Global Health

Lord Crisp Excerpts

Monday 25th March 2013 Grand Committee

Asked By

[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?