Human Resources for Health challenges in dealing with HIV/AIDS in Sub-Saharan Africa Gilbert Kombe, MD, MPH Senior HIV/AIDS Technical Advisor Partners for Health Reformplus Project April 4, 2006 Pan American Health Organization World Health Week Washington DC 5

Outline of Today’s Presentation Brief background Why Sub Sahara Africa What we should care about HRH Emerging questions Current Challenges and Opportunities for HRH Possible Solutions Key messages and the way forward

Brief Background HRH is not a new problem HRH is a very complex and dynamic issue Growing evidence that HRH is major constraint in providing basic health services in SSA HRH is not a priority for most donor support Investing in drugs and supplies rather than salaries More focus short-term measurable outcomes than HR requirements

Major Human Resources Issues in SSA Severe shortage of HRH Few available Where available, unaffordable to be hired due to budgetary and fiscal constraints Low production and retention Personnel with inadequate & inappropriate training Poor distribution of staff Low motivation

Why Focus on Sub Saharan Africa Region has 10% of world pop with very high disease burden e.g. 25% of the global disease burden 60% of HIV/AIDS (25.8 M), 3.2 M new infections (2005) SSA has 1/3 of HW struggling to combat diseases Many countries have few HRH today than they did 30 years ago 38 of the 47 countries do not WHO min standard of doctor-pop ratio of 1:5, 000 13 countries have fewer than 1:10,000 e.g. Malawi has 139 doctors for a population of 12 M

Why should we care about HRH Investments in drugs and supplies will be wasted Countries with greatest disease burden have severe shortage No staff to run facilities Targets of major initiatives will not be achieved e.g MDG, WHO 3 by 5, PEPFAR Provision of basic health services will deteriorate

Emerging Questions on Human Resources for Health in SSA How big is the issue HRH across the continent? Needs and resources not uniform How many doctors, nurses, laboratory technicians, counselors does the region have? Are they really available? How are they distributed? What proportion of total HR should go to HIV/AIDS, Malaria, TB? What are the system wide effects of HR shortage? Can national governments and international community address HRH issues?

Selected Categories of HRH per 100,000 population Region Doctors Nurses Midwives Africa 17 71 20 Americas 212 414 N/A Europe 327 663 42 East Mediterranean 96 159 South East Asia 45 59 3 Source: WHO 2004

Basic HIV/AIDS Indices and Human Resource Status in the 15 PEPFAR Countries Country Population* Population with HIV (15-49)** HIV Prevalence (15-49) - %** Total Number of Doctors (year)*** Doctor PopulationRatio**** Total Number of Nurses (year)*** Nurse per Population ratio**** Botswana 1,722,000 270,000 37.3 488 (1999) 3,448 4090 (1999) 415 Cote d'Ivoire 16,835,000 530,000 7.0 1,322 (1996) 11,111 6,785 (1996) 2,174 Ethiopia 68,613,000 1,400,000 4.4 1,162 (2003) 33,333 14,123 (2003) 4,762 Kenya 31,916,000 1,100,000 6.7 3,616 (1995) 7,692 24,679 (1995) 1,111 Mozambique 18,791,000 1,200,000 12.2 435 (2000) 50,000 5,078 (2000) 3,571 Namibia 2,015,000 200,000 21.3 516 (1997) 3,333 4,978 (1997) 352

Basic HIV/AIDS Indices and Human Resource Status in the 15 PEPFAR Countries Nigeria 135,632,000 3,300,000 5.4 30,885 (2000) 3,704 154,000 (2003) 840 Rwanda 8,251,000 230,000 5.1 155 (2002) 50,000 1,745 (2002) 4,762 South Africa 45,294,000 5,100,000 21.5 30,740 (2001) 1,449 172,338 (2001) 258 Tanzania 35,889,000 1,500,000 8.8 822 (2002) 13,292 (2002) 2,703 Uganda 25,280,000 450,000 4.1 1,175 (2002) 20,000 2,200 (2002) 1,111 Zambia 10,403,000 830,000 24.6 756 (2003) 14,286 10558 (2003) 885 Haiti 8,440,000 260,000 5.6 1,949 (1998) 4,000 834 (1998) 9,091 Guyana 769,000 11,000 2.5 366 (2000) 2,083 1,738 (2000) 437

What do these numbers really mean? A Case of Zambia Not many medical workers are practicing Doctors 646 Nurses 8706 Clinical Officers 1161 Paramedics 1865 Administrative 16868 Total 29284 Source: MOH/CBOH Internal Data 2004

Projected HR Stock in Zambia 2004 - 2009 Staff Type Annual Grads Annual Attrition Rate Year 2004 2005 2006 2007 2008 2009 Doctors 49 9.8% 756 731 708 688 669 653 Pharmacy Staff 132 4.6% 807 902 993 1080 1164 1243 Lab Techs 38 3.5% 292 320 347 373 398 422

Part II: Critical Challenges and Emerging Opportunities The Greatest Challenge for HRH in the new millennium is to keep pace with new and emerging diseases. Either we take hold of future or the future will take hold of us -Patrick Dixon, 2004

Critical Challenges I: Demand of HRH is greater than supply Shifting and increasing disease burden due to HIV/AIDS, TB and Malaria Several modeling exercises have shown that need is greater than supply Using outdate staff mixes Staffing ratios that are not based on reality HRH efficiency

Human Resource Growth in Ethiopia 2003-2008 Staff Cadre Annual # of Graduates Annual Attrition Rate Total Public Sector Staff 2003 2004 2005 2006 2007 2008 Doctors 159 9.6% 1,162 1,210 1,253 1,292 1,328 1,360 Nurses 2,002 3.2% 14,123 15,419 16,673 17,887 19,061 20,197 Pharmacists 326 6.3% 1,140 1,166 1,190 1,212 1,233 Lab Techs 1,915 1,892 1,870 1,850 1,831 1,813

Critical Challenges II: Mal-distribution of staff in Zambia Province Doctor:Population Population:Clinical Officers Central 28922 7669 Copperbelt 7828 8456 Eastern 45040 9465 Luapula 51690 11929 Lusaka (16% pop) (38%) 5435 6563 North Western 27779 10606 Northern 57213 11764 Southern 31898 6966 Western 27325 8408 Source: MOH/CBOH Internal Data 2004

Critical Challenges III: High Attrition Rates in Cote d I’voire

IIIa. Rates of Attrition by Cause in Zambia (2004) MDs 9.2% Nurses 3.2% Pharmacists 6.3% Source: MOH Survey, 1/2003 – 6/2004

IIIb. Zambian nurses Recruited by the United Kingdom 1998-2003 Under the Commonwealth Code of Practice for International Recruitment of health workers, the UK has not reciprocated for the advantages gained by recruiting nurses from Zambia. (1) Limited transfer of technical skills, and financial assistance (2) No training program for those who return and (3) No arrangements to facilitate the return of recruitees. (Commonwealth Minister’s Meeting 5/2003) Source: Nursing and Midwifery Council, 2004. www.nmc-uk.org

Other Critical HRH Challenges The effect of fiscal policies Ceiling on country’s overall spending (health 10% GDP) Growth restrictions on civil service budget leading to hiring freezes Need to conform to PRSP 8.1% public servant personal emoluments Weak HR management information system Resulting in piecemeal solutions and redundant studies

Emerging Opportunities DFID support to Malawi – 6 Year Emergency HR program to top salaries Ghana increasing salaries and allowances Enormous funding going to expanding capacity building and training through PEPFAR, Global Fund, World Bank initiatives Public-private partnership evolving The Clinton Foundation hiring 150 nurses in Kenya for 3 years

Part III. Meeting PEPFAR Targets for ART in Cote d I’voire

PART IV. Potential Solutions Scaling up successful demonstration projects Maximize the use of existing resources Redistribution of HW from urban to rural Introducing incentives to improve morale and retention Rethinking roles and responsibilities –shifting Not to build new schools but strengthen exiting ones –twining of institutions

Part V. Three Key Messages HRH must be on the national and international agendas and action must be taken now HRH interventions must not be more of the same….. we need to be ready for new and emerging infections Outcome oriented, innovative, learning oriented and system linked We must not walk away from HRH issues, we must walk into them Long-term cost of not acting is very high

Thank you URL: www.PHRplus.org The PHRplus Project is funded by U.S. Agency for International Development and implemented by: Abt Associates Inc. and partners, Development Associates, Inc.; Emory University Rollins School of Public Health; Philoxenia International Travel, Inc. Program for Appropriate Technology in Health; SAG Corp.; Social Sectors Development Strategies, Inc.; Training Resources Group; Tulane University School of Public Health and Tropical Medicine; University Research Co., LLC. URL: www.PHRplus.org