the global health workforce: crisis, solutions & opportunities
DESCRIPTION
Overview:Overview of health workforce in Africa: Numbers and beyondCauses of crisis and solutionsFinancing the health workforceGlobal attentionYou can helpTRANSCRIPT
The Global Health Workforce: Crisis, Solutions &
OpportunitiesBy Eric A. Friedman
Physicians for Human Rights
Physicians for Human Rights National Student Conference
Providence, RI, Jan. 31-Feb. 1, 2009
[Contact: [email protected]]
Overview
Overview of health workforce in Africa: Numbers and beyond
Causes of crisis and solutions Financing the health workforce Global attention You can help
Overview of health workforce in Africa: Numbers and
beyond
Scope of the health workforce crisis in sub-Saharan Africa
Sub-Saharan Africa has 24% of the world’s disease burden, but only 3% of the world’s health workers
Countries without 2.3 doctors/nurses/midwives per 1,000 population “very unlikely” to achieve Millennium Development Goals (World Health Organization) 57 countries with severe shortages,
including 36 in sub-Saharan Africa
By the numbers: A closer look
Sub-Saharan Africa Short more than 800,000
doctors/nurses/midwives Short about 1.5 million health workers including
managers and other health workers Health workforce needs to more than double
Diversity (doctors/nurses/midwives per 1,000 population) Ethiopia: 0.25 per 1,000 (2003) Kenya: 1.42 per 1,000 (2002) South Africa: 4.85 per 1,000 (2004)
Nurses, midwives, and physicians per 100,000
population
0
200
400
600
800
1000
1200
1400
1600
Ethiopia Malawi Zimbabwe Sub-SaharanAfrica
Nigeria WHOtarget
SouthAfrica
USA UK
Beyond numbers Severe internal inequities, underserved rural
areas Failure to update health workers’ skills and
knowledge Poor management and lack of regular,
supportive supervision Lack of medicines and supplies Lack of key skills such as human resource,
financial, and program management Restrictive policies (responsibilities of nurses
and mid-level workers, retirement ages) Inadequate support for community health
workers, caregivers
Internal inequities common
Deep internal inequities of health worker distribution
Ghana: Physicians
Northern Region: 1 physician per 100,000 population
Greater Accra Region: 30 physicians per 100,000 population
Nurses Northern Region: 34 nurses per 100,000 population Greater Accra Region: 120 nurses per 100,000
population
Causes and solutions
Causes of health workforce crisis
Massive underfunding of the health sector (low salaries, poor working conditions, lack of medicines & supplies, insufficient training capacity)
HIV/AIDS (health worker death, burden on health systems)
Inadequate recognition of importance of health workforce
Brain drain (push and pull factors) Sub-Saharan Africa loses about 28% of its
doctors and 11% of its nurses to brain drain
Brain drain causes: Push factors
Health professionals’ own needs: unmet Low salaries Dangers of occupational infection: HIV, other diseases Stress from high workloads Inadequate training, supervision, and management Lack of opportunities for continuing education,
professional advancement, and research Pre-service training often poor preparation for actual
practice Needs of patients: unmet
Lack of medicines, supplies, equipment, and other support required to be healers
Pull factors
Opposite of push factors Recruitment Health worker shortages in
Northern countries U.S. shortage of 340,000-1 million
nurses by 2020 U.S. shortage of 80,000-200,000
doctors by 2020
Health workforce solutions Beyond the health system (addressing economy, political
situation, corruption, etc.) Health system investments
Medicines, supplies, equipment, facility infrastructure Logistic systems, referral systems, financial management, etc. Infection prevention and control (e.g., gloves)
Health worker-specific investments: Financial and non-financial incentives Massive scale-up of pre-service training Continuing professional development Comprehensive health and HIV/AIDS services Health workforce management
Policy changes Mid-level and community health workers Retirement age
Health system investments
Central to any comprehensive approach Ondo State, Nigeria
62% of health workers surveyed said they most needed adequate medicines, supplies, and equipment
State government focused investments in these areas Proportion nurses working in rural areas increased from
28% to 66% within 3 years Other development efforts contributed
Partners In Health, Haiti Poor, rural area in central Haiti Comprehensive strategy includes adequate supply of
essential medicines and removing user fees and patient payments for medicines > health workers can better help their patients
Strategy to retain health workers extremely effective, perfect in some clinics
Health workforce investments: Management Considerable potential to improve health worker
experience and effectiveness Human resource management skills rarely
prioritized Examples
Supportive supervision Distribute health workers based on actual workload Performance-based promotions Match health workers’ skills and training to facility needs Adjust training curriculum to match actual health worker
experiences Increase efficiency of recruitment procedures Opportunities for health worker input and feedback Clear job descriptions and career pathways
Health workforce investments: Salaries
Malawi’s 52% salary increase Central to Emergency Human Resource
Programme Funding from Malawi government, Global
Fund, United Kingdom Assessment of first 8 months found positive
impact on retention Lesson on managing expectations: Increase
led to higher tax bracket so effective increase was 24%, leading to some frustration
Health workforce investments: Incentives
Incentives Uganda: Lunch allowance Ghana: Car loan scheme
Director of Eastern Region reports loans (and post-graduate medical education) have had very positive impact on retention
Ghana has also built affordable housing for health workers Rural incentives
Increasingly being introduced Zambia has set of incentives for physicians who agree to
serve 3 years in designated rural areas Hardship allowance, housing allowance, education allowance
for the doctors’ children, eligibility and some funding for post-graduate training
70+ physicians participating Expanding to other categories of health workers
Health workforce investments: HIV/AIDS
Services Special confidentiality concerns and challenges On- and off-site models Comprehensive HIV/AIDS care in Swaziland
HIV and TB Wellness Centre of Excellence for HIV provides range of services for health workers and immediate families in largest urban area of country, including
testing, counseling and treatment for HIV and TB stress management training center for continuous professional development occupational health and safety
Similar centers planned in Malawi, Zambia, and Lesotho Positive impact on morale and retention Should include efforts to reduce stigmatization among
health professionals
Health workforce investments: Training
Pre-service training Long neglected, now new investments Malawi’s College of Medicine will more than
double its overall capacity by 2011, while its main nursing school will nearly double its capacity by the same year
Opportunities for re-thinking curricula, such as fully incorporating AIDS, human rights, community focus, health professional response to violence against women
Task-shifting Develop models of care, and possibly new
cadres, that enable all health workers to make the best use of their competencies
Health Surveillance Assistants in Malawi are community health workers who provide a wide range of basic health services at the community level
Ghana strategy includes creation of Health Assistants, Laboratory Assistants, Nurse Assistants, etc.
Ethiopia training 30,000 Health Extension Workers to extend primary care
Nurses becoming major provides of AIDS treatment
Retention strategies in rural areas (1)
Incentives Zambia, elsewhere Incentives to reduce social and professional isolation
including Internet/phone and expenses-paid trips into the city (Partners In Health)
Hire certain health workers on contract with requirement that remain in rural area
Clinton AIDS Initiative, Global Fund, and US government supporting Kenya government to hire unemployed nurses (and other HCWs) in Kenya to work on contract in rural areas, including 830 through US government support
Improving basic health infrastructure Ondo State, Nigeria
Retention strategies in rural areas (2)
Community-based health workers Community Health Officers (2 years training) contributing
to dramatic improvements in health in Ghana One district: In 5 years or less, childhood immunization
rate tripled, maternal and child mortality fell significantly, and rate of tuberculosis defaulters dropped from 73% to 0%
Focus recruitment for health professional students in rural areas
South Africa study found that students from rural areas 3-8 times more likely to return to practice in rural area
Expose students to rural health care during training
Moi University (Kenya) nursing students spend significant time in rural areas
Financing the health workforce
Financing: Africa needs estimates
World Health Organization: ~$10 per capita to train and pay new doctors/nurses/midwives, ~$20 per capita if include doubling salaries for retention
Sub-Saharan Africa: $7.5 billion in 2010, $14.6 billion in 2015 at higher salaries
Global Health Workforce Alliance Scaling Up Education & Training Task Force
Education investments for 1.5 million new health workers: $26.4 billion over 10 years + infrastructure
Combined estimate of US fair share for sub-Saharan Africa
$1.8 billion in 2010 $4.0 billion in 2015
Global attention
PEPFAR Already some health worker focus, with
emphasis on task-shifting PEPFAR reauthorization
Train and support the retention of at least 140,000 new health professionals and paraprofessionals
Help countries achieve 2.3 doctors/nurses/midwives per 1,000 population and strengthen primary health care
Support national health strategy, advance safe working conditions, promote codes of conduct on ethical recruitment
G8 and Global Fund G8 (2008)
Help countries achieve 2.3 health workers per 1,000 population
Support countries in developing robust health workforce plans
Global Fund Round 8 (2008) included at least 25
successful proposals with significant health system strengthening elements, including expanding pre-service training, improving health worker retention, and incentivizing health workers to serve in rural areas
You Can Help
In-district PEPFAR meetings on health
workers Law sets stage, now need successful
implementation In-district meetings
Appropriations!!! – Overall foreign aid, PEPFAR Ensure that PEPFAR does train and retain at least
140,000 new health workers Help countries develop and fully implement rights-based,
needs-based health workforce strategies Establish policy to enable (at the least) all health workers
in PEPFAR-supported programs to have access to HIV and other health services and safe working conditions
Train on respecting rights and dignity of all patients Dear Colleague letters?
Health workforce legislation
African Health Capacity Investment Act on 2007 Investments in health workforce and systems
in sub-Saharan Africa Senate and House progress, but
overshadowed by PEPFAR Strong interest from Rep. Lee and others
in re-introducing revised health workforce bill
We’ll need your help!
Health care and safety for health workers
Right to access health care, right to safe working conditions
Improves retention Petition to have PEPFAR establish policy
ensuring health care and safety for all health workers in its programs
Material for endorsements: yours, friends and colleagues, professors, deans, organizations, universities