JLi Hrh Report

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Joint Learning Initiative

In this analysis of the global health workforce, the Joint Learning Initiativea consortium of more than 100 health leadersproposes that mobilization and strengthening of human resources for health is central to combating health crises in some of the worlds poorest countries and for building sustainable health systems everywhere. This report puts forward strategies for the community, country, and global levels in overcoming this crisis through cooperative action.

Human Resources for Health: Overcoming the Crisis

Human Resources for HealthOvercoming the crisis

st fir ry he isto e r t h th Fo in ve nd e ha s a to tim we rce ge e u led e th o so w m s t re no o at lth k erc re ea y he ov al th l h uit t h loba eq et g l

Global Equity Initiative Harvard University

Joint Learning Initia

Copyright 2004, The President and Fellows of Harvard College Library of Congress Cataloging-in-Publication Data has been applied for. ISBN 0-9741108-7-6

The Joint Learning Initiative (JLI), a network of global health leaders, was launched by the Rockefeller Foundation and was supported by a secretariat at Harvard Universitys Global Equity Initiative (GEI). The JLI acknowledges the generous nancial support of the Rockefeller Foundation, Swedish Sida, the Bill & Melinda Gates Foundation, the Atlantic Philanthropies, and the World Health Organization in the production of this report. The responsibility for the contents and recommendations of the report rests solely with the leadership of the JLI, with Harvard Universitys GEI assuming ultimate technical and corporate responsibility.

Photo credits: Cover, title page, and pages 39, 40, 99, and 100, Lincoln C. Chen; pages 11 and 12, Jacob Silberberg/ Panos Pictures; pages 63, 64, 131, and 132, Carol Kotilainen. Editing, design, and production by Communications Development Incorporated in Washington, D.C., with art direction by its U.K. partner, Grundy Northedge.

ContentsPage number

vii x 1 13 14 16 18 21 26 29 41 42 49 53 65 66 68 70 84 88 101 102 112 117 133 134 137 138 139 143 149 181

Preface Abbreviations Executive Summary Chapter 1 The Power of the Health Worker Todays health crisis Fresh opportunities Health workforce crisis Why health workers are so important Workers as a global health trust Five clusters of countries Chapter 2 Communities at the Frontlines Workers at the frontlines Workers in community systems Mobilizing health workers Chapter 3 Country Leadership Engaging leaders and stakeholders Planning human investments Managing for performance Developing enabling policies Learning for improvement Chapter 4 Global Responsibilities Migration: Fatal ows Knowledge: An under-tapped resource Financing: Investing wisely Chapter 5 Putting Workers First Strengthening sustainable health systems Mobilizing to combat health emergencies Building the knowledge base Completing an unnished agenda: Action and learning Appendix 1 Glossary Appendix 2 Quantitative Information Appendix 3 Joint Learning Initiative

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Page number Boxes 1.1 HIV/AIDS: Triple threat to health workers 1.2 Norms or standards? 1.3 Shortages giving a sense of scale 2.1 The invisible workforce 2.2 Recruiting locally is the most important rst step 2.3 SEWAs community nancing 2.4 Smallpox eradication in India: Tensions and harmony with the health system 2.5 Ethiopias militarymobilizing against HIV/AIDS 2.6 Mobilizing workers to eradicate polio 2.7 Primary health care workers in Costa Rica 3.1 Workers on strike 3.2 Ghosts and absentee workers 3.3 Networks for learning and health 3.4 Professional associations as partners 3.5 Irans revolution in health 3.6 Human resources in transitional economies 4.1 Codes of practice on international recruitment 4.2 The Global Commission on International Migration 4.3 Cubas international health workforce 4.4 Health worker migration: A global phenomenon 4.5 Toolkits for appraising health workforces 4.6 The PAHO Observatory of Human Resources in Health 4.7 Tanzanian health workforce: Impact of stabilization, adjustment, and reform 4.8 Ghana: Initiatives in human resources for health 4.9 Worker-friendly donor policies 5.1 Key recommendations 5.2 High stakes, high leverage 5.3 Action & Learning Initiative Figures 1 Human resources and health clusters 2 Managing for performance 3 Investing in national capacity for strategic planning and management 4 Decade for human resources for health 1.1 Life expectancyadvancing and slipping 1.2 The glue of the health system 1.3 Health service coverage and worker density 1.4 Higher incomemore health workers 1.5 More health workersfewer deathsv

19 33 34 44 51 53 54 55 56 58 69 76 82 83 86 88 107 108 110 111 115 116 120 121 123 135 137 140

3 5 7 10 15 22 24 25 26

Page number

27 29 30 32 42 43 48 50 66 71 78 80 81 102 103 104 119 183 197

1.6 1.7 1.8 1.9 2.1 2.2 2.3 2.4 3.1 3.2 3.3 3.4 3.5 4.1

Stocks and ows Worker density by region Human resources and health clusters Five clusters Human resource functions for health Family workers at the base of the pyramidprofessionals at the top Sample survey of national workforce patterns Achieving balance in accountability Key dimensions of country strategies Managing for performance Workers want more than money Huge regional disparities in medical schools and graduates Investment pipeline of learning Foreign-trained doctors can make up a third of the total number of doctors 4.2 New registrants from sub-Saharan Africa on the UK nursing register 4.3 South Africa: Main channels for out and in-migration 4.4 Investing in national capacity for strategic planning and management A3.1 JLI working groups A3.2 JLI meetings and consultations Tables 2.1 Community health workers in Asia 4.1 Recent trends in development assistance for health A2.1 Global distribution of health personnel A2.2 Global distribution of medical schools and nursing schools A2.3 Selected health indicators A2.4 Health workforce nancing

46 118 157 163 169 174

Preface

This report presents the ndings and recommendations of the Joint Learning Initiative (JLI), an enterprise engaging more than 100 global health leaders in landscaping human resources for health and in identifying strategies to strengthen the workforce of health systems. Why did we embark on this journey? What was our destination? And what did we do along the way? The JLI was launched because many of us believed that the most critical factor driving health system performance, the health worker, was neglected and overlooked. At a time of opportunity to redress outstanding health challenges, there is a growing awareness that human resources rank consistently among the most important system barriers to progress. Paradoxically, in countries of greatest need, the workforce is under attack from a combination of unsafe and unsupportive working conditions and workers departing for greener pastures. While more money and drugs are being mobilized, the human foundation for all health action, the workforce, remains under-recognized and under-appreciated. To address this gap, the JLI was designed as a learning exercise to understand and propose strategies for workforce development. Seven working groups were established: supply, demand, priority diseases, innovations, Africa, history, and coordination. The open, collaborative, and decentralized design enabled each autonomous working group to draw the best from its diverse membership. Working groups were encouraged to ask tough questions, bring new ideas to the surface, and foster creativity and innovation. The JLIs work was conducted in three phases. In a planning phase in 2002, leaders were recruited, a program framework was developed, and the work agenda was planned. 2003 was devoted to literature reviews, research, and consultations. More than 50 papers, many cited in this report, were commissioned, and more than 30 consultations were conducted around the world. These consultations engaged partner organizations and provided opportunities for us to listen to the voices of the health workers themselves. A third phase in 2004 focused on analyses and distilling lessons to generate the evidence base for the advocacy and dissemination of the JLIs ndings and recommendations.vii

The JLI beneted from a truly unique combination of participation and leadership. Our co-chairs and members all volunteered their talents and time. Very importantly, an early priority was to achieve consensus that equity in global health would form the bedrock value for all JLI endeavors. This report thus represents not simply an analytical product but also an expression of our collective social commitment. As our interactions intensied over time, professional collegiality and personal friendships emerged. Even more important, mutual trust characterized our evolving relationships. This exceptional process was facilitated by the exible nancing provided by our core donors: the Rockefeller Foundation, the Swedish International Development Cooperation Agency (Sida), the Bill & Melinda Gates Foundation, and The Atlantic Philanthropies. With the release of this report, the JLI has reached its destination. Given the challenges before us, completing this rst leg simply launches us into the next phase of the journey. We in the JLI invite our colleagues and allies to join us on this road of strengthening human resources for health. Our hope is that this report, however modestly, illuminates the path ahead for us all.

Lincoln C. Chen Co-chairs, JLI Coordination

Tim Evans

viii

JLI Coordination working group members Orvill Adams Marian Jacobs Jo Ivey Boufford Joel Lamstein Mushtaque Chowdhury Anders Nordstrom Marcos Cueto Ariel Pablos-Mendez Lola Dare William Pick Gilles Dussault Nelson Sewankambo Gijs Elzinga Giorgio Solimano Elizabeth Fee Suwit Wibulpolp