Overview of the Human Resources for Health Crisis in Developing · PDF file ·...

Overview of the Human Overview of the Human

Resources for Health Crisis in Resources for Health Crisis in

Developing CountriesDeveloping CountriesWay out of the crisis, implications for Way out of the crisis, implications for

NigeriaNigeria31 October 201131 October 2011

First National Conference on HRH , AbujaFirst National Conference on HRH , Abuja

Dr George W. Pariyo (Dr George W. Pariyo (MBChBMBChB, MSc, PhD), MSc, PhD)

Medical Officer, Country Facilitation TeamMedical Officer, Country Facilitation Team

Global Health Workforce Alliance SecretariatGlobal Health Workforce Alliance Secretariat

Outline of the presentation

Overview of human resources for health global crisis

Part 1

Global Health Workforce AlliancePart 2

Country actions – a way out of the crisis

Part 3

Human Resources for Health:Shortages, Inequitable Distribution

A global crisis!

Part 1

In Sub-Saharan Africa…� 24% of global burden of disease but only 3% of

world's health workers

� 1 of 4 doctors and 1 of 20 nurses trained in Africa are working in developed countries.

Global health workforce crisis

Globally…� Shortfall of 4.3 million health workers globally

� Education and training insufficient

� Monthly wages: < $100 in some countries vs> $14 000 in other countries

Density of health workers and skilled birth attendance

Source: WHO, World Health Report 2006

Countries with a critical HRH shortage Countries with a critical HRH shortage (< 2.3 nurses, midwives and doctors per 1,000 population)(< 2.3 nurses, midwives and doctors per 1,000 population)

[Source] WHO. (2006). World Health Report 2006. WHO: Geneva.

Uneven global distribution: nurses

Source: www.worldmapper.org and WHO Global Atlas Health WorkforceLegenda: the size of the countries is proportional to density of nurses

Uneven distribution of health workers within countries …

Source: WHO Global Atlas of the Health Workforce, 2009 update.

26 selected Countdown countries with urban/ rural distribution data available.

Africa has greatest burden of disease, least health workforce!

Countries with a critical HRH shortage

Of 57 HRH crisis countries, 39 (68%) are in Africa.

36 (63%) are in SSA


19

29 30

45

62

131

142

0

20

40

60

80

100

120

140

160

Africa South-East Asia Eastern Mediterranean Western Pacific World Europe Americas

Health Service Providers (per 10,000 population) by WHO Region, 2005

Note:1. Data as reported by countries (compiled at WHO Regional offices and the Headquarter)

2. Reference year of data for some countries may differ from the reported year 2005

3. Health service providers include : (i) Physicians (ii) Nurses (iii) Midwives (iv) Dentists (v) Phramacists (vi) Environmental and public health personnel

(vii) Lab workers (viii) Community health workers (ix) other health workers

Number per 10,000 population

Global situation of health workforce

Source: WHO SEARO

Health workforce crisis in Africa

In Africa, there are, on average, only 1.08 doctors, In Africa, there are, on average, only 1.08 doctors, In Africa, there are, on average, only 1.08 doctors, In Africa, there are, on average, only 1.08 doctors, nurses and midwives per 1000 populationnurses and midwives per 1000 populationnurses and midwives per 1000 populationnurses and midwives per 1000 populationIn real terms, this means that there are 17 doctors, 71 In real terms, this means that there are 17 doctors, 71 In real terms, this means that there are 17 doctors, 71 In real terms, this means that there are 17 doctors, 71 nurses and 20 midwives for each 100,000 people in nurses and 20 midwives for each 100,000 people in nurses and 20 midwives for each 100,000 people in nurses and 20 midwives for each 100,000 people in AfricaAfricaAfricaAfrica1 in 4 doctors and 1 nurse in 20 trained in Africa is working in developed countriesThe current rate of health worker production in these The current rate of health worker production in these The current rate of health worker production in these The current rate of health worker production in these countries is such that the deficit will never be met and countries is such that the deficit will never be met and countries is such that the deficit will never be met and countries is such that the deficit will never be met and will only continue to growwill only continue to growwill only continue to growwill only continue to grow

Distribution of health workers by level of healthDistribution of health workers by level of health

expenditure and burden of disease, by WHO regionsexpenditure and burden of disease, by WHO regions

Health Personnel in Asia

Pacific

Source: Asia-Pacific MDG Report 2010, 2010

Focus on Nigeria

Health worker availability and coverage of essential health services

Threshold = 2.3 HWs per 1000 pop


Nigeria = 2.01 HWs per 1000 pop

Some Country Indicators

Population – 158 million

Density of Nurses, Midwives and Doctors per 1,000 population – 2.01

Number of maternal deaths – 50,000

Percent of all births registered – 33%

Health workforce shortage to attain 95% skilled birth attendance by 2015 – 6,790

Source: State of the World's Midwifery 2011, Nigeria Country Profile

Some MDG Indicators

Maternal Mortality Ratio (per 100,000 live births) - 840

Births attended by skilled health personnel – 39%

Under-5 Mortality Rate (per 1,000 live births) – 143

Source: Based on data in State of the World's Midwifery 2011, Nigeria Country Profile

Inequitable Distribution of Health Professionals

Regional Distribution of Doctors and Nurses in

Nigeria, 2007

0

10

20

30

40

50

North

Central

North

East

North

West

South

East

South

South

South

West

Region

Perc

en

t

Doctors

Nurses

Source: Nigeria HRH profile (page 23) - based on data from Professional Regulatory Agencies 2008

Regional Disparities in Mortality

Distribution of Mortality by Geo-political Zones

050

100150200250300

N/Cent

ral

N/E

ast

N/West

S/E

ast

S/Sou

th

S/Wes

t

Zones

Mo

rtali

ty p

er

1,0

00 L

B

NNMR

PNNMR

IMR

CMR

U5MR

Source: Nigeria HRH profile (page 24) - based on data from NDHS Report 2003

Stagnant Production of Health Workers

Training Outputs from Health Training Institutions

from 2002 to 2005

0

2000

4000

6000

8000

10000

2002 2003 2004 2005

Year

Actu

al

An

nu

al

Ou

tpu

ts

Physicians

Nurses and midw ives

Pharmacists

Radiographers

Health records officers

Community health

practitioners

Source: Nigeria HRH profile (page 26) - based on data from National Universities Commission, Professional Regulatory Agencies, 2007

Need for Scaling Up Education

Rate of Increase of HRH Stock and Attrition Rate by

Cadre in the Nigerian Public Sector, 2006

05

101520

Docto

rs

Nurs

es a

nd

Mid

wiv

es

Labora

tory

Sta

ff

Pharm

acis

ts

and

technic

ians

CH

O/C

HE

Ws

Staff Category

Perc

en

t

Increase from New

Graduates

Attrition Rate

Source: Nigeria HRH profile (page 24) - based on data from National AIDS Control Agency, 2006

Slow progress towards MDG target


Nigeria Trends in Maternal Mortality 1990-2015

1100 1100980

900 840

275

0

200

400

600

800

1000

1200

1990 1995 2000 2005 2010 2015

Year

Mate

rnal

death

s p

er

100,0

00 l

ive b

irth

s

Health Workers Save Lives!

Evidence base

Joint Learning Initiative on Human Resources for Health (JLI). Human Resources for Health: crises, strategies, sustainability. Cambridge, MA: Harvard University, Global Equity Initiative, 2004.

Link HRH policies to HRH availability: Dussault G, Dubois CA Human resources for health policies: a critical component in health policies. Hum Resour Health. 2003 1(1):1

Link health workers and health outcomes: Anand S, Bärnighausen T. Human resources and health outcomes: cross country econometric study. Lancet. 2004; 364(9445):1603-9

Chen, Lincoln, Timothy Evans, Sudhir Anand, Jo Ivey Boufford, Hilary Brown, MushtaqueChowdhury, Marcos Cueto, Lola Dare, Gilles Dussault, Gijs Elzinga, Elizabeth Fee, Demissie Habte, Piya Hanvoravongchai, Marian Jacobs, Christoph Kurowski, Sarah Michael, Ariel Pablos-Mendez, Nelson Sewankambo, Giorgio Solimano, Barbara Stilwell, Alex de Waal, Suwit Wibulpolprasert (2004). Human resources for health: overcoming the crisis (2004). The Lancet, Volume 364, Issue 9449, Pages 1984 - 1990, 27 November 2004 . doi:10.1016/S0140-6736(04)17482-5

Evidence base

Department for International Development, Management Sciences for Health and Management Solutions Consulting (2010). Evaluation of Malawi's Emergency Human Resources Programme. Final Report.

Global Health Workforce Alliance (2010). Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems. Global Health Workforce Alliance. Available online at http://www.who.int/workforcealliance/knowledge/publications/CHW_FullReport_2010.pdf

World Health Organization (2006). World Health Report 2006 - Working together for health. http://www.who.int/whr/2006/en/index.html. Accessed 02 May 2011.

Link HRH plans to HRH policy implementation: Global Health Workforce Alliance. Reviewing Progress, Renewing Commitment. Progress report on the Kampala Declaration and Agenda for Global Action; 2011, Geneva: WHO.

Density of health workers and skilled birth attendance

Source: WHO, World Health Report 2006

Health worker availability and survival

In other words, higher health worker density => lower mortality rate


HRH availability and impact on

MDG targets

0

1

2

3

4

5

6

7

8

9

0 1 2 3 4 5

Density (workers per 1,000, log)

Mo

rtality

(p

er

1,0

00, lo

g)

Maternal

Infant

Under-5

Source: Anand & Source: Anand & BarnighausenBarnighausen 20042004

No health workforce, no health Millennium Development Goals!

MDG 4:MDG 4: reduce child mortality

MDG 5: MDG 5: reduce maternal mortality

MDG 6: combat HIV/ AIDS, malaria and other diseases

Future priorities: control chronic and non-communicable diseases

A Global Crisis Needs a Global Response!

Part 2

Global health workforce crisis and health outcomes

Lower health service coverage

Higher mortality rate and disease burden

Fewer health workers

Lower macro economic outcome


The Global Health Workforce Alliance

"The Painful Fact

Worldwide, one billion people never see a health worker all their lives"

Amb. Sigrun Mogedal (former Chair, GHWA)

A global vision

“all people, everywhere, shall have access to a skilled, motivated and facilitated health worker within a robust health system” Kampala Declaration and Agenda for Global Action

The Roadmap: Kampala Declaration and The Roadmap: Kampala Declaration and

Agenda for Global ActionAgenda for Global Action

1. Building coherent national and global leadership for HW solution

2. Ensuring capacity for an informed responsebased on evidence and joint learning

3. Scaling up education and training

4. Retaining an effective, responsive and equitably distributed health workforce

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

6. Securing additional and more productive investment in the health workforce

� Vision: Access for all to a skilled, motivated, and supported health worker as part of a functioning health system

What is the Alliance?

� Mission: Mobilize all stakeholders to advocate and take appropriate actions to achieve access for all to health

workers, with a focus on the 57 countries in crisis.

� Composition: 336 Alliance Members and 27 Alliance

Partners from a variety of constituencies

� Organization: The Alliance is an international partnershiphosted by WHO, which brings together a variety of stakeholders� Government ministries and agencies, professional associations,

academia, civil society, UN agencies, donor agencies, private sector, etc

Three core functions “ABC”:

Core functions of GHWA

Convening all stakeholders => (1) CCF, (2) Global

consultation on community health workers.

Advocating for keeping HRH issues high on the global agenda => (1) Global forum on HRH, (2) High level

commitment at G8 – 2008, 2009, 2010 (3) Global code of practice on int’l recruitment of health personnel

Brokering knowledge => (1) Task forces, (2) technical tools, (3) community of practice, (4) knowledge centres, etc.

How does the Alliance work?

Allliance•Members •Partners •Secretariat•Board

Advocacy

Brokering knowledge Convening

Design, implement, monitor and evaluatea national comprehensive HRH plan

Academia

MoL

Civil

society

MoF

Prof Ass’n

MoH

Private

Sector

MoE

Convening: intersectoral coordination for integrated health workforce development

•19 countries have established/strengthened multi-sectoral HRH coordination mechanisms (as at October 2011)

Way Out of the Crisis, Country Actions and Progress

Part 3

The Roadmap: Kampala Declaration and The Roadmap: Kampala Declaration and

Agenda for Global ActionAgenda for Global Action

1. Building coherent national and global leadership for HW solution

2. Ensuring capacity for an informed responsebased on evidence and joint learning

3. Scaling up education and training

4. Retaining an effective, responsive and equitably distributed health workforce

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

6. Securing additional and more productive investment in the health workforce

The problem: HRH plans lacking or not costed or not implemented

57 priority countries

51 countries submitted data

43 countries had

evidence based HRH plans

29 countries were

implementing HRH plans

25 countries had

costed HRH plans

24 countries

had evidence basedand costed HRH

plans and were

implementing

them

Need to increase production

"…..with existing pre-service training patterns, countries would need:

36 years for physicians and 29 years for nurses and midwives - to reach the threshold of 2.28 health workers per 1,000 population, the level associated with at least 80% coverage of essential health services e.g., skilled birth attendance and fully immunized child…".

Kinfu et al BullWHO, 2009

The implication is that pre-service training of health workers needs to be expanded as well as combined with other measures to increase health worker inflow and reduce the rate of outflow.

45

Quantity

:

Pre

-serv

ice

train

ing

Quality:

In-service train

ing

Pro

fessional d

ev’t

Recruitment

Deployment &distribution

Migration & retention

Accred

itation

Soci

al rec

ognitio

n

MOH

MOLMOPS MOFA

MOE=>Education

MOF=> Investment

Health professional associations

Private sector

MOH

Civil society

NGOs

HRH as a complex polyhedronHRH as a complex polyhedron

Migration

Source: Nigeria HRH profile (page 30)

Destinations for Nurses Seeking Employment

Outside Nigeria, 2004 to 2007

0

500

1000

1500

2000

2500

3000

2004 2005 2006 2007

Year

Nu

mb

er

of

Nu

rse

s

United Kingdom

USA

Ireland

Australia

Canada

British Columbia

New Zealand

South Africa

Ghana

Botsw ana

Need to accelerate progress towards MDG target


Nigeria Trends in Maternal Mortality 1990-2015

1100 1100980

900 840

275

0

200

400

600

800

1000

1200

1990 1995 2000 2005 2010 2015

Year

Mate

rnal

death

s p

er

100,0

00 l

ive b

irth

s

HRH as a complex “polyhedron”

Qua

ntity

:

Pre

-ser

vice

trai

ningQ

uality:

In-service training

Professional

dev’t

Recruitment



Accreditation

Soci

al rec

ogni

tion

(1) MOH

(4) MOL(5) MOFA

(2) MOE=>Education

(3) MOF=> Investment

(6) Health professional association

(7) Private sector

(1) MOH

(4) Civil society

(5) NGO

HRH as a complex “polyhedron”

Qua

ntity

:

Pre

-ser

vice

trai

ningQ

uality:

In-service training

Professional

dev’t

Recruitment



Accreditation

Soci

al rec

ogni

tion

(1) MOH

(4) MOL(5) MOFA

(2) MOE=>Education

(3) MOF=> Investment

(6) Health professional association

(7) Private sector

(1) MOH

(4) Civil society

(5) NGOCOORDINATION CHALLENGESCOORDINATION CHALLENGES

Inadequate dialogue

Poor information sharing

Stakeholders engagement

Coordination mechanisms

Coordination capacity

Consensus building

50

Design, implement, monitor and evaluatea national comprehensive HRH plan

Academia

MoL

Civil

society

MoF

Prof Ass’n

MoH

Private

Sector

MoE

National HRH committeeNational HRH committee

CCF

CC

FC

CF

The CCF

PROCESS

HRH PLANCompressive, Costed, Evidence-based

REDUCED HRH CRISIS

HRH COMMITTEE

Ministry of Health

Ministry of

Education

Ministry of

Labour

Ministry of

Finance

Ministry of

Local Govt.

Academia Researchers

Professional associations

Regulatory

bodies

NGOs and

civil society

Private

sector

UN agencies and International organizations

Other HRH related stakeholders

De

ve

lop

F

ina

nce

Implement

Mo

nito

r E

va

lua

te

Sta

ke

ho

lde

rs a

na

lys

is a

nd

id

en

tifi

ca

tio

n

Oth

er

HS

S c

oo

rdin

ati

on

me

ch

an

ism

s

Contributing to a Contributing to a

solutionsolution

Current status of CCF roll-out

21

14

43

0

5

10

15

20

25

Total Completed Under process Planned

Total Completed

Under process Planned

21

12

4 5

0

5

10

15

20

25

Total Completed Under

process

Planned

Total Completed

Under process Planned

HRH situation analysis

through the CCF process

Evidence based, and costed

HRH plan through the CCF process

Positive developments but….

but much remains to be

done!

A long-term monitoring agendaImportant evidence gaps persist

Factors underpinning quality and implementation of HRH plans and function of coordination mechanismsTraining curricula and competency frameworks Workforce movement, availability, distributionQuality and performance of health workforceTrends in health expenditure for HRH

Need to focus on results!

Shift from input and process to output indicators

New HRH benchmarks

Monitoring to be embedded in national mechanisms

Implementation of WHO Global Code

Implement the Roadmap

KD-AGA remains valid framework

Accelerate development, costing and implementation of multi-sector HRH plans

Enhance monitoring for improved tracking and use of data

Attention to quality of education

Role of Community Health Workers and Mid-Level Health Providers

Implement initiatives to favour retention (e.g. WHO guidelines)

Laws, systems and procedures to implement Code on International Recruitment

Investment: both domestic and international resources

Implement the Roadmap

A long-rough-winding road to reach our HRH vision

Inspired by dedicated health workers

“…There is no house in the village that I have not visited.”

“…There are many health workers like me, silently serving the communities... if one recognizes these silent heroes, give them opportunities, one could harness their talents and motivate them to serve better…our world will become a better and a healthy place to live.”

P.D. Lalitha Padmini

Public Health Midwife, Sri Lanka

Thanks for your attention

Contacts:

Dr. Mubashar SheikhDr. Mubashar Sheikh

Executive DirectorExecutive Director, , the the GHWAGHWA

Email: Email: [email protected]@who.int

URL: URL: http://http://www.who.int/workforcealliance/enwww.who.int/workforcealliance/en//

Dr. George PariyoDr. George Pariyo

Medical OfficerMedical Officer

Email: Email: [email protected]@who.int

http://http://www.who.int/workforcealliance/enwww.who.int/workforcealliance/en//

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