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.