implications **for** ministries of health (Berman et **al.** 1986). Although community health workers are likely to be used more selectively in the future, they are unlikely to be entirely abandoned, especially in rural areas where population density is low and health facilities are scarce.

18. Another group of professional health workers that is conspicuously scarce in nearly all countries in sub-Saharan Africa is that of health service administrators and managers. There are few formal training programs or care; pdths for such critical staff, and managerial responsibility has largely been assumed by admiaistrative and clerical staff or by doctors and nurses untrained in health program management. These positions also call for leadership and associated skills that depend on an understanding of the local culture. The need for more management training is well recognized, particularly for regional and district level staff.

19. Various other support workers - clerks, drivers, cooks, cleaners, informally trained assistants - constitute another group of health workers, one that accounts for a significant portion of the total health budget expenditure. In Ghana, support personnel accounted for approximately 53 percent of the total staffing expenditures for the ministry of health (Sector Report 1984). This varied group of workers - many of them local patronage appointees - requires considerable supervision at the district level. Their numbers sometimes rise well above the number of established positions and since their employment may be "hidden', the health ministry may lack information on the total number actually employed. Thus the true situation in the districts may often be revealod only through local investigation.

20. Brain drain among health professionals is another serious concern. Doctors and nurses with internationally recognized qualifications find it easy to emigrate and to find jobs elsewhere. Some move to other countries in Africa, but large numbers of Africans are also working in Europe and the Middle East. Ghana and Sudan have experienced especially severe losses of health professionals **to** other countries. Some of this migration is temporary, such as for postgraduate specialization, but much of it appears to be long term, if not permanent, and represents a considerable loss of both health workers and the investment in their training. Some health workers leave for professional, econowic, or political reasons, and some of the best public health specialists employed by ministries of health are recruited by international and other agencies. This recruitment of public health specialists can have a critical effect on their home countries and highlights the scarcity of good public health skills in sub- **Saharan** Africa. The problem requires some imaginative, long-term solutions, including attention to regional plans for strengthening undergraduate and postgraduate traimng centers for public hea'th in sub-Saharan Africa.

21.

21. Thus despite great advances in the numbers of health personnel and a wealth of experience experimenting with different cadre6, most countries in sub-Saharan Africa are still in a critical state **_w"'_** regard to the availability of health workers. There is a scarcity of health personnel, both protessional **and** managerial, at all levels, and available personnel are not effectively used, managed, or developed. In particular, there is a serious shortage of senior professionals who combine both public health and managerial skills. Cutbacks in ministry of health budget allocations in recent years make it even more critical that countries explore ways to apply new developments in skill mix and distribution and improved management of these scare human resources to increase their efficiency.

# m. Planning

22. Even though health personnel planning has been based mostly on simple projections of numbers of staff, the basic information needed for these calculations is frequently absent, incorrect, or difficult to obtain. For many countries, numbers of health personnel in various categories and their current status are often not available in any consistent or useful format. The most reliable national data probably exist for doctors and nurses, because they are usually legally required to be registered. But registry data such as home address, working location, employment status, and professional qualifications are rarely up to date, and some registries even retain the names of physicians and nurses 8