In 2012 a national training strategy8 and corresponding plan9 identified the need to double the number of AHW in the system by 2020. This was confirmed in the National Health Development Plan.5 This study was an attempt to integrate this priority into the national health workforce strategy 2013-2025.7
The Government Program for 2009-2012 set as 2012 targets 3 doctors, 20 nurses and 9 AHW per 10 000 inhabitants, resulting on ratios of 6,67 nurses and 3 AHW per doctor. This was achieved for AHW but nor for nurses.7
To respect this ratio of 3 AHW per doctor, the national health workforce strategy 2013-2025 develops several scenarios for health workforce development. These predict the need for AHW to vary between 37666 and 43101 by 2025.7 The 2014 baseline acknowledges the existence of 6414 AHW in public service, 4699 of these in the national health service; 75% were auxiliaries with basic training; of the remaining 25% it was not possible to differentiate between those with mid-level or higher education training. There was no data on the distribution among the different professional groups that integrate the career. Hence, the scenarios of national health workforce strategy 2013-20257 require the number of AHW to increase at least five fold7, far more ambitious target than what was stipulated in the national training strategy and corresponding plan identified8,9 and the National Health Development Plan5.
In 2014 the major effort to train AHW was being developed by the private educational sector, particularly at the higher education level16. There was no data on the effort to train AHW abroad.
This study reflects a positive message. Students are recruited with a wide geographical base; they are satisfied with their choice of training and their performance is satisfactory (less so in the private sector, where about a quarter were repeating curricular units). After training they want to settle in Angola, preferable in a hospital practice, preferably in the public sector. As the public sector does not have the capacity to absorb all students, it is satisfying to notice that many are open to practice in private sector institutions, mostly based in the provincial or national capitals, preferably in accumulation with public sector work (self-employment is still a limited option as regulations are not clear and financial support form banking or other financial institutions is not easily accessible for young graduates).
The study also provides some alert signs.
Although, in 2012, there were 165 municipal, 25 provincial and 20 national hospitals5, most students, despite family links to rural areas, wanted to settle professionally in the national or provincial capitals, rather than in the municipal hospitals.
Only a minority of students were receiving support on the form of a bursary, this may limit access to training, particularly higher education, mostly provided by private sector institutions. While the public sector has health facilities where practical training is well organized the private institution do not provide laboratories or other health facilities for adequate practical training, a difficulty acknowledged by the students.
Training is a significant investment by students or their relatives hence, training institutions, in respect for this effort, and to improve academic performance, must strive to improve support systems in terms of access to libraries, laboratories, clinical cases, informatic support, canteens, accommodation and leisure activities.
The great majority of students are women, with all the implications of this for health workforce planning in terms of gender balance, geographical distribution, long-term retention and availability to work overtime and in isolation, as well as lack of recognition of these professions (as reflected in the lack of bursaries and of public sector investments in their training). This feminization of the AHW workforce can potentially catalyze women’s empowerment and equity and address the gender issues in society at large.25
Lastly, the findings of this study are aligned with those of other studies of medical and nursing students in Angola, Brasil, Cabo Verde, Guiné-Bissau, Moçambique and Timor Leste. Everywhere, except Guiné-Bissau, the student corps was feminized. Parents and relatives are the main source of support for students. Students are usually satisfied with the quality of training, with their teachers and the study calendar, but less so with support systems. After completing their studies, trainees want to settle in urban hospital practice.17-23
Most students in all countries studied17-23 report family members in the health professions and highlight their importance in influencing their decision to follow health professional training, reinforcing the importance of social reproduction mechanisms in education.26
Limitations of the study
A limitation of the study is the lack of a denominator for the number of AHW students and mid-level training institutions in the country. The study covers 4 of the 8 public and 3 of the 15 private higher education institutions training AHW in Angola. Still, this is a unique study both in Angola an Africa, with findings relevant for the planning of health workforce education and development.
A second limitation refers to the inability to identify the professional training being followed by the AHW students. Although there was a specific question on this, most of the students did not reply to this question.
The study was conducted in 2014. It is reported now because there are attempts to repeat it. In the last two years, in the context of the major political changes observed in the country, more than 16 000 health workers – physicians, nurses and AHW – have been recruited into public sector health services, and there is a need to evaluate the implementation of the national health workforce strategy and to update it.
A final limitation refers to the classification of localities as either rural or urban. This is a difficulty acknowledged in the literature27. We opted to follow the recommendations of Couper28 accepting as rural any place outside the national capital city (Luanda) and/or outside the provincial capitals. This is aligned with the classification followed by the 2014 Angolan population census (http://onuangola.org/agencias/unhabitat/atlas/).