Human Resources for Health: Migration and Retention

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Human Resources for Health Migration and
Retention 

• Yoswa M Dambisya
• University of Limpopo
• EQUINET Steering Committee
• Regional Research Coordinator, MoHProf

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Introduction

• HRH issues have been researched, defined
• Shortage-Migration, attrition, underproduction
• Imbalances skills mix, deployment
• Poor utilisation low productivity
• Weak HRH governance
• The strategies and solutions through which these
  issues can be addressed have been researched,
  defined and articulated
• Limited demonstrable commitment that translates
  into actions and results.

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Demand for health services/HRH

• Aging populations, increasing population growth
  rates, and a growing burden of chronic and
  non-communicable disease
• Aging health workforce, inadequate funding to
  support new recruits into the professions and
  growth of other career opportunities for women
• Internal and external migration, high attrition
  (poor work environments, low professional
  satisfaction and inadequate remuneration)
• HIV and AIDS
• Weak political will to address these challenges

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African health worker paradoxes

• High disease burden, low HW density
• Macroeconomic constraints
• Inequity in HW distribution within countries,
  globally
• Increasing policy attention, limited routine data
• HW profiles and curricula vs. health profiles
• Inappropriate skills mixes
• Anti-mid-level HW posture
• High use of traditional HWs
• Poor recognition of community HWs
• From JLI 2004 EQUINET SC 2007

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Migration of HCWs

• Migration is not new, not confined to health
  professionals not always negative
• Urgent need to rapidly scale up health worker
  supply to cover the 4.3 million shortage
• Poverty, inequality and political instability
  will continue to fuel migration
• Managed migration has potential to benefit source
  and destination countries as well as migrants and
  patients
• Why do health workers move?

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Global Conveyor Belt of Health Personnel
HEALTH SERVICES, HIGH INCOME COUNTRY
HEALTH SERVICES, MIDDLE INCOME COUNTRY
PRIVATE SECTOR LOW INCOME COUNTRY
URBAN CLINIC
URBAN HOSPITAL
RURAL CLINIC IN LOW INCOME COUNTRY
Padrath et al 2003, EQUINET Discussion paper 3
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(No Transcript)
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Face of HRH Migration Zambia c.2005

• Migration the highest cause of attrition for
  all heath cadres, more for Nurses
• Resignations in Zambia's health sector could be
  explained by recruitment in developed countries
• Zambia lost more nurses to the UK, and other
  countries than it produced
• Between 2003 2004, Zambian General Nursing
  Council processed 1222 applications for
  Nurses/Midwives to work abroad compared to 994
  nurses graduated.

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Impact on Health Service Delivery

• Due to HRH crisis Zambia could not guarantee the
  provision of the basic health care package.
• MDG targets not attainable.
• Zambia had inadequate staff to administer the
  HIV/AIDS programmes efforts for ART programme
  scale up stalled.
• Hence need for health worker retention strategy
  developed, with assistance from devt. partners
  Netherlands, USAID/PEPFAR, GFATM.

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Dimensions of the challenge Zimbabwe
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PEPFAR Programme in Mozambique

• Flight from the public sector, internal brain
  drain gtgtgtexternal brain drain
• Loss of physicians from the public sector (N75),
  the majority (54.7) with NGOs, others with
  bilateral and multilateral donors(28.0) and the
  private sector (17.3).
• 44 (33 of 75) now work for institutions funded
  primarily through PEPFAR.
• Loss of senior managers and public health
  specialists.. ?effects on public sector
  management.

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Why retention of health workers?

• Training costly, time consuming, trainee service
  not certain
• Direct and knock-on costs
• Systems loss of institutional memory, loss of
  morale for remaining workers, increased workload
• Community care seeking at higher levels,
  unmanaged disease
• Retention signals valuing health workers
• Retention cheaper than replacement

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Retention an Equity issue

• Service in areas of greatest need poor
  infra-structure, rural, remote.
• Service to poor populations, limited access to
  health care, unable to pay for private health
  care.
• Incentives to attract and retain skilled
  personnel in rural, underserved areas ?
  pro-equity measure.

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Opportunities

• More political commitment at higher levels
• HRH topical issue at country, regional global
  levels
• Recognized requirement for national health policy
  strategies
• Urgency to achieve the MDGs
• Global initiatives- e.g.GAFTM, GAVI, GHWA, IHP
• Advocacy for multi-sectoral,coordinated
  approaches to solving HRH issues

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Resolutions of ECSA Health Ministers

• Resolution on improving conditions of service and
  protecting the rights of workers who emigrate
  (2002) Improving quality of care by improving
  training of health workers (2004) The need to
  improve retention of health workers, improving
  leadership and governance for better health
  worker and health systems performance (2004)
  Strengthening HRIS ? inform retention and
  migration (2006)
• 2008 and 2009 Even more comprehensive ones

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Financial non financial incentives used in ESA

• NON FINANCIAL
• Career paths and recognition
• Training opportunities scholarships, study
  leave, skills enhancement, research opportunities
  
• Assistance with housing, schooling, transport,
  child care, food.
• Working conditions Improved facilities,
  conditions of service, security.
• Health coverage ART, insurance
• Management Strategic planning,
• HRIS, open appraisal systems, supervision

• FINANCIAL
• Salary top ups
• Differential salary levels for health vs other
  civil servants
• Scarce skills and rural allowance
• Permitting dual practice
• Reasonable access to loans (car, housing)
• Per diems, sitting allowances

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Mkapa Fellowship Remuneration package
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Success factors for retention Strategies

• Linked to longer term strategic planning
• Consultation with and input from HCWs
• Immediate signals through financial incentives
• Longer term stability through non financial
  incentives
• Sustainability of funding SWAp vs project
  specific funding
• Monitoring and evaluation
• Evidence used for feedback periodic review.

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Issues arising from ESA retention schemes

• Impacts of targeting areas of most critical
  shortage vs universal application of incentives
  across grades
• Measures to minimise destabilisation and consult
  workforce (between cadres between facility type)
• Systems to support incremental expansion
  planning, management, monitoring, adjusting
• Building on existing and working (district-level)
  initiatives
• Preference for simpler unambiguous systems
• Consistency with wider HR and health sector
  strategies

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Challenges Engagement with Diaspora HRH

• Numbers and whereabouts often unknown
• Lack of mechanisms for re-absorption of returning
  health workers (registration, CPD requirements)
• Lack of capacity to absorb them rigid staffing
  structures
• Hostility towards those who left and wish to
  return
• Unrealistic expectations on part of returning
  health workers
• The stick factors.

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Other options explored

• Short-term return teaching, specific clinical
  services (e.g. surgical camps)
• Support for health facilities in home country
  equipment, telemedicine
• Participate in training external examiners,
  visiting lectureships, joint research projects
• High level advocacy through alumni associations
  Old Boysnetworks
• Examples from the audience

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UK registered charity, established in 1997
exclusively for charitable, educational and
scientific purposes.   Recent projects have
included the provision of medical books to
Nigerian Universities, and the donation of a
truckload of medical equipment to primary care
centres in Nigeria.
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Association of South African Nurses in the UK
(ASANUK)

• Enable health services in South Africa to benefit
  from the knowledge, skills and participation of
  South African nurses in the UK.
• Specifically Establish a working partnership
  with relevant organisations in SA UK to
  facilitate
• Contribution to healthcare policy and service
  development in South Africa
• The sharing of specialist clinical knowledge and
  information through, for example, joint seminars
  and exchange visits.

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ECSA HC HRH Strategy 2008-2012

• Strengthening HR management approaches based on
  best practices, including programmes on health
  worker health, productivity and efficiency,
  retention strategies and responses to migration
• Member stated to
• Develop and implement country-specific responses
  to health worker migration.
• Secretariat to
• Work with member states to conduct country level
  HRH retention and migration studies

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• Mobility of Health professionals to and from the
  EU
• Lead institution WIAD IOM one of the major
  partners
• 25 country studies, 6 African countries
• Angola, Egypt, Ghana, Kenya, Morocco and South
  Africa
• African component coordinated by IOM Pretoria
  IOM also responsible for Asia, and for
  publication dissemination.

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Acknowledgements

• EQUINET, ECSA-HC, SIDA, University of Namibia.
• Colleagues at University of Limpopo
• Colleagues from IOM, and the MoH Prof Group.