Session 4 Dovlo

ABUJA HIGH LEVEL FORUM-2004HUMAN RESOURCES FOR HEALTH SITUATION REPORTA Summary of international fact-finding on HRH: 

ABUJA HIGH LEVEL FORUM-2004 HUMAN RESOURCES FOR HEALTH SITUATION REPORT A Summary of international fact-finding on HRH Presentation by DELANYO DOVLO

The Storyline : 

The Storyline The Global HRH situation The HRH Crisis and likely MDGs Impact Examples of Regional & Country HRH Situations Africa’s Special Case Conclusion - A Call to Action: Mobilizing –Governments, Agencies, Donors, Initiatives, Communities Sources: “Health Workforce Challenges: Lessons learned from country experiences” -HLF “Addressing Africa’s health workforce crisis: an avenue for action” - WHO Report of the Joint Learning Initiative: “HRH-Crisis, Strategies, & Sustainability” ICN: “The Global Shortage of Registered Nurses” Other Papers, Publications & reports etc.,.JLI, ICN, Countries

THE COST OF INACTION?: 

THE COST OF INACTION? Complete Failure to reach MDGS in most of the world- (2.5 billion people) Inefficient utilization/Wastage of available resources for health Dysfunctional/Collapsed Health Systems Poor ability to react to health/ medical disasters and emergencies ?A turning point in Global Development?

1:The Global HRH Situation: A Crisis: 

1:The Global HRH Situation: A Crisis Global shortages Skill Imbalances Maldistribution – global/national Unbridled/Unplanned Migration Poor work environments Low Productivity Weak Knowledge Base on HRH Dealing with Emergencies in vulnerable/crisis countries

Generic Framework for HRH Stocks-Flows: 

Production of Health Inflow Education In-migration Retirement Disability/Death Out-migration Outflow Coverage Motivation Competence Generic Framework for HRH Stocks-Flows Stock Health Workers Source: JLI 2004.

Slide6: 

Health Worker Density Comparisons by World’s Regions From: JLI 2004.

The Five Clusters: Health Worker Density and Child Mortality: 

The Five Clusters: Health Worker Density and Child Mortality From: JLI 2004.

World Workforce & Health Status: The Global Picture: 

World Workforce & Health Status: The Global Picture From: JLI 2004.

Projected Nursing Shortfalls in Rich Countries – A Danger for Poor Source Countries?: 

Projected Nursing Shortfalls in Rich Countries – A Danger for Poor Source Countries? . Derived from data at - http://www.state.gov/s/gac/rl/or/29737.htm (October 2004)

2: HRH & HEALTH MDGS IMPACT CONCERNS: 

2: HRH & HEALTH MDGS IMPACT CONCERNS Related to: Density of HWs and Service Coverage Density of Health Workers and IM, U5 & Maternal Mortality. In Crisis Countries: Absorptive Capacity, Health Systems capacity, for new initiatives/funds constrained by staff shortages Macro-Economic Constraints, Fiscal restraints – Restrict staffing levels in public sector Urgency: HRH Investment and Time Lag

Worker Density & Service Coverage: 

Worker Density & Service Coverage From: JLI 2004.

Slide12: 

Worker Density and Mortality Source: Anand & Baernighausen- 2004 (JLI)

HW DENSITY & MIGRATION: 

HW DENSITY & MIGRATION The Trends - The Conveyor belt/Carousel Effects – Health Status, Health Systems Other issues & Influences – Health/Medical Exceptionalism GATS, Rights, The Health Initiatives Strategies Codes of Conduct, (?Fig Leaves) Substitution (non-export cadres), Retention: Compelled Public Service; Incentives Remittances & other gains Managed migration International recruitment – Cuba, ODCs

Migration Intentions-Proportion of health workers who intend to migrate, (6 African Countries: 2002): 

Migration Intentions- Proportion of health workers who intend to migrate, (6 African Countries: 2002) Source: WHO AFRO 2002

Main Source Countries to the UK Nurse Register 1998 – 2003 Source: UK-NMC in Buchan & Dovlo 2004: 

Main Source Countries to the UK Nurse Register 1998 – 2003 Source: UK-NMC in Buchan & Dovlo 2004

HRH SUPPLY & PRODUCTION ISSUES: 

HRH SUPPLY & PRODUCTION ISSUES Intake into HW worker training Ghana: Intakes are 50% of migrant verifications Malawi: Staff deaths are 40% of training outputs Attractiveness of health work/Pay Kyrgyz Professional “Turfs” & Auxiliaries/Substitutes Bans of Aux. Nurses in several African countries Scopes, Numbers & Use of Clin Officers, AMOs Loss of Trainers to migration Low investments in Pre-Service Training Public Sector Employment Ceilings: Macro-Economic Conditionalities & Fiscal Restraints

Slide17: 

Source: MoH / CBoH internal data. 2004 ZAMBIA HLF Case Study ZAMBIA: MOH/CBOH PROJECTION OF HRH NEEDS AND SHORTFALLS

EFFICIENCY & PRODUCTIVITY ISSUES: 

EFFICIENCY & PRODUCTIVITY ISSUES Inappropriate Skill Mix E.g.; Aux/Professional Mix, Unskilled Workers Scopes of Practice & lack of Skill delegation Professional turf protection: use of Clinical Officers & AMOs Impact of vertical/Priority programs: Re-aligning staffing resources, Systems Strengthening Bureaucracy & Dysfunctional health Systems – Supervision, Logistics, Morale and Motivation. Non Financial Incentives and Motivation Issues? Mal-distribution and Utilization of professionals – e.g.; Professionals in management Other Wastage of Health Workers? Into “Non-health” work HIV/AIDS

Slide19: 

Managing for Performance

Country Example: - Nigeria: Distribution of doctors on the National Registration Database: 

Country Example: - Nigeria: Distribution of doctors on the National Registration Database Source: Osegie H. et.al 2003 for JLI/AWG

Slide21: 

TANZANIA: Reductions in Public Sector Workforce Size (Different Cadres) 1994/1995 and 2001/2002 Derived from HLF Tanzania Country Case Study 2004

AFRICA: A SPECIAL CASE: 

AFRICA: A SPECIAL CASE 4 Heralds of Apocalypse HIV-AIDS + Other CDs Migration Under investment in Health and within Health in HRH Economic & Health Systems fragility A Deficit Of A Million Or More Health Workers! Source: Kurowski/JLI (2003)

HIV/AIDS & Health Workforce in Africa: 

HIV/AIDS & Health Workforce in Africa Significant increase of workload Attrition due to death from HIV/AIDS death of nurses represents almost 40% of the annual output from training in 2 countries! Low productivity due to absenteeism, illness & burnout Need of new skills, techniques-Palliative, Counseling etc Deterrent to new entrants into nursing - perceived risk Paradox – Higher demand for HWs but Lower supply Protecting the Provider?

ZAMBIA STAFF ATTRITION JAN. 2003-JUN 2004 : 

ZAMBIA STAFF ATTRITION JAN. 2003-JUN 2004 Zambia Country Case Study 2004

Slide25: 

ZAMBIA: Assessment of need for additional HIV/AIDS related staff at 10 hospitals (For “PEPFAR” only/GF Separate needs). Source: Scaling up HIV/AIDS Services: Preliminary HR Plans for 10 Public Hospitals (Excludes Global Fund activity estimates)

EXAMPLES OF COUNTRY STRATEGIES: 

EXAMPLES OF COUNTRY STRATEGIES WORKFORCE SUPPLY Expansion in numbers – Professionals/Mid-Level cadres mix? Enrolled Nurses/AMOs in Tanzania External Recruitment – Cuba, ODCs WORKFORCE PRODUCTIVITY Decentralization, Delinkage – Outcomes mixed (eg; Ghana, Zambia,) New CB, PB curricula. Utilizing Community Resources – Ghana CHPS, Ethiopia HEWs RETENTION AND MIGRATION MANAGEMENT Income enhancement – Ghana-ADHA Botswana-30% Nurses enhancement, SA – Rural and Rare Skills; Comm. Service INCENTIVES AND MOTIVATION IMPACT Non financial Incentives? Huge variation in migration intent not always related to PPP differential. RESTRUCTURING AND GOVERNANCE Leadership & HW Frustrations HIV/AIDS – Zambia – ARV for Health Workers

A CALL TO ACTION: Mobilizing –Governments, Agencies, Donors, Initiatives, Communities: 

A CALL TO ACTION: Mobilizing –Governments, Agencies, Donors, Initiatives, Communities Wider Cross-systems Capacity Required Logistics Support Basic Infrastructure Management and Governance Systems Skills and Motivation Strong Country Led actions/ strategies Technical Support/Knowledge networks Global Responsibility Macro-Economic Framework/factors Redesigning Donor investments Managed migration & remittances Protecting the poor & vulnerable

CHALLENGES : 

CHALLENGES Managing “Plethora Of Global Initiatives” - Welcomed Financing but? “Passing the HRH test” – effects on HRH/System Expanding Financing for HRH & Macro-economic barriers “Taming” Migration Resistance of Professional Associations, Unions Obstacles from Regulatory Bodies & vested interests Political Leadership & Policy Development Expanding Knowledge Base & Technical Assistance: Expand/Network of HRH technical expertise and experiences of best practices (Observatory Method – PAHO) National data systems Research for workforce efficiency Expansion in HRH investment and understanding new ways of making macro-economic and fiscal policy also work for health