The AMREF team arrived in Bangkok, Thailand amid the peaceful red shirt protests, which have been well highlighted in the news. We are here to discuss what needs to be urgently done to increase numbers of doctors, nurses, clinical officers and health managers in developing and developed countries.
I anticipate that the meeting will review efforts since the First Global Forum on Human Resources for Health in Kampala (2008), asking the tricky question: have we made lasting progress on the human resources for health crisis? I also anticipate that this meeting will result in realistic human resources for health targets being for Africa, in light of the urgent efforts required on the continent to achieve the Millenium Development Goals (MDGs).
Africa takes centre stage at 2nd Global Forum on Human Resources for Health pre-meeting
Today was HRH in Africa day and the theme of the day was “producing evidence and policy through joint collaboration”. AMREF was highlighted as a key contributor to the African HRH platform which last met in 2010 in Nairobi, Kenya.
The key messages were as follows:
· Sub-Saharan Africa has made progress towards increasing overall numbers of health workers.
· There is need to improve HRH data, and country-level data in particular.
· HRH shortage and deficiency remains a problem of rural areas in Africa.
· The impact of health worker migration from Africa is not as great as that of the low production of health workers or internal rural-urban migration of health workers in sub-Saharan Africa.
· Absorption of health workers into the health system is a significant problem in Africa.
· There is limited fiscal space for health worker wages; the private sector and NGOs are willing and ready to absorb health workers.
· There are 168 medical schools in Africa and there has been an increase in numbers of medical schools. 22% are private (including private not for profit or faith based institutions).
· WHO 2006 estimate - 2.28 doctors, nurses and midwives per 1000 patients required to ensure 80% live births, may not be appropriate for Africa. Calculation did not take into account rural–urban population distributions, types and quality of facilities etc.
· Governance, Leadership and management in the health systems must be strengthened in Africa. This is the only way Africa can increase efficiency and productivity of existing HRH, and manage workforce increases. Will also reduce migration from rural to urban areas, and from public to private sectors.
The thought that keeps running through my mind as I am here, participating in discussions about what to do about the shortage of health workers, is that one of every seven of our children in sub-Saharan Africa will die before she or he is five years old. And the fact that there is simply no one there to take care of them is part of the reason. I want to keep that urgency and sense of outrage front and center during these days of lofty talk about systems and targets. While it is essential to deal with process, we do our children no favors by cloaking their fate in numbers and charts. I visualize that child taking her last breath, the deep sorrow of her mother, the sense of hopelessness. And then, I want to know what we can do.
AMREF is doing much. Here in Bangkok we are giving evidence to our global approach, with AMREF Africa, UK, Italy and USA working together to present what we know—and to offer it to others to follow. I thought our Dr. Peter Ngatia (AMREF Director of Capacity Building) was brilliant in his presentation of the study of the training of nurses in Kenya: of the 20,000 deemed qualified to be trained, only 5,000 spaces were available. Of the 5,000 trained, only half were actually hired. That meant that we lost 2500 trained nurses—who could have been engaged in saving lives - who went back to other jobs. Clearly when we demand the training of health workers, and insist that we’re missing upwards of 4 million of them, we need to be thinking about “what then?”
Today was the first formal day of the Second Global Forum on Human Resources for Health (HRH) in Bangkok, Thailand. It was a day packed full of side-events (plenary sessions begin tomorrow) all competing for the attention and participation of hundreds of international delegates from North and South, including health workers, technical experts, high-level decision-makers, and journalists.
As an AMREF team, we divvied ourselves up to ensure that we attended as many of the different side-events as possible. Today was a big day for us: AMREF’s Peter Ngatia was opening the Health Workforce Advocacy Initiative’s important side-event, and we were also hosting three of our own events throughout the course of the day.
A number of common themes recurred throughout the day’s events:
· Reviewing progress and establishing a clear way forwards: The general consensus is that since the first HRH Forum in Kampala in 2008, progress on HRH development at a global level has been ‘weak and uncoordinated’. Whilst there have been examples of real success (e.g. the U.S. PEPFAR partnership framework in Kenya, WHO Code of Practice) there is a strong call for more aggressive and focused action. In particular, there is a strong appeal from civil society for a ‘global target’ (numbers and retention of health workers) on HRH.
· Information – more and better used: The ‘information deficit’ on HRH at both country and international levels, continues to hinder progress. There should be a strong focus on obtaining this information and ensuring there is the political commitment to do so (e.g. Ministries are often reluctant to reveal data on absenteeism, ghost workers, vacant posts etc); and on better using it where it does exist. Delegates made the point that HRH will fail to attract the funding required unless we as advocates can better make the link between HRH and improved health outcomes.
· Tension – national vs. global: We heard criticism that international advocates and decision-makers are prone to talking ‘in the abstract’ about the ‘global crisis’ and ‘global targets’; national actors were rightly demanding more practical and tangible country-level action. Participants were reminded of the importance of learning and sharing ‘in context’ at the country level, rather than discussing the crisis in the abstract. The UK’s Lord Crisp provided an excellent example of this, in his newly established Zambian-UK Health Workforce Alliance (which looks explicitly at how UK organisations in Zambia can help solve the crisis).
AMREF hosted three successful side-events and workshops:
The first was AMREF’s all-day eLearning workshop. During the course of this six-hour session, experienced staff from AMREF’s HQ delivered training on the delivery of eLearning to health workers in different locations. The workshop attracted participants from countries as diverse as Egypt, Taiwan, Tanzania, Southern Sudan and Kenya. Despite these countries having their own unique characteristics, it became increasingly clear to AMREF that the human resources for health challenges in these countries were remarkably similar, and that eLearning – as a tool to scale up numbers of trained health workers, has significant - and widespread, potential.
AMREF UK co-hosted an event with the UK Human Resources for Health Working Group, which it established last April 2010. The purpose of the session was to reflect on the efforts of the group over the past nine months: how and why it got together, key successes, and lessons learned and challenges. The group also wanted to learn from the audience – particularly from civil society in the South, and from key UK and European decision-makers, about how the group could be more effective in the future. The session attracted over 50 participants from both North and South, including high-level European and UK decision-makers (e.g. UK Department of Health, 3 European MPs, ex-DFID staff, and one European Commission delegate). Excitingly, we obtained new recruits to the UK Working Group, including the UK Faculty for Public Health, as well as important and strategic advice for how best to move forwards.
In a side-event hosted by AMREF Italy and attended by European government representatives and HRH experts, AMREF’s Giulia Deponte presented findings from AMREF Italy’s recent report entitled: “Personale sanitario per tutti, e tutti per il personale sanitario” (“Health workers for all, and all for health workers”!) In this session, Giulia posed the important question: can we, and should we, track the contribution made by northern countries to the health workforce crisis? The consensus from participants was a resounding ‘yes’: we should track northern contributions. However, it was agreed that establishing such accountability would be impossible without clear targets and tools by which to monitor progress. The need for such tools and targets will be incorporated into the civil society platform statement published at the end of the Forum.
It is so exciting to be with so many people from around the world who are so committed to ensuring that there are adequate numbers of trained and motivated health workers! We know that a well-trained, motivated health workforce means the absolute difference between life and death for families around the world
Today was a day dedicated to field trips. AMREF’s Giulia Deponte joined the group visiting Phnomsarakam Community Hospital, about 130 kilometers out of Bangkok. Giulia writes:
This rural province is not an attractive place for the health workforce to work. The province is located far from Bangkok, and the due to limited capacity, health workers are faced with a heavy workload. As a result, the Community Hospital has implemented a “pay for performance” retention scheme, by which all hospital staff receive salary incentives proportional to the quantity of tasks they carry out, through a point system. Staff seemed to be satisfied with this system. I had just one doubt: does such a system encourage health workers to carry out inappropriate tasks, in order to maximise the number of patients they see and thus their financial incentives? We also had the opportunity to meet the Hospital Director, and see the hospital’s wards and outpatient departments.
We then visited the Tonna Community Health Centre, which provides primary health care services to its patients. We were shown how Thai traditional medicine is integrated as part of more conventional health service delivery. Whilst we were rather concerned that the hospital had closed for our benefit, we were extremely impressed by the level of organisation and cleanliness we saw – far better than in any hospital I have seen in Europe or Africa.
We also learned that today, the Global Health Workforce Alliance selected its next Chair – Dr. Masato Mugitani. He will replace the current Chair – Dr. Sigrun Mogedal from the Norweigan government, following the Second Global Forum. Dr Mugitani is a medical doctor currently working as the Assistant Minister for Global Health at the Ministry of Health, Labour and Welfare in Japan.
I dedicated the end of my day to working on the civil society statement/platform, being drafted by the Health Workforce Advocacy Initiative (HWAI) (of which AMREF is a member). The statement will contain the perspective of international civil society on progress made since the First Forum in Kampala in 2008, and on future challenges. It will be made public at the close of this Forum.
One billion people will never see a health worker in their lifetime.
AMREF strongly believes that investment in human resources for health development, for example through a Global Fund for HRH is paramount in resolving this unacceptable situation.This is a position that was the general feeling on the fourth day of the forum, which was officially opened by Her Royal Highness Princess Maha Chakri. In her opening speech, she heralded the valiant spirit of Thailand’s Father of Public Health, Prince Mahidol who revolutionised the country’s health system through his leadership.
Reflecting on the role of leadership in ensuring access and equity in health, Lisa Meadowcroft, CEO AMREF in the USA noted the key role played by political will at the national, regional and global levels. It is crucial for national leaders to create specific health functions at the community level.
There is therefore need to focus on building the capacity of community health workers to deliver primary health care services. Nevertheless, the capacity building of CHWs must go hand in hand with all the building blocks required to strengthen the health system. One way of achieving this is through linking national plans with national, supporting this through a well-coordinated of development efforts and backed by the necessary financing. Another, as Nzomo Mwita noted, is the importance of incentivising the health workforce especially those in the rural areas be it social, financial or infrastructural incentives.
In discussing the progress since the 2008 forum, Carol Jenkins, AMREF in the USA, emphasised the importance of measuring progress to ensure accountability and transparency. For instance, WHO’s progress report on Kenya indicates 100% improvement on all key indicators, except health information systems (HIS). This monitoring does not only apply to countries in the south; the northern countries need to be taken to task to ensure that they adhere to the WHO Global CODE of Practice on the international recruitment of health personnel.
From Malawi’s HRH success story, it is clear that with concerted effort, this crisis can be resolved. At AMREF, we work together – it is the only way to achieve access and equity in health care services. A health worker for everyone, everywhere…imagine that.
NB. To follow AMREF’s participation at GHWA follow AMREF USA @amrefusa Carol Jenkins @caroljenkins, Caroline Mbindyo @shakwei and Diana Mukami @moqami on Twitter.
To me, the highlight of the day was the first formal session: “From Kampala to Bangkok”, in which the Global Health Workforce Alliance launched their latest report outlining progress made in human resources for health since the First Global Forum in Bangkok three years ago.
The report measures progress against the six key strategies recommended in the 2008 Agenda for Global Action (leadership, evidence, education and training, investment, migration and retention). The report details some interesting findings: 43 out of the 57 human resources for health ‘crisis countries’ (86%) now have a human resources for health strategy or plan; 80% have increased rates of recruitment since 2008. But on the whole the findings were rather depressing. Less than half of all plans are actually costed or have an accompanying budget, and the majority of countries reported that their implementation was seriously ‘lagging’.
The Director of the Global Health Workforce Alliance also drew attention to the issue raised repeatedly in this conference so far: the issue of the human resources for health ‘information gap’. According to Dr. Mubashar Sheik, the Alliance was overwhelmed by the struggle to gather data from the 57 priority countries, where information systems remain ‘rudimentary’.
In particular, the session highlighted three key areas in which serious progress was needed:
1. Dramatically scaling up and supporting community health workers (CHW);
2. Improved retention of health workers in rural areas; and
3. Implementation of the WHO Code for the international recruitment of health workers.
For more details on the report, please visit:
http://www.who.int/workforcealliance/forum/2011/progressreportlaunch/en/index.html
There about 2,400 medical schools in the world, most of which are located in the global north, whereas the greatest need for medical personnel is in the global south. The same can be said for nursing, midwifery and public health educational institutions. With the global shortage of skilled health workers – and critical shortage in Africa - it is not surprising that countries are grappling with the challenge of rapidly and cost-effectively training, re-training and retaining health workers who are “fit for purpose” in the 21st century.
One thing is clear from the day’s deliberations: innovation (from recruitment of potential heath workers, through their training, employment and retention) is critical to mitigating this health worker shortage. AMREFs eLearning program to up-skill in-service nurses in Kenya rapidly and cost effectively is seen as one of these innovative strategies. This program is run in collaboration with the Ministry of Health (Medical Services) and the Nursing Council of Kenya and has enrolled over 7000 nurses across 108 eLearning Centers over a 5-year period. Evidence from numerous eLearning projects indicate that eLearning can make a significant contribution to easing educational costs, scope, access quality and instructor shortages – all challenges in health workforce training. However, in speaking of innovation we are not just looking at technology but innovation in curricula, in selection of students, in location of school, in retention of health workers, and so forth.
As mentioned in Day 4, WHO’s progress report on Kenya indicated that the country improved 100% in all key indicators being measured except in the implementation of Human Resource Information Systems (HRIS). Examples of implementation of HRIS in Angola and Tanzania illustrate that a HRIS customized to local needs provides leadership and healthcare managers with data to answer key policy questions. HRIS also provides evidence for production, recruitment, deployment and further development of the health workers. Another example of the use of HRIS is Norway that has forecast its HRH supply and demand for the next 20 years and developed policy to ensure that they produce enough for their own consumption, alleviating the need to ‘import’ HRH from developing countries. No doubt undertaking context-based health systems research will enable countries implement appropriate policy and plans.
Of concern to AMREF is the fact that these HRIS only document facility-based heath workers – what about the community health workers and/or traditional birth attendants who provide care in many developing countries? How can they be effectively monitored, supported and managed if they are not documented? In addition to documenting the community health workers, AMREF believes there is a need to create a professional body to govern the training, practice, recognition and remuneration of this cadre of health worker.
Throughout the day, individual practitioners from diverse countries and with diverse experiences shared a “voice from the field”. Their message to policy makers is “listen to us, talk to us not about us”. The competence-based inter-professional education mode of teaching is one good way to achieve competence-based health workers who are able to work together, share ideas and learn from each other regardless of their cadre.
Clearly there is no one right answer to the challenge of education of health professionals for the 21st Century. There is a need to break boundaries and to engender inter-professional practice, teamwork and collaboration amongst all stakeholders to increased access and equity and improve health outcomes.
