Brazil, Cuba, Ghana, Kenya, & Nepal: Service Availability & Readiness

There are a variety of different strategies that can be used to promote a sufficient supply and equitable distribution of providers. Beginning in 2013, Brazil addressed geographic disparities in access to health services through a multi-faceted workforce program called Mais Medicos (More Doctors). Prior to Mais Medicos, the distribution of physicians ranged from 0.71 to 3.09 per 1000 people measured at the state level with significant disparities between states.1 Brazil had historically experienced challenges retaining doctors due to poor infrastructure and job security as well as an absence of well-articulated career development pathways.

Brazil used a three-part approach to increase provider availability throughout the country. The first focused on increased infrastructure. Municipalities were invited to apply for funds to improve facilities or secure necessary equipment.  The second and long-term strategy within the Mais Medicos program was the development of medical school programs in rural regions or regions with few doctors. Areas that were more than 75km from a medical school were given priority for this program. In the final component of Mais Medicos, Brazil increased recruitment of primary care physicians, many of whom came from Cuba where there was an overproduction of physicians specifically trained in comprehensive primary care.1 Within two years, the government of Brazil had recruited and provided training to more than 18,000 physicians.2 At this time, Brazil was spending approximately 9% of its GDP on health.3 While the strategy of recruiting foreign physicians successfully improved provider availability in this context, it remains to be seen whether this strategy is sustainable over time. There are many ethical considerations when recruiting doctors internationally. More information on the ethics of international recruitment of providers can be found in Global Code of Practice on the International Recruitment of Health Personnel adopted by the sixty-third World Health Assembly.

Through these three components of Mais Medicos, Brazil doubled the number of municipalities with greater than one doctor for every 1000 individuals between 2013 and 2015 and increased coverage of PHC services from 77.9% to 86.3% in the same time period.1

In 2006, Nepal initiated a similar rural health workforce strengthening program, instead focusing on posting of domestically-trained family physicians. This program – called the Rural Staff Support Programme - was motivated by the extremely low capacity of district hospitals to perform caesarean sections due to inadequate human resources.4 For each participating hospital, the program recruited two post-graduate doctors who were posted for three years of service. The program provided a scholarship for the participants’ three-year post-graduate program in family medicine as well as personal, professional, and management support in the hospital. Additionally, two nurse coordinators administered the program and provided support to doctors in seven hospitals. The program cost approximately $66,000 per hospital per year. Although staff were very supportive of the program, some doctors reported personal challenges integrating into the rural hospitals, suggesting a need for greater support. Initial evaluations of the program found that participating hospitals had a higher increase in safe deliveries and were able to provide continuous emergency obstetric services.

Cuba’s primary health care training and deployment programs are so robust that they send approximately 30,000 physicians to Latin America and Africa each year, including those who supported the Mais Medicos program in Brazil. Cuba achieves this supply of doctors through free, comprehensive medical education. Additionally, they mandate that all graduates work in family medicine prior to specialization. After mandatory service, 70% of providers remain practising in primary care. As a result, Cuba has achieved a robust primary care system which accounts for 80% of all health encounters.5 More information on Cuba’s primary health care system including their community-based approach can be found here.  

Task shifting involves careful planning, training, and supervision in order to successfully support changes in the delegation of responsibilities. A qualitative evaluation in Ghana explored implementers’ and health workers’ views on the status and acceptability of task shifting in the rural Upper East Region.6 Although Ghana has a number of innovative primary health care programs in place, many regions still suffer from poor health outcomes and a shortage of trained and available health personnel. The evaluation surfaced some challenges related to task shifting. Many health workers reported that they were expected to perform additional non-clinical tasks that were outside of their scope, which took time away from patient encounters, increasing their workload without appropriate incentives. Additionally, some stakeholders felt that there was not sufficient training provided to accompany task shifting. However, there were also positive findings from the evaluation; some health workers reported that their expanded scope was building their skills and capacities and contributed to their feelings of internal motivation. These findings suggest that while task shifting can be embraced by managers and health workers and contribute to more efficient service delivery, it must be implemented as part of a whole-system shift with planned and monitored training, supervision, and motivational mechanisms in place.

As many LMIC undergo epidemiological transitions and experience a growing burden of non-communicable diseases (NCDs), countries are developing strategies to effectively integrate NCD care and management into PHC systems within the constraints of often limited inputs. This is the case in Kenya where NCDs have typically been managed in tertiary hospitals. Starting in 2009, The Ministry of Health and Medecins Sans Frontieres (MSF) collaborated on task shifting of NCD care to primary care facilities and specifically to clinical officers, one member of a care team that also comprises physicians, nurses, counselors, social workers, health promoters, and laboratory staff.7 In 2014, care for hypertension, diabetes, asthma, sickle cell, and epilepsy was further shifted to nurses to alleviate an increased burden on clinical officers. Training and support were integrated into the program; each nurse received a one-week training and a decision support protocol. An evaluation of the program found a 69% adherence to the protocol for routine screening questions and 81% for routine laboratory monitoring. These findings were considered to be successful and suggest that task shifting for NCDs may be achievable, effective, and efficient in low-resource settings.


  1. Santos LMP, Oliveira A, Trindade JS, Barreto IC, Palmeira PA, Comes Y, et al. Implementation research: towards universal health coverage with more doctors in Brazil. Bull World Health Organ. 2017 Feb;95(2):103–12.
  2. Campos GW de S, Pereira NJ. Primary care in Brazil, and the Mais Medicos (More Doctors) Program in the Unified Health System: achievements and limits. Cien Saude Colet. 2016 Sep;21(9):2655–63.
  3. Macinko J, Harris MJ. Brazil’s family health strategy--delivering community-based primary care in a universal health system. N Engl J Med. 2015 Jun;372(23):2177–81. 
  4. Zimmerman M, Shah S, Shakya R, Chansi BS, Shah K, Munday D, et al. A staff support programme for rural hospitals in Nepal. World Heal Organ Bull World Heal Organ [Internet]. 2016;94(1):65–70. Available from:
  5. Cuba: Emphasis on community-based primary care in a tiered system improves outcomes. Primary Health Care Performance Initiative.
  6. Okyere E, Mwanri L, Ward P. Is task-shifting a solution to the health workers’ shortage in Northern Ghana? PLoS One. 2017;12(3):1–22.
  7. Some D, Edwards JK, Reid T, Van Den Bergh R, Kosgei RJ, Wilkinson E, et al. Task shifting the management of non-communicable diseases to nurses in Kibera, Kenya: Does it work? PLoS One. 2016;11(1):1–9.