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The Global Crisis • Global shortage of nurses & other health professionals • Migration of nurses & doctors to developed countries • Impact on delivery of care & health outcomes • Undermines Africa’s effort to achieve Millennium Development Goals Major Studies & Publications • Joint Learning Initiative (JLI) • World Health Report 2006 – Extended the JLI report – Additional data The Glue of the Health System The Health Worker Density Index (HRH index) 1. A composite index 2. A density of 2.5 workers per 1,000 -a threshold to cover essential health interventions & core MDG-related health services. 3. Sub-Saharan Africa need 1 million additional health workers. Association between Mortality & Health Worker Density Health Worker Density Comparisons by World’s Regions From: JLI 2004. COUNTRY HRH INDEX MATERNAL UNDER 5 MORTALITY MORTALITY Niger 0.30 920 265 Togo 0.30 980 141 Benin 0.34 880 158 Cameroun 0.45 720 155 Ivory Coast 0.55 1200 175 Ghana 0.93 590 100 1.45 1100 183 Nigeria Numerical Approach Valuable for advocacy Prompted debate & discussion Stimulated policy review Systematic Analysis: Back to basics 1. Task analysis – – – 2, Identify needed skills & competence Design training & apprenticeship Review job descriptions / deployment Managing migration – – Dimensions & determinants Amelioration 3. Balanced investment in health systems . . . . . HOME / COMMUNITY Home based care Community based care Information exchange Technology transfer PRIMARY CARE FACILITY Basic health care Referral FIRST REFERRAL HOSPITAL SECOND / THIRD REFERRAL HOSPITALS . Complicated cases: Emergency Obstetric care Severe malaria Life-threatening illnesses Specialist care: Internal Medicine Paediatrcis Surgery Obstetrics PUSH PULL • Higher income • Better working environment • Security • • • • Low income Unpaid salaries Shortage of drugs, etc Poor logistic support •Loyalty to nation • Family ties • Social & other interests Managing Migration Realistic national human resource policy Gather data & monitor trends Tackle ‘push’ factors Negotiate managed migration Make most effective use of health workers Note: the large amount of funds repatriated by African workers Amelioration of PUSH factors • Financial incentives – Realistic salaries in terms of local realities – Regular payment of salaries. Allowances & pensions • Non-financial incentives – Improving working environment – More efficient management of services • Consultations accredited representatives of: – Health workers – Civil society Balanced investment in the health system Mismanaged, malfunctioning health systems ‘Sick System Syndrome’ • Staff salaries - high percentage of recurrent budget (60-80%) • Infrastructure, supplies, logistics, etc. inadequate • Vertical programmes fragment health systems Strengthening Health Care Units •Infrastructure PHYSICAL •Equipment •Maintenance MANAGEMENT •Evidence •Procurement/Distribution •Human resources •Financing •Stewardship RELATIONSHIPS •Development partners •Health education •Community mobilisation Dare & Reeler, 2005 Training Obstetricians in Ghana Period To 1989 1989-2006 Trained UK 30 Ghana 38 Working in Ghana 3 37 Can other nations adopt lessons learnt? Training manual • Developed in Ghana • Translated to French, Spanish, Vietnamese, Russian, etc. • Used in 30 countries