Brain Drain:Africa’s Health Workforce Crisis

Doug MenuezAllafrica.com

Leslie RetiAllafrica.com

Crisis in Africa’s Health Workforce

Africa has 25% of the world’s disease burden, 13.8% of the world’s population, but only 1.3 % of the world’s health workforce (Source: WHO)

Joint Learning Initiative estimate: 600,000 doctors, nurses, and midwives now; 1 million more needed to achieve Millennium Development Goals This is needed to achieve a health worker density of 250

doctors, nurses, and midwives per 100,000 population In contrast, the U.S. and Europe have more than 1,000

doctors, nurses, and midwives per 100,000 population (Source: WHO)

Crisis In Africa’s Health Workforce

Rural and poorest areas are worst off Ghana’s Greater Accra Region has 120 nurses

and 30 physicians per 1,000 population. By contrast, Ghana’s Northern Region has only 34 nurses and 1 physician per 100,000 population (Source: Ghana’s MoH)

More auxiliary and community health workers are key No ideal health worker density or skills set, but

magnitude of challenge immense Personal/Local experience

World Workforce & Health Status: The Global Picture

From: JLI 2004.

Health Worker Density Comparisons by World’s Regions

From: JLI 2004.

Why It Matters:The Cost of Our Inaction

Major constraint to increasing coverage of essential health interventions in Africa (where money is available). Without addressing the shortage, the Millennium Development Goals and Abuja Declaration cannot be achieved.

AIDS treatment cannot be successfully and sustainably scaled up without more health workers Studies in Cote d’Ivoire, Ethiopia, and Zambia indicate that without

more health workers these countries cannot achieve AIDS targets while maintaining current (woefully inadequate) level of health services

“Putting in place the health workforce needed for scaling up maternal, newborn, and child health services towards universal access is the first and most pressing task.” (Source: WHO)

More Health Workers – Fewer Deaths

From: JLI 2004.

Health Care Workers:The Glue of the Health System

From: JLI 2004.

Causes and Solutions to the Health Workforce Crisis

Shortage of Health Workers and HIV/AIDS

HIV prevalence among health care workers is similar to general adult population

HIV/AIDS and health care workers’ care obligations Attrition due to death from HIV/AIDS Stigma discourages many health workers from

learning their HIV status HIV/AIDS causes significantly increased workload Deterrent to new entrants into healthcare-perceived

risk of occupational infection Paradox-higher demand for health care workers but

lower supply

Causes: Massive Under-Investment in Health Sector

Massive underspending in health sector Least-developed countries spend an average of

US$11/capita on health (1997), including US$6/capita in public spending. A minimum health package costs US$34/capita. (Source: Commission on Macroeconomic and Health [2001])

To contrast, the U.S. spent $4,178/capita on health in 1998. (Source: OECD)

Economic policies place ceilings on government spending and wage bills, limiting the public sector’s ability to employ additional health workers.

Many countries cannot even afford to hire nurses and other health workers who are already trained.

Health workforce has not been prioritized Insufficient/irrelevant training capacity

Causes: Health System and Non-Health System

Health system-related causes: Health professionals unable to meet their

own goals Health professionals unable to meet their

patients’ needsNon-health system-related causes:

Corruption, crime, instability, lack of development, poor human rights practices, etc.

Causes: Unmet Health Worker Needs; Unmet Patient Needs

Health professionals own needs: unmet Low salaries Dangers of occupational infection: HIV, other diseases Stress from high workloads Inadequate training, supervision, and management Lack of opportunities for research and continuing

education Pre-service training often poor preparation for actual

practice Needs of patients: unmet

Lack of medicines, supplies, equipment, and other support required to be healers

Workers Want More than Money

Brain Drain of Health Professionals Out of Africa

Significant numbers of nurses and other health professionals migrate to wealthy countries, including the United Kingdom, United States, Canada, and Australia.

In 2002/2003, more than 3,000 nurses from South Africa, Zimbabwe, Nigeria, Ghana, Zambia, and Kenya registered in the United Kingdom. (Source: James Buchan and Delanyo Dolvo)

Only 360 of 1,200 doctors trained in Zimbabwe in the 1990s were still practicing in the country by 2001. (Source: EQUINET/HealthSystemsTrust/MEDACT)

Brain Circulation Rural to urban, public to private and NGOs, intra-

Africa

Migration Intentions-Proportion of Health Workers Who Intend

to Migrate, (6 African Countries: 2002)

49.361.6

37.9

58.3

26.1

68

0

10

20

30

40

50

60

70

Percentage

Source: WHO AFRO 2002

Causes: Health Professionals Shortages in Wealthy Countries

Shortages of health professionals in wealthy countries US nursing shortage: 111,000 short in

2001, 275,000 by 2010, and 808,000 short by 2020 (Source: US Department of Health and Human Services)

US physician shortage: 85,000 to 200,000 by 2020 (Source: USA Today)

Active recruitment (amount unknown)

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

Countries?

.COUNTRIES PROJECTED NURSE

SHORTFALLS & YEAR.

United States 500,000 – 2015

Canada 113,000 – 2011

United Kingdom 35,0000 – 2008

Australia 31,000 – 2006

Derived from data at - http://www.state.gov/s/gac/rl/or/29737.htm (October 2004)

Huge Regional Disparities inMedical Schools and Graduates

Foreign-Trained Doctors can Make up a Third of the Total Number of Doctors

What Should Be Done?

Solutions: Investments and Policy Changes

Investments (salaries and incentives, health workforce management, safe workplaces, pre-service training capacity, continuous learning opportunities, overall health systems improvements)

Policy changes (integration of community and auxiliary health workers into health systems, advanced practice roles for nurses, respect for all cadres of health workers)

End World Bank/ International Monetary Fund mandated policies that restrict health budgets  

Solutions: Self-Sufficiency; “Do No Harm” in Recruitment

Wealthy countries should increase their own training capacity and ability to recruit and retain health professionals, especially in rural areas

End active recruitment of health professionals from developing countries or form mutually beneficial agreement with those countries UK has a code of practice covering National

Health Service; independent sector also encouraged to comply—code can’t succeed otherwise

Commitments and Responses Underway

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

Multilateral Commitments G8 commitment (July 2005): commitment to: “investing in

improved health systems in partnership with African governments, by helping Africa train and retain doctors, nurses, and community health workers

UN World Summit (September 2005): commitment to: “increase investment…to improve health systems in developing countries…with the aim of providing sufficient health workers, infrastructure, management systems and supplies to achieve the health related Millennium Development Goals.”

African Union health ministers conference (October 2005): commitment to: “prepare and implement costed human resources for health development plans”

Sources of Funds Global Fund to Fight AIDS, Tuberculosis, and Malaria

Permits funding for health systems strengthening, including health workforce strengthening

Has funded proposals to pay for salaries, incentives, pre-service training, universal precautions

Global Alliance for Vaccines and Immunization (GAVI) Expected to approve health system strengthening as a new major area

of investment United Kingdom

In December 2004, the UK committed $100 million over 6 years to support Malawi’s Emergency Human Resource Program (are receiving significant support from the Global Fund, Malawi’s own budget)

Other donors Some support from other donors (e.g., Dutch, Swedes, Norwegians) as

well

US Support Scattered through increasing responses,

primarily through President’s Emergency Plan for AIDS Relief (PEPFAR)(rural incentives for Zambian physicians, salaries for Namibian health professionals providing AIDS treatment, Kenyan nursing database)

New requirement that US develop health workforce strategy in 15 PEPFAR focus countries

What You Can Do

Support US Investments Abroad

Write to and call the President and your Members of Congress to encourage them to include $650 million in global health workforce strengthening in fiscal year 2007

Urge the Administration and Congress to support full funding for the Global Fund to Fight AIDS, Tuberculosis, and Malaria (needs $1.2 billion from the U.S. in the next (2007) budget cycle)

Join the AIDS Advocacy Network(http://www.amsa.org/global/aids)

Support US Strategy on Health Workforce Self-Sufficiency

Support development of explicit U.S. strategy to meet health workforce needs through reduced reliance on foreign health workers

Support investments that will increase the total number of U.S. health professionals and the number serving in areas suffering shortages of health professions (such as through expanding the National Health Service Corps and fully funding the Nurse Reinvestment Act)

Oppose efforts to ease recruitment of foreign health professionals American Hospital Association and 10 other organizations

seeking to speed the flow of foreign nurses in to the U.S. Wrong solution

Support ethical recruitment principles at your health facility Convince your colleagues that health workforce strengthening at

home and abroad is not zero sum

AIDS Advocacy Network-AAN

Mobilize! Join @ http://www.amsa.org/global/aids/Chance to network with local and national AIDS activists.

Speak at schools in your area

Plan events for World AIDS day: Dec 1st

Help coordinate Global AIDS Week of Action in February