The commitment of the 5th Millennium Development Goal (MDG5) is extremely far-reaching: to reduce the maternal mortality ratio by 75% by the year 2015. Of all MDGs this goal is the one least likely to be attained. This goal is particularly problematic because the levels of maternal mortality at the starting point, 1990, suffer from a high degree of uncertainty. Under-reporting of maternal deaths was (and is) a very significant problem and numerous studies have shown this to be a serious problem whatever the setting.1–5 The finding of significant under-reporting in wealthy countries shows how difficult it is to assess the true maternal mortality ratio, even when large amounts of funding are available. For countries with small budgets for health care, the problem of under-reporting is even more marked, making the baselines rates highly unreliable.
Statistical doubts mean that we may never be able to determine whether or not the MDG5 has really been attained. But a far greater worry is that we may not be able to enroll sufficient health workers to reduce maternal mortality at all. Although there are famous examples of maternal mortality reductions both nationally (e.g. Sri Lanka and Malaysia6,7) and locally (e.g. Tanzania8), these examples are the exceptions. Elsewhere the picture is not so good. In Malawi, for example, preliminary data indicate that over the last decade the maternal mortality ratio has almost doubled from around 600 to more than 1100 maternal deaths per 100,000 live births.9
There is one common denominator if we consider the ‘success stories’ mentioned: human resources. This was a crucial factor both in Sri Lanka6 and Malaysia,7 as well as in Kigoma, Tanzania.8 The issue of human resources is increasingly recognised as an issue that was insufficiently contemplated when the MDGs were formulated. In a recent overview article in the Lancet10 focussed on human resources for health, it was noted that current spending patterns on human resources are inefficient and fragmented. The authors emphasise ‘… the legacy of chronic under-investment in human resources. Two decades of economic and sectoral reform capped expenditures, froze recruitment and salaries and restricted public budgets, depleting working environments of basic supplies, drugs and facilities. These forces have hit economically struggling and politically fragile countries the hardest’.10 The authors also measure ‘health worker density’ and use it to demonstrate the correlation between this indicator and survival rates. They calculate that ‘sub-Saharan Africa has a tenth of the nurses and doctors for its population that Europe has: Ethiopia has a fiftieth of the professionals for its population that Italy does’.10 Furthermore, low-density areas have a much higher burden of disease than high-density areas. Dr Tim Evans of the WHO has calculated that Africa has approximately 25% of the burden of the world's diseases but only 1.3% of the world's health work force.11 On a global scale it has been estimated that the global shortage of health workers is more than four million and that sub-Saharan countries must nearly triple their current number of workers by adding the equivalent of one million workers through retention, recruitment and training if they are to come close too approaching the MDGs for health.9 This applies particularly to MDG5 and the target of a drastic reduction in maternal mortality by 2015.
One of the most dramatic examples of the depletion of human resources for health is the emigration of nurses and midwives in Africa. WHO has calculated that there will be a net decline in numbers of physicians, nurses and midwives between 2000 and 2015.11 Furthermore, the simultaneous increase in population means that the number of health work force/population is decreasing even more markedly.11 And this effect is not only seen in Africa. WHO statistics on the number of nurses and midwives who applied for registration in UK between 1998 and 2004 indicate that there was a 100-fold increase in applications from both India and the Philippines. Applications from the Philippines rose from 52 in 1998/1999 to 4338 in 2003/2004 while from India they rose from 30 in 1998/1999 to 3073 in 2003/2004.12
Malawi is one of the countries in Africa most severely affected by ‘brain-drain’. There was a time when it was estimated that there were more Malawian doctors in Manchester (UK) than in the whole of Malawi. Even if this statement is not based on formal statistical assessments, it demonstrates the reality of the human resource crisis in poverty-stricken countries in Africa.