Jeff Collins Online Textbook Chapter African Health Care Worker Shortage The dire need for health care services that many African countries are currently experiencing is one that has begun to receive much more attention from developed nations, as well as international organizations. As a corollary, recent trends have shown a surge in official development assistance to African nations, ending a swift and steady decline since the end of the Cold War (5). Given the fact that Africa shoulders the largest disease burden of any continent and has the least amount of resources with which to combat it, a policy reversal of this type has become an imperative. To this point, the majority of this aid has been focused on supplies and medications. The current emphasis of the international community is on supplying already existing clinics with tools to prevent and treat prevalent disease entities. There is, of course, a need for this type of relief, as a lack of access to medications and proper disease prevention tools plays a major role in the disproportionately large burden of disease seen in Africa. The problem, however, is that there are no complimentary investments being made in health care infrastructure. The most acute of these infrastructural shortfalls is the lack of health care workers. In fact, if current trends continue, there will be far too few workers to properly distribute the supplies and medications that donor countries intend to contribute. This has the potential to create a severe bottleneck for the increasing amounts of aid being offered by donor countries. With insufficient manpower to provide health education, implement prevention efforts, and properly dispense medications, levels of foreign aid will essentially become irrelevant.The current shortage of health care workers in Africa has a variety of etiologies. The situation may be caused, in part, by several years of reduced education and health care spending. Structural adjustment programs, implemented by the International Monetary Fund and the World Bank over the course of the last 25 years, have required developing nations to drastically reduce public spending in order to qualify for further financial assistance. Reductions in spending have included publicly funded education and health care programs. The largest contributor to the shortage, however, is the mass exodus of trained health care workers from their native countries to industrialized nations around the world. There are several factors, including poor working and living conditions, that cause this migration of health professionals, which results in a huge loss in human capital for their countries of origin. The situation is exacerbated even further by health care worker shortages in developed nations. These shortages result in the active recruitment of foreign health care workers by institutions in countries like the United States, in an attempt to supplement a domestically trained workforce that is insufficient to meet the nation’s health care demand. Therefore, it is clear that policy changes are needed at many levels in order to ameliorate the growing African health care worker crisis. Structural Adjustment Lending and Reductions in Public Spending In the midst of the world financial crisis of the late 1970’s, World Bank president Robert Macnemara put forth a radical new financial plan to help normalize the growing account deficits of African nations. The cornerstone of this new plan was the introduction of Structural Adjustment Lending. Structural Adjustment Lending consisted of new, large-scale lending programs to African nations that carried with themstipulations that individual governments were required to follow in order to qualify for additional development loans. The notable conditions to be met included fiscal adjustment, trade liberalization and, in general, a movement towards free markets and away from state intervention (3). According to the 1980 World Bank annual report, the goal was to “reduce current account deficits to more manageable proportions by supporting programs of adjustment . . . to strengthen the balance of payments, while maintaining their growth and developmental momentum” (2). The line of thinking that predominated at this point, and continued to predominate over the course of the next 25 years, was that the African state had become oversized and that a reduction in spending was necessary to achieve fiscal balance (1). Therefore, in order to meet the criteria for adjustment lending, governments began reducing expenditures. This relatively dramatic policy shift did eventually result in a reversal of the trend of increasing fiscal imbalance. By 1995, the indebtedness of African nations was on the decline (4). Global Debt by Region, 1980-20030100200300400500600700800900198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003YearAFRICADEVELOPING ASIAMIDDLE EAST AND TURKEYWESTERN HEMISPHERECENTRAL AND EASTERN EUROPE Source: International Monetary Fund, World Economic Outlook Database, 2003There was a price to pay for this reduction in fiscal imbalance, however. Throughout this 23-year period, the decline in education and health care spending was severe, immediate and prolonged. As one study points out, “the average annual growth rate of public expenditure on education between 1970 and 1980 was 4.4%, but between 1980 and 1983 the annual growth rate was -9.2%” (6). Africa’s share of world education expenditures continued to fall across the entirety of the adjustment era, with consistent declines during the 1980’s and 1990’s (1). The trend in health care spending was similar. During the 1990’s, the African continent demonstrated an average per capita health care expenditure between $25 and $35 and “never approached even 1.5 percent of the level spent by rich states in the North” (1). These strict economic policies have limited the growth of African health care infrastructure. Reduced investment in education has contributed to reduced quality of tertiary and professional education and has left many nations unable to cope with a disproportionately large burden of disease. Inadequate health care spending has further exacerbated this issue, limiting the number of qualified health care workers governments are able to employ. In this way, structural adjustment lending has contributed to shortcomings in both the ability to educate