Models for Training & Maintaining the Global Health Workforce Ann Kurth, RN, CNM, PhD NYU, UW GHEC Conference Seattle 4/5/09

Global Health Workforce Health care workers (HCWs) = all people engaged in the promotion, protection or improvement of the health of the population Health mgmt & support workers: Professionals e.g. accountants, IT Associates e.g. administrators Support staff e.g. clerical, ambulance drivers Craft and trade workers e.g. hospital gardener HCWs: Professionals e.g. physicians, professional nurses, pharmacists, mental health professionals Associates e.g. associate nurses, lab techs Other community providers e.g. traditional practitioners

Current HCW Density Imbalances: Gender (>70% MDs male, >70% RNs female) Geographical Urban Sector? Public (2/3rds) vs. private (1/3rd) WHO ’06; Zurn ‘04

Distribution 16 million nurses globally; 2.2 million nurses in the US (8% foreign-trained) Hagopian 9/07; Aiken ‘07

Projected Needs WHO: 4 million HCW shortfall Recently called for 4 million workers for HIV care alone SSAf Analysis 12 countries: 6/12, pre-svs training insufficient to maintain #s Even 2 countries where current training will ↑ HCW, density won’t meet target 2.28 physicians, nurses, midwives/1000 till > 2015 W/ current training would take 29 yrs for nurses/mw to meet this target - & some countries will never get there Kinfu ‘09

WHO: 4 million HCW shortfall

Recently called for 4 million workers for HIV care alone

SSAf

Analysis 12 countries: 6/12, pre-svs training insufficient to maintain #s

Even 2 countries where current training will ↑ HCW, density won’t meet target 2.28 physicians, nurses, midwives/1000 till > 2015

W/ current training would take 29 yrs for nurses/mw to meet this target - & some countries will never get there

Health Expenditure Inequality WHO ‘07

Brain Drain of HCWs Source countries Unsafe work conditions Low salaries, living conditions Lack of respect/abuse Lack of advancement/ladder Recipient countries Aging people Aging workforce Internal as well (NGO “poaching”) NHS hospital website

Source countries

Unsafe work conditions

Low salaries, living conditions

Lack of respect/abuse

Lack of advancement/ladder

Recipient countries

Aging people

Aging workforce

Internal as well (NGO “poaching”)

Migration 1/5 MDs, 1/10 nurses African-born are working abroad (Clemens ’08) Egypt Liberia Malawi

Impact: Fewer Health Workers = Higher Mortality JLI report 75 low-density countries (<2.5 workers per 1000) 45 of these have high age <5 mortality 186 countries studied Hagopian 9/07

JLI report

75 low-density countries (<2.5 workers per 1000)

45 of these have high age <5 mortality

186 countries studied

WHO ‘06

Tracking HCWs Data Quality & Timeliness Admin records; census/surveys; labor/house surveys; nat’l pop & housing censuses Dal Poz ‘06 Move from paper to digital… Hagopian 9/07, Salmon Kenya Registry

Data Quality & Timeliness

Admin records; census/surveys; labor/house surveys; nat’l pop & housing censuses

Workforce Support Incentives to Stay Better work conditions & salaries, housing/loans, rural bonuses, financial & non-financial, role opportunities Approaches Increase local production of HCWs in Western & low-income Recruit, retain, sustain TASK SHIFTING: Expanding scope of practice, serving as center of team care Hagopian 9/07; Kinggma ‘07

Incentives to Stay

Better work conditions & salaries, housing/loans, rural bonuses, financial & non-financial, role opportunities

Approaches

Increase local production of HCWs in Western & low-income

Recruit, retain, sustain

TASK SHIFTING: Expanding scope of practice, serving as center of team care

Task Shifting “… rational redistribution of tasks among health workforce teams… from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of available human resources for health.&quot; Examples: Specialist to general practice doctors Doctors to non-physician clinicians, nurses Clinicians to community counselors ROLE FOR ALL CADRES & including pts/communities WHO ‘08 Vitiello ‘06

“… rational redistribution of tasks among health workforce teams… from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of available human resources for health.&quot;

Examples:

Specialist to general practice doctors

Doctors to non-physician clinicians, nurses

Clinicians to community counselors

ROLE FOR ALL CADRES & including pts/communities

Task Shifting -> Skill Distribution Evidence-base for expanded roles Team including community health workers / peers Training models? Support for training/QA/continuing education

Evidence-base for expanded roles

Team including community health workers / peers

Training models?

Support for training/QA/continuing education

Nurse Trainers Teaching HIV/AIDS Nurse Specialists (HANS) in Ethiopia Vitiello ‘06

Traditional Roles of the Nurse (Task Oriented) Vital Signs & Weight Paperwork, completing forms Taking blood Support/ Counselling Dispensing Medication with specific orders from the MD Administrative Duties, Attending meetings Konjore, Vitiello, Weaver, Winters I-TECH 7/08

Expanded Role of the Nurse Side Effect Management, Laboratory Testing & interpretation of results Initiation and Refill of ART for stable patients ART readiness counselling Comprehensive assessmen t of pre-ART patients Nursing Leadership role as a active member of the Multidisciplinary Team On-going ART Adherence Assessment and Counselling Konjore, Vitiello, Weaver, Winters I-TECH 7/08

Nurse to physician ratio: 1.8 worldwide 0.5 in Mexico 3.5 in US 30 in Malawi Physicians per 100K Nurses & midwives per 100K Nurse to doctor ratio Community Health Workers per 100K Botswana 40.0 265.0 6.6 na Ethiopia 3.0 20.0 6.7 26.0 Kenya 14.0 118.0 8.4 na Lesotho 5.0 62.0 12.4 na Malawi 2.0 59.0 29.5 na Mozambique 3.0 31.0 10.3 na Namibia 30.0 306.0 10.2 na Rwanda 5.0 39.5 7.9 148.0 South Africa 77.0 408.0 5.3 32.0 Swaziland 16.0 662.0 41.4 434.0 Tanzania 2.0 35.0 17.5 na Uganda 8.0 66.0 8.3 na Zambia 12.0 189.0 15.8 na Zimbabwe 16.0 72.0 4.5 4.0 Above average 16.6 166.6 10.0 128.8 US average 256.0 937.0 3.7 na

Principles? Primary health care since ’78 Alma Ata From equitable access, community participation, intersectoral, to… = “low-quality care”? NGOs, private sector Must address widening gaps/vulnerable, & non-communicable disease Link prevention, acute care & chronic care across health system Continuously assess / improve performance Jong-wook Lancet ‘03

Primary health care since ’78 Alma Ata

From equitable access, community participation, intersectoral, to…

= “low-quality care”?

NGOs, private sector

Must address widening gaps/vulnerable, & non-communicable disease

Link prevention, acute care & chronic care across health system

Continuously assess / improve performance

Burden of Disease Increasing mortality from non-communicable diseases… “ Chronic diseases have not simply displaced acute infectious ones in developing countries. Rather, such countries now experience a polarized and protracted double burden of disease.” - D. Yach Lopez et al, Global Burden of Disease and Risk Factors ’06

Increasing mortality from non-communicable diseases…

Psych-Neuro Mental health 90% people w/ needs in poor countries do not get care Up next? Alzheimer’s 26 million now, 106 million in 2050 Impact on care burden & costs Training needs Brookmeyer ‘06 Atlas: Nurses in Mental Health 2007, ICN Lancet 9/07

Mental health

90% people w/ needs in poor countries do not get care

Up next?

Alzheimer’s

26 million now, 106 million in 2050

Impact on care burden & costs

Training needs

Capacity-building Gov’ts-Academic Centers Twinning Other models? MoH collaboration (e.g., HAI)

Twinning

Other models?

MoH collaboration (e.g., HAI)

Role for Service Learning? International exchanges A privilege, not a right Strive to leave more than take Cultural humility / responsiveness / competence Framework Ideally, ongoing or institutional relationships that are bilateral See e.g. Institute for Int’l Education of Students model Tervalon ’98; Betancourt ’03 Kumas¸-Tan et al. ‘07

International exchanges

A privilege, not a right

Strive to leave more than take

Cultural humility / responsiveness / competence

Framework

Ideally, ongoing or institutional relationships that are bilateral

See e.g. Institute for Int’l Education of Students model

Educational Models Pre-service I-TECH Haiti, Guyana, Namibia, Mozambique Clinical mentoring I-TECH toolkit Distance learning CONJ 553 – 150 students,11 countries HIV Clinical Seminar Series http://www.globalhivlearning.org/ Standards for DL

Pre-service

I-TECH Haiti, Guyana, Namibia, Mozambique

Clinical mentoring

I-TECH toolkit

Distance learning

CONJ 553 – 150 students,11 countries

HIV Clinical Seminar Series

http://www.globalhivlearning.org/

Standards for DL

HCWorkforce Solutions Short-term: Skill distribution / task shifting Aggressive retention, ↑ pay & work conditions, address unemployment Use ehealth/telemed Encourage shortterm in-migration from surplus to deficit countries w/ donor $? Prevent AIDS/↑ ART to ↓ premature mortality Resigning to migrate or change careers – int’l issue More expensive, longerterm but still vitally needed: preservice training Solution requires addressing ALL these Kinfu ‘09

Short-term:

Skill distribution / task shifting

Aggressive retention, ↑ pay & work conditions, address unemployment

Use ehealth/telemed

Encourage shortterm in-migration from surplus to deficit countries w/ donor $?

Prevent AIDS/↑ ART to ↓ premature mortality

Resigning to migrate or change careers – int’l issue

More expensive, longerterm but still vitally needed: preservice training

Solution requires addressing ALL these

Kampala Declaration & Agenda for Global Action 3/08 Framework for coordinating, expanding & supporting health workforce next decade Urge gov’t leaders to form public-private partnerships & invest in &quot;scaling up&quot; of community & non-MD health workers Calls for rigorous accreditation & gov’t quality standards Emphasize close cooperation between professional organizations & education, training, curriculum development

Framework for coordinating, expanding & supporting health workforce next decade

Urge gov’t leaders to form public-private partnerships & invest in &quot;scaling up&quot; of community & non-MD health workers

Calls for rigorous accreditation & gov’t quality standards

Emphasize close cooperation between professional organizations & education, training, curriculum development