Brain Drain: Africa

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Brain DrainAfricas Health Workforce Crisis

Doug Menuez Allafrica.com
Leslie Reti Allafrica.com
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Crisis in Africas Health Workforce

• Africa has 25 of the worlds disease burden,
  13.8 of the worlds population, but only 1.3
  of the worlds 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)

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Crisis In Africas Health Workforce

• Rural and poorest areas are worst off
• Ghanas Greater Accra Region has 120 nurses and
  30 physicians per 1,000 population. By contrast,
  Ghanas Northern Region has only 34 nurses and 1
  physician per 100,000 population (Source
  Ghanas 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

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World Workforce Health Status The Global
Picture
From JLI 2004.
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Health Worker Density Comparisons by Worlds
Regions
From JLI 2004.
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Why It MattersThe 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 dIvoire, 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)

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More Health Workers Fewer Deaths
From JLI 2004.
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Health Care WorkersThe Glue of the Health System
From JLI 2004.
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Causes and Solutions to the Health Workforce
Crisis
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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-perceive
  d risk of occupational infection
• Paradox-higher demand for health care workers but
  lower supply

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Causes Massive Under-Investment in Health Sector

• Massive underspending in health sector
• Least-developed countries spend an average of
  US11/capita on health (1997), including
  US6/capita in public spending. A minimum health
  package costs US34/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
  sectors 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

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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 needs
• Non-health system-related causes
• Corruption, crime, instability, lack of
  development, poor human rights practices, etc.

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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

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Workers Want More than Money
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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

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Migration Intentions-Proportion of Health
Workers Who Intend to Migrate, (6 African
Countries 2002)
Source WHO AFRO 2002
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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)

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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)
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Huge Regional Disparities in Medical Schools and
Graduates
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Foreign-Trained Doctors can Make up a Third of
the Total Number of Doctors
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What Should Be Done?
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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  

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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 complycode cant succeed otherwise

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Commitments and Responses Underway
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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

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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 investmentto improve health systems
  in developing countrieswith 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

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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 Malawis Emergency Human
  Resource Program (are receiving significant
  support from the Global Fund, Malawis own
  budget)
• Other donors
• Some support from other donors (e.g., Dutch,
  Swedes, Norwegians) as well

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US Support

• Scattered through increasing responses, primarily
  through Presidents 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

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What You Can Do
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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)

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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

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AIDS Advocacy Network-AAN

• Mobilize! Join _at_ 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