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DGH Lecture Series: Amy Hagopian

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Department of Global Health Lecture Series …

Department of Global Health Lecture Series

Amy Hagopian
October 7, 2008
'HELP WANTED! Problems in Health Workforce Globalization.'

Published in: Education, Health & Medicine

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    • 1. HELP WANTED : Problems in Health Workforce Globalization Amy Hagopian U.W. Department of Global Health October 7, 2008
    • 2. Today’s questions…
      • Is there evidence of a problem with health workforce supply and distribution?
      • If there’s a problem, what caused it?
      • Who are the stakeholders in this problem?
      • If we don’t solve the problem, what are the consequences?
      • What is being done to solve the problem?
      • What is the research agenda?
    • 3. Caveats about this talk: Focus on physicians Focus on Africa
    • 4. How does a country know how many health workers it has?
      • Or where they are?
      • Or how old they are?
      • Or where they were trained?
      • Or where they are working?
    • 5. How many health workers do you need?
      • Enrollment ratios (Group Health)
      • Doctor to nurse ratios
      • Population ratios (Cuba)
      • Global budgeting (Canada)
      • Care package driven (HIV protocols; Workforce Indicators of Staffing Need)
      • Market driven
      • Historical increments
    • 6. An example from Mozambique A computer model using interlocking spreadsheets to predict health workforce needs based on treatment guidelines. Hagopian & Micek, HRH 2008.
    • 7. How many health workers are there?
      • 59.2 million full-time paid health workers (WHO)
      • 57 countries have shortages totaling 2.4 m doctors, nurses, midwifes, 4.3 m total (WHO)
      • 1 to 1.5 million needed in sub-Saharan Africa (JLI, WHO)
    • 8. New Graduates, 1985 to 2005 Slide from Pascal Zurn New grads per capita, OECD avg.
    • 9. WHO: Africa has 24% of the world’s disease burden, but only 2% of the world’s health care workers. (Scheffler, 2008)
    • 10. Physician Density per 100,000 Population Source: World Health Organization (2006) Working Together for Health. The World Health Report 2006: WHO Press.
    • 11. Countries with a critical shortage of health service providers and respective emigration factors 13.9 13.9 10.7 8.4 1.3 1.7 5.2 1.6 1.4 Source: Mullan, F. (2005). The Metrics of the Physician Brain Drain. NEJM: 353:1810-1818. Source: World Health Organization (2006) Working Together for Health. The World Health Report 2006: WHO Press.
    • 12. African docs in the U.S.= 6127 10 medical schools in 5 countries produce 75% of African migrants to the U.S. http://www.human-resources-health.com/content/2/1/17 Source: AMA masterfile School Country U.S. Physicians Nigeria 2636 South Africa 1901 Ghana 561 Ethiopia 359 Sudan 268 Others 546
    • 13. Characteristics of Physician Workforces of US, UK, Canada, & Australia Source: Mullan, F. (2005). The Metrics of the Physician Brain Drain. NEJM: 353:1810-1818. Geez. Country Physicians per 100,000 population % IMGs in MD workforce (total IMGs) % IMGs from lower income countries % IMGs from other three countries U.S. 293 25.0 (208,733) 60.2 6.5 U.K. 231 28.3 (39,266) 75.2 2.5 Canada 220 23.1 (15,701) 43.4 22.3 Australia 271 26.5 (14,346) 40.0 33.5
    • 14. Foreign-trained proportion of new doctors in rich countries is growing over time As a result of the growth in the demand for health professionals, combined with reduced domestic training rates, foreign trained doctors have made a progressively greater contribution to the health workforce in many OECD countries.
    • 15. Source: OECD population censuses and population registers, circa 2000. Authors’ calculations Foreign-born doctors and nurses in OECD countries, by birthplace 50,000 20,000
    • 16. Nurses Applying for External Licensing by Qualification, Uganda 2000-2005 (n=586) Over 75% of the nursing workforce applying for out-migration are Registered Nurses or Midwives. … Using routine licensure data (newly computerized)
    • 17. New York Times June 24, 2007, graphic by Farhana Hossain from UN Population Division data http://www.nytimes.com/ref/world/20070622_CAPEVERDE_GRAPHIC.html Global Migration Snapshot
    • 18. Today’s questions…
      • Is there evidence of a problem with health workforce supply and distribution?
      • If there’s a problem, what caused it?
      • Who are the stakeholders in this problem?
      • If we don’t solve the problem, what are the consequences?
      • What is being done to solve the problem?
      • What is the research agenda?
    • 19. Why are there not enough health workers where we need them?
      • White follows green
        • Rural to urban
        • Public to private
        • Generalist to specialist
        • South to North
        • Poor to wealthy
      2002 Health Affairs
    • 20. What are the threats to a health workforce?
      • Internal drains:
        • Private practice commitments
        • NGO siphoning of talent
        • Weak systems that underutilize talent and time
        • Morale and motivation
      • External drains: Migration
    • 21. Migration theory Equinet diagram: Padarath
    • 22. Branch office theory
      • Families diversify the locations in which members are placed as a way to “insure” against losses and spread risk.
    • 23. Culture of Leaving
      • Most faculty members have been abroad
      • Most students have relatives or other contacts abroad
      • Long history of post-graduate education abroad
      • Mark of prestige and signal of quality
      Source: Hagopian, Social Science and Medicine, 2005.
    • 24. Push factors
      • Pay
      • Residency training
      • Political & economic conditions
      • Practice conditions
      Slave castle cannons, Ghana
    • 25. Living conditions: big problems
      • 75% say they don’t have safe and efficient transport to work
      • 65% have problems with access to good schooling for their kids
      • 65% say their communities have low shopping and entertainment
      • 65% say they don’t have good electricity at home
      Uganda study, 2006
    • 26. Working conditions
      • Uganda, 2006
    • 27. Working conditions: problems
      • Workload is not manageable - 64% agree
      • Problems with access to equipment - 52% agree
      • No good access to electricity - 51% agree
      • Problems with access to supplies - 49% agree
      • Problems with access to drugs - 43% agree
      • No access to safe, clean water - 34% agree
      • Supervisor abuse reported - 24% agree
      • Uganda study, 2006
    • 28.  
    • 29. Lure (pull) factors
      • $$
      • More collegial training conditions
      • E.R. on satellite T.V.
      • Chain migration
      • BUT: divorce, racism are discouraging
    • 30. Money Source: Lancet, Vol 371 February 23, 2008, p. 675-681 - McCoy, Bennett, et al. Zambian doctor makes $1400/month Ghanaian doctor makes $1200/month after moonlighting American doctor makes $160,000 per year. Any questions?
    • 31. Mitigating factors to push/pull
      • Predictors of emigration:
        • English language curriculum
        • Immigration networks
        • Political rights & freedoms
        • Absence of a medical school
      Hussey, 2007
    • 32. Ugandan nursing student intent to practice locations 70% say it’s likely they’ll work outside Uganda
      • Predictive factors:
      • Urban origins
      • Value safety,
      • Stability,
      • Working conditions
    • 33. Today’s questions…
      • Is there evidence of a problem with health workforce supply and distribution?
      • If there’s a problem, what caused it?
      • Who are the stakeholders in this problem?
      • If we don’t solve the problem, what are the consequences?
      • What is being done to solve the problem?
      • What is the research agenda?
    • 34. Stakeholder: low-income country communities who invested in training health professionals
      • Health professions training is virtually free
      • $2K to $10K per year cost to government for medical school
      Students in Accra, 2003
    • 35. August 2003 headline, Accra
    • 36.
      • Nurse migration and its implications for Philippine hospitals
      • Perrin, M.E.; Hagopian, A.; Sales, A.; Huang, B.
      • International Nursing Review, Volume 54, Number 3, September 2007 , pp. 219-226(8)
    • 37. Stakeholder: foreign medical schools
    • 38. Stakeholder: U.S. medical schools
      • Medical school enrollment doubled in the 1960s and 70s.
      • Then there were warnings of a surplus
      • medical school seats frozen in the 1980s and 1990s.
      • Doctors got older, now we’re worried about a shortage again (85,000 short by 2020) .
      ( http://www.aamc.org/workforce/workforceposition.pdf ).
      • AAMC calls for a 30% increase in medical school enrollment over 10 years.
      • 2007 med school classes totaled 17,800--a 2.3% increase over 2006; expected to hit almost 20,000 by 2012.
      • .
      UW Medical School campus
    • 39. UW increasing its capacity
      • Addition of Spokane campus this year (N=20)
      • Gives us 4 years to gear up GME capacity
      • New osteopathic school in Yakima, too--started with 75 students in August
      216 students 2008
    • 40. Stakeholder: U.S. residency training programs and their funders (Medicare)
      • First year residency slots total 144% more than the number of US medical school grads.
    • 41. Stakeholder: U.S. populations, especially rural and uninsured
      • To practice in the US, (most) physicians graduated from foreign medical schools must complete a U.S. residency program.
      • That’s a good deal for the U.S., because we use those foreign residents to care for America’s poor and underserved in big city E.R.s
      • … and rural towns.
    • 42.  
    • 43. Stakeholders: Certain key U.S. states NY CA TX MD IL GA PA NJ FL OH MA
    • 44. Stakeholder: Migrant doctors
      • email 9-29, 2008 8:45:56 AM PDT
      • Dear U-,   Is anyone here listening to the voice of health workers especially those in developing countries whose parents have invested heavily in their training and their entire village looks up to them for something better? Does it mean that if one was born in poor Africa they should die there and are lesser human beings? They need to have something good for their children and future generations and if migration offers this then why not?I rest my case. Peace, M I
    • 45. Seattle’s immigrant rights march May 1, 2006
    • 46. Amy’s studies of IMGs in the U.S.
      • IMGs in the US: changes since 1981 ( Health Affairs )
      • Changing geography of Americans graduating from foreign medical schools ( Academic Medicine )
      • The role of IMGs in America’s small rural critical access hospitals ( J Rural Health )
      • Health departments’ use of international medical graduates in physician shortage areas ( Health Affairs )
      • New paper with UW medical student Talia Kahn on Washington State IMGs ( coming soon !)
    • 47. Today’s questions…
      • Is there evidence of a problem with health workforce supply and distribution?
      • If there’s a problem, what caused it?
      • Who are the stakeholders in this problem?
      • If we don’t solve the problem, what are the consequences?
      • What can be done to solve the problem?
      • What could you do to get involved?
    • 48. At 2.5 workers per 1,000, health service coverage tends to level off 1yr olds fully Immunized against measles Births attended by skilled health personnel JLI report Fig. 1.3 Liberia, CAR, Chad, Mali, Eritrea, Ethiopia, the Gambia, Rwanda and Somalia have <.25 workers per 1,000 2.5 workers per 1000 population is minimum standard to achieve basic health goals
    • 49. Fewer health workers = higher mortality
      • JLI report
      • Fig. 1.8
      • 75 low-density countries (<2.5 workers per 1000)
      • 45 of these have high age <5 mortality
      • 186 countries studied
    • 50. Doctors leave with other professionals Source: OECD International Migration Outlook, 2007, p. 177-Slide thanks to Pascal Zurn High rates of emigration of doctors is also generally associated with high rates of emigration of tertiary trained people in general . Highly skilled Doctors R=.6723
    • 51. Today’s questions…
      • Is there evidence of a problem with health workforce supply and distribution?
      • If there’s a problem, what caused it?
      • Who are the stakeholders in this problem?
      • If we don’t solve the problem, what are the consequences?
      • What is being done to solve the problem?
      • What could you do to get involved?
    • 52. African Proverb
      • “ The best thing to do is to have planted a tree twenty years ago…
      • the next best thing to do is to plant a tree today.”
    • 53. Global Health Workforce Alliance conference (Kampala Declaration)
      • Government responsibility for workforce planning, financing & political will
      • Massive scale-ups needed
      • Accreditation
      • Management improvements, information systems
      • International code of practice on migration
      • Working conditions
      • Richer countries to be self-sufficient
      • Macro-economic constraints to be lifted
      March 2008
    • 54. U.S. response to Kampala
      • Statement Regarding the First Global Forum on Human Resources for Health-- Representatives from the United States have joined leaders and experts from around the world at the First Global Forum on Human Resources for Health, organized by the Global Health Workforce Alliance this week in Kampala, Uganda. This meeting highlighted many important issues regarding the shortage of health workers. The United States is fully committed to working with all stakeholders to address this shortage, and demonstrates this commitment every day through our partnerships in international public health and development worldwide. While the U.S. Government has not signed on to the Kampala Declaration or its associated Agenda for Global Action, we look forward to continuing to work on this critical issue in the future.
      • Accessed 3/27/08 http://kampala.usembassy.gov /
    • 55. Focus on the public sector
    • 56. Appeal to rich countries “ T he obvious solution is for wealthier countries to reimburse Africa's health and educational systems for the cost of poaching their professionals .” August 13, 2004 Africa's Health-Care Brain Drain s Africa tries to fight AIDS, the single most serious obstacle is a desperate shortage of health workers. Yet at the same time, doctors, nurses and pharmacists in English-speaking African countries are emigrating in droves to Britain, the United States, Canada and Australia. In Ghana and Zimbabwe, three-quarters of all doctors emigrate within a few years of completing medical school. Randall Tobias, President Bush's global AIDS coordinator, said in a recent speech that there were more Ethiopian-trained doctors practicing in Chicago than in Ethiopia. The problem isn't new, particularly when it comes to African doctors, but as Celia Dugger wrote recently in The Times, the flight of nurses is a growing phenomenon, fueled principally by the nursing shortages in wealthy nations. Instead of paying salaries that would attract homegrown nurses, American hospitals recruit in the Caribbean, the Philippines, India and Africa. The same is true in Britain. From 1994 to 2001, the number of nurses registering to work in Britain who came from outside Europe grew to 15,000 from 2,000. The group Physicians for Human Rights recently published a detailed report about this problem and its consequences. One is that the world's poorest countries are providing enormous quantities of medical aid to the richest. The United Nations estimates that every time Malawi educates a doctor who practices in Britain, it saves Britain $184,000. It's understandable why overseas work is attractive. AIDS and tuberculosis have stretched African health services to the breaking point, placing impossible demands on nurses in particular. They do their jobs without adequate equipment or drugs. Their paychecks sometimes arrive months late. They risk infection - in some places, even gloves are scarce. While rich countries average 222 doctors per 100,000 people, Uganda has fewer than 6. Malawi has 17 nurses for every 100,000 citizens; many rich countries have more than 1,000. This is a problem with no easy solutions. One of the worst ideas would be any sort of restrictions on emigration, which would not only be discriminatory, but also counterproductive. Africans would be even less likely to choose careers in medicine. Nevertheless, it's unseemly for wealthy countries, which could afford to pay nurses enough to create an ample homegrown supply, to run ads instead to recruit skilled staff in places like South Africa. In 2001, the British National Health Service swore off recruiting nurses from countries without their governments' agreement, but private hospitals and nursing homes still do it. African doctors and nurses understand how much they are needed at home, and many would resist relocation if the conditions under which they work were more bearable. The obvious long-term solution to the medical brain drain is for wealthier countries to reimburse Africa's health and educational systems for the cost of poaching their professionals, and to greatly increase the financing and technical help for Africa's health systems - in their entirety, not just the clinics that deal with AIDS. The concern over AIDS, paradoxically, has created an opportunity by focusing world attention on Africa's miserable health care. Improving it would cost very little money, relatively speaking, and end the exodus of doctors and nurses that is exacerbating the epidemic's devastation. Copyright 2004   The New York Times Company | Home | Privacy Policy | Search | Corrections | RSS | Help | Back to Top
    • 57. Norwegian Principles
    • 58.
        • Prohibits active recruitment from developing countries without their consent
        • Health workers are free to migrate of their own initiative
      UK Code of Practice on International Recruitment
    • 59.
      • Ngocodeofconduct
      • ..dot…
      • org
    • 60. APHA international health section resolutions
      • Promotes codes of conduct with regard to recruitment from low-income countries
      • (11/06 approved)
      • Opposes the spending limits on health and education imposed by lenders
      • (12/05 approved)
      • Strengthen health systems in low-income countries
      • (10-08 proposed)
    • 61.  
    • 62. Today’s questions…
      • Is there evidence of a problem with health workforce supply and distribution?
      • If there’s a problem, what caused it?
      • Who are the stakeholders in this problem?
      • If we don’t solve the problem, what are the consequences?
      • What is being done to solve the problem?
      • What is the research agenda?
    • 63. Research projects needed
      • Answer more specific questions about supply and distribution
        • By physician specialty
        • By country and region
        • Nurses a critical element
        • For dentists, pharmacists
      • Establish human resources
      • information systems
    • 64. Research agenda…more
      • What can be done to improve working conditions?
        • Accreditation?
        • Debt relief and macro-economic policy changes
        • Align incentives (Rwanda)
        • Information systems to track conditions
    • 65. Research agenda…
      • Continuing professional development
      • Task shifting
      • Health professions associations
      • Francophone, Spanish and Luciphone migration
      • Countries with positive deviance re. migration
      • IMGs not practicing up to their training
      • Quantifying workforce gaps (WISN)
      • New market problems (eg, Nepal)
      • Private school proliferation
      • Policy options
    • 66. Mostly…
      • We need to publish a research agenda
      Ibadan Hospital, Nigeria
    • 67. END END.

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