Human Resources for Health Innovations

SDGs and Innovative Partnerships

Francis Omaswa,

TICH, Kisumu, 22.08.18

Presentation

• Background: from neglect to a global movement

• Current status

• New directions:

- Entry: HWF Planning, Education & training

- Stay: Retention

- Exit: Retirement, Migration

Global Health Workforce Crisis : Context

• Populations living longer demanding extended care for pain free life

• Disease burden in low income countries especially SSA increasing: double burden of Infectious and NCDs

• Global Shortage estimated 4million, mal-distribution, poor working conditions

• Long history of neglect: complexity, wrong policies SAPS, professionalism in developed countries

• African Health Ministers outcry at three consecutive World Health Assemblies

Global Health Workforce Crisis: Milestones

• The Joint Learning Initiative 2002 -2004

• Annual Commonwealth Health Ministers Conferences

• African Ministers at three World Health Assemblies

• World Health Report 2006

• High Level Forum on Health MDGs

• Oslo 1, Oslo II

• Global Health Workforce Alliance

Changes in life expectancy in selected African countries with high and low HIV prevalence: 1950 - 2005

with high HIV prevalence:

Zimbabwe

South Africa

Botswana

with low HIV prevalence:

Madagascar

Senegal

Mali

Source: UN Department of Economic and Social Affairs (2001)

World Population Prospects, the 2000 Revision.

30

35

40

45

50

55

60

65

Lif

e e

xp

ec

tan

cy (

ye

ars

)

1950–

1955

1955-

1960

1960-

1965

1965-

1970

1970-

1975

1975-

1980

1980-

1985

1985-

1990

1990-

19951995-

2000

2000-

2005

African Partnership

London

WHA Resolution 2

African Union Summit Abuja

African Stakeholder Consultation

Brazzaville

African Regional Health Ministers

Maputo

AU Ministers of Health meeting

Gaborone

Africa Commission Report

Transitional WG

Oslo Consultation

HL Forum II Abuja

JLI Report

G8 Summit Gleneagles

Asia Network Bangkok

UNGA Summit

PAHO Observatory Toronto

HL Forum III Paris

World Health Report

World Health Day

WHA

WHA Resolution 1

HL Forum I GenevaJan

2004

Jan

Feb Feb

Mar Mar

Apr Apr

May May

Jun Jun

Jul Jul

Aug Aug

Sep Sep

Oct Oct

Nov Nov

Dec Dec

Jan

2005

Jan

Feb Feb

Mar Mar

Apr Apr

May May

Jun Jun

Jul Jul

Aug Aug

Sep Sep

Oct Oct

Nov Nov

Dec Dec

Jan 2006

Jan

Feb Feb

Mar Mar

Apr Apr

May May

Jun Jun

African Leadership Global Momentum

Africa Shortages

*combined physicians, nurses, midwives per 1,000 population

Source: JLI (2004) compiled from WHO estimates of health personnel 2004

0.8

10.3

Sub-

Saharan

Asia South &

Central

Global Middle

East

Western

Pacific

North

America

Europe

0.0

2.5

5.0

7.5

10.0

12.5

per 1,000 pop

4.0

Africa's Burden of the

World's Diseases

25%

Africa's Share of the

World's Health Workforce

1.3%

The overwhelming burden

Africa’s health status (2)

25%

1.3% 1%

03

69

12

15

18

21

24

27

30

Afr

ica's

% s

hare

Burden of disease Health workforce Health finance

Africa's share of Global burden of disease and health resources

"To ensure access to a motivated, skilled & supported health worker by every person, in every village, everywhere."

Dr LEE Jong-wook, 1945-2006

WHO Director-General

Health Workers for All and All for Health Workers

12

Kampala Declaration and Agenda for Global Action

• Key elements:

– Building coherent national and global leadership for health workforce solutions

– Ensuring capacity for an informed response based on evidence and joint learning

– Scaling up health worker education and training with needs based skill mix

– Retaining an effective, responsive and equitably distributed health workforce

– Managing the pressures of the international health workforce market and its impact on migration

– Securing additional and more productive investment in the health workforce

Global Strategy HRH: Workforce 2030...

1. Optimize the existing workforce in pursuit of UHC and the Sustainable Development Goals (e.g. education, employment, retention)

2. Anticipate future workforce requirements by 2030 and plan the necessary changes (e.g. a fit for purpose, needs-based workforce)

3. Strengthen individual and institutional capacity to manage HRH policy, planning and implementation (e.g. regulation)

4. Strengthen the data, evidence and knowledge for cost-effective policy decisions (e.g. Minimum Data Set + National Health Workforce Accounts)

MDG era: but words don’t always translate to action……

Sources: WHR 2006; Global Health Observatory (2014 update)

“24% burden of disease, 3% global health workforce”

(2004-2005 vs 2013-2014)

African Platform on HRH

• Launched 2005 WHO Hq. and Afro.

• Abeyance 2010.

• Reconstituted following wide consultation in 2012.

• Transition at WHO Afro

• Secretariat at ACHEST. Lean resourced.

• Providing technical support at all Milestones

• Providing voice as needed

• Convening Members Forum in April 2017.

• Available to contribute

Expected Outcomes

• Target: SDG Index: 4.45 (midwives, nurses and physicians) per 1,000 population. Home grown solutions Needs based response.

• Renewed energy: African Platform on HRH.- Annual communities of practice meetings in Africa- Biennial joint meeting between Global HRH Forum- Strong African Voice at Global level: migration, fiscal space,

partnerships as equals• Knowledge and evidence available and in use. HRH

Research• Strong advocacy movement• Superior performers numbers growing

Looking ahead: GHWN

• Needed more than ever before: forum for sharing, joint learning, mutual accountability

• Credible voice to call order beyond WHO

• Governance of the Network: listening, inclusive, professional, management

• Focus: Building synergy and capacity between global, regional and country level networks. Context critical

• Technology

Progress is Slow; Need is Growing!

Weak leadership and governance of HRH

Inadequate HRH regulatory capacity

Weak education and training capacity

Inadequate utilization, retention and performance of the available health workforce, migration growing

Insufficient information and evidence base

Insufficient financial resources

Uncoordinated partnerships and weak dialogue

Challenges Leadership and Management capacity for Health

Services (centre and districts) Human resources – recruitment, retention and

deployment Capacity of Institutions Integrated Health System Delivery of Minimum Package

Intersectoral collaboration Sustaining partnership and trust

Implement Paris Declaration on Aid Effectiveness Sustaining level of commitment and mutual respect

Global Initiatives Resurgence of vertical programmes

Low health sector public resource envelope Macro-economics and Health

20

Scale-up frameworkGOAL: HEALTH OUTCOMES

Integrated Health Service Delivery Networks

PRIORITIZED SKILL MIX

"CLOSE-TO-CLIENT HEALTH TEAMS"Defined within country context

EXISTING CAPACITY DEVELOPMENT OF NEW CAPACITIES

FINANCIALPOLITICAL TECHNICAL

- Resources- Incentives- Partnerships

- Supportive environment

- Leadership- Commitment- Legislation- Policy- Partnerships

- Training- Institutions- Infrastructure- Connectivity- Partnerships

INDICATOR:

MDGs

Household & community

Sub-district level

District level

Regional

referral

Nat'l

referral

More than just a health issue

Super-specialists

Specialists

Mid-level

CHWs

SHA

RED

Contributing factors:•Good governance, law and order

•Gender

•Social justice

•Social and economic development

O4: Strengthen data, evidence and knowledge

Section 3.2: Data and evidence for sound planning and decision-making

Countries should invest in strengthening their analytical capacity of HRH and health system data on the basis of policies and guidelines for standardization and interoperability of HRH data, such as the Minimum Data Set.

National and subnational data collection and reporting of health workforce data should be encouraged by means of standardized, annual reporting to the WHO Global Health Observatory.

Countries should establish National Health Workforce Accounts that extend the Minimum Data Set to a comprehensive set of key performance indicators on the health workforce labour market

Location of Doctors

Concerns with working in Districts.

- 299Low Salary, delays, no benefits

- 251Inadequate facilities- 155Political inteference and corruption- 108Heavy Work Load- 87Remoteness- 57No funding for further education- 28no incentives-poor housing, no allowances

- 25No opportunities for CMEs/supervision/training

- 24Difficulty getting on payroll- 12Poor staff morale- 10No business opportunities

Good Reasons to work in Sub

220 Experience : clinical, managerial and leadership

• 139 Incentives: top-up, housing, scholarships 66Opportunity to serve

• 44 Job security

• 23 Promotion opportunities

• 14 Time to do other things

• 13 Low cost of living

Why New Directions?

• Global shortage: 4.3m,African shortage 1m.

• Globalized connected world with inequities

• Tensions: Health Professionals vs Population expectations: vocation or jobs, distribution, commercialization, working environment

• Changing scope of practice; unmet skills needs: Nurse Practitioners, Task Shifting, Needs based training etc

Required Attributes and Competencies

• Prepared to work where services are most needed: selection process, attitudes, socially accountable

• Able to respond to health needs of community: training in real life situations in community

• Able to deliver quality care with available (limited) resources. (Achieving the most with available resources.)

• Clinical excellence as foundation for teaching and research.• Able to be leaders and change agents: mentors• Continuous self directed learners• Effective communicators: team based learning, practice

Education: Critical Solution

• Underlying global HWF crisis is failure to train and retain enough

• Education Institutions are factories: good factory = good product; bad factory = bad product

• Sub Saharan African Medical Schools Study: faculty shortages, infrastructure, private sector

Critical success factors for scaling up

Study of GHWA Task Force on Education and Training • 9 country experiences across regions

Critical factors identified:

• Political commitment and good governance– Sustained high level support, 'one' country-led health plan, significant

financial investment

• Enabling environment– Multi-sector participation, Good information systems, effective management

and leadership, labour market capacity and policy

• Workforce planning– Plan long term, act short-term and update regularly, commitment to

production / appropriate skill mix integrated teams, needs based, expansion of pre-service programmes

New directions

Needs Based Education

Competency/Outcome

Based Education

Competency Based Education

• Education aimed at imparting underlying characteristics related to job performance

• Encompasses knowledge, traits, skills and abilities.

• Fit for Purpose

Achieving Competencies

• Selection process for candidates• Right attitudes, belong to community (underserved areas)

• Training in real life practice environment

• Mentorship

• Team Based Learning

• Strong linkages with communities

Implications for Countries

• Prioritize Education and Training of HWF

• Link with National Development Plans

• Plan long term, act short and review frequently

• Link E &T to Population health needs & health systems

• Create Country Multi-stakeholder Alliances (CCF)

• Establish HWF Information Systems (Observatories)

THE UNITED NATIONS HIGH-LEVEL COMMISSION

• The High-Level Commission on Health Employment and Economic Growth established by the UN Secretary-General in March 2016

• Co-chaired by the Presidents of France and South Africa and co-vice-chaired by the Heads of the ILO, OECD and WHO

• The 19 Commissioners’ task: Make recommendations to stimulate and guide the creation of at least 40 million new jobs in thehealth and social care sectors, and to reduce theprojected shortfall of 18 million health workers by 2030

• Report launched on 20 September 2016– 10 Recommendations– 5 Immediate actions

http://www.who.int/hrh/com-heeg/en/

Baumol (1967)

– Growth in health sector employment without increase in productivity could constrain economic growth (data from USA)

Hartwig (2008 and 2011)

– Confirmation of Baumolhypothesis (data from OECD countries)

Arcand et al., World Bank (In press, 2016)

– larger dataset; data from low-, middle- and high-income countries

– establishes positive and significant growth inducing effect of health sector employment; multiplier effect on other economic sectors

– magnitude of effect greater than in other recognized growth sectors

Health as a cost disease and a drag on the

economy

Health as a multiplier for inclusive economic

growth

Decent work, inclusive economic growth, UHC

Global economy is projected to create around 40 million new health and social sector jobsby 20301

1 World Bank . 2 World Health Organization

High income

Upper-middle income

Lower-middle income

Low income

++++++++++++++++++++++++++++++++++++++++++

++++++

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

+++++++

+++++++++++++++++++++++++

+

+++++++++++++++++++++++++++

+++++++

++

+++++++++++++++++++++++++

Projected shortfall of 18 million health workers to achieve and sustain the SDGs and UHC2

A GLOBAL SUPPLY AND DEMAND MISMATCH

WHO Global Code of Practice

• Adopted in May 2010 though consensus by the 193 WHO Member States – Only the second instrument of its

kind promulgated by the WHO

– Broadest possible articulation of the challenges: elaboration of ethical norms, principles, and practices.

Figure 3. Sub-Saharan African-based institutions with the largest numbers of medical graduates appearing in the US physician workforce.

Tankwanchi ABS, Özden Ç, Vermund SH (2013) Physician Emigration from Sub-Saharan Africa to the United States: Analysis of the

2011 AMA Physician Masterfile. PLOS Medicine 10(9): e1001513. https://doi.org/10.1371/journal.pmed.1001513

http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001513

Critical U.S. Leadership

President Obama’s speech in Ghana, July 11th 2009:

In recent years, enormous progress has been made in parts of Africa. Far more people are living productively with HIV/AIDS, and getting the drugs they need. But too many still die from diseases that shouldn't kill them. When children are being killed because of a mosquito bite, and mothers are dying in childbirth, then we know that more progress must be made.

Yet because of incentives - often provided by donor nations - many African doctors and nurses understandably go overseas, or work for programs that focus on a single disease. This creates gaps in primary care and basic prevention.

41

Uganda’s Strategies that Leave No One Behind and Address Inequity

• Provide a minimum health care service package for all. SWAPs, Aggressively implement Service Standards at all levels especially house hold and Community level. Affirmative action for vulnerable groups

• Abolish user-fees for the minimum service package to promote a FAIR distribution of the burden of health financing on households (PHC)

• Rational financial allocation of public funding for health care including PPP

• Institutionalize a Total Quality Management approach through systematic entrenchment of continuous quality improvement and performance culture in services delivery at all levels. Increase client participation and demand for quality of health services.

• Strengthen Independent Bodies, and Supportive/Facilitative Supervision

Trends in Newborn, Infant and Child Mortality – UDHS 2016

2733 29 27 27

8188

76

5443

147 152

137

90

64

0

20

40

60

80

100

120

140

160

1995 2001 2006 2011 2016Neonatal Mortality Infant Mortality

Leadership forTaking Action

• “African Health Leaders: making change and claiming the future: a new book’s messages:

- The role of African techno-professionals. Need to feel the pain and shame of African condition. Partnership with communities, politicians, global

- Evidence that when committed a lot can be achieved.

- International partners to see Africa in new way- Create a global health system leaving no one

behind. Universal health coverage.