Nurses—Making a Difference in Global Health
GOAL 5: Improve maternal health
Nursing and Midwifery: offsetting negative influences of globalization
By Barbara A. Parfitt
Nursing and midwifery, writes the author, are much more than a support system for delivery of a medical model. Rather, the multiskilled approach of nurses within a holistic framework is a model critical in its own right for the health and well-being of communities and individuals around the world.
All who work in health care, particularly nurses and midwives, are aware of the major challenges that face us. Changes in the political landscape and world economy and shifts in the balance of power have made world events increasingly apparent in our daily experience. We aimed to achieve “Health for All” by 2000 but have not succeeded. We all know that poverty and ill health are breeding grounds for discontent and instability. We are again faced with the old enemies of pestilence and war. Infectious diseases once thought conquered are rearing their heads with new vigor and deadly menace. Tuberculosis and malaria are once again life-threatening, and science does not yet have the answers. HIV and AIDS continue to elude long-term solution and millions are dying. If there are solutions, they are often not used because of their threat to the economy of large companies, organizations and governments.
We live in a world where the economy drives and humanity is lost. The threat that we live under, called globalization, seemed to promise a redistribution of wealth, but it is making the rich wealthier, while the poor still exist in poverty.
Globalization, a patriarchal model of economic development that is largely politically driven, ignores the economic situation of women and their contribution to health, often alienating them from the development process. Women are both providers and beneficiaries of health care, yet their education, preparation and financial support are largely neglected. The absence of health in much of the world is more about the impact of poverty and injustice than it is about disease processes. As physicians, nurses and midwives, we spend a great deal of time trying to address the clinical outcomes of these issues, while ignoring the context of poverty and injustice from which they arise.
Until recently, nursing and midwifery had been seen as an important support system only for the delivery of a medical model. It is now increasingly recognized that the unique, multiskilled approach of nurses and midwives within a holistic framework is a model critical in its own right for the health and well-being of communities and individuals and for improving health outcomes.
A threat even greater than those mentioned above, however, is insufficient human resources to meet future health needs. Global health care is in crisis for both developed and developing countries—North and South—and that crisis is shown most graphically by the general worldwide shortage of professionals who deliver health care, particularly nurses and midwives. During a presentation at the 2004 Nursing and Midwifery WHO Collaborating Centre network general meeting, Dr. Orvill Adams, then director of human resources for WHO, warned that the future health threat of this millennium is not a disease, but lack of human resources to deliver the necessary services (Adams, 2004).
Human resource supply has faced years of national and international neglect. Africa suffers 25 percent of the world’s burden of disease but has only 1.3 percent of the world’s health care workforce. To achieve millennium development goals (United Nations, 2000), the minimum level of health workforce density is estimated at 2.5 workers to 1,000 people. Out of 46 countries in Africa, only six have a health care workforce of more than 2.5 workers per 1,000. Africa’s workforce density averages 0.8 per 1,000 population, compared to a world median density of 5 per 1,000 (WHO, 2004a).
The low density of the global health workforce is attributed to four key reasons: 1) insufficient training opportunities; 2) deteriorating health of the workforce, particularly in Africa, as a result of HIV/AIDS; 3) rural imbalance; and 4) brain drain (WHO, 2004a). To confront this problem at a global level, particularly in developing countries, human resource issues of education and professional expertise must be addressed.
Changing health systems
Another important issue in health care development is the need for health care systems that serve their purpose (World Bank, 1993). Little reference is made these days to the 1978 Declaration of Alma-Ata (WHO, 2004b), with its objective of achieving primary health care service that is community-based. Health reform is now largely about developing financial and economic strategies to support new organizational structures, rather than fulfilling philosophical statements relating to community participation and accessibility of services.
The new approach to health reform as decentralization and reduced public spending as its main elements. It also ncludes basic packages of care, financed through increased cost sharing or privatization and improved information systems (Hearst & Blas, 2001).
What is often missing in the new health reform policies is incorporation of a cultural context. Hofstede (1991) and Atkinson (2002) state that these missing values focus on relationships with people, community organization, decision making and balance of power within the system. The influence of masculinity, collectivism and individualism also is highlighted.
The World Bank development reports of 1993 and 1995 argue that, to establish effective health systems, it is necessary to secure sustainable health financing. Without adequate financing, no system will achieve the outcomes it strives for, whatever the philosophical underpinning. Conversely, the effectiveness of any health care system, however well-financed, needs to be measured in terms of its overall impact on the health of the community. Simplistic vertical medical interventions often fail because they do not take into account behavioral changes of individuals and communities over time.
Where do women, nursing and midwifery fit into the picture of globalization and health? Women are not only the primary providers of health care to the family, but also comprise the greater part of the health care workforce as nurses, midwives, allied health professionals and uncertified health care workers. The main economic role of women has been seen in reproduction, child-rearing and homemaking. Women are largely seen as merely beneficiaries of development and not as contributors to it, despite the fact that so many women are nurses, midwives and health care providers. Major health development projects often focus on in-depth training for physicians (mostly male), while development of nurses (mostly female) tends to be relegated to small-scale short programs and workshops.
Boserup (1970) proposed that women do not necessarily benefit from development—that in many instances, misguided development can actually erode their role, deteriorate their situation and endanger their traditional status. Thirty-six years later, that conclusion is still largely valid. Full equality for women within the framework of economic development is essential if we are to see any real improvement in reducing poverty and improving health services. Aid organizations eager to make development more effective are now focusing on both gender and development by increasing women’s participation and benefits.
WHO has identified eight key goals for this millennium. These goals recognize the holistic nature of health by shifting away from a single focus on disease to the fostering of environments in which humans thrive. If we are to make a commitment to the millennial goals through globalization, the benefits must be seen in terms of reduction of poverty and redistribution of wealth; improved health status and global management of disease and ill health; pooling of resources with improved levels of education and increased tolerance of cultural and religious differences; positive migration with shared expertise; and improved technology and communications.
Negative consequences of globalization might well be described as an upsurge in sectarianism with global unrest and terrorism, a widening gap between rich and poor, and migration that leads to the rapid spread of disease. The rise of free trade leads not only to an economic boom, but also to increased availability of cigarettes, drugs and pornography.
The work of WHO thus becomes paramount in the fight for equity and peace. Never has the challenge been so great as it is now.
WHO Collaborating Centres and the Global Network
WHO Collaborating Centres (WHOCC) are recognized by WHO as a technical arm providing expertise at a local, national and international level. Thirty-eight of more than 900 WHOCCs specialize in nursing and midwifery development.
The primary responsibility of Nursing and Midwifery Collaborating Centres is to support the regional WHO offices and the headquarters office in Geneva in achieving millennial goals. In addition to working as individual units, they also are encouraged to maximize opportunities by working together as a network. Through their joint vision of “Health for All Through Nursing and Midwifery Excellence,” the centers achieve maximum global impact by reflecting the philosophy of equity, justice, participation and empowerment that is embodied in the Declaration of Alma-Ata. We are committed to this set of values. The models we adopt, therefore, are holistic and inclusive. The approaches to care and intervention that nurses and midwives have identified and adopted are those that match the aspirations of “Health for All.”
The responsibility of the Global Network Secretariat, now located at the School of Nursing, Midwifery and Community Health at Glasgow Caledonian University in Scotland, United Kingdom, is to facilitate the achievement of these strategic goals. The network has a unique blend of expertise with access to many countries and cultures. We can make a significant contribution globally by working together and collaborating with other organizations, including the International Council of Nurses, International Council of Midwives and, of course, the Honor Society of Nursing, Sigma Theta Tau International.
Working together as nurses and midwives at a global level is essential if we are to make a difference in the quality of life of the communities and individuals we serve. Demonstrating the value of the model of holistic practice that we universally espouse is needed if we are to influence the negative impacts of globalization. We empower ourselves when we work together, but we need to understand the nature of the challenges we face: rising poverty, civil breakdown, increasing threats from war and disease, unequal distribution of resources, and a damaged environment that is adversely affecting our health.
Most of all, we need to recognize that nurses and midwives are critical to the future of health care delivery. There are simply not enough physicians, nurses and midwives to deliver the care needed in the future, and radical solutions are necessary. These solutions may impact upon our own understanding of what a nurse, midwife or physician does, or is, but that should not matter if we can secure the core values that drive our practice and influence the development of new systems that reflect a holistic approach to care.
Barbara A. Parfitt, RGN, RM, FNP, PhD, professor and dean of the School of Nursing, Midwifery and Community Health at Glasgow Caledonian University, Scotland, United Kingdom, is secretary general of the Global Network of WHO Collaborating Centres for Nursing and Midwifery Development.
Adams, O. (2004). Opening presentation at the general meeting of the Nursing and Midwifery WHO Collaborating Centre Network, Johannesburg, South Africa.
Atkinson, S. (2002). Political cultures, health systems and health policy. Social Science and Medicine, 55, 113-124.
Boserup, E. (1970). Women’s role in economic development. New York: St. Martins Press. Hearst, N., & Blas, E. (2001). Learning from experience: Research on health sector reform in the developing world. Health Policy and Planning, 16 (supplement 2).
Hofstede, G. (1991). Culture and organisations: Software of the mind. London: McGraw-Hill.
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World Health Organization. (2004a). Addressing Africa’s health workforce crisis: An avenue for action. High level forum on the health MDGs. Retrieved March 1, 2006, from http://www.hlfhealthmdgs.org/Documents/ AfricasWorkforce-Final.pdf
World Health Organization. (2004b). Declaration of Alma-Ata. Retrieved March 1, 2006, from http://www.euro.who.int/AboutWHO/Policy/ 20010827_1
RNL - Reflections on Nursing Leadership - Published 3/3/2006 , Vol. 32 No. 1