IN our previous article on this topic, we looked at some of the economic issues that serve as a barrier to health care access. Beyond economic issues, there are, however, many issues that limit access and this week we shall look at manpower and geographic issues.

Manpower

Health care delivery depends on human capital to a significant degree despite the increasing use of technology. If there are no doctors, nurses, or ancillary health-care personnel, then there is effectively no health care to access. Jamaica has 0.5 physicians per 1,000 population and 1.8 nurses per 1,000 population (2016 World Bank data). Our Caribbean neighbour Barbados has 2.5 physicians per 1,000 population and 3.1 nurses per 1,000 population. The United States has 2.6 physicians per 1,000 population and 15.7 nurses per 1,000 population. High-income countries on average have 3.7 physicians per 1,000 population compared with 0.3 physicians per population in low-income countries. When we look at specialty care, the gap is much wider and shows why many citizens will unfortunately not have access to speciality care. In the USA, for example, there are 22.3 neurologists per 100,000 population but in Jamaica, we have about 0.0000023 neurologists per 100,000 or 2.3 neurologists per one million. There are 33,701 cardiologists in active practice in the USA resulting in a ratio of about 102 cardiologists per one million population. In Jamaica, we have less than 30 cardiologists in active practice for a population of three million resulting in a ratio of less than 10 cardiologists per million. Many subspecialty areas in neurology, cardiology and other specialities have no representation in the physician pool. Likewise, many of the smaller Caribbean islands have no specialists in many medical fields.

In terms of nurses, high-income countries average 11.4 nurses per 1,000 population when compared with 0.9 nurses per 1,000 population in low-income countries.

While it is sometimes difficult to accurately estimate how many physicians are needed for any one country as this may vary significantly depending on the health, age, and disease burden of a population, the World Health Organization (WHO) recommends one physician per 1,000 population.

It is not difficult to see how manpower shortages affect health care delivery. In our public hospitals and clinics (particularly specialist clinics at our tertiary hospitals) there are long waits both for an appointment to be seen and also long waits during the clinical encounter. Many of our specialists’ units which require nurses with advanced qualifications. Intensive-care units (ICUs), labour and delivery wards and operating rooms have critical nursing shortages. In an ICU setting it may very well be that a bed is available for an ill patient but there is no nurse available to deliver care. Operating rooms can sit empty despite physicians who are able to operate because there are no nurses to assist in the operating room or recover the patient after surgery.

These issues are not only noted in the public sector. There are several areas of medicine in the private care arena for which specialists are in relatively short supply or non-existent leading to long waits to see a physician or in some scenarios result in the need to seek care abroad. Interestingly issues of manpower availability are not confined to low-and middle-income countries. The crisis in the National Health Service (NHS) of the United Kingdom is frequently in the news. One of the causes of the failure of health care delivery is a shortage of personnel. The British Medical Association estimates that in their secondary care system there are physician vacancies of 9,053 posts and nursing vacancies of 47,496 posts. Nursing shortages are a problem in most high income countries leading to aggressive recruitment from low and middle income countries which in most cases are unable to compete with the remuneration that is offered.

A manpower issue that is particularly affects low and middle countries is the use of allied health-care practitioners. More developed health care systems have long recognised that much of medical and nursing care is relatively routine and does not require the relatively high cost of physician and nursing labour to deliver. The use of technicians, nursing aides and physician extenders can allow the delivery of health care in a more efficient fashion and to a wider range of individuals. A good example of this is the use of technicians to acquire images for cardiac ultrasound (echocardiography). Echocardiographic images are obtained in a certain sequence, from defined areas for each study. This is standard for every patient. A technician can be trained to do this competently within a few months allowing the cardiologist to spend minutes reviewing the images and reporting vs spending 30 minutes acquiring the images. In the United States the use of technicians for cardiac ultrasound has been routine for more than 30 to 40 years. A technician doing cardiac ultrasound frees the cardiologist to do work for which he is uniquely qualified and which cannot be performed by those with lesser levels of training. The use of midwives for routine delivery is another example. Obstetricians can focus on the delivery of infants that are at high risk for complication or who have problems during labour and delivery. There are, however, many other roles for which allied health-care providers can be useful and generally these are often ignored in health-care systems of low- and middle-income countries.

Geographic distribution of health-care resources

In our previous article we discussed the disparities between countries in terms of access to care but in almost all countries there are significant disparities within countries. These can be seen most easily when comparing the urban rural divide. Globally and within countries, there is significant inequity in the distribution of health-care resources with 80 per cent of resources often accessible to the top 20 per cent of the population in terms of economic position while the bottom 80 per cent have access to 20 per cent of the resources. If we were to think of the distribution of cardiologists in Jamaica. Most of these physicians practice in Kingston, St Andrew, and St Catherine. Mandeville and Montego Bay have probably four cardiologists between them. Aside from outreach clinics, seeing a cardiologist does require travel to one of these areas. Imagine if you live in Portland; then seeking care likely means a day devoted to health care alone. On that day you will not be able to go to work, you may have to think about how do you arrange childcare? If you do not have a car, how will you travel to the hospital or cardiologist’s office and at what cost? For many low- and middle-income countries economic opportunities, amenities and quality of life are greater in urban settings, leading both physicians and nurses to gravitate towards those areas leaving rural populations relatively underserved. Globally it is estimated that half of the population lives in rural areas compared with 38 per cent of nurses and 25 per cent of physicians.

This disparity between urban and rural areas is not only a problem of low and middle income countries. In the United States the ratio of primary care physicians to 10,000 population is 39.8/10,000 in rural areas compared to 53.3/10,000 in urban areas. Studies have documented that treatment for heart attack which is time dependent has worse outcomes in the rural United States. Patients in rural areas often have to travel further for care. For example, one study found that patients in need of radiation therapy in rural America needed to travel an average of 40.8 miles when compared with a patient in an urban setting who travelled an average of 15.4 miles. In Europe living in a rural area has been associated with a lack of access to qualified health-care workers, greater distance to major hospitals, less effective emergency care services and greater demands on health-care workers.

In future articles we will address other issues related to health care access.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for the Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Send correspondence to info@caribbeanheart.com or call 876-906-2107