|07. Health Professionals for Maternity Services: Experiences on Covering the Population with Quality Maternity Care|
|Distribution Problems of Health Professionals|
Important imbalances in human resources are found in the distribution of health personnel. Many developing countries have insufficient primary care providers and too many specialists. Even these are concentrated in urban areas. The rural/urban disparity in qualified personnel trained in obstetrics is further aggravated by migration of medical and paramedical personnel (nurses, midwives) to other countries. South Africa draws many medical people from other southern African countries, as do the Arab countries from East and Central Africa. In the 90s more Sudanese doctors worked in Arabia than in Sudan. This brain drain is damaging health care in their countries of origin and also the home economy. The high input to training of medical personnel is also lost to the country. Career development paths and in-service training are needed to retain staff. For improving the balance, non-physician primary care providers have many advantages: their training cost less (Myanmar, Pakistan and Sri Lanka indicate that 2.5 to 3 nurses can be trained for the cost of training one physician) they receive lower salaries, they are easier to attract to rural areas, and they communicate more efficiently with the patients (World Bank 1993).
In many governmental health systems 60% (SA) to 90% (Senegal, Nigeria) of medical doctors work in the main cities (Solanke 1997). Specialists in surgery or obstetrics and gynaecology are almost never found outside the national hospitals other than in private clinics. In China only 3% of senior medical doctors work in country hospitals (Xiang et al. 1996). In the whole country of Malawi only one specialist in anesthesia is working (Adeloye 1993). In Pakistan we find 3 times more registered doctors than registered midwives (Government of Pakistan 1997). Even with 7% of unemployed medical doctors and 11% working outside the medical profession in Mexico, the rural areas go seriously under-served with medical doctors. They are strictly not willing to leave the major cities (World Bank 1993). In Indonesia, Ethiopia, South Africa and even Australia rural hospitals (first referral level) are staffed by general practitioners or midwives, who are either not trained to perform emergency treatment in obstetrics, and are therefore reluctant to intervene, or who are not allowed to do so (Craig & Nichols 1993, Loutfi et al . 1995, Reid et al . 1998, Thouw 1992).
In Tanzania, as in many other countries, the rural areas are served by general practitioners and assistant medical officers. Here most of the population manages to access first line health services. E.g. one dispensary covers on average 5,000 population and 80% of them live within a 5 km radius (Tanzania / Bureau of Statistics 1996). Obstetric care is provided by a network of regional and district hospitals, with the non-academic assistant medical officers providing the backbone. Still rural areas are underserved as the effective catchment area drops sharply beyond a distance of 10 km (Jahn et al . 1998).
Emergency obstetric care is a male dominated field. Most surgeons the world over are men, only in the states of the former Soviet Union are female obstetricians the rule. At health centre level and dispensaries delivery care is mostly provided by female staff. In China the demand for female rural doctors has led to increased recruitment, training and deployment of female doctors. Since 1997 there is at least one female doctor in every village (Koblinsky et al . 1999). In Nepal a cadre of mother child aids was formed to staff dispensaries and health centres. Their tasks include assisting in institutional and home delivery and mobile antenatal clinics. Due to strong caste rules the cadre does not work very efficiently (higher caste can not deliver lower caste)(Dar Iang 1999). In Pakistan lady health workers provide antenatal care through home visits. For women living in strict Purdah the visit to the dispensary or hospital is not acceptable (Jahn 1995). In Burkina Faso male midwifes (maieuticiens) are trained and work in health centres and hospitals. Training men as midwifes has been necessary to fill the gap left by female midwifes leaving the rural areas to join their husbands in the major cities (there is a legal right of rejoining families for civil servants) (Hien, pers. comm.). For women living in the big cities female trained assistance at delivery is the rule, for rural settings it is by chance.