ELearning for Tackling the Health Worker Shortage
Space travel and global health have more in common than is evident at first glance. In the last 15 years, the European Space Agency has been exploring how information and communication technologies can improve health worldwide. One use of these new communication technologies – eLearning – could help tackle the estimated 4.3 million global shortage in health workers, whose ranks need to be sufficiently increased if Millennium Development Goals (MDG) targets are to be achieved1. ELearning is especially promising in sub-Saharan Africa where remote areas need a better supply of services. But how feasible has online eLearning for health worker training been so far? And what obstacles will it face in the future?
The World Health Organization (WHO) estimates that 2.4 million nurses, midwives and physicians and 1.9 million health aid workers, pharmacists, technicians and auxiliary personnel are needed to meet MDG targets2. Africa, which is having the most difficulty reaching the MDGs, has been hit hardest by the health worker shortage. WHO’s World Health Report 2006 states that the African continent is facing 24% of the global burden of disease but only possesses 3% of the global health care workforce.
Child deaths and maternal mortality have hit low-income countries the worst. The risk of a death for a woman during childbirth is 1 in 31 women in low-income countries, compared to only 1 in 4,300 in high-income countries3. Moreover, 7.6 million children under the age of 5 die each year, with children in low-income countries being 18 times more likely to die than those in high-income countries.
ELearning, or computer-
assisted distance learning,
can help broaden the skills
of existing professionals,
reach those who live in
areas and reduce costs of
Most of these deaths are preventable. Ready-to-use high-nutrition foods, optimal breastfeeding, and safe complementary feeding can reduce malnutrition and have the potential to save millions of lives. The provision of skilled care during pregnancy and the presence of a skilled birth attendant significantly increase the chance for newborn survival. However, for the achievement of MDGs 4 and 5 – the reduction of child mortality by two-thirds and the improvement of maternal health – it is estimated that approximately 819 000 additional health workers are needed in the African region; an increase of 139% compared with current levels. The skills of existing health workers must be broadened in order to compensate for this shortage, permitting them to provide a wider range of health services4,5.
ELearning, or computer-assisted distance learning, can help broaden the skills of existing professionals, reach those who live in geographically isolated areas and reduce costs of learning-related travel6,7. In the face of a health worker shortfall, the advantage of eLearning is that health workers from remote locations do not need to leave their post for training. Online training allows them to learn theoretical components at work or at home, so that they can broaden their skills whilst continuing to supply crucial services to their communities6.
The Ethiopian Experience
Ethiopia is one of 57 countries identified by the World Development Report 2006 as being unable to achieve a basic standard for health care coverage in the near future8,9. In early 2011, the Ethiopian government launched the eLearning programme ‘Health and Education Programme’ (HEAT) together with the Open University, the African Medical and Research Foundation (AMREF), the WHO and UNICEF (Ethiopia)10. In six regions of Ethiopia, a pilot group of 1,000 health workers are being trained online with support from 100 tutors, in order to broaden their skills11. The course is composed of 13 modules consisting of 450 hours of training that are freely available on the Internet. They encompass subjects such as the management of childhood and newborn illnesses, labour and ante- and postnatal care, hygiene and family planning12.
In six regions of Ethiopia,
a pilot group of 1,000
health workers are
being trained online with
support from 100 tutors
This is not the first training programme the Ethiopian government has initiated for health workers. In 2003, it invested in health worker vocational training for young women with 10th grade education10. Over 6 years (from 2003 to 2010) 30,000 women became health workers13. Though this programme made an important contribution to broadening health services in remote areas, it required the young women to travel to training centres for their education. The advantage of HEAT is that it can reach more people in a shorter period of time.
The director of HEAT, Lesley-Anne Long, states “There are some really good training projects happening all over Ethiopia, but they are dealing with 10 students here, and 20 students there. We are talking about reaching thousands and thousands of students.”14 With appropriate funding, HEAT could broaden the skills of 250,000 health workers across sub-Saharan Africa by 201614.
Another advantage of eLearning is that the training is delivered using local infrastructure. Local health science colleges function as regional distance learning centres where tutors from partner NGOs deliver practical skills training and assessment in conjunction with the online training. In this way, the responsibility of the programme and the evaluation of students can remain in each region11. Also, students can meet with tutors when collecting their monthly salary at the regional centre, allowing for better integration of work and training15.
Remote areas in
developing countries will
only fully benefit from
eLearning when the
has been extended
Moreover, training within the community keeps the teaching tailored to local needs. The content of the courses has been developed with 50 leading African academics and health practitioners. As Long says, “at some point we back out of the picture and what we leave here are people who can write their own curriculum.”19 Moreover, local experts give students practical advice, an example being guidance on implementing supplementary feeding programmes that are based on the demand of their community14.
Scaling Up eLearning – A Long Way to Go
There is great potential for the scaling up of eLearning projects. Discussions for the extension of HEAT have taken place with Ghana, Rwanda, Kenya, South Africa, Nigeria, Southern Sudan, Uganda, Tanzania and Zambia. Moreover, India, Pakistan, Afghanistan and South American countries have shown interest16.
However, the use of eLearning is facing infrastructural problems that need to be overcome. The availability of broadband in Ethiopia is restricted. Therefore, the theoretical material of HEAT needs to be available both online and offline in a printed format. Remote areas in developing countries will only fully benefit from eLearning when the broadband infrastructure has been extended.
First steps have been taken towards the delivery of better broadband. In October 2011, UNESCO and the International Telecommunication Union (ITU) organized a Broadband Leadership Summit in order to emphasize the importance of access to stable broadband in developing countries17. Under the theme ‘Broadband for a Global Good’, the Broadband Commission for Digital Development headed by senior policy makers, international organizations and industry leaders made commitments to enhance broadband access in developing countries17. Moreover, alternative routes are being explored. The initiative uses mobile technology to provide students with access to telephone tutorials. A Java application is currently being tested by AMREF in order to distribute eLearning material on mobile phones18.
eLearning needs to be
embedded within a
health system that makes
it valuable for health
workers to remain in their
The cost of eLearning is another potential obstacle to a large-scale rollout. Distance learning resources that are contextualised and up-to-date are expensive and tutorial staff need to be paid for the practical support and monitoring of student progress11. The funding of HEAT amounts to around £2.8 million and another £10 million would be needed for the rollout over 9 sub-Saharan countries19.
A further challenge to the success of eLearning is the global system within which it operates. High-income countries have a considerable need for health workers due to demographic change towards older populations, and more will be required during the coming years. The European Union predicts that 2 million health workers will be needed by 2020 and the United States expects a shortfall of physicians of 20% by 202520,21. Health workers from low-income countries, especially highly trained workers such as doctors and nurses, are naturally attracted by higher salaries in high-income countries22,23. Qualifications attained through eLearning might be recognized in other countries11. In this instance, eLearning has the potential to enhance health worker migration and it therefore needs to go hand in hand with incentives for health workers who have earned diplomas through eLearning to stay within the area they have been trained11.
ELearning contributes to stabilization of health workers in rural areas during training, and, when there is ownership of training programmes by developing countries, a fit-for-purpose curriculum and a good integration of work and training. But in the long run the challenges are considerable: the broadband infrastructure needs to be improved, substantial funding has to be generated and eLearning needs to be embedded within a health system that makes it valuable for health workers to remain in their local communities.
Katharina Reinhardt is a research intern at the Centre on Global Health Security, Chatham House, Royal Institute of International Affairs. Her work focuses on both the role of the military in medical provision in fragile states and the response to emerging infectious diseases. She also has a strong interest in gender and health research.
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 Long, L. A. (2011) Turning the HEAT up for frontline health workers in Ethiopia. [online] Available at: <http://www.africa-health.com/articles/may_2011/HEAT.pdf> [Accessed 27 November 2011]
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 Knebel E. (2001) The use and effect of distance education in healthcare: What do we know? [online] Available at: <http://pdf.usaid.gov/pdf_docs/PNACN245.pdf> [Accessed 28 November 2011]
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 UNAIDS (2011) Megabits and MDGs: How broadband can work for greater good. [online] Available at: <http://www.unaids.org/en/resources/presscentre/featurestories/2011/october/20111025mbitsmdg/> [Accessed 27 November 2011]
 Iheed Institute (2011) mHealth Education: Harnessing the Mobile Revolution to Bridge the Health Education & Training Gap in Developing Countries. [online] Available at: <http://www.mhealthed.org/iheed_report_updates.pdf> [Accessed 25 November 2011]
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 American College of Surgeons (2011) Future Labor Shortfalls of Medical Professionals Predicted due to New Demands of Health Care Reform. Journal of the American College of Surgeons Study. [online] Available at: <http://www.facs.org/news/jacs/laborshortfalls0611.html> [Accessed 26 November 2011]
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 Kuehn B. M. (2007) Global Shortage of Health Workers, Brain Drain Stress Developing Countries. JAMA. 298: 1853-1855.