Health Workers In Africa Research Articles

Projected health workforce requirements and shortage for addressing the disease burden in the WHO Africa Region, 2022–2030: a needs-based modelling study

IntroductionAn adequate health workforce (HWF) is essential to achieving the targets of the Sustainable Development Goals (SDG), including universal health coverage. However, weak HWF planning and constrained fiscal space for...

Study protocol for a pilot quasi-experimental study on oral health education for nurses and community health workers in Nigeria.

The primary health care system provides an ideal setting for the integration of oral health into general health care as well as equitable access to oral health care. However, the limited oral health knowledge of primary health care workers necessitates appropriate training before they can participate in health promotion efforts. This pilot training was designed to examine the impact of the Oral Health Education module for Nurses and Community Health Care Workers on their oral health awareness and referral practices. This study will utilize a quasi-experimental design (pre-and post with a non-equivalent control group) to assess the impact of a five-day pilot oral health education program on the knowledge and referral practices of Nurses and Community Health Workers in primary health care centers in three states in Nigeria-(Lagos, Oyo, and Kano). The training modules were developed based on the six iterative steps described in the intervention mapping framework - needs assessment, highlighting program objectives and outcomes, selection of theory and mode of intervention, designing program based on theory, designing implementation plans, and developing an evaluation plan. Only the intervention group will participate in the full educational training sessions but both groups will complete the pre-and post-intervention questionnaires. This pilot training combined the standardized training modules from the recently launched "Oral Health Training Course for Community Health Workers in Africa" and a newly developed maternal and child oral health module by our group using an evidence-based approach. To the best of our knowledge, this is the first program to examine the impact of the standardized OpenWHO modules. The success of this training will lay the foundation for developing a sustained channel for providing oral health education at the primary health care level in Nigeria, West Africa, and Africa.

The paradoxical surplus of health workers in Africa: The need for research and policy engagement.

In many countries in Africa, there is a 'paradoxical surplus' of under and unemployed nurses, midwives, doctors and pharmacists which exists amidst a shortage of staff within the formal health system. By 2030, the World Health Organisation Africa Region may find itself with a shortage of 6.1 million health workers alongside 700,000 un- or underemployed health staff. The emphasis in policy debates about human resources for health at most national and global levels is on staff shortage and the need to train more health workers. In contrast, these 'surplus' health workers are both understudied and underacknowledged. Little time is given over to understand the economic, political and social factors that have driven their emergence; the ways in which they seek to make a living; the governance challenges that they raise; nor potential interventions that could be implemented to improve employment rates and leverage their expertise. This short communication reflects on current research findings and calls for improved quantitative and qualitative research to support policy engagement at national, regional and global levels.

Determinants of Knowledge, Attitudes, and Practices of Frontline Health Workers During the First Wave of COVID-19 in Africa: A Multicenter Online Cross-Sectional Study.

BackgroundDuring its first wave of COVID-19 infection in sub-Saharan Africa, there was insufficient understanding of the pandemic among frontline health workers. This study was carried out to determine the knowledge, attitude, and practices (KAP) of frontline health workers (HWs) towards COVID-19 in Africa and their related factors.MethodsThis was a multicenter online cross-sectional study conducted between April 2020 and July 2020 using a Google survey link among frontline HWs involved in the COVID-19 response in 26 African countries. Bivariate and multivariate logistic regression were used to analyse the determinants of KAP. Data were analyzed using STATA ver 16; all tests were two-sided with 95% confidence interval.ResultsFive hundred and seventeen participated in this study from 26 African countries; 289 (55.9%) were male and 228 (44.1%) female. Most of HWs, 379 (73.3%) showed poor knowledge about COVID-19 infection and preventive measures. In contrast, majority of them showed good attitude (89%) and practice (90.3%) towards prevention of COVID-19 infections. Knowledge varied among countries; Uganda had the greatest number of HWs with good knowledge (OR: 28.09, p<0.0001) followed by Ghana (OR=10.92, p=0.001) and DRC (OR: 4.59, p=0.015). The cadre of HWs also influenced knowledge; doctors were the most knowledgeable as compared to other cadres (OR: 3.4, p= 0.005). Attitude and practice were both influenced by HWs country of workplace and their cadre (p<0.05).ConclusionMajority of the frontline HWs in the African region had an overall good attitude and practice towards COVID-19 infection and practice measures despite relatively poor knowledge. The KAP is influenced by HWs country of workplace, their cadre. The knowledge of HWs in Africa should be increased to concourt with their attitude and practice to reduce the burden of intra-hospital transmission of the COVID-19.

Factors influencing motivation and job satisfaction of community health workers in Africa and Asia-A multi-country study.

As key stakeholders continue to affirm the relevance of community health workers (CHWs) in universal health coverage, there is a need for a commensurate focus on their motivation and job satisfaction especially in low- and middle-income countries (LMICs) where they play prominent roles. Despite the wealth of literature on motivation and job satisfaction, many studies draw on research conducted in high-income settings. This study explored factors influencing motivation and satisfaction among CHWs in LMICs. Thirty-two focus group discussions and 116 key informant interviews were conducted with CHWs, programme staff, health professionals and community leaders in Bangladesh, India, Kenya, Malawi and Nigeria. Data were analysed using thematic analysis. Overall, CHWs desired: (1) CHW programmes with manageable workload; work schedules that address concerns of female CHWs on work-life balance; clear career pathway; and a timely, regular and sustainable remuneration. However, no remuneration type guaranteed satisfaction because of an insatiable quest for additional financial reward. (2) Relationship with stakeholders that enhances their reputation. This was more important for unsalaried CHWs. (3) Opportunities to support community members. This was popular among all cadres as it resonated with their altruistic values. This study provides insights for developing a 'comprehensive motivation package' for CHWs.

COVID-19 Prevention Practices and Associated Factors Among Frontline Community Health Workers in Jimma Zone, Southwest Ethiopia.

BackgroundA timely understanding of the frontline community health care workers’ prevention practices towards COVID-19 is very crucial to combat the pandemic. Despite this, no study has been conducted among frontline community health workers in Africa, particularly in Ethiopia. The study aimed to determine the status of implementation of preventive measures of frontline community health care workers towards COVID-19 and its associated factors.MethodsAn institution-based cross-sectional study was conducted on 421 health extension workers among selected districts. Data were collected using a pretested structured questionnaire adapted from different pieces of literature. Respondents who scored above mean score on the item measurement such as knowledge, attitude, and practice questions were categorized as knowledgeable, having positive attitude, and having good prevention practices, respectively. Data were entered in EpiData 3.1 and analyzed using Statistical Package for Social Sciences (SPSS) version 23.0 software. A multivariable logistic regression model was used to identify significant predictors. P– values less than or equal to 0.05 were declared as statistically significant.ResultsThe mean age of study participants was 31.35 years (±4.83 SD), and almost half (217; 51.54%) of respondents were single and 273 (62.47%) were trained for COVID-19 prevention measures. Of the total study subjects, 194 (46.08%; 95% CI=41.6–50.7%) had good prevention practices towards COVID-19. Being married (AOR=3.36, 95% CI=2.20–5.13), being trained (AOR=2.28, 95% CI=1.39–3.74), having good knowledge (AOR=2.4, 95% CI=1.52–3.99), and having positive attitude towards COVID-19 prevention measures (AOR=5.88, 95% CI=3.52–9.80) increase the likelihood of implementing prevention measures.ConclusionThis study showed that prevention status was low; therefore, government and non-governmental organizations working around the study area should emphasize providing training to increase their level of knowledge and to change the attitude towards implementation of prevention measures, and these can ultimately increase the status of prevention practices.

Intersectionality of gender in recruitment and retention of the health workforce in Africa: a rapid review

Background: Despite the importance of gender and intersectionality in policy-making for human resources for health, these issues have not been given adequate consideration in health workforce recruitment and retention in Africa. Aims: The objective of this review was to show how gender intersects with other sociocultural determinants of health to create different experiences of marginalization and/or privilege in the recruitment and retention of human resources for health in Africa. Methods: This was rapid review of studies that investigated the intersectionality of gender in relation to recruitment and retention of health workers in Africa. A PubMed search was undertaken in April 2020 to identify eligible studies. Search terms used included: gender, employment, health workers, health workforce, recruitment and retention. Criteria for inclusion of studies were: primary research; related to the role of gender and intersectionality in recruitment and retention of the health workforce; conducted in Africa; quantitative or qualitative study design; and published in English. Results: Of 193 publications found, nine fulfilled the study inclusion criteria and were selected. Feminization of the nursing and midwifery profession results in difficulties in recruiting and deploying female health workers. Male domination of management positions was reported. Gender power relationship in the recruitment and retention of the health workforce is shaped by marriage and cultural norms. Occupational segregation, sexual harassment and discrimination against female health workers were reported. Conclusion: This review highlights the importance of considering gender analysis in the development of policies and programmes for human resources for health in Africa.

Intersectionality of gender in recruitment and retention of the health workforce in Africa: a rapid review.

Despite the importance of gender and intersectionality in policy-making for human resources for health, these issues have not been given adequate consideration in health workforce recruitment and retention in Africa. The objective of this review was to show how gender intersects with other sociocultural determinants of health to create different experiences of marginalization and/or privilege in the recruitment and retention of human resources for health in Africa. This was rapid review of studies that investigated the intersectionality of gender in relation to recruitment and retention of health workers in Africa. A PubMed search was undertaken in April 2020 to identify eligible studies. Search terms used included: gender, employment, health workers, health workforce, recruitment and retention. Criteria for inclusion of studies were: primary research; related to the role of gender and intersectionality in recruitment and retention of the health workforce; conducted in Africa; quantitative or qualitative study design; and published in English. Of 193 publications found, nine fulfilled the study inclusion criteria and were selected. Feminization of the nursing and midwifery profession results in difficulties in recruiting and deploying female health workers. Male domination of management positions was reported. Gender power relationship in the recruitment and retention of the health workforce is shaped by marriage and cultural norms. Occupational segregation, sexual harassment and discrimination against female health workers were reported. This review highlights the importance of considering gender analysis in the development of policies and programmes for human resources for health in Africa.

Development of a Mobile, Self-Sovereign Identity Approach for Facility Birth Registration in Kenya

Birth registration is a critical element of newborn care. Increasing the coverage of birth registration is an essential part of the strategy to improve newborn survival globally, and is central to achieving greater health, social, and economic equity as defined under the United Nations Sustainable Development Goals. Parts of Eastern and Southern Africa have some of the lowest birth registration rates in the world. Mobile technologies have been used successfully with mothers and health workers in Africa to increase coverage of essential newborn care, including birth registration. However, mounting concerns about data ownership and data protection in the digital age are driving the search for scalable, user-centered, privacy protecting identity solutions. There is increasing interest in understanding if a self-sovereign identity (SSI) approach can help lower the barriers to birth registration by empowering families with a smartphone based process while providing high levels of data privacy and security in populations where birth registration rates are low. The process of birth registration and the barriers experienced by stakeholders are highly contextual. There is currently a gap in the literature with regard to modeling birth registration using SSI technology. This paper describes the development of a smartphone-based prototype system that allows interaction between families and health workers to carry out the initial steps of birth registration and linkage of mothers-baby pairs in an urban Kenyan setting using verifiable credentials, decentralized identifiers, and the emerging standards for their implementation in identity systems. The goal of the project was to develop a high fidelity prototype that could be used to obtain end-user feedback related to the feasibility and acceptability of an SSI approach in a particular Kenyan healthcare context. This paper will focus on how this technology was adapted for the specific context and implications for future research.

Subclinical anthracycline therapy-related cardiac Dysfunction: an ignored stage B heart failure in an African population.

Anthracyclines are potent antineoplastic agents with a proven efficacy in the treatment of many paediatric and adult haematological and solid-organ cancers. Anthracycline therapy-related cardiac dysfunction (ATRCD) is the commonest and most well-studied chemotherapy-induced cardiovascular toxicity. Therefore patients who received anthracycline therapy are considered in stage A heart failure. Recent study findings suggest that anthracycline cardiotoxicity represents a continuum that begins with subclinical myocardial cell injury, followed by an early asymptomatic decline in left ventricular ejection fraction that can progress to symptomatic heart failure if left untreated. In Western countries, ATRCD has been reported in 57% of anthracyclines-treated patients. However, data on incidence and spectrum of ATRCD in Africa are not available. This literature review aimed to highlight the concept of subclinical ATRCD as a stage B heart failure in the spectrum of ATRCD, and the importance of early detection. We emphasise the potential burden and risk of subclinical ATRCD in the African population, with the ultimate aim of drawing the attention of health workers in Africa to improve care of the relevant population.

Travel burden and clinical presentation of retinoblastoma: analysis of 1024 patients from 43 African countries and 518 patients from 40 European countries

BackgroundThe travel distance from home to a treatment centre, which may impact the stage at diagnosis, has not been investigated for retinoblastoma, the most common childhood eye cancer. We aimed...

Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya, Nigeria, South Africa and Uganda

BackgroundAfrica’s health systems rely on services provided by mid-level health workers (MLWs). Investment in their training is worthwhile since they are more likely to be retained in underserved areas, require shorter training courses and are less dependent on technology and investigations in their clinical practice than physicians. Their training programs and curricula need up-dating to be relevant to their practice and to reflect advances in health professional education.This study was conducted to review the training and curricula of MLWs in Kenya, Nigeria, South Africa and Uganda, to ascertain areas for improvement.MethodsKey informants from professional associations, regulatory bodies, training institutions, labour organisations and government ministries were interviewed in each country. Policy documents and training curricula were reviewed for relevant content. Feedback was provided through stakeholder and participant meetings and comments recorded. 421 District managers and 975 MLWs from urban and rural government district health facilities completed self-administered questionnaires regarding MLW training and performance.ResultsQualitative data indicated commonalities in scope of practice and in training programs across the four countries, with a focus on basic diagnosis and medical treatment. Older programs tended to be more didactic in their training approach and were often lacking in resources. Significant concerns regarding skills gaps and quality of training were raised. Nevertheless, quantitative data showed that most MLWs felt their basic training was adequate for the work they do. MLWs and district managers indicated that training methods needed updating with additional skills offered. MLWs wanted their training to include more problem-solving approaches and practical procedures that could be life-saving.ConclusionsMLWs are essential frontline workers in health services, not just a stop-gap. In Kenya, Nigeria and Uganda, their important role is appreciated by health service managers. At the same time, significant deficiencies in training program content and educational methodologies exist in these countries, whereas programs in South Africa appear to have benefited from their more recent origin. Improvements to training and curricula, based on international educational developments as well as the local burden of disease, will enable them to function with greater effectiveness and contribute to better quality care and outcomes.

Correlates of observing and willingness to report stigma towards HIV clients by (TB) health workers in Africa.

Health care facilities in Kenya, Tanzania and Namibia. To study the factors associated with the observation of and willingness to report stigmatising behaviour towards persons living with the human immunodeficiency virus (HIV) among health care workers (HCWs). Mixed-effect logistic regression analyses of 9516 HCW interviews, including those of 4062 (43%) TB workers carried out as part of the Service Provision Assessments (SPAs) between 2006 and 2010. Discrimination (i.e., enacted stigma) was observed by respectively 1042 (60%), 384 (40%) and 907 (69%) TB workers in Kenya, Namibia and Tanzania, similar to the trend observed among all HCWs. Observations of discrimination were clustered at facility level in Kenya, and mapping of facility-level discrimination suggested geographic clustering. HCWs were more likely to observe discrimination in facilities without regular supportive supervision (adjusted OR [aOR] 2.33, 95%CI 1.09-4.96). No HCW characteristics were found to predict intention to report. Training in patients' rights and in confidentiality predisposed HCWs to recognise discrimination (aOR 2.51, 95%CI 1.19-5.28) and the willingness to report it (aOR 2.23, 95%CI 1.11-4.47). Exposure to training in TB infection control (IC) was associated with greater willingness to report discrimination (aOR 2.13, 95%CI 1.03-4.39). Supervision and exposure to training in patient's rights and confidentiality improved HCWs' understanding and advocacy of dignified and respectful TB-HIV care. All HCWs are equally likely to be allies, agents of change and amplifiers of an anti-stigma message, and broad engagement is required. Innovative approaches to reduce discrimination-while ensuring proper IC-should be explored.

Health Workforce Measurement: Seeking Global Governance and National Accountability

2013 • Population Dynamics: Dhaka Declaration (Global Leaders) • Comprehensive Health Labor Market Framework (Sousa and Scheffler) • Labour Market for Health Workers in Africa (Soucat and Scheffler) • Transforming the Global Health Workforce (DeLuca and Soucat) • 3rd Global Forum on HRH, Recife, Political Declaration on HRH (GHWA) • Recife, Country and Stakeholder Commitments (GHWA) • A Universal Truth: No Health without a Workforce (GHWA)

Headache prevalence and its characterization amongst hospital workers in Enugu, South East Nigeria.

BackgroundHeadaches are probably the commonest neurological complaint worldwide. Amongst workers it contributes significantly to loss of productive time and work efficiency. It is an important cause of disability and reduced quality of life. The prevalence and pattern amongst health workers in Africa has not been extensively studied.ObjectiveThis epidemiological sampling-based preliminary study examined the frequency and pattern of headache in a population of health workers of a tertiary hospital in Enugu, South East Nigeria.MethodsStudy participants, recruited by balloting, completed a self-administered questionnaire to screen for headache and its associations (defined as headache unrelated to fever and experienced within 6 months prior to the date the questionnaire was administered). Data analysis was by SPSS version 16. Ethical approval was obtained from the Hospital Ethical Review Committee.ResultsOne hundred and thirty-three workers aged 18 – 70 years, were evaluated (males 53.4%, n = 71 and females 46.6%, n = 62). Headache was experienced by 88% of workers with primary headaches constituting more than 70% of cases. Females were more affected in both instances. Primary and secondary headaches occurred more in younger and older workers respectively and the association was significant (P <0.05). Headaches were not a significant cause of disability and loss of productivity.ConclusionHeadaches are very prevalent in hospital workers in Enugu, Nigeria. In older workers screening for underlying causes is indicated. Disability, work absenteeism and loss of productive time are minimal despite the high headache prevalence.

Health workers’ knowledge of and attitudes towards computer applications in rural African health facilities

BackgroundThe QUALMAT (Quality of Maternal and Prenatal Care: Bridging the Know-do Gap) project has introduced an electronic clinical decision support system (CDSS) for pre-natal and maternal care services in rural primary health facilities in Burkina Faso, Ghana, and Tanzania.ObjectiveTo report an assessment of health providers’ computer knowledge, experience, and attitudes prior to the implementation of the QUALMAT electronic CDSS.DesignA cross-sectional study was conducted with providers in 24 QUALMAT project sites. Information was collected using structured questionnaires. Chi-squared tests and one-way ANOVA describe the association between computer knowledge, attitudes, and other factors. Semi-structured interviews and focus groups were conducted to gain further insights.ResultsA total of 108 providers responded, 63% were from Tanzania and 37% from Ghana. The mean age was 37.6 years, and 79% were female. Only 40% had ever used computers, and 29% had prior computer training. About 80% were computer illiterate or beginners. Educational level, age, and years of work experience were significantly associated with computer knowledge (p<0.01). Most (95.3%) had positive attitudes towards computers – average score (±SD) of 37.2 (±4.9). Females had significantly lower scores than males. Interviews and group discussions showed that although most were lacking computer knowledge and experience, they were optimistic about overcoming challenges associated with the introduction of computers in their workplace.ConclusionsGiven the low levels of computer knowledge among rural health workers in Africa, it is important to provide adequate training and support to ensure the successful uptake of electronic CDSSs in these settings. The positive attitudes to computers found in this study underscore that also rural care providers are ready to use such technology.

Initiation of antiretroviral therapy and viral suppression after home HIV testing and counselling in KwaZulu-Natal, South Africa, and Mbarara district, Uganda: a prospective, observational intervention study

Antiretroviral therapy (ART) significantly decreases HIV-associated morbidity, mortality, and HIV transmission through HIV viral load suppression. In high HIV prevalence settings, outreach strategies are needed to find asymptomatic HIV positive persons, link them to HIV care and ART, and achieve viral suppression. We conducted a prospective intervention study in two rural communities in KwaZulu-Natal, South Africa, and Mbabara district, Uganda. The intervention included home HIV testing and counseling (HTC), point-of-care CD4 count testing for HIV positive persons, referral to care, and one month then quarterly lay counselor follow-up visits. The outcomes at 12 months were linkage to care, and ART initiation and viral suppression among HIV positive persons eligible for ART (CD4≤350 cells/μL). 3,393 adults were tested for HIV (96% coverage), of whom 635 (19%) were HIV positive. At baseline, 36% of HIV positive persons were newly identified (64% were previously known to be HIV positive) and 40% were taking ART. By month 12, 619 (97%) of HIV positive persons visited an HIV clinic, and of 123 ART eligible participants, 94 (76%) initiated ART by 12 months. Of the 77 participants on ART by month 9, 59 (77%) achieved viral suppression by month 12. Among all HIV positive persons, the proportion with viral suppression (<1,000 copies/mL) increased from 50% to 65% (p=<0.001) at 12 months. Community-based HTC in rural South Africa and Uganda achieved high testing coverage and linkage to care. Among those eligible for ART, a high proportion initiated ART and achieved viral suppression, indicating high adherence. Implementation of this HTC approach by existing community health workers in Africa should be evaluated to determine effectiveness and costs.

Access to essential technologies for safe childbirth: a survey of health workers in Africa and Asia

BackgroundThe reliable availability of health technologies, defined as equipment, medicines, and consumable supplies, is essential to ensure successful childbirth practices proven to prevent avoidable maternal and newborn mortality. The majority of global maternal and newborn deaths take place in Africa and Asia, yet few data exist that describe the availability of childbirth-related health technologies in these regions. We conducted a cross-sectional survey of health workers in Africa and Asia in order to profile the availability of health technologies considered to be essential to providing safe childbirth care.MethodsHealth workers in Africa and Asia were surveyed using a web-based questionnaire. A list of essential childbirth-related health technologies was drawn from World Health Organization guidelines for preventing and managing complications associated with the major causes of maternal and newborn mortality globally. Demographic data describing each birth center were obtained and health workers reported on the availability of essential childbirth-related health technologies at their centers. Comparison analyses were conducted using Rao-Scott chi-square test statistics.ResultsHealth workers from 124 birth centers in 26 African and 15 Asian countries participated. All facilities exhibited gaps in the availability of essential childbirth-related health technologies. Availability was significantly reduced in birth centers that had lower birth volumes and those from lower income countries. On average across all centers, health workers reported the availability of 18 of 23 essential childbirth-related health technologies (79%; 95% CI, 74%, 84%). Low-volume facilities suffered severe shortages; on average, these centers reported reliable availability of 13 of 23 technologies (55%; 95% CI, 39%, 71%).ConclusionsSubstantial gaps exist in the availability of essential childbirth-related health technologies across health sector levels in Africa and Asia. Strategies that facilitate reliable access to vital health technologies in these regions are an urgent priority.

A model for the adoption of ICT by health workers in Africa

PurposeTo investigate the potential of information and communication technology (ICT) adoption among maternal and child health workers in rural Nigeria. MethodsA prospective, quantitative survey design was used to collect data from quasi-randomly selected clusters of 25 rural health facilities in 5 of the 36 states in Nigeria over a 2-month period from June to July 2010. A total of 200 maternal and child health workers were included in the survey, and the data were analyzed using a modified theory of acceptance model (TAM). ResultsThere was no significant difference between ICT knowledge and attitude scores across states. There were significant differences in perceived ease of use (P<.001) and perceived usefulness scores (P=.001) across states. Midwives reported higher scores on all the constructs but a lower score on endemic barriers (which is a more positive outcome). However, the differences were only statistically significant for perceived usefulness (P=.05) and endemic barriers (P<.001). Regression analysis revealed that there was no interaction between worker group and age. Older workers were likely to have lower scores on knowledge and attitude but higher scores on perceived ease of use and perceived usefulness. Lastly, we found that worker preference for ICT application in health varied across worker groups and conflicted with government/employer priorities. ConclusionsAlthough the objective of this study was exploratory, the results provide insight into the intricacies involved in the deployment of ICT in low-resource settings. Use of an expanded TAM should be considered as a mandatory part of any pre-implementation study of ICT among health workers in sub-Saharan Africa.

The health worker shortage in Africa: are enough physicians and nurses being trained?

To estimate systematically the inflow and outflow of health workers in Africa and examine whether current levels of pre-service training in the region suffice to address this serious problem, taking into account population increases and attrition of health workers due to premature death, retirement, resignation and dismissal. Data on the current numbers and types of health workers and outputs from training programmes are from the 2005 WHO health workforce and training institutions' surveys. Supplementary information on population estimates and mortality is from the United Nations Population Division and WHO databases, respectively, and information on worker attrition was obtained from the published literature. Because of shortages of data in some settings, the study was restricted to 12 countries in sub-Saharan Africa. Our results suggest that the health workforce shortage in Africa is even more critical than previously estimated. In 10 of the 12 countries studied, current pre-service training is insufficient to maintain the existing density of health workers once all causes of attrition are taken into account. Even if attrition were limited to involuntary factors such as premature mortality, with current workforce training patterns it would take 36 years for physicians and 29 years for nurses and midwives to reach WHO's recent target of 2.28 professionals per 1000 population for the countries taken as a whole--and some countries would never reach it. Pre-service training needs to be expanded as well as combined with other measures to increase health worker inflow and reduce the rate of outflow.