the right to health and health workforce planning
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The Right to Health and Health Workforce Planning
By Eric A. FriedmanPhysicians for Human Rights
Physicians for Human Rights National Student
ConferenceProvidence, RI, Jan. 31-Feb. 1, 2009
[Contact: efriedman@phrusa.org]
Overview
Refresher on health workforce crisis Right to health overview Value of human rights approach to
health workforce planning Human rights and health workforce
planning What you can do
Overview of health workforce crisis
Africa has 24% of the world’s disease burden, but only 3% of the world’s health workers
WHO has identified 57 countries with severe shortages, including 36 in sub-Saharan Africa Shortage is 4.3 million health workers
total, 1.5 million in Africa
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
Poor management and lack of regular, supportive supervision
Lack of medicines and supplies Unsafe working conditions Mistreatment of patients
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
Right to health overview
Right to health (1) States “recognize the right of everyone to the
enjoyment of the highest attainable standard of physical and mental health. ” – International Covenant on Economic, Social and Cultural Rights, article 12
Further defined in General Comment 14 of the Committee on Economic, Social and Cultural Rights
Health services, goods, and facilities must be accessible, available, acceptable, and of good quality
Obligation to respect, protect, and fulfill right
Right to health (2) State must spend “maximum of its available
resources” towards fulfilling this and other rights States must progressively realize this right
“continuing obligation to move as expeditiously and effectively as possible towards the full realization of” the right
Minimum “core obligations” that states must meet now
Equitable distribution of health goods, services, and facilities
Non-discriminatory access To adopt and implement a national public health
strategy
Value of human rights approach to health workforce
planning
A necessary combination
Technical considerations + Human rights
= Skilled, motivated, equipped, supported health workforce for everyone
Value of human rights approach
Guides what plan aims to achieve Health services must be accessible to
everyone Emphasizes certain areas Adds additional aspects
Right to health and health workforce planning
Elements
Accountability Participation Equity and non-discrimination Comprehensiveness Funding Quality Sustainability & human rights
education
Guiding goals: Accountability to commitments (1)
Health workforce plan as accountability mechanism Accountability to right to health, universal
access HIV and other to health services, Millennium Development Goals
If you don’t plan for a sufficient health workforce, you won’t get one
Reality: Many countries developing policies, few with comprehensive, costed plans
Not all plans aimed at achieving goals Uganda scenarios: Business as Usual v. Health for
People
Guiding goals: Accountability to commitments (2)
Goals Meet commitments – suggest what is achievable with
maximum of available resources and progressive realization
Progressive realization: “continuing obligation to move as expeditiously and effectively as possible towards the full realization….”
Near term: Essential health care to be available to all “Minimum basket” concept
Build towards health care at all levels accessible to all How measure?
One approach: Determine number of health workers by considering level of coverage needed to meet goals, which workers, and how long for each activity
Adding emphasis: Participation
Recognized that needs to be more than Ministry of Health involved in developing plan, but…
Who is involved? How are they involved?
Adding emphasis: Participation diverse
perspectives Health consumers Health workers Poor and rural populations Home caregivers Women Youth and elderly People living with HIV/AIDS People with disabilities
Adding emphasis: Features of participation
Resources are dedicated to participation People meaningfully informed and opinions
respected Possibilities
Inclusive team leading plan development Community and national forums open to all Consultations with NGOs and health worker groups Opportunities for written input
Continued participation in monitoring and evaluating plan implementation
Adding emphasis: Benefits of participation
Ondo State, Nigeria Asked health workers their needs 62%: Equipment, supplies,
medicines Government responded Proportion of nurses serving in
rural areas 28% > 66% (3 years)
Added emphasis: Equitable distribution (1)
Equitable distribution and emphasis on needs of marginalized and vulnerable populations central to right to health
Requires using all levers to improve distribution and reach underserved
Added emphasis: Equitable distribution (2)
Incentives Zambia: more than 70 physicians on 3-year contract
in rural areas receive: hardship allowance accommodation allowance education allowance for children eligibility/funding for post-graduate training eligibility for a loan
Expanding to nurse tutors, nurses, clinical officers, more
Basic infrastructure Ondo State, Nigeria Zambia to receive support from GAVI to bring clean
water and power to rural health facilities
Added emphasis: Equitable distribution (3)
Education Recruitment from rural areas Scholarships to serve in rural areas Training in primary health care Service in rural areas
Skills mix Who is most likely to serve in rural
areas?
Additional aspects: Countering health worker
discrimination (1) “Clinic staff were reluctant to test me because
they didn’t think older people like myself were at risk.” – 62-year old South African grandmother, HIV-positive
“Unfortunately the nurse I met knew that I was HIV positive; she refused to touch my wound and gave me the bandage to stop the bleeding myself.” – HIV/AIDS patient, Nigeria
“Governments tell drug users to act responsibly and not to infect others, but the clinics shut the doors in the faces of those seeking to take care of themselves.” – Open Society Institute
Additional aspects: Countering health worker
discrimination (2)
Proper information and training (pre-service and in-service)
Clear policies against discrimination Management and leadership sensitized
to dangers of discrimination and lack of respect for patients
Avenues of redress for patients Protective equipment (universal
precautions)
Additional aspects: Human rights education for health
workers Human rights training for health workers
Own practice Advocacy Policymaking
“A deep understanding of human rights compels one to stand in solidarity with marginalized groups who suffer discrimination in terms of access to healthcare service delivery.” – Physician, Niger State, Nigeria
“Human rights education changes your perception from seeing medicine as an employment – where you can make some money – to a service to humanity.” – Medical Student, Kampala, Uganda
Additional aspects: Dissemination of plan
Government accountable to people Should publicly disseminate plan
(and key aspects) Translate into local languages Educate people on rights and
entitlements under the plan
What you can do
Steps taken so far PHR published The Right to Health and Health
Workforce Planning: A Guide for Government Officials, NGOs, Health Workers and Development Partners (2008)
Broad distribution Turning guide into more user-friendly indicators Seeking to have indicators part of Global Health
Workforce Alliance (GHWA) monitoring and evaluation process of country actions
GHWA is international partnership addressing health workforce crisis
Seeking to have Guide part of standard package of tools to assist countries in developing health workforce plans
How you can help Share health workforce planning guide
http://physiciansforhumanrights.org/library/documents/reports/health-workforce-planning-guide-2.pdf
Potential project Review health workforce plans Analyze plans based on right to health and
health workforce indicators Please let me know if you would be
interested (efriedman@phrusa.org)
PEPFAR and health workers
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
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 New health worker legislation?
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
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