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.
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:
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:
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).
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:
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.
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:
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.
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:
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).
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:
Key questions in this dimension include:
Risk factors for this strategy include the following:
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.
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).
1
Freer, Joseph. "Sustainable Development Goals and the Human Resource Crisis." International Health 9, no. 1 (January 2017): 1–2. https://doi.org/10.1093/inthealth/ihw042.
2
Ighobor, Kingsley. “Diagnosing Africa’s Medical Brain Drain.” Africa Renewal (United Nations), December 2016 – March 2017. https://www.un.org/africarenewal/magazine/december-2016-march-2017/diagnosing-africa’s-medical-brain-drain.
3
World Health Organization. “Global Health Workforce Shortage to Reach 12.9 Million in Coming Decades.” News release, November 11, 2013. http://www.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/.
4
“Safeguarding the Quality of Maternal Medicine to Save Mothers’ Lives.” USAID Global Health Supply Chain Program. January 24, 2018. https://www.ghsupplychain.org/node/424.
5
Lee Anne C.C., Simon Cousens, Gary L. Darmstadt, Hannah Blencowe, Robert Pattinson, Neil F. Moran, G. Justus Hofmeyr, Rachel A. Haws, Shereen Zulfiqar Bhutta, and Joy E. Lawn. “Care during Labor and Birth for the Prevention of Intrapartum-Related Neonatal Deaths: A Systematic Review and Delphi Estimation of Mortality Effect.” BMC Public Health 11, suppl. 3 (2011): S10. https://doi.org/10.1186/1471-2458-11-S3-S10.
6
Araújo, Edson, and Akiko Maeda. "How to Recruit and Retain Health Workers in Rural and Remote Areas in Developing Countries." Health, Nutrition, and Population Discussion Paper. Washington, DC: World Bank, June 2013. http://documents.worldbank.org/curated/en/273821468154769065/pdf/785060WP0HRHDC00Box377346B00PUBLIC0.pdf.
7
Dion, Anna. “Putting It into Practice: Building Local Capacity to Improve Maternal Health.” Young Champions (Ashoka blog), October 26, 2010. https://www.ashoka.org/en/node/3693.
8
Sturchio, Jeffrey L., Louis Galambos, and Tina Flores. “Tackling NCDs Effectively Will Require More Health Workers.” The Blog, Huffington Post, June 8, 2014. https://www.huffingtonpost.com/jeffrey-l-sturchio/the-simple-fact-is-that-t_b_5107146.html.
9
World Health Organization. Health Workforce Requirements for Universal Health Coverage and the Sustainable Development Goals. Human Resources for Health Observer Series no. 17. Geneva: World Health Organization, 2016. http://apps.who.int/iris/bitstream/handle/10665/250330/9789241511407-eng.pdf?sequence=1.
10
“Delivery Care.” UNICEF Data: Monitoring the Situation of Children and Women. New York: United Nations Children’s Fund, 2018. https://data.unicef.org/topic/maternal-health/delivery-care/.
11
Nguyen, Mai Phuong, Tolib Mirzoev, and Thi Minh Le. "Contribution of Health Workforce to Health Outcomes: Empirical Evidence from Vietnam." Human Resources for Health 14 (November 2016): 68. https://doi.org/10.1186/s12960-016-0165-0.
12
“Living Goods Invests in Best in Class Impact Measurement.” Living Goods. https://livinggoods.org/what-we-do/measuring-impact/.
13
“Key Figures.” North Star Alliance. Accessed June 6, 2018. http://www.northstar-alliance.org/key-figures/.
This mapped evidence shows what outcomes and impacts this strategy can have, based on academic and field research.
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.
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.
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.
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.
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).
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.
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.
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.
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.
Boston Consulting Group (BCG). The Advance market commitment pilot for Pneumococcal Vaccines: Outcomes and impact evaluation, 2015.
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.
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.
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.
This metric is intended to capture the number of unique individuals who belong to minority or previously excluded groups and who are employed by the investee in full- or part-time roles at the point in time defined by the end date of the reporting period. This metric excludes Temporary Employees (OI9028).
The term “minority” can be adapted to each investor’s specific goals and targets (e.g., women, youth, other minorities).
Given the difficulty of obtaining data on this metric, data may be collected by survey. Organizations may use a representative sample of clients to gather data or may adopt lean data approaches (for details, refer to Acumen at Lean Data).
Calculations of a living wage are not standardized. Some online tools are available to estimate living wages in different geographies. Examples include the Wage Indicator and Living Wage. Note that the latter is only for U.S. states.
For further details on what a living wage means around the world and for methods to estimate it, refer to the International Labour Organization's Conditions of Work and Employment Programme.
Given the difficulty of obtaining data on this metric, and since it might not apply to very small organizations, data may be collected by survey. Organizations may use a representative sample of clients to gather data or may adopt lean data approaches (for details, refer to Acumen at https://acumen.org/lean-data/). Alternatively, investors may ask the financial service provider to implement an environmental, social, and governance policy that screens investees on living wages.
Investors can request an SPI4 score from financial service providers or conduct an SPI4 ALINUS themselves. ALINUS is a streamlined version of the full SPI4, developed for and by investors as a common tool for social due diligence and monitoring (see CERISE).
(Number of patients completing treatment within the clinically recommended time frame during the reporting period) / (Number of patients who started treatment and who were expected to complete treatment during the reporting period)