Models for Training &  Maintaining the Global Health Workforce Ann Kurth, RN, CNM, PhD NYU, UW GHEC Conference Seattle 4/5...
Global Health Workforce  Health care workers (HCWs)  = all people engaged in the promotion, protection or improvement of t...
Current HCW Density Imbalances: Gender  (>70% MDs male, >70% RNs female)   Geographical Urban Sector? Public (2/3rds) vs. ...
Distribution 16 million nurses globally; 2.2 million nurses in the US (8% foreign-trained) Hagopian 9/07; Aiken ‘07
Projected Needs  <ul><li>WHO: 4 million HCW shortfall  </li></ul><ul><ul><li>Recently called for 4 million workers for HIV...
Health Expenditure Inequality  WHO ‘07
Brain Drain of HCWs  <ul><li>Source countries </li></ul><ul><ul><li>Unsafe work conditions </li></ul></ul><ul><ul><li>Low ...
Migration 1/5 MDs, 1/10 nurses African-born are working abroad   (Clemens ’08) Egypt Liberia Malawi
Impact:  Fewer Health Workers = Higher Mortality <ul><li>JLI report </li></ul><ul><li>75  low-density countries (<2.5 work...
WHO ‘06
Tracking HCWs <ul><li>Data Quality & Timeliness </li></ul><ul><ul><li>Admin records; census/surveys; labor/house  surveys;...
Workforce Support <ul><li>Incentives to Stay   </li></ul><ul><ul><li>Better work conditions & salaries, housing/loans, rur...
Task Shifting <ul><li>“…  rational redistribution of tasks  among health workforce teams… from highly qualified health wor...
Task Shifting -> Skill Distribution <ul><li>Evidence-base for expanded roles </li></ul><ul><li>Team including community he...
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/ Coun...
Expanded Role of the Nurse Side Effect Management, Laboratory Testing & interpretation of results Initiation and Refill of...
Nurse to physician ratio: 1.8 worldwide 0.5 in Mexico 3.5 in US 30 in Malawi  Physicians per 100K Nurses & midwives per 10...
Principles? <ul><li>Primary health care since ’78 Alma Ata </li></ul><ul><ul><li>From equitable access, community particip...
Burden of Disease <ul><li>Increasing mortality from non-communicable diseases… </li></ul>“ Chronic diseases have not simpl...
Psych-Neuro <ul><li>Mental health  </li></ul><ul><ul><li>90% people w/ needs in poor countries do not get care </li></ul><...
Capacity-building Gov’ts-Academic Centers <ul><li>Twinning </li></ul><ul><li>Other models? </li></ul><ul><li>MoH collabora...
Role for Service Learning? <ul><li>International exchanges </li></ul><ul><ul><li>A privilege, not a right </li></ul></ul><...
Educational Models <ul><li>Pre-service </li></ul><ul><ul><li>I-TECH Haiti, Guyana, Namibia, Mozambique </li></ul></ul><ul>...
HCWorkforce Solutions <ul><li>Short-term: </li></ul><ul><li>Skill distribution / task shifting  </li></ul><ul><li>Aggressi...
Kampala Declaration & Agenda for Global Action 3/08 <ul><li>Framework for coordinating, expanding & supporting health work...
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Models for Training/Maintaining the Global Health Workforce: Ann Kurth

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This session will focus on different model programs incorporating novel techniques to optimize training of health workers. Discussion will include the realities of “brain drain,” health worker migration, and maintaining a vibrant health workforce.

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  • Models for Training/Maintaining the Global Health Workforce: Ann Kurth

    1. 1. Models for Training & Maintaining the Global Health Workforce Ann Kurth, RN, CNM, PhD NYU, UW GHEC Conference Seattle 4/5/09
    2. 2. 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
    3. 3. 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
    4. 4. Distribution 16 million nurses globally; 2.2 million nurses in the US (8% foreign-trained) Hagopian 9/07; Aiken ‘07
    5. 5. Projected Needs <ul><li>WHO: 4 million HCW shortfall </li></ul><ul><ul><li>Recently called for 4 million workers for HIV care alone </li></ul></ul><ul><li>SSAf </li></ul><ul><ul><li>Analysis 12 countries: 6/12, pre-svs training insufficient to maintain #s </li></ul></ul><ul><ul><ul><li>Even 2 countries where current training will ↑ HCW, density won’t meet target 2.28 physicians, nurses, midwives/1000 till > 2015 </li></ul></ul></ul><ul><ul><li>W/ current training would take 29 yrs for nurses/mw to meet this target - & some countries will never get there </li></ul></ul>Kinfu ‘09
    6. 6. Health Expenditure Inequality WHO ‘07
    7. 7. Brain Drain of HCWs <ul><li>Source countries </li></ul><ul><ul><li>Unsafe work conditions </li></ul></ul><ul><ul><li>Low salaries, living conditions </li></ul></ul><ul><ul><li>Lack of respect/abuse </li></ul></ul><ul><ul><li>Lack of advancement/ladder </li></ul></ul><ul><li>Recipient countries </li></ul><ul><ul><li>Aging people </li></ul></ul><ul><ul><li>Aging workforce </li></ul></ul><ul><li>Internal as well (NGO “poaching”) </li></ul>NHS hospital website
    8. 8. Migration 1/5 MDs, 1/10 nurses African-born are working abroad (Clemens ’08) Egypt Liberia Malawi
    9. 9. Impact: Fewer Health Workers = Higher Mortality <ul><li>JLI report </li></ul><ul><li>75 low-density countries (<2.5 workers per 1000) </li></ul><ul><li>45 of these have high age <5 mortality </li></ul><ul><li>186 countries studied </li></ul>Hagopian 9/07
    10. 10. WHO ‘06
    11. 11. Tracking HCWs <ul><li>Data Quality & Timeliness </li></ul><ul><ul><li>Admin records; census/surveys; labor/house surveys; nat’l pop & housing censuses </li></ul></ul>Dal Poz ‘06 Move from paper to digital… Hagopian 9/07, Salmon Kenya Registry
    12. 12. Workforce Support <ul><li>Incentives to Stay </li></ul><ul><ul><li>Better work conditions & salaries, housing/loans, rural bonuses, financial & non-financial, role opportunities </li></ul></ul><ul><li>Approaches </li></ul><ul><ul><li>Increase local production of HCWs in Western & low-income </li></ul></ul><ul><ul><li>Recruit, retain, sustain </li></ul></ul><ul><ul><li>TASK SHIFTING: Expanding scope of practice, serving as center of team care </li></ul></ul>Hagopian 9/07; Kinggma ‘07
    13. 13. Task Shifting <ul><li>“… 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; </li></ul><ul><li>Examples: </li></ul><ul><ul><li>Specialist to general practice doctors </li></ul></ul><ul><ul><li>Doctors to non-physician clinicians, nurses </li></ul></ul><ul><ul><li>Clinicians to community counselors </li></ul></ul><ul><ul><li>ROLE FOR ALL CADRES & including pts/communities </li></ul></ul>WHO ‘08 Vitiello ‘06
    14. 14. Task Shifting -> Skill Distribution <ul><li>Evidence-base for expanded roles </li></ul><ul><li>Team including community health workers / peers </li></ul><ul><li>Training models? </li></ul><ul><ul><li>Support for training/QA/continuing education </li></ul></ul>
    15. 15. Nurse Trainers Teaching HIV/AIDS Nurse Specialists (HANS) in Ethiopia Vitiello ‘06
    16. 16. 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
    17. 17. 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
    18. 18. 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
    19. 19. Principles? <ul><li>Primary health care since ’78 Alma Ata </li></ul><ul><ul><li>From equitable access, community participation, intersectoral, to… </li></ul></ul><ul><ul><li>= “low-quality care”? </li></ul></ul><ul><ul><li>NGOs, private sector </li></ul></ul><ul><ul><li>Must address widening gaps/vulnerable, & non-communicable disease </li></ul></ul><ul><ul><li>Link prevention, acute care & chronic care across health system </li></ul></ul><ul><ul><li>Continuously assess / improve performance </li></ul></ul>Jong-wook Lancet ‘03
    20. 20. Burden of Disease <ul><li>Increasing mortality from non-communicable diseases… </li></ul>“ 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
    21. 21. Psych-Neuro <ul><li>Mental health </li></ul><ul><ul><li>90% people w/ needs in poor countries do not get care </li></ul></ul><ul><li>Up next? </li></ul><ul><ul><li>Alzheimer’s </li></ul></ul><ul><ul><ul><li>26 million now, 106 million in 2050 </li></ul></ul></ul><ul><ul><ul><li>Impact on care burden & costs </li></ul></ul></ul><ul><li>Training needs </li></ul>Brookmeyer ‘06 Atlas: Nurses in Mental Health 2007, ICN Lancet 9/07
    22. 22. Capacity-building Gov’ts-Academic Centers <ul><li>Twinning </li></ul><ul><li>Other models? </li></ul><ul><li>MoH collaboration (e.g., HAI) </li></ul>
    23. 23. Role for Service Learning? <ul><li>International exchanges </li></ul><ul><ul><li>A privilege, not a right </li></ul></ul><ul><ul><li>Strive to leave more than take </li></ul></ul><ul><ul><li>Cultural humility / responsiveness / competence </li></ul></ul><ul><ul><li>Framework </li></ul></ul><ul><ul><li>Ideally, ongoing or institutional relationships that are bilateral </li></ul></ul><ul><ul><li>See e.g. Institute for Int’l Education of Students model </li></ul></ul>Tervalon ’98; Betancourt ’03 Kumas¸-Tan et al. ‘07
    24. 24. Educational Models <ul><li>Pre-service </li></ul><ul><ul><li>I-TECH Haiti, Guyana, Namibia, Mozambique </li></ul></ul><ul><li>Clinical mentoring </li></ul><ul><ul><li>I-TECH toolkit </li></ul></ul><ul><li>Distance learning </li></ul><ul><ul><li>CONJ 553 – 150 students,11 countries </li></ul></ul><ul><ul><li>HIV Clinical Seminar Series </li></ul></ul><ul><ul><li>http://www.globalhivlearning.org/ </li></ul></ul><ul><ul><li>Standards for DL </li></ul></ul>
    25. 25. HCWorkforce Solutions <ul><li>Short-term: </li></ul><ul><li>Skill distribution / task shifting </li></ul><ul><li>Aggressive retention, ↑ pay & work conditions, address unemployment </li></ul><ul><li>Use ehealth/telemed </li></ul><ul><li>Encourage shortterm in-migration from surplus to deficit countries w/ donor $? </li></ul><ul><li>Prevent AIDS/↑ ART to ↓ premature mortality </li></ul><ul><li>Resigning to migrate or change careers – int’l issue </li></ul><ul><li>More expensive, longerterm but still vitally needed: preservice training </li></ul><ul><li>Solution requires addressing ALL these </li></ul>Kinfu ‘09
    26. 26. Kampala Declaration & Agenda for Global Action 3/08 <ul><li>Framework for coordinating, expanding & supporting health workforce next decade </li></ul><ul><li>Urge gov’t leaders to form public-private partnerships & invest in &quot;scaling up&quot; of community & non-MD health workers </li></ul><ul><li>Calls for rigorous accreditation & gov’t quality standards </li></ul><ul><li>Emphasize close cooperation between professional organizations & education, training, curriculum development </li></ul>

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