Global Perspectives on the Health Workforce

1. Global Perspectives on the Health Workforce Manuel M. Dayrit MD, MScDirector Department of Human Resources for Health

2. Health workers save lives.

3. What is the health workforce? “People engaged in actions whose primary intent is to enhance health” Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization

4. Health workers save lives … but we need enough of them Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization

5. “We have to work together to ensure access to a motivated, skilled, and supported health worker by every person in every village everywhere.” Why build the health workforce? Dr LEE Jong-wook, late Director-General World Health Organization

6. There are shortages of health workers worldwide Distribution of the global health workforce Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization

7. Causes of shortages vary from country to country • health workforce not a priority • poor HRH planning • insufficient HRH production • migration • unjustified control of HRH production by professional organizations • death from HIV/AIDS

8. Many African health workers migrate Dr. Alain Maxime Mouanga Psychiatrist, Democratic Republic of Congo

9. Percentage of doctors trained in African countries but now working abroad

10. Inequities in health workforce distribution Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization

11. Health Workforce Crisis in Sub-Saharan Africa Africa's burden of disease: 25% Percentage of the world's health workers in Africa: 1.3%

12. Loss of health workers due to HIV/AIDS HIV prevalence = 15%  up to 33 % loss of health workers in 10 years • Zambia: • -1980: 2 nurses out of 1000 died • - 2001: 27 nurses out of 1000 died • Botswana: • - 1999─2005: 17% of health workforce died • - 1999─2010: 40% of health workforce will die (projection if no action is taken)

13. What must be done to lower maternal mortality? Maternal mortality ratio per 100 000 live births in 2000 Source: WHO (2005). The World Health Report 2005 – Make Every Mother and Child Count. Geneva, World Health Organization

14. We need innovative approaches Investment HRH Development Better Health Outcomes + =

15. We must build “capacity” or “potential” just like a battery or or

16. Working lifespan strategies to build capacity and performance ENTRY:Preparing the workforce Planning Education Recruitment WORKFORCE PERFORMANCE WORKFORCE: Enhancing worker performance Supervision Compensation Systems support Lifelong learning Availability Competence Responsiveness Productivity EXIT:Managing attrition Migration Career choice Health and safety Retirement Source: WHO (2006). The World Health Report 2006 – Working Together for Health.Geneva, World Health Organization

17. What can defeat efforts to build capacity and performance? • migration of health workers • lack of managerial capacity to retain and support them • HIV/AIDS • pull factors from developed countries • unintended negative effects of health system reform, e.g. decentralization

18. "Our personal safety is not guaranteed. Patients are harassing us and shouting at us. They have guns ..." Unsafe workplaces push health workers to leave Primary health care nurse, South Africa

20. Percentage of foreign-trained doctors in nine industrialized countries

21. Challenges to performance improvement vary across sectors Transaction intensity (decision process complexity) Source: Capacity building in Africa: an OED evaluation of World Bank support. World bank, 2005

22. Bangkok vs. Rural Northeast(Doctor to Population Ratio) Regulatory: compulsory contract of 3 years of public work after graduation Economic: rural development project and financial incentives Education: rural recruitment and training in rural health facilities; development of community medicine Managerial: personnel management Social: movement for rural development Promoting multiple strategies to improve retention in Thailand Strategies that worked: Source: S. Wibulpolprasert, 2003

23. Will Filipino health workers return-migrate?

24. Link the education, labour and health services markets Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization

25. HRH Action Frameworktools for an effective and sustainable health workforce country specific context including labour market Preparation & Planning Critical Success Factors Policy BETTER HEALTH SERVICES EquityEffectivenessEfficiencyAccessibility Leadership Finance Improved Health Workforce Outcomes H R M Systems BETTER HEALTH OUTCOMES Situation analysis Implement-ation Partnership Education other healthsystemcomponents M & E Go to CD-Rom / Internet [http://www.capacityproject.org/framework/]

26. Ten-year action plan

27. Strategic directions 2006-2015 (WHO 11th Global Programme of Work) • Strengthen coordination and harmonization of human resources policies across service delivery channels and levels of the health systems as well as across sectors and improve partnershipswith private providers, nongovernmental organizations, and community partners. • Adapt the skill-mix of health workers to ensure adequate distribution geographically and by specialty, including matching the skills and competences of graduates of health professional institutions with specific national priorities and health care needs. • Enhance the enabling environmentto increase motivation, effectiveness and retention of workforce at national level (addressing the incentive barriers for recruiting, retaining and motivating staff - salaries, career structure, working conditions, etc.). • Develop realistic and long-term global and regional solutions to manage the outflows of workforces, including meeting the requirements of national health systems and respecting the rights of individuals to cross national boundaries.

28. FOR THE IMMEDIATE ATTENTION OF THE DELEGATES OF THE UN HIGH LEVEL DIALOGUE ON MIGRATION AND DEVELOPMENT A number of preliminary recommendations came out of our discussions including: • A Global Code of Practice should be adopted which builds on lessons from existing Codes such as the Commonwealth Code of Practice. A Global Code should serve as a basis for further bilateral and multilateral agreements. • The 57 countries identified by the WHO with critical shortages of health workers should be the focal point of immediate international action with respect to short-term and long-term solutions. • All countries should have a comprehensive health workforce strategy for addressing the demand for health services and attaining self-sufficiency. • Developing countries should focus on retention strategies and working conditions to encourage health workers to stay in their country of origin and remain in the health care profession.

29. FOR THE IMMEDIATE ATTENTION OF THE DELEGATES OF THE UN HIGH LEVEL DIALOGUE ON MIGRATION AND DEVELOPMENT • Governments should develop policies which allow health workers to move between sending and receiving countries and contribute to the development of both. • The skills of members of diasporas should be harnessed and managed to contribute to development and health care needs in developing countries. • Significant increases in spending on health care are needed in developing countries requiring the support of international financial institutions which in some cases still place restrictive ceilings on social spending. • The role of other cadres of health workers including mid-level providers, community health workers and other substitute workers to address the health workers crises and in supporting national health systems should be explored further. • A Global Observatory for data collection on health worker mobility should be established.

30. "There is a tide in the affairs of (wo)men Which, taken at the flood, leads on to fortune; Omitted, all the voyage of their life Is bound in shallows and in miseries. On such a full sea are we now afloat; And we must take the current when it serves, Or lose the ventures before us. " William Shakespeare, Julius Caesar

31. Health workers save lives. Support them. Educate them. Love them. Don't leave them. Or they'll leave you… That's not a threat. That's not a promise. It's already a fact of life.