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: efriedman@phrusa.org]

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