Negative Changes in life expectancy occurring in some African countries comparing high

1
Africas burden of the worlds diseases
Africas share of the health workforce
2
Progress towards health MDGs
3
of health care professionals who intend to
migrate In Zambia, the public sector only
retained 50 out of 600 doctors trained in the
countrys medical school from 1978-1999
4
Outflow (from Clemens Pettersson 2006)

• Nurses

Physicians
UK, USA, France, Canada, Australia, Portugal,
Spain, Belgium, South Africa
5
Nurse Population

• Norway
• 1100
• Many sub-Saharan countries
• 15000
• Zimbabwe
• 1700 (1998)
• 1900 (2001)
• Gweru 1200
• Nyanga 13,000
• Kadoma 17,500

6
ZIMBABWE

• 425 doctor posts
• 105 (25) filled
• 237 Z doctors, 3283 nurses in 7 OECD countries
  alone
• 21 of DMO posts filled
• 1/8 of Provincial Specialists
• 22 of Hospital Specialists
• 8 of Registrars
• 50 of all health posts vacant

7
Retention

• Definition in country 3½ years after graduation
• Doctors 18 (1980 55)
• Nurses 30 (1980 90)
• gt30 of sputums ?TB not examined because no lab
  scientists and no microscopists

8
Why are we leaving?

• ECONOMIC
• Pay
• Accommodation
• Transport
• INFLATION
• POLITICAL
• Safety
• Freedom of speech

9
Why are we leaving?

• Inadequate equipment and drugs
• Fear of getting infected with HIV
• Poor slow moving management
• Mortality from HIV/AIDS
• deaths of Zambian nurses 2x UK registrations

10
Why are we leaving?

• Destruction of private education system
• Inadequacy of local universities for OUR kids
• Capacity / affordability of private health care
  for ourselves and our families
• HIV stigma

11
Why are we leaving?

• Pushed by our families
• 77 of final year university students were being
  actively encouraged by their parents to emigrate

12
Why do they want us?

• Cheaper ?
• Probably not, in fact
• Better paid
• Better educated
• Make fewer mistakes

13
Why do they want us?

• They need us
• Australia in 2042
• ¼ population gt65
• Growth in 16-64 zero
• UK between 2005-2050
• Proportion gt80 will have doubled
• 4.4 to 9.2

14
And they are employing us

• UK
• 2002 58 of newly registered doctors graduated
  elsewhere
• 2004 44 of newly registered nurses
• 1999-2004 number of newly registered nurses
  foreign-trained tripled from 5000-15000

15
And they are employing us

• USA
• Nurses doing Long Term Care work
• 1980 6 Africa 3
• 1990 7 3
• 2000 13 11
• 7 OECD countries
• 237 Zimbabwean doctors
• 3283 nurses

16
Effects

• Huge loss of educated workers at age of peak
  productivity
• Gross inequities in health
• Rich poor
• Rural urban
• but
• Incoming FOREX
• US 93 billion (2003)
• Training and exposure

17
Rights and Responsibilities

• Rights
• Of Health Workers to migrate
• To health and life of those left behind
• Responsibilities
• Governments
• International community

18
Bilateral Agreements

• eg South Africa and UK
• gt5000 SA nurses registered 2001-2003
• Improving conditions of nurses in recipient
  countries

19
Why are we staying?

• Love the country and our families
• Working in ones own community
• Freedom of practice, and challenges
• Earning more
• Private practice
• NGO salaries (forex)
• Stuck

20
How to pull us back?

• Fix the economy
• Increase pay (Global Fund, bilateral donors)
• Higher priority for health by Government
• Sharpen up management
• Institutional accommodation for all graduates
• Realistic house and car loan schemes
• Better defined career pathways
• Improved working environment
• Gloves and working machines

21
How to pull us back?

• Top ups for rural postings
• Phones
• Transport (ambulance and personal)
• housing
• Priority treatment for HIV
• Insurance for civil servants
• Treatment at contracted private clinics

22
How to plug the gaps

• Minimise obstacles for expatriate doctors
• Certification, supervision
• While ensuring competence
• Support young HWs from rich countries
• Medical Service Corps
• Repaying student loans cf US Public Health
  Service
• Bonding

23
Training

• Yes we need more doctors and nurses
• BUT
• Currently trying to get 200 medical students per
  year through a medical school which was designed
  for 70
• With fewer lecturers
• With fewer demonstrators
• With less teaching material
• Much higher failing
• Schools must be more attractive places to work

24
Bonding

• Ethiopia
• Rural-urban imbalance
• In-country brain-drain
• Lots of things important
• Including intrinsic motivation
• Access to training
• Access to education for ones children
• Fear of getting stuck
• Living conditions for ones family

25
Bonding

• Thought experiment
• Urban post with basic salary
• vs
• Rural post with basic premium
• The premium does not have to be too expensive
• 31 for nurses
• 39 for doctors
• i.e. health budget increase of 0.9 to get all
  doctors and nurses out to the rural areas
• doubling the workforce increase of 7.9
• With high intrinsic motivation 2

26
Under-five mortality in Sri Lanka(Good Health at
low numbers low cost)
U5 mortality per 1000 live births (1995-2000) by
GNP per capita (1995, US)
27
Maternal Mortality in Sri-Lanka

• MMR reduced from 500-600 per 100,000 live births
  in 1950 to 60 per 100000 live births today
• Halved maternal deaths every 12 years since 1935
• Approach to strengthen the health system
• Building and training of professional para
  professional health workers
• Improving access to both basic and higher level
  services
• Ensuring availability of basic medical supplies
  and medications
• Lesson Rapid progress can occur at low cost when
  the fundamental building blocks are in place

Source Millions saved Proven success in Global
Health. Ruth Levine and the what works group with
Molly Kinder (2004)
28
Kenya

• 1600 doctors, 4700 nurses working outside (in the
  Diaspora)
• Calling up retirees (took 1500)
• Need 10,000 HWs
• PEPFAR (et al) going to employ 2500 on contract
• Government committed to integrating them

29
Kenya

• Per capita expenditure
• 2003/4 2006/7
• US 6.5 US 14.2

30
Malawi

• 15/27 districts have lt1.5 nurses per institution
• 5 districts have lt1
• 4 districts have 0 doctors

31
Malawi

• 6 year Emergency Human Resources Programme
• Improved salaries
• External recruitment of doctors and nurses
• Expansion of training capacity
• Policies for postings and promotions, training
  and upgrading
• Housing
• Management strengthening

32
Malawi

• Global Fund/DFID/Malawi Government
• US 278 million
• 98m for salary top-ups
• 35m for staff housing
• 64m for expansion of training capacity

33
Malawi

• 5400 health workers getting salary top-ups
• 700 new staff since 2004 (200)
• Expansion of training schools
• Infrastructure
• Teaching staff
• Increasing capacity by 50
• Triple the number of doctors
• Double the number of nurses

34
Philippines

• Special arrangements for remittances
• Returnees
• Tax-free shopping for a year
• Loans for business capital at preferential rates
• Subsidised scholarships

35
Philippines

• Pay package
• Safety
• Education and health for family
• Working conditions
• Opportunities for advancement

36
New cadres

• Surgical /Obstetric technicians (Mozambique),
• Assistant Medical Officers (Tanzania)
• Medical Licentiates (Zambia)
• Clinical Officers (Malawi)
• Medical Assistants (Ghana)
• Clinical officers, primary care nurses, primary
  care counselors (Zimbabwe)

37
The Community Health Workforce

• Valuable, not recognized not remunerated, but not
  a stand alone alternative
• Link to formal services and a strengthened health
  system
• Supervision
• Supervision
• Supervision
• Remuneration
• Defining skills competence sets
• Training curriculum
• Intermediary, linked training institutions
• Establishing a career pathway
• 
  

38
The DiasporaAfricaRecruit Survey

• 3000 African Diaspora
• 75 had postgraduate qualifications
• 54 left Africa for career and professional
  developments
• 67 would like to return to Africa within the
  next 0-5 years

39
(No Transcript)
40
Why the diaspora?

• Significant hidden and untapped ready made
  resource
• Cultural/ethnic resource and indigenous knowledge
• Local yet international Transnational citizens
• Vested and active stake holders
• Micro donors Human, Financial and Social
  capital (over 300 billion dollars annually)

41
Diaspora Investors
Emerging Investors
SourceDFID presentation at Africa Diaspora
Investment 2005
42

• Countries must commit to releasing professionals
  from their jobs for extended periods without
  jeopardising them in any way.
• This no jeopardy right needs to be entrenched
  in labour law, like protection against any other
  discrimination.
• NEPAD March 2006 Mobilising African Diaspora
  Healthcare Professionals for Capacity Building in
  Africa

43
Possible approaches

• Labour and migration laws, tax concessions
• Circular migration
• debt forgiveness
• sabbatical and long leaves encouraged and
  facilitated
• Strategic partnerships between host countries and
  sending countries
• Address constraints on public spending
• decent employment opportunities in the public
  sector
• Enable assimilation of the critical skills
  deployed back from the Diaspora

44

• The international community should commit in
  2005 to provide US 500 million a year, over 10
  years to revitalise Africas institutions of
  higher education and up to US3billion over 10
  years to develop centres of excellence in science
  and technology, including African Institutes of
  Technology
• Commission for Africa
• Recommendation on Governance and Capacity
  Building

45

• Put pressure on the International Finance
  Institutions to remove the crippling effects of
  the unreasonably tight budget caps on recruitment
  and salaries
• Create mechanisms to ensure that recipient
  countries do not reduce their own expenditure on
  health as donor funding increases

46

• DR Peter Iliff
• For the ZVITAMBO Study Group

47
(No Transcript)