WILL WE ACHIEVE UNIVERSAL ACCESS TO HIV/AIDS SERVICES WITH THE HEALTH WORKFORCE WE HAVE? A SNAPSHOT FROM FIVE COUNTRIES

Report of the Technical Working Group on Human Resources for Health (HRH) and Universal Access (UA) Global Health Workforce Alliance (GHWA) Dr Thomas Kenyon, Country Director, PEPFAR/CDC-Ethiopia

Composition of the GHWA technical working group on HRH and universal access

• • • • • • • • Mark Stirling, UNAIDS – co chair Tom Kenyon, PEPFAR/CDC – co chair Estelle Quain – PEPFAR/USAID Karl-Lorenz Dehne and Jantine Jacobi, UNAIDS Jim McCaffery and Wilma Gormley – Capacity Project (Secretariat) Joan Holloway – PEPFAR/OGAC Badara Samb – WHO Sonia Diaz-Monsalve and Erica Wheeler – GHWA

Background

• • GHWA commissioned Task Force to examine interactions between efforts to reach universal access to HIV services and efforts to address the HRH crisis TWG emerged to complete this work in four phases – Literature review – Protocol development for common rapid situational analysis across countries – Rapid situational analysis conducted in five countries – Final report and dissemination of results and follow on actions http://www.who.int/workforcealliance/about/taskforces/access/en/index.html

Countries with a critical shortage of health service providers (doctors, nurses and midwives)

Cote d’Ivoire Ethiopia Zambia Mozambique Thailand Source: McCoy et al. Human Resources for Health 2008 6:16 doi:10.1186/1478-4491-6-16

• • • •

Rapid situational analysis objectives

Identify and document country-specific gaps and obstacles, which impede HRH scale-up for universal access Identify and document country-specific promising mechanisms and practices that promote scale-up towards universal access and enhance the health system in general Develop practical and actionable guidance for countries, including policy considerations, to further scale-up HRH for universal access and strengthen the health system in general Initiate a sustained process to ultimately catalyze and enhance the active engagement of in-country stakeholders to support scale-up towards universal access and health systems improvement through strengthening HRH

Key elements of country analysis

• • • 2-3 member team spent 10 days in country collecting information and writing report Supported by WHO national office and a national level Steering Group Collected available information – HIV epidemiology and program indicators – Strength of health workforce – National HRH plans/strategies – Status of task shifting and training

Major questions posed to key informants

• • • • What promising practices exist that are having a positive impact on scale up on universal access?

What are the HRH gaps and challenges that specifically relate to the country’s goals/targets for HIV/AIDS?

What are the most critical interventions that will address challenges and lead to effective scale up?

What leadership action and partner support is required to enable implementation of HRH scale up?

HIV , universal access, and HRH indicators

Indicator

Population HIV+ % PLHA

Zambia

12 million 14.3% 1.1 million PLHA in need of treatment 362,392 PLHA on treatment - For each doctor 216,576 431 % treatment coverage 66% (2009) Health worker per 1000 pop 0.79

Mozambique Ethiopia

20 million 79 million 14% 1.5 million 460,000 2.3% 1.1 million 330,000 300,000 526 66% (2010) 0.4

204,000 153 62% (2009) 0.25

Cote d’Ivoire

19 million

Thailand

65 million 3.9% 480,000 190,000 1.4% 610,000 250,000 52,000 NA 27% (2007) NA 171,000 8 68% (2008) 4.0

Major findings Promising practices

• • • • • • Countries have 5-10 year HRH Strategic Plans Production of new health workers is increasing Pilot efforts underway to increase retention and improve work force distribution Task shifting used to support decentralization and increase access Efforts to scale-up community responses are underway HIV services are being integrated into mainstream service delivery

800

The extrapolation of the professional staffs to deliver ART services, Thailand 2008 - 2015

Total 700 600 500 400 300 200 100 0 2008 2009 2010 2011

Year

2012 2013 2014 2015 Nurse Doctors Conselor Doctor Nurse Pharm.

Counselor Lab. Tecnhician Total Source: Ministry of Public Health, Thailand

Examples of increased production

• • • Ethiopia – 30,000 Health Extension Workers for PHC and MDGs – 9,000 Health Information Technicians for HMIS – From 683 health officers in 2004 to 1600 in 2009 – Increasing medical student intake to 8,000 per yr Mozambique – Increasing workforce by 79% by 2015 – Doctors, nurses, skilled birth attendants emphasized Thailand – 60 year history of building an appropriate workforce • Have reached ratio of 4 health workers/1000 population

Workforce projections, Mozambique, 2006-2015

Thailand •Population of 65 million •GDP/capita of 3,050 $US •Life expectancy 73.5 years •The top causes of burden of diseases are unsafe sex, alcohol and tobacco consumption, and hypertension Source: Ministry of Public Health, Thailand

Health Facilities

9,762 rural health centres, 730 community hospitals, 150 big public hospital 2007 Total public beds 141,451. 344 private hospitals, 35,806 beds (20.2 %) 16,800 private clinics, 14,000 drug stores

Health Manpower

30,000 MDs, 120,000 nurses, 10,000 dentists, 10,000 pharmacists, 40,000 CHWs, mainly produced by public institutes

National Health Expenditure

From 3.82% GDP in 1980 to 6.1 % in 2005 13

Examples of steps taken to improve retention

• • • • • Thailand – Salary incentive offered to serve in rural areas Zambia – HIV/AIDS services for health workers themselves – Rural retention scheme Ethiopia – – Beginning private ward and fee retention schemes Various incentives being offered to work in rural areas Cote d’Ivoire – Salary incentive offered to work in embattled north Mozambique – 14% of HRH budget planned for retention incentives

Status of task-shifting in countries

• • • • • • • • • Widely practiced and improving access HIV counseling and rapid testing – all but Thailand Perform male circumcision – Ethiopia, Zambia Order CD4 tests – all countries Provide ARVs to pregnant women – all countries Initiation of ART by clinicians other than doctors – all but Cote d’Ivoire and Thailand ART refills in stable patients – all countries Provide ARVs for PEP – all countries Prescribe OI drugs – all but Thailand

Major findings Gaps and challenges

• • • • • Many country HRH scale-up efforts remain unfunded and delayed in implementation HR management systems extremely weak Insufficient attention has been given to HRH as a health systems component for reaching universal access – Estimated workforce needs have not been calculated – Scaling up production is costly and time-consuming – Shortage of tutors and instructors is problematic – Formal policies on tasking shifting are lacking Over-reliance on HIV in-service training rather than integration of HIV into pre-service curricula Little attention being given to a HIV prevention workforce

Roles of a prevention workforce

• • • • •

Preventing Sexual Transmission

Behavior change programs (to increase condom use, delay initiation of sexual behavior in young people, and reduce the number of partners) Condom promotion HIV testing Diagnosis and treatment of sexually transmitted infections Adult male circumcision • • • •

Preventing blood borne transmission

Provision of clean injection equipment to injection drug users Methadone or other substitution therapy for drug dependence Blood safety (including routine screening of donated blood) Infection control in health care settings (including injection safety, universal precautions, and antiretroviral prophylaxis following potential HIV exposure) • • • • •

Preventing mother-to-child transmission

Primary HIV prevention for women of childbearing age Antiretroviral drugs Prevention of unintended pregnancy in HIV-positive women Breastfeeding alternatives Caesarean delivery (in the case of high maternal viral load) Source: http://www.globalhivprevention.org/pdfs/pwg_access_factsheet_6_07.pdf

Limitations of country snapshots

• • Data on human resources is lacking Specific workforce issues that could not be addressed in-depth: – HIV prevention activities – Pediatric HIV/AIDS services – Strategic information and public health workers – Effect of HIV/AIDS on health workers themselves – Contribution of the private sector workforce – Capacity of pre-service training institutions – Workforce issues outside health institutions

TWG conclusions

• • • • Countries visited are making substantial progress towards universal access and integration of HIV Workforce innovations, including task-shifting, are contributing to that success The projected workforce is a major obstacle to reach and maintain universal access amidst a growing HIV/AIDS epidemic Existing National HRH plans represent an important opportunity for country leadership and development partners to expand the workforce in support of universal access, HIV integration, and meeting other Millennium Development Goals

Critical interventions needed at country level (based on country cases)

• • • • • • Move from costed HRH strategic plan to prioritized implementation, addressing both HIV and other health service needs Estimate HR requirements for universal access and scale up HRH production, making certain pre-service curricula includes appropriate HIV/AIDS content Continue working on task shifting and building community health worker cadres including involvement of PLHA Address HRH retention and distribution to hard to reach populations and areas Strengthen HW performance (low motivation and job satisfaction), includes work place safety programs Strengthen Human Resources Management Systems

Acknowledgments

• • • •

Cote d’Ivoire Team

Dr. Virginie Ettiegne-Traore, Ministry of Health, Director, PNPEC Mr. Dick Wall, Capacity Plus Project consultant Dr. Juma Kariburyo, HIV Administrator, WHO Cote d’Ivoire Dr. Abo Kouame, Senior Technical Advisor, PNPEC • • • • • • •

Ethiopia Team

Samrawit Nigussie, Ministry of Health Dr. Gebrekidane Mesfin, WHO Ethiopia Dr. Degu Jerene, WHO Ethiopia Dr. Gijs Elzinga, Capacity Plus Project consultant

Zambia Team

Susan Tembo-Ziomba, WHO Zambia Isaac Kakumbi, Ministry of Health Dr. Gijs Elzinga, Capacity Plus Project consultant • • • • • •

Mozambique Team

Ms. Wanda Jaskiewicz, IntraHealth International Dr. Maria Ines Tomo, World Health Organization Dr. Francisco Langa, Ministry of Health Dr. Hilde de Graeve, World Health Organization Dr. Catherine McKinney, CDC Dr. Lucy Ramirez, CDC • • •

Thailand Team

Thidaporn Jirawattanapisal, Ministry of Public Health Sombat Thanprasertsuk, WHO Thinakorn Noree, Inter-HRH

On behalf of the Global Health Workforce Alliance TWG on HRH and Universal Access THANK YOU!