Inequalities in Health Care


A couple of years ago the London School of Tropical Medicine and Hygiene piloted its famous Diploma in Tropical Medicine course in East Africa. Obviously it’s been a huge success, as not only do you get to learn about exciting medicine from a world leading institute, you get to do it in vivo, with unequalled access to local expertise and clinical cases. As one of the many hopefuls applying for this course in 2013, I was interested to note human resources for health as their choice of topic for discussion on the enrolment form.

Human resource for health (HRH) involves analysing the distribution and quantity of healthcare workers worldwide, treating them in a similar way to more traditional ‘resources’ such as coal, minerals, etc. This allows for powerful analysis of the data available, which in turn is used by policy makers and governments to make decisions about the number of healthcare workers they need to train and employ.

It is just such a topic where one might lead a wonderfully fulfilling life without being aware of its importance, until its implications are brought to bear on one’s health system. Almost universally, the statistics about HRH make for pretty grim reading. Did you know for instance that there is a worldwide shortage of health care professionals to the tune of about 4.3 million? Even worse, of the 57 countries deemed to have severe shortages of healthcare professionals, 36 are in Africa. One more shocking fact? Although Sub-Saharan Africa shoulders 24% of the world’s disease burden, it is home to only 3% of the world’s healthcare workers.

The reasons for this inequality include a lack of workers being trained, migration (the ‘brain drain’), anomalous data on HRH, and burden of disease. It’s a complex problem, and one that is gaining increasing recognition as being the next big barrier to improving healthcare in Africa. The development of the Millennium Development Goals has mobilised a lot of funding towards healthcare in Africa, but without the right people on the ground money alone cannot solve the problems.

We’ll be revisiting this topic on our trip, as well as reporting on any examples we encounter, and looking at the potential solutions to the HRH crisis.


(Image adapted from the WHO Health Report 2006)

A New Objective

According to the World Health Organization, just under 300,000 maternal deaths occur worldwide each year, with over half of them in Sub-Saharan Africa. Amongst the more major causes of mortality is eclamsia, a condition of unknown cause which can result in the death of both mother and foetus. Blood pressure monitoring in pregnancy helps to identify those at risk of eclampsia, and facilitate appropriate intervention. However, delivering a service that provides regular monitoring and intervention in Africa is currently a huge challenge.
With this in mind we are pleased to announce that we have agreed another major additional objective to our trip. We have been in communication with Kings College London regarding their CRADLE trial, which is an international research project supported by the Bill and Melinda Gates Foundation with the following objectives:
–  Improve the data that we have on maternal mortality across Sub-Saharan Africa
–  Pilot the use of a new compact, solar powered blood pressure monitor
–  Investigate the effect of the regular use of this monitor on the rates of maternal mortality in Sub-Saharan Africa
–  Allude to the cost effectiveness of establishing blood pressure monitoring services in Sub-Saharan Africa
We will work to introduce these devices to Ethiopia, and gather and analyse data from their use over the period of approximately a month. We are hugely excited to be a part of this project; we’ll keep you updated as we know more.

The Locum Phenomenon

A curious yet seemingly essential phenomenon in filling medical staffing rotas nationally is the existence of the locum doctor. ‘Locums’ are generally short term, (reasonably!) highly paid contracts, similar to supply work for teachers, or subcontracting for builders. A doctor is parachuted into a new team, often in a hospital where they have no previous experience, and potentially into a role where they have had minimal post-graduate experience. The roles filled by locums are often key to the functioning of a given team within a hospital (such as general medical, general surgical, and orthopaedic teams). Often a fairly hair-raising and exhausting experience, veteran locums become hardened to unfamiliar work environments, clapped out NHS on-site accommodation and loneliness (if working in new pastures for short times).

 These contracts are highly costly to NHS trusts, but I suppose are justified by the logic that ‘anyone is better than no-one’. Trusts cannot leave themselves open to criticism by leaving these key roles unfilled lest a patient come to harm from understaffing. However from the inside it often appears as though many of these holes in rotas are predictable – there must be a better way!

 One solution might be to adopt a similar system to the antipodes, where junior doctors are required to complete a ‘relief run’, a period of 3-4 months where they plug holes in rotas in a similar way to locums but are paid a salaried wage. I duck as I write this however, for this suggestion may bring slander and outrage from my colleagues who would consider this period to be of poor educational value.

 An arguably unnecessary waste of NHS money perhaps, but until a better system is devised, locum shifts will continue to plug the gaps in essential medical rotas throughout the UK. They are great for the three of us however, as back to back locum shifts are what we are depending upon to finance our expedition!