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Summary of Present Experience

The unequal distribution of trained medical personnel for obstetric interventions has several reasons. One of the main factors is the influence of politics. Often the political will to staff rural hospitals with qualified medical personnel is not seriously formulated, or the political power to exert such policy is weak. By the example of Norway we can see that a strong government can insist on staffing rural posts. Beneficiaries of state bursaries either go to the Northern provinces or they must reimburse the received money. In Burkina Faso exemptions to the staffing regulations undermine the system. Female staff can apply to be posted near to their husbands (if they are governmental employees too). The law on protection of the family guarantees the relocation. By this practice almost all registered midwives are posted in the two main cities. In other countries e.g. Tanzania influential individuals just do not comply with posting to rural areas without fearing any retribution.

Another reason for unequal distribution of health workers is a shortage in absolute numbers of qualified medical personnel. The debate has been going for more than twenty years on whether training of more medical personnel or non-academic staff will be the solution. In between many countries have experimented with different approaches to cover the under-served rural areas with adequate obstetric care. The results are encouraging. The experiences show that in the absence or scarcity of physicians at first referral level, non-physician teams can be trained to undertake effectively all functions attributed to that level, including emergency operative procedures (General Assembly at the XIII World Congress of Gynecology and Obstetrics 1992).

The World Bank encourages the employment of paramedical staff for several reason, not the least being their training is cheaper and their salaries lower. They are also easier to attract to rural areas, and generally communicate more efficiently with patients (World Bank 1993). Still the recognition of non-academic staff by professional organisations and governmental bodies is missing in many parts of the world.