership that really understands the nature and scope of the situation can make a difference.

In fact we none of us are immune to the impacts of the inequalities in the health care system – even though we may live in countries with some of the most advanced medical systems in the world. As much as the inequality is a problem of poverty and under development, the increased globalization of the world serves to remind us that this is a system problem.

For example, in my own affluent western Canadian province, we have a major shortage of doctors taking up practice in family medicine. Although an increasing number of individuals in the urban centres do not have family doctors and have to rely on anonymous medi-centres for medical advice, the shortage is especially noticeable in rural areas. As a result, incentives are being given to encourage young medical students to set up family practices out of the large urban centres.

In addition, there is a dire shortage of nurses. The nursing problem has been severely exacerbated by poor human resource planning of the early 1990s that saw hospital based nursing schools closed, and some 30 per cent of the workforce laid off. The short-term remedy of choice has been to recruit from other countries in the world, in particular the UK and the Philippines and there are major ongoing recruitment initiatives in this direction. To counter these short term measures, politicians are trying to think long term – they have put money into new nursing schools that provide creative incentives to attract new nursing recruits including partial tuition reimbursement if students spend a certain number of weekend, evening and holiday hours volunteering in hospitals and care centres. Summer holiday and school work programs are now being introduced as a means of encouraging students still at school to consider a health career.

It is indeed ironic that some 15 years after politicians decimated the health care labour force in my province, paradoxically we are taking such extreme measures to attract people to work in our health care institutions. Our recruiters are literally begging nurses to come here and work. We are competing with other Canadian provinces. We are offering bonuses to nurses to come back to their jobs even after they have officially retired. Such actions speak to the crisis in the supply of health care workers as a global crisis. The situation clearly demonstrates that we are all intimately connected wherever we live, and whatever kind of health care system we have. The ongoing migratory circulation and flow of health care professionals – sometimes seen as a brain drain-has changed the face of health care for all of us.

The ever-increasing inequalities in health and sickness challenge us to change our paradigms about how we view our global health delivery systems and the possible ways of addressing the imbalances. Too often, the short-term solution of poaching from other countries or areas of the world has become not just a short-term solution but also the only solution. As long as shifting the burden is viewed as the method of choice for resolving health care inequalities, the burden remains and becomes even greater for those parts of the world where extreme poverty and sickness are rampant.

I am proud to say that the articles in this issue begin to address some of these different ways of thinking. Michael Aherne and José Pereira’s article, reflective of the work of Dr Mwanga-Powell, demonstrates the creation of a capacity-building project to scale up learning and development in “rural, remote, and resource-constrained Canadian delivery settings” for the purpose of delivering palliative and end of life care services. The paper shows what can be done if we are prepared to think differently, and put to use both formal and informal models of adult learning in creative practice. Aherne and Pereira demonstrate how it is possible to build communities of care that transcend the traditional, centralized, and somewhat narrow boundaries of the professional health services. In a personal e-mail to the editor, author Michael Aherne explains that this is:

… likely “one of those projects where the bureaucrats did not really understand what we wanted to try. … We had a chance to implement a lot of what I had been working on conceptually since I penned my M.Ed back in 1996. I had very carefully examined the formal and informal performance-based learning of professional engineers and geo-scientists in Alberta.”

What better use of adult education theory can there be than to put it into practice for health care service delivery? Unfortunately, bureaucrats are necessary. Although they have a bad reputation for trying to fix things that are not broken, for wasting resources, for failing to take account of complexities, and not challenging the status quo, sometimes they do well. Just occasionally, they take a risk and are prepared to operate on faith – faith that the value of the money through non- traditional methods of learning and service delivery can be returned many times over. This is one of those cases and represents a model well deserving of replication in other parts of the globe. I believe we have much to learn from the work of Aherne and Pereira.

Yet another Alberta-based paper is that of Dr Ken Zakariasen and Associates who write about a new public health leadership program incorporating contemporary organization development methods to develop a case based learning strategy. The program, developed for global students, has been developed from an Appreciative Inquiry perspective; it points to the importance for leadership training for students of public health, and serves to develop their leadership expertise through making sense of their own experiences, so that they are better able to make a difference in their home countries. Most importantly, it recognizes that the western model based on our cultural values no longer suffices in today’s world. Such learning models underpinned by constructivism and humanism – provide so much more room for creativity and cultural relevance.

The final three articles in this issue again take us to the continent of Africa. They all speak to the issues that Dr Mwanga-Powell reminds us of in her interview. As Drs Chamberlain and Watt starkly note:

The adult lifetime risk of maternal death in Africa – the likelihood of a 15 year old dying from a pregnancy complication during her lifetime – is one in 26 women while in developed regions it is 1 in 7,300 women.

They emphasise that this is much more than a medical service delivery issue – it is in their words “a complicated labyrinth of social issues and health related issues.” The paper based on a program in Uganda, describes a case study of a post graduate program for multi-disciplinary professionals to become public health leaders for safe motherhood in developing countries. This program also incorporates modern theories of adult learning, and is based on a modular delivery system where students learn to work in local communities on change initiatives.

Finally the papers on Ghana and Rwanda draw graphic pictures of the severe constraints that both of these countries face in their efforts to scale up the production of health workers. Hampered by lack of resources including adequate infrastructure, training, qualified personnel, equipment, and outdated policies, and in the Sekyere district of Ghana with a decentralized program thrust which has little or no meaning in reality, their situations scream out for initiatives that can make a real difference. We see the frustration of yet new programs implemented by well meaning NGOs or governments – which may well be desperately needed but which serve to compete with and draw resources away from other health programs, through better wages, or working conditions. These are complex systems – no initiatives operate in isolation – all impact the other – and often too often lead to unexpected and negative results.

Aherne and Pereira argue that simply looking at the situation from a resource constrained perspective, with too much emphasis on straight training and development as solutions to correcting imbalances do little to really help us change the situation. The papers from Africa reinforce their argument. We can start to see that money, and formal training and development programs are only parts of the equation; they are one-way inputs that do not necessarily build the capacity for change. Building learning into systems may be complex, but it is not necessarily complicated. It can be done if we have the imagination, the will, and the creativity to go beyond the commonplace. I hope that even though these papers were submitted for this special issue, these writers and others can go on to document their achievements and their successes in yet more papers for this journal. What better testament to leadership can there be than to share one’s experiences, and one’s successes in this difficult area of health service delivery?


This special issue was led by WHO, Department of Human Resources for Health (HRH). For more information, please visit www.human-resources-health.com

Jennifer BowermanEditor

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