Investments in this strategy aim to improve the health workforce by creating new models for training health workers in hard-to-reach areas, improving the skills of existing workers, and better coordinating the provision of care to ensure that specific population health needs are met. The sections below include an overview of the strategy for achieving desired goals, supporting evidence, core metrics that help measure performance toward goals, and a curated list of resources to support collecting, reporting on, and using data for decision-making.


Dimensions of Impact: WHAT

Investors interested in deploying this strategy should consider the scale of the addressable problem, what positive outcomes might be, and how important the change would be to the people (or planet) experiencing it.

Key questions in this dimension include:

What is the problem the investment is trying to address? For the people experiencing the problem, how important is this change?

Health systems in emerging markets must commonly confront challenges related to human resources: insufficient numbers of workers, workers with inadequate skills, and even workers providing the wrong services given population needs. Further, these obstacles persist at all levels, including providers and those who facilitate care (such as network and hospital administrators). Seeking to directly address these challenges, this strategy aims to improve the health workforce by implementing new training models, incentives, and technology.

Unless greatly improved, the availability, performance, and distribution of health workers will hinder progress toward ensuring healthy lives and well-being for all people at all ages (1). Investments in this strategy can improve the health workforce by:

  1. training community health workers to act as self-employed entrepreneurs providing much-needed basic services in remote or hard-to-reach areas;
  2. improving existing workers’ skills so they can provide a greater array of services, some of which were perhaps previously unavailable;
  3. shifting the workload from tertiary to primary institutions by teaching primary providers new skills, improving efficiency and affordability;
  4. providing policymakers and managers of health systems with more, better-skilled provider networks, increasing their flexibility to respond to population-health needs; and
  5. improving the efficacy of concurrent health investments through improvement of services provided by health workers at multiple points along the continuum of care (for example, a higher-skilled provider workforce can better deploy investments in technology at the point of care).

Interested in understanding how gender relates to this strategy? Check out the gender lens summary and metrics created to complement this theme: Improving Health Systems through Gender Equitable Policies and Decision-Making.

What is the scale of the problem?

The problem has many different causes and manifestations. Related challenges are partially due to incentives that encourage qualified medical personnel to move away from emerging markets. Doctors in emerging markets may seek greater employment prospects and remuneration in the developed world; there are 8,000 Nigerian doctors in the United States, leaving only 35,000 to attend the nation's population of 173 million (2).

Such shortages and skill gaps lead to formidable health outcomes, especially related to maternal and child health. As of 2014, 58 countries account for 80% of stillbirths and 90% of maternal deaths worldwide, principally because they lack skilled birth attendants (3).


Dimensions of Impact: WHO

Investors interested in deploying this strategy should consider whom they want to target, as almost every strategy has a host of potential beneficiaries. While some investors may target women of color living in a particular rural area, others may set targets more broadly, e.g., women. Investors interested in targeting particular populations should focus on strategies that have been shown to benefit those populations.

Key questions in this dimension include:

Who/What is helped through this strategy?

Improving the capacity of the health workforce could not just greatly improve population health but also help providers themselves. Some of the groups most directly impacted by this strategy are below.

Pregnant Women, Infants, and Children: A skilled birth attendant can greatly mitigate maternal and infant mortality, reducing the risk of stillbirth or death due to intrapartum complications by 25% in emerging markets (4,5).

People in Rural Areas: Many fewer and less-capable health workers are present in rural areas; even in South Africa, a middle-income country, just 12% of doctors and 19% of nurses serve 46% of the population (6). Innovative organizations are equipping entrepreneurs with the basic skills and equipment needed to cover this gap (7).

Providers: As providers at any level of care, from primary to tertiary, become enabled to better serve their local populations, they gain from increased demand for their services.

Administrators and Policymakers: Poor distribution or shortages of skilled health workers make it challenging for policymakers and health systems administrators to develop strategies and plan, especially when preparing for emergencies.

What are the geographic attributes of those who benefit?

Shortages of health workers affect many countries around the world; as of 2013, 83 countries failed to meet the World Health Organization’s basic threshold of 23 skilled health workers per 10,000 people (3).

However, poorer countries face disproportionate shortages of skilled health workers. As of 2013, there were only 168 medical schools in all 47 countries of Sub-Saharan Africa; 24 of these countries had only one medical school, and 11 had none. Put in other terms, Sub-Saharan Africa has 25% of the world's disease burden, but just 3% of its health workers (8).

Developed countries face shortages largely due to shifting incentives rather than lack of capacity. In 2013, a World Health Organization report estimated that, within a decade, 40% of nurses in developed countries will no longer work in healthcare due to low pay and long hours (3).


Dimensions of Impact: CONTRIBUTION

Investors considering investing in a company or portfolio aligned with this strategy should consider whether the effect they want to have compares to what is likely to happen anyway. Is the investment's contribution ‘likely better’ or ‘likely worse’ than what is likely to occur anyway across What, How much and Who?

Key questions in this dimension include:

Is the investment’s contribution ‘likely better’ or ‘likely worse’ than what is likely to occur anyway across What, How Much and Who?

Though governments and countries around the world are already investing in their health workforces, the resulting improvements will not likely meet demand. The World Health Organization and the World Bank project that the world will need an additional 18 million health workers by 2030 to achieve the health-related Sustainable Development Goals (9).

Investments in this strategy will most likely succeed when they focus on innovative models for improving the quantity and quality of health workers in rural areas, because rural areas are the most acutely affected by shortages of skills and personnel. Concurrent investments in cost-containment strategies and removal of financial barriers to care can also help in rural areas, which are generally more affected by poverty and inability to afford care.

How Much

Dimensions of Impact: HOW MUCH

Investors deploying capital into investments aligned with this strategy should think about how significant the investment's effect might be. What is likely to be the change's breadth, depth, and duration?

Key questions in this dimension include:

How many can receive the outcome through this strategy?

Given the substantial global gap in human resources for health, billions could gain from increased capacity in the health workforce. The exact number of potential beneficiaries depends on the investment’s scope and focus. For instance, considering human resources for maternal health, roughly 31 million births worldwide (22%) were unattended. Consequently, improved access to skilled birth attendants could annually prevent as many as 303,000 maternal and 2.7 million newborn deaths attributable to inadequate or non-existent care during pregnancy and delivery (10).

How much change can beneficiaries experience through this strategy?

The potential impact of investments in this strategy depends on whether they aim to increase the number of skilled health workers or improve existing workers' abilities to provide essential services. Consider several examples of impact from increased health workforce capacity:

  • One study across emerging markets showed that access to skilled birth care reduced intrapartum-related neonatal deaths by 25%, while access to a comprehensive package of emergency obstetric care led to an 85% reduction (5).
  • An analysis in Vietnam found that an increase of just one doctor per 10,000 people led to a 4.1-month increase in life expectancy per person (11).
  • This strategy can also affect economic outcomes; an independent evaluation of Living Goods, an innovative organization that empowers community health entrepreneurs to deliver crucial services and products in their communities, found that their agents’ activity reduced drug prices at local clinics and drug stores by 17% (12).



Dimensions of Impact: RISK

Key questions in this dimension include:

What risks do investments in this strategy run in terms of either people/planet experiencing impact or society as a whole? What is the probability that those risks happen?

Risk factors for this strategy include the following:

  1. Execution Risk: Interventions in this strategy may not, depending on execution, result in increased capacity or quantity of health workers; for instance, a successful pilot program to train and equip community-health entrepreneurs might not prove scalable or might fail in new contexts.

  2. Stakeholder-Participation Risk: As necessary stakeholders for any interventions within this strategy, health workers may require consistent engagement and deliberate consultations, even during investment design, to ensure success.

  3. Drop-Off Risk: Many low- and middle-income countries are experiencing a serious “brain drain” of medical personnel moving from villages to cities or to richer countries in search of better paying jobs and higher standards of living. This migration has led to major health workforce shortages in emerging markets and has left already-struggling health care systems in an even more desperate state. To mitigate this risk, investments that target frontline health workers are a good way to help strengthen and rebuild health systems with a cadre of workers less likely to migrate and more culturally in sync with local needs and beliefs, thus ensuring care reaches those who need it most.

What are likely consequences of these risk factors?

Risks for this strategy would dilute impact, not produce negative impact. Execution Risk and Stakeholder-Participation Risk might dilute immediate impact, while Drop-Off Risk would dilute longer-term impact.

Illustrative Investment

The North Star Alliance, founded in Malawi in 2005, builds basic clinics—termed "Blue Boxes"—in disease hotspots identified jointly with partners in local government and the private and social sectors. North Star Alliance then trains local community-health workers to staff those clinics and provide key services. The organization now operates more than 30 roadside health centers across South Africa, Tanzania, and Kenya, providing services at their clinics to more than 207,000 patients in 2016. These patients are often in hard-to-reach areas and members of disadvantaged or previously underserved communities; 20% of patients identified as sex workers who would otherwise face difficulty seeking treatment due to stigma (13).

Draw on Evidence

This mapped evidence shows what outcomes and impacts this strategy can have, based on academic and field research.

Evaluation of a mHealth Data Quality Intervention to Improve Documentation of Pregnancy Outcomes by Health Surveillance Assistants in Malawi: A Cluster Randomized Trial

Joos O, Silva R, Amouzou A, Moulton LH, Perin J, Bryce J, et al. (2016) Evaluation of a mHealth Data Quality Intervention to Improve Documentation of Pregnancy Outcomes by Health Surveillance Assistants in Malawi: A Cluster Randomized Trial. PLoS ONE 11(1): e0145238.

Can a community health worker administered postnatal checklist increase health-seeking behaviors and knowledge?: evidence from a randomized trial with a private maternity facility in Kiambu County, Kenya

McConnell M, Ettenger A, Rothschild CW, Muigai F, Cohen J. Can a community health worker administered postnatal checklist increase healthseeking behaviors and knowledge?: evidence from a randomized trial with a private maternity facility in Kiambu County, Kenya. BMC Pregnancy Childbirth. 2016 Jun 04;16(1):136.

Improvement in Integrated Management of Childhood Illness (IMCI) Implementation through use of Mobile Technology: Evidence from a Pilot Study in Tanzania

Mitchell M, Hedt B, Msellemu D, Mkaka M, Lesh N. Improvement in Integrated Management of Childhood Illness (IMCI) Implementation through use of Mobile Technology: Evidence from a Pilot Study in Tanzania. BMC Med Inform Decis Mak. 2013;13:95.

Short message service (SMS) reminders and real-time adherence monitoring improve antiretroviral therapy adherence in rural Uganda

Haberer JE, Musiimenta A, Atukunda EC, Musinguzi N, Wyatt MA, Ware NC, et al. Short message service (SMS) reminders and real?time adherence monitoring improve antiretroviral therapy adherence in rural Uganda. AIDS. 2016;30(8): 1295.

Early BCG vaccine to low-birth-weight infants and the effects on growth in the first year of life: a randomised controlled trial

Biering-Sorensen S, Andersen A, Ravn H, Monterio I, Aaby P, Benn CS. Early BCG vaccine to low-birth-weight infants and the effects on growth in the first year of life: a randomised controlled trial. BMC Pediatr. 15, 137 (2015).

Introducing rapid diagnostic tests for malaria to drug shops in Uganda: a cluster-randomized controlled trial

Mbonye AK, Magnussen P, Lal S, Hansen KS, Cundill B, Chandler C, et al. (2015) A Cluster Randomised Trial Introducing Rapid Diagnostic Tests into Registered Drug Shops in Uganda: Impact on Appropriate Treatment of Malaria. PLoS ONE 10(7): e0129545.

The impact of training informal health care providers in India: A randomized controlled trial

Das J, Chowdhury A, Hussam R, Banerjee AV. The impact of training informal health care providers in India: A randomized controlled trial. Science2016;354:aaf7384.

Effect of a micro entrepreneur-based community health delivery program on under-five mortality in Uganda: a cluster-randomized controlled trial

Nyqvist, M. B., Guariso, A., Svensson, J., Yanagizawa-Drott, D. Effect of a Micro Entrepreneur Based Community Health Delivery Program on Under-Five Mortality in Uganda: A Cluster-Randomized Controlled Trial (CEPR Discussion Paper Series DP 11515). London: Centre for Economic Policy Research.

Measuring What Works: An Impact Evaluation of Women’s Groups on Maternal Health Uptake in Rural Nepal

Sharma S, Van Teijlingen E, Belizán JM, Hundley V, Simkhada P, Sicuri E. Measuring What Works: An impact evaluation of women’s groups on maternal health uptake in rural Nepal. PloS one. 2016;11(5):e0155144.

The Advance Market Commitment Pilot for Pneumococcal Vaccines: Outcomes and impact evaluation

Boston Consulting Group (BCG). The Advance market commitment pilot for Pneumococcal Vaccines: Outcomes and impact evaluation, 2015.

A low-cost ultrasound program leads to increased antenatal clinic visits and attended deliveries at a health care clinic in rural Uganda

Ross, et al, 2013. A Low-Cost Ultrasound Program Leads to Increased Antenatal Clinic Visits and Attended Deliveries at a Health Care Clinic in Rural Uganda. PloS One. 2013.

Each resource is assigned a rating of rigor according to the NESTA Standards of Evidence.

Define Metrics

Core Metrics

This starter set of core metrics — chosen from the IRIS catalog with the input of impact investors who work in this area — indicate performance toward objectives within this strategy. They can help with setting targets, tracking performance, and managing toward success.

Additional Metrics

While the above core metrics provide a starter set of measurements that can show outcomes of a portfolio targeted toward this goal, the additional metrics below — or others from the IRIS catalog — can provide more nuance and depth to understanding your impact.