The Global Health Workforce: Crisis, Solutions & Opportunities By 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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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?

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!

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

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