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