Global Health
(11 years, 6 months ago)
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Lord Crisp
To ask Her Majesty’s Government what action they will take to promote skills mix changes and task sharing in low- and middle-income countries in order to improve quality, access and cost in health services in line with the report of the All Party Parliamentary Group on Global Health All the Talents.
Lord Crisp
My Lords, I very much welcome the opportunity for this debate on what action the Government are going to take to promote skills-mix changes and task-sharing in low and middle-income countries to improve quality, access and costs in health services.
I am very grateful to the noble Lords who are taking part in this debate and to the many others who contributed to the report on which this Question is based. I shall explain in a little more detail what I mean by task-sharing and skills-mix changes to make sure that we are all in the same position on that but, first, perhaps I may say a few words on the background.
Health and health services are very much about people and knowledge. The Department for International Development has a good record on both but on people, in particular, I think there is more that DfID could do, and I shall make that point here in relation to this issue.
There are four key points relating to the background. The first is that there is a pressing need in the world for more health workers. The best estimates I have seen are that there are about 1 billion people in the world who do not have access to a health worker. In Africa, it is estimated that there need to be about 1.5 million more health workers in order that 80% of the women who want to can have access to a skilled health worker when they are in labour. That is not even a high standard; it is not what we expect, which is 100%. Therefore, there is a massive shortage of health workers, and people die or are damaged or diseased for lack of access to a health worker who has some knowledge and who can help them.
The second point of background is that if, through the efforts of DfID, national Governments and everybody else, there is to be a real improvement in health in, for example, India’s million villages, then the staffing structure for looking after people in those villages will not be the same as it is in the UK. There will not be a GP in every one of those villages or, indeed, in Africa’s million villages. People will have to do things differently and there will have to be a different range of skills mix. Nurses will perhaps be doing what doctors are doing, and other people will perhaps be doing what nurses are doing, all enabled by technology. That is the real theme that we are talking about.
My third point is that we actually know what to do. The report demonstrates how a skills mix can be changed successfully to reach more people. Finally, the UK has a particular role that it can play in this, and I shall deal first with this final point.
I know that other noble Lords are going to speak about education and training and about the role of British institutions. In this country we have a fantastic track record of educating and training health workers and, indeed, others, and there is a part that we can play in that. However, I also suggest that we have an important role in training and educating more health workers, not least because of our history and links with so many of the countries that we are talking about—the low and middle-income countries—through the Commonwealth and through our history of education. We know that many people from those countries have emigrated to our country and have become health workers here, and we know that emigration is part of the problem faced by other countries. I make it clear that it is not the whole story. The best estimates I have seen are that 135,000 health workers from Africa have moved to other, richer countries over the past 35 years. That is a very big number but it should be compared with the 1.5 million that are needed in Africa. If everyone went home, the problem would not be solved. The bigger issue is getting more people on to the pitch to provide more education and training.
Those are the issues that we set out to address in the report, All the Talents. We undertook a review and were joined by expert witnesses. We had a group of parliamentarians who quizzed those witnesses, and we came up with four or five clear recommendations, which are the ones that I want to put to the Government.
Let me say a little more about what we mean by changed skills mix and better teamwork. We looked at examples from about 20 countries where access was improved because of using staff members to do different things from what would happen traditionally. The example we give in the brief version of the report is in Malawi, where some 135,000 manipulations of bones have been undertaken by technically trained people, not by doctors. As a result there has been improved access. Incidentally, they were trained by British doctors in this particular case in Malawi. So, we have seen improved access by changing the skills mix and allowing different members of staff to do work that others had previously done.
We have seen improvements in quality. The example given in the report is in the UK, where nurse practitioners doing more prescribing has improved quality as perceived by the patient. It is just as safe as it being done by doctors but it has improved quality, as perceived by the patient. Finally, there are examples of improving cost. The example that we use here is that in Mozambique for the past 25 years almost all the caesarean sections outside the capital have been done by nurses with additional training at a third of the cost of using doctors in that country.
These issues of changing skills mix, task-sharing and changing what professionals do can have profound effects on access, quality and costs. We looked at the success factors because we know that many such examples have failed. We identified some very clear success factors that are obviously spelt out in the report. They are about leadership, planning, training, supervision, ability to refer and teamwork. They are about some very obvious ways of doing things. We also identified failure in the absence of those things. It was also interesting for our all-party group to notice that a lot of the most innovative and interesting examples were happening in low and middle-income countries that did not have our resources and, to some extent, our baggage and vested interests. Here, we saw a compelling story.
We also decided that we would want to phrase the report in positive terms, in part thanks to the noble Viscount, Lord Eccles, and call it All the Talents. It is about how to bring all the talents of all the health workforce together to have the biggest impact on the biggest health problems in the world—those in low and middle-income countries. We think that it is a compelling story. If DfID and other organisations are to help national Governments to deliver healthcare in the million villages in India or the million villages in Africa we need this sort of change in how services are delivered to be effective. How can DfID act? We know that it is always difficult for Governments and international development agencies to deal with staffing issues. The argument is: if we train more people, will they not just migrate? How will we handle the professions and the recurring costs? Our four recommendations to DfID are clear. The first is to assist national Governments to develop their human resources and workforce planning. We must help them to make those changes. Secondly, we want to ensure that workforce innovations are mapped and shared. We need to collect and capture the innovation, then share it. Thirdly, together with others, we need to invest more in workforce research and develop better metrics. Fourthly, we should undertake systematic analysis of the effectiveness of role and skills-mix change. Changes can fail as well as succeed.
We are not the only people making similar proposals. As the Minister will know, Jeff Sachs, in a recent meeting in Parliament which we both attended, pointed out strongly that if we had a million more community health workers—the lowest trained group of health workers in the world—we would have a much better chance of delivering the millennium development goals. It will be interesting to hear the Government’s response to that as well. We argue in the report that professionals need to lead the changes but Governments, international agencies and DfID, with its very high standing—the highest standing of any development agency in the world—need to lead and to stress the importance of these sorts of issues.
People will be the biggest part of the solution in healthcare. They are not the only one—knowledge, science and technology are important—but caring hands, the knowledgeable helper, the professional and the well-trained non-professional are the biggest need and the biggest deficit in healthcare. That means investing in education and training, setting examples, supporting organisations such as the Global Health Workforce Alliance and promoting the needed solutions. I ask the Minister three questions. How does she respond to those four recommendations? How do she and the Government respond to the million community health workers campaign? Will DfID give people and health workers even higher prominence in policy?
Viscount Eccles
My Lords, the noble Lord, Lord Crisp, is a tireless worker in the cause of global health, including, as we know on this occasion, through the development of a mix of appropriate and innovative skills in many places—here and elsewhere, but predominately in countries less fortunate than ours. He referred to the UK resource, and I want to go down a rather narrow path, talking about the UK’s capability to assist in the campaigns on tropical medicine and the contribution that we can make.
I should briefly declare my interests. I am involved with development at UCLH. I am also involved with the Hospital for Tropical Diseases and have on a number of occasions been involved with the London School of Hygiene and Tropical Medicine. It is usual for us in this House to discuss malaria and parasites, of which there are many different types which can lead to all sorts of very nasty results, and, lately, neglected tropical diseases. I am slightly less certain about our debating neglected tropical diseases. As a matter of fact, if you take the total UK capability, I am not sure that much is being neglected. As we know, ever since Manson and Ross connected the mosquito to malaria and the schools in London and Liverpool were founded, we have made an important contribution to fighting tropical diseases. Indeed, the Hospital for Tropical Diseases itself was founded nearly 200 years ago.
First, I want to talk briefly about London as a centre for excellence. It could perhaps be entitled “The Bloomsbury Campus”. The London School of Hygiene and Tropical Medicine in Keppel Street and the hospital, with its beds in Gower Street and outpatients and diagnostic laboratories in Mortimer Market, off Tottenham Court Road, are a real centre. Of course, we need to add the Wellcome Foundation, which is very close by. All those institutions are within walking distance and work very closely together. In particular, if a tricky case comes into the hospital, the conversations that go on between those institutions are close and entirely relevant. The people who practise in the hospital are also teachers and lecturers at the school, so there is a close combination of skills.
They have two agendas. The first is the domestic agenda, given the amount of travel and immigration. I expect that some noble Lords will know Dr Paul Clarke, who founded a tropical disease clinic called MASTA. Paul said to me one day, “John, you know that there are people who have come into Southwark”—he lived in Southwark—“from some strange places and have brought things that I have never seen before”. That is the domestic agenda. There is the rapid diagnosis of malaria and the concentration of quite rare diseases going on in the Hospital of Tropical Diseases. There is still some leprosy in this country, and it has often been misdiagnosed, and therefore having that capability is extremely important. Also important is the service whereby all GPs in the country can go on line or ring up for rapid advice if they are faced with a patient who they think may have returned from a foreign part quite recently.
On the overseas challenge, training, study and research are enormously endorsed by the Wellcome Trust, which makes large grants every year to both the London and Liverpool schools, as do Bill and Melinda Gates. It is an extraordinary amount of money, in one sense, and a great endorsement of the contribution of the Bloomsbury campus in London. Other institutions also make a contribution. DfID, as has been mentioned, is a strong supporter of this endeavour, as, indeed, is HEFCE, because they are either connected to or counted as higher education institutions.
This proliferation of support and the institutions involved bring challenges. Several departments of government are involved, and government departments are not always brilliant at talking to each other and providing a co-ordinated response. I wonder whether there is co-ordination.
Notably, the NHS, which is under pressure, changing configuration and always under some reorganisation, does not have the same agenda as DfID or the charitable institutions. I should like reassurance that DfID fully endorses this Bloomsbury campus and its contribution to those countries overseas which need that contribution, and that it will continue to give the participants enthusiastic support. Given that several departments are involved—notably the Department of Health and the NHS, with the ever present problems that they have to face—I ask the Government to make sure that nothing slips between the cracks.
Do the Government agree that the UK’s leading position in study, research, teaching and tropical disease clinical practice can continue to be a growth point for the economy? This endeavour has grown over the years and I see no reason why it should not grow further. Enormously satisfying careers are available in this activity and there is a huge job to be done overseas. If we can continue to get international support, surely this is an opportunity—and we are looking for such opportunities wherever we can.
Baroness Warwick of Undercliffe
My Lords, All the Talents is an excellent report from the two All-Party Parliamentary Groups on Global Health and Africa. It gets straight to the point—that there is a critical shortage of healthcare workers in many countries—and it sets out clearly what can be done to tackle the problem. Crucially, it also provides us with the evidence that global health services can be improved by giving people extra skills and changing their roles to enable them to expand their capability. I congratulate the groups on their work in bringing the evidence together in this report. I also take the opportunity to thank the noble Lord, Lord Crisp, for his tireless commitment and great contribution to international development.
I was particularly struck by the example of the creation of orthopaedic clinical officers, or OCOs as they are called in the report, in Malawi. Currently—this is an astonishing statistic—there are only seven orthopaedic surgeons for Malawi’s 14 million people. Here in the UK we have roughly one per 30,000 people. It is an astonishing contrast. These OCOs were once local medical assistants, people who left school at around GCSE level and, after a two-year course in basic clinical care, ran the country’s small health centres. An 18-month training course in orthopaedics has enabled these medical assistants to develop sufficient skills to give good-quality care to around 90% of all injuries. They are expected to be competent to treat burns, septic joints, osteomyelitis and Malawi’s high incidence of club foot deformities. They can provide casts for the most common fractures and emergency resuscitation in the case of severe injuries. Every district hospital in Malawi now has at least one OCO and they are estimated to treat more than 30,000 fractures a year. What a great example of task-shifting that is, and there are others throughout this report that are similarly inspiring.
Of course, task-shifting, or task-sharing, is not a new concept. We have been reminded by the noble Lord, Lord Crisp, that there is a shortage of 4.2 million health workers world wide, with 1.5 million needed in Africa alone. Therefore, in many countries with severe shortages of trained professionals, health workers often have no choice but to get stuck in and carry out tasks which are not in their job title.
This makes the words of warning contained in the report all the more important. If changes to a health workforce are managed badly, they can lead to poor-quality and unsafe services. We must not risk more burden being placed on poorly trained, poorly paid workers who are expected to deliver an increasing range of priorities. But done well, as this report shows us, giving people new skills can improve access to services, improve quality and possibly reduce costs. The report’s list of recommendations forms a sensible checklist of what will make the difference between success and poor-quality, even dangerous, care. When a health worker takes on a new task or responsibility, it is essential that they are effectively trained, supervised and supported.
The report emphasises that successful skills-mixing starts with health professionals and local health organisations leading the changes, with Governments and national health systems enabling them to do so. We need more evidence of the effectiveness of skills-mixing to help support further development. I was struck by the point made in the report that significantly more investment is made in drug research than in human resources research, even though health workers account for a much greater proportion of costs. This was reinforced for me by OECD Health Working Paper No.54, helpfully provided by the Library, which emphasised the many barriers to be overcome and how Governments have to support the process to overcome them. In her response to this debate, will the Minister tell us what measures the Department for International Development is taking to assist Governments to develop their HR and workforce planning capacity?
The real benefit of skills-mixing is that experiences can be shared between countries. That is where international and national volunteering can play an important role. International development agencies such as VSO can assist national Governments to train medical staff and draw up sustainable plans for skill-mix changes. I declare an interest as a life vice-president of VSO and draw your Lordships’ attention to the work that VSO is doing with regard to task-shifting, or skills-mixing.
VSO sees these as positive ways of getting skills and health services to the grassroots, and as close as possible to those who need access to services and education. Skills-mixing also supports VSO’s belief that citizens are active agents of change and that communities will prosper if people are given the skills and opportunities to develop. But—and there is always a but—for this approach to be successful and sustainable, it must receive continuous investment. If community health workers and volunteers are to be given increased skills, responsibility and tasks, they must have the equivalent increase in support. They need the professional training and management that will ensure that they are able to deliver this work effectively, and their increased responsibility must be reflected in their remuneration.
In every situation, in every country, ongoing training and support are vital in health services. Health workers should be supported to learn continuously, and to be trained in the latest medical developments, healthcare approaches and effective techniques.
VSO makes this happen whenever it can. I will give just one example, still in Malawi, where VSO volunteers are training health workers because, again, the country has a critical shortage. VSO is pushing for improved supervision and management of these health workers. The Malawian Government are listening and making a concentrated effort to tackle the shortage through recruitment, training and retraining. I hope the common sense approach contained in All the Talents will give extra support to VSO's representations in Malawi. I know VSO will make some of these points tomorrow to the APPG's review on overseas volunteering, which itself acknowledges the importance of the direct exchange of knowledge and skills between people.
The UK has taken some positive steps in this area. DfID's £20 million four-year health partnership scheme enables volunteer British doctors, nurses and midwives to train overseas healthcare workers across many disciplines. These skilled health professionals offer practical assistance to their counterparts in the developing world, including one-to-one mentoring and developing guidelines to ensure that clinics run more effectively. Will the Minister give us any assurances that opportunities for skills mix changes and task-sharing are being promoted as part of the health partnership scheme?
Health workers—midwives, clinical officers, community workers, nurses and doctors—provide healthcare in many of the world's hardest to reach areas. They face daily challenges and do amazing work, but there are not enough of them to get the job done properly. They often lack support and supervision, the right training and equipment. In the best possible way, All the Talents states the obvious when it addresses these points. It makes sense to develop the talents of everyone working in healthcare, so that money is not wasted, quality can continue to improve, and above all, so that more people can access the health services that they need.
Baroness Flather
My Lords, I have just had tea with a friend from Nigeria. She said that she spoke to her mother over the weekend. Her mother told her about her cousin, who had come home from having a baby and had blown up because part of the placenta had been left inside her. Nobody could give her antibiotics—no antibiotics were available—so she died. This is what we are talking about today. I unashamedly say that I am passionate about women’s issues and how women in Africa and India suffer the most. I know because I have had opportunities to visit and see for myself what goes on for women. Nobody really cares: “A woman dies, so what? There are so many others”. That is why this debate and the report of the noble Lord, Lord Crisp, are so valuable. Everything the noble Lord said is absolutely correct. Any support that can be given for what he wants done would be wonderfully valuable.
We have talked about birth attendance, village women helping and so on, but it has never been done in a proper way. The noble Lord is so right to say that if things are not done properly, it is better not to do them at all. My friend also told me that in her village, the woman with the smallest hands pulls the baby out and the mother usually ends up with a fistula. Things are not getting better; they are getting worse in the developing countries and we have to recognise that. Why are they getting worse? Because the population is increasing by a very large number and more people need help.
We know that family planning is absolutely essential. We have a shortage of nurses, skilled midwives and obstetricians and an increase in population to more than 7 billion people. Every day, 800 women die from easily preventable pregnancy or childbirth-related complications. There are 215 million women in urgent need of family planning services.
Current health systems cannot meet these demands. Mix changes could increase women’s access to services, which is exactly what the noble Lord, Lord Crisp, is saying. We need access at least to the most basic of services because sometimes basic services can change a woman’s life. They can make the difference between life and death, or a woman being inflicted with a lifelong problem.
I am an active member of the APPG on Population, Development and Reproductive Health. We produced a report some years ago about maternal morbidity. No one knows the figures because we just cannot get them. However, we took a figure of 25%. The report was called Better Off Dead because, in many cases, the women would be better off dead than suffering through a lifetime of problems due to pregnancy and childbirth.
In India there were a lot of not quite hospitals but places where there were doctors and nurses. The problem has always been that doctors and nurses do not want to work in rural areas because they can earn more money in the towns. They would go to work in the towns and when people arrived at those rural centres there would be no one there. The idea was that either the nurse or the doctor would be there at all times, but this was not always the case.
While I have sympathy for the view of the noble Viscount, Lord Eccles, on tropical disease, the Gates Foundation has really taken that on board and has certainly done a lot in regard to African diseases. As the noble Lord, Lord Crisp, has mentioned, Mozambique, Tanzania and Malawi have seen success in the strategy of people being trained to do something. There are quite a lot of things that semi-trained people can do, such as giving antibiotics. In some places they perform surgery and it has been found that their obstetric operations are no worse than those of the doctors. If you have no one else, it is absolutely amazing that someone can do that.
I hope that this will become an issue with DfID, which has put girls and women at the top of its agenda for almost the first time. However, to be fair, Andrew Mitchell also put girls and women at the top of the agenda. We need to remember that the value of girls and women in African countries is pretty well zero. If women die or are sick, it is of no importance. If children die, it is of very little importance—perhaps a tiny bit more, but not much. It is there for us all to know and all to see.
We held a family planning summit last year. It was a wonderful thing for us to have done and I am very proud of the fact that our Government initiated it. Family planning by itself saves lives and money. One pound spent on family planning can save lives and many pounds if it is available. I hope that we will keep in mind that it is cost-effective and necessary.
I hope the Government will promote skills-mix changes and task-sharing in low and middle-income countries where family planning programmes are now being rolled out. That will improve access to family planning for the hardest to reach. They are the ones who will probably respond more to someone who is familiar with them than to someone who is from elsewhere.
Nothing can be more effective than this initiative, and I hope that the Minister will take that on board. I am not sure how much our Government can do, but perhaps the Governments in those countries could be involved. A lot of money was promised at the family planning summit, but the problem is always to get the Government of the country to support the programme. If the Government of the country do not support the programme, no matter what outside Governments do, it will never work as well as it should.
Lord Collins of Highbury
My Lords, I, too, thank the noble Lord, Lord Crisp, for initiating this debate. In particular, I thank him and the all-party groups for their excellent report. Its evidence-based approach with best practice case studies not only makes fascinating reading but shows how capturing people’s aspiration can be a positive force in meeting the healthcare challenges that we face both here and globally. As we have heard today, health is global and interdependent. It is no longer possible to separate health issues between countries. We increasingly face the same global threats and rely on the same people and technologies for solutions.
In previous debates in this House, I have referred to the book of the noble Lord, Lord Crisp, on the search for global health in the 21st century, but it is worth an extra plug. The book gives an excellent analysis of global health and provides a superb description of how richer countries such as ours can learn about health from low and middle-income countries. I note what the noble Viscount said about how proud we can be of our centres of excellence. I certainly also note what my noble friend said about volunteering and how training and support can be vital. We also need to understand how low and middle-income countries, with their innovation with limited resources, can be extremely valuable to us. If we see it as a two-way dialogue, perhaps we can gain public support for positive change.
As we have heard, there is growing interest in exploring how we use all the talent, skills and experience of health workers to their full extent. Developing a team approach so that all members of a team, under direction and leadership and with training, can collectively hold casework and workload can bring huge benefits that we have not been able to garner so far.
However, as the report recognises, attempts to make change without addressing those factors may well fail and can damage existing health services. Alongside the examples of success there are many cases where innovations have failed to achieve positive health outcomes and have not been sustainable because, as the noble Lord, Lord Crisp, said, of poor design and an unsupportive environment.
In the report we are given examples where health workers in Africa have not been trained properly and in the UK where nursing assistants received little or no supervision when taking on new tasks. As the noble Lord said, training programmes must be relevant and lead to some formal qualification necessary for recognition or promotion if they are to be sustainable.
An interesting quotation was from Dr Peter Carter, chief executive of the Royal College of Nursing. He said:
“You don’t need registered nurses to do all of the tasks that historically have been carried out by qualified nurses. Healthcare assistants can do many of those tasks, perfectly satisfactorily, providing they’ve had the proper induction, training, and education. And where it goes wrong, in some parts (and I do stress some parts of the NHS) is where there has been task shifting onto unqualified people who’ve not been given even the most rudimentary induction into the fundamentals of nursing care”.
The All the Talents report shows us that giving people extra skills, designing jobs that allow them to work to the limit of their capabilities, providing better supervision and creating more effective teams can bring enormous improvements to healthcare. Under the right circumstances—and we have heard examples in today’s debate—nurses can prescribe and take on additional roles. Nursing assistants and community workers can treat common conditions, and we have even had examples of patients supporting each other. Someone who has been diagnosed as a diabetic can self-manage, and non-communicable diseases, which pose the biggest health threat, are good examples.
The report describes where such changes have greatly increased the population’s access to services, improved the quality of a service and reduced costs. The noble Lord, Lord Crisp, gave some extremely good examples of that. However, I repeat that improvements can be achieved only if the changes are planned carefully and are implemented well. This of course is where the Government’s support and role are vital. There have been as many failures as successes, with examples of people taking on tasks beyond their competency without adequate training and support which can result in poor quality and even dangerous care being provided, as the noble Baroness, Lady Flather, indicated.
However, one of the fantastic things about this report is that such failures can be avoided if the lessons highlighted in it are learnt. I, too, should like to ask the Minister how the Government will support research to evaluate and strengthen evidence on best practice and what steps her department will take to ensure that that is shared as widely as possible across all nations. What action will she take to provide more education and training through DfID programmes, and what steps will the department take to assist national Governments to develop their human resource and workplace capacity?
Baroness Northover
My Lords, I, too, thank the noble Lord, Lord Crisp, for securing this debate. His commitment to improving the health workforce is international and has been internationally valued. This debate on skills-mix changes and task-sharing is very welcome and is derived from the extremely interesting report, All the Talents.
One of the refreshing aspects of the report for me, as spokesperson for both DfID and the Department of Health, is that it applied its analysis and conclusions and took its evidence not only internationally, across a range of both developed and developing countries, but from across the United Kingdom. That meant that it brought fresh perspectives in both quarters. Often, the assumption is that in developing countries it would be good if more basically trained personnel undertook more work, whereas in the United Kingdom we need a workforce that is as regulated and as trained as possible. I note the reference made by the noble Lord, Lord Collins, to what Peter Carter of the RCN said in the report and I look forward to discussions in health debates. However, this report challenges us to think again and to look beyond our assumptions to what works and why it works in various settings and what does not work in various settings. The noble Lord, Lord Crisp, emphasised leadership, planning, supervision and teamwork as being essential. The noble Baroness, Lady Warwick, also emphasised how important it is to do this work well, otherwise it will not work at all.
We fully support the principle that a strong health service needs skilled and motivated health workers in the right place at the right time. As the noble Baroness, Lady Flather, knows, we have promised to save the lives of at least 50,000 women during pregnancy and childbirth, and the lives of 250,000 newborn babies by 2015 in developing countries. We have promised to support 2 million women to deliver their babies safely with the support of skilled midwives, nurses and doctors. As the noble Baroness, Lady Flather, made clear, meeting these commitments means improvements across the health systems in developing countries but, above all, demands skilled health workers across all levels of the workforce. We strongly agree with the noble Lord, Lord Crisp. We are supporting the workforce in 28 of the countries in which we work. This includes training new health workers, building skills among existing health workers and supporting government planning.
Even in the wealthiest countries it is not easy to make sure that everyone, rich or poor, living in town or country, can see a health worker when they need to. Many countries, especially in Africa, suffer from a critical shortage of health workers, as we have heard. Tackling this shortage demands creative and innovative approaches. Task-sharing and organising the roles of health workers can be such a creative approach. Around the world, health workers are taking on new responsibilities as countries try new ways of building an effective health workforce in the face of financial constraints and a serious shortage of health professionals.
The excellent report of the All-Party Parliamentary Group on Global Health, of which the noble Lord is co-chair, is a valuable addition to the thinking about the issue. The report pinpoints the factors that create success when reorganising roles and makes practical recommendations on how professionals, Governments and institutions can best support the talents of health workers. With increasing global focus on universal health coverage, the timing of this report is excellent.
I can assure noble Lords that we share their concern about the importance of this area. We agree that task shifting can improve health service access and quality. I can assure the noble Baroness, Lady Warwick, and others that we support partner countries which wish to do this. In Ethiopia, for example, DfID is supporting the Ethiopian Government to expand access to health services through the training and deployment of village health extension workers. With one year of training, these workers can take on basic preventive and curative services that would otherwise be seen as the preserve of health officers, nurses and doctors, who remain scarce. UK support means an additional 2,000 community health extension workers will provide a package of basic health services for 5 million people. Other countries, such as Zambia, are looking to learn from Ethiopia’s experience with UK support. It is important to learn from the good and bad examples of where this is happening.
To answer the noble Lord, Lord Crisp, on assisting national Governments with human resource planning, which is a key point, it is very clear that robust health workforce planning is recognised as being critically important. That is why DfID works with Governments, such as the Government of Nepal, to develop such national health workforce strategies.
There are other areas where strengthening the health workforce is key. The noble Baroness, Lady Flather, is right to make reference to the significance of family planning. I thank her for what she said. The UK’s leadership of last year’s family planning summit encouraged new thinking about expanding access to contraception. It was notable that several countries included task-shifting for family planning within their summit commitments, and DfID is working with country partners on implementing these. For example, Zambia has just confirmed its summit commitment to allow community health assistants to provide contraceptive injectables, an excellent development that will expand access to family planning.
A number of organisations are focusing on task-shifting and I hear with interest what the noble Baroness, Lady Warwick, had to say about VSO. In east Africa, a mid-level cadre of ophthalmic clinical officers provides most of the community eye care services. This cadre has only recently been admitted to the professional body for ophthalmologists, the East Africa College of Ophthalmologists. I can assure the noble Baroness, Lady Warwick, that through the United Kingdom Government’s health partnership scheme, about which she asked, the UK’s Royal College of Ophthalmologists will work with its east African counterparts to integrate these clinical officers and boost the quality of their work still further.
Sharing skills beyond those traditionally considered to be the responsibility of the health workforce can also be successful. Again, the Health Partnership Scheme is also supporting the East London NHS Foundation Trust to work with Butabika Hospital in Uganda. In this innovative project, recovered psychiatric patients work alongside community mental health services to provide care—an example of task-shifting.
My noble friend Lord Eccles has spoken compellingly about the UK’s track record on research—in particular, the practice of the London School of Hygiene and Tropical Medicine, the Hospital for Tropical Diseases and other institutions. He is, as are we, rightly proud of the international contribution that our institutions have made, not least in rendering neglected tropical diseases less neglected, as he says. I assure him that UK institutions successfully secure a high proportion of the global funds available for research, including from DfID. The London School of Hygiene and Tropical Medicine and the Liverpool School of Tropical Medicine are two among many centres of excellence for health research in the United Kingdom, and we expect UK institutions to continue to compete effectively for funding in the future.
My noble friend also asked about working across government departments. I would point out that the Department of Health, for example, funds the National Institute for Health. The London School of Hygiene and Tropical Medicine and other institutions can and do apply for grants, and there is a lot of discussion between DfID and the Department of Health on this.
As noble Lords will be aware, and as the noble Baroness, Lady Flather, pointed out, DfID puts women and girls front and centre, recognising that they are likely to be the poorest and the most vulnerable in the world. Supporting women and girls brings particular benefits to the individuals themselves, as well as to their families and their communities. Task-shifting can bring particular benefits to women both as employees—many community health worker programmes prioritise women’s training—and as beneficiaries of expanded services. Pakistan’s Lady Health Worker Programme, which we support, makes it easier for women to access healthcare. However, as All the Talents points out, and as noble Lords have emphasised, task-shifting needs to be done well. Fragmented approaches, delivered separately from the wider health system or driven solely by efforts to cut costs, are not the way forward. Crucially, Governments need evidence of what works to be able to design effective programmes. Research and evaluation need to establish best practice and inform policy. The noble Lord, Lord Crisp and the noble Baroness, Lady Warwick, are right in this regard.
The noble Lord, Lord Crisp, asked me, interestingly, about Jeffrey Sach’s campaign to train 1 million community health workers. We believe that the initiative to expand access to good-quality healthcare is welcome. However, we are concerned that the evidence to support such a dramatic scale-up in community health workers is weak. Any such initiative needs in-built evaluation plans to build evidence and understand impact. The noble Lord, Lord Crisp, emphasised that and so do we.
The UK Government support research into task-shifting. DfID has commissioned a cost-effectiveness study on using community health workers to deliver essential health services, and the ReBUILD research programme looks at opportunities to reallocate health worker responsibilities in fragile and post-conflict situations. An overarching policy question for this research is: can they be a cost-effective investment for MDG progress? If so, can a defiaced set of competency-based roles and functions, founded on a strong evidence base, be specified to maximise value for money and health systems requirements for effective scaling-up?
How might things move further forward, given that we are already strongly supporting this in a number of countries? This November, there will be a Global Forum on Human Resources for Health in Brazil, convened by the Global Health Workforce Alliance and hosted by the Government of Brazil. This will be an important opportunity to ensure that the human resources for health agenda remains relevant to current global health policy discussions. Task-shifting will undoubtedly form part of this. We are playing our role in the run-up to this conference and looking forward to hearing the evidence brought to it. This will be a chance to map and share, in the way that the noble Lord, Lord Crisp, outlined.
In conclusion, I thank all noble Lords for taking part in this debate, and even more for all the work they are doing, nationally and internationally, to ensure that, wherever people need medical assistance or healthcare of one sort or another, we work across barriers to do everything possible to maximise their chance of receiving such support. DfID will continue to work with developing countries, to support them in their efforts to build health service quality and access, including where this means rethinking health worker roles.
The Deputy Chairman of Committee (Baroness Harris of Richmond)
My Lords, that completes the business before the Grand Committee this afternoon. The Committee stands adjourned. I apologise for the lack of warmth in this room. This has been reported to the authorities.