Health Workers and the Millennium Development Goals (MDGs) . . Health Workers and the Millennium Development Goals (MDGs) Dr. Mirta Roses Periago Director The UN and You: Making a Difference Together. GWU. Washington, D.C., October 2006.

MILLENNIUN DEVELOPMENT GOALS (MDGs) THE HIGHEST LEVEL OF POLITICAL CONSENSUS ON THE MEASURES TO COMBAT POVERTY 1 2 HEALTH’S IMPORTANCE GIVES IT A KEY ROLE IN DEVELOPMENT Why are the MDGs important? Commitment to Action QUANTIFIABLE AND AMBITIOUS GOALS AND INDICATORS TO MEASURE ADVANCEMENT AND DEMAND PROGRESS 3 BY DIFFERENTIATING BETWEEN THE AVAILABLE AND THE NECESSARY IT IS POSSIBLE TO CALCULATE ACHIEVEMENT COSTS 4 A GLOBAL PARTNERSHIP FOR DEVELOPMENT THAT EMPHASIZES THAT GLOBAL SECURITY AND PROSPERITY ARE RELIANT ON A MORE EQUITABLE WORLD. 5

MILLENNIUM DEVELOPMENT GOALS (MDGs) 1. Halve extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce under-five mortality rate by two thirds 5. Reduce maternal mortality by three quarters 6. Reverse the spread of diseases, especially HIV/AIDS and malaria 7. Ensure environmental sustainability 8. Create a global partnership for development Skilled Health Personnel is critical to achieve these goals

Overview of progress towards the Goals The region is on track to meet the targets for: Reducing hunger Reducing under nutrition among children Reducing infant mortality Access to drinking water Gender equity in education The region has not made enough progress towards the targets concerning: Extreme poverty (adverse pattern: countries with higher poverty rates have advanced less) Maternal mortality Universal primary education Access to sanitation Environmental sustainability The Shortage of Health Workers The Millennium Development Goals: A Latin American and Caribbean Perspective United Nations/ECLAC

Mortality rate for children under five years of age in 2003 and 2004 Latin America and the Caribbean (20 countries): Mortality of children under 5 in 2003 and progress since 1990 Source: World Population Prospects, The 2004 revision, calculations by ECLAC Progress since 1990 Source: PAHO Core Health Data System Mortality rate for children under five years of age in 2003 and 2004 Progress since 1990 ON THE RIGHT TRACK Expected progress: 52% In the period 1990-2003 the region made significant strides in improving the health of its population, particularly children’s health as is demonstrated by the substantial reduction seen in all the child mortality indicators and the resultant increase in life expectancy at birth. In Latin America and The Caribbean, infant mortality has fallen faster than any where else in the world, and in 2003 it was lower in Latin America and the Caribbean than in any other developing region. Percentages Percentages progress Source: PAHO Core Health Data System Fuente: World Population Prospects. The 2004 revision

Maternal mortality ratio, 2003/2004 Latin America and the Caribbean (7 countries with data available): Maternal mortality ratio in 2003-2004 and progress since 1990 Maternal mortality ratio, 2003/2004 Progress since 1990 Maternal mortality, and morbidity associated with its determinants, is a major public health problem that highlights some of the most severe inequities in living conditions and reflects the health status of women of reproductive age, their access to health services and the quality of the care they receive, including access to contraception. Ratio per 100,000 live births Percentage progress Source: PAHO Core Health Data System

Relationship between mortality and health workers density

Mortality in selected groups of countries in LAC by density levels of Human Resources for Health Source: PAHO/WHO Basic Indicators 2006 Source: PAHO/WHO Basic Indicators 2006

Percentages of Skilled Care at Delivery Percentages of Births Attended by Trained Personnel Selected Countries of the Americas, c 2000 Percentages of Skilled Care at Delivery LAC average:87.9%

Health Workers and the MDGs The shortage of health workers in many places is among the most significant constraints to achieving the millennium development goals Health Workers shortage has replaced finance issues as the most serious obstacle to implementing national treatment plans Achieving the MDGs will depend on finding effective human resources approaches that can implement rapidly. Source: WHO World Health Report 2006

Constraints Inadequate numbers and skills of health workers Uneven distribution of workers at different levels of service delivery, from national program officers to health facility personnel Inappropriate or inadequate training, with curricula that are not needs-based Poor access to information and knowledge resources Source: WHO World Health Report 2006

Human Resource for Health by WHO Regions 1995-2004

Percentage of the Population assisted by doctors & nurses, 37 & 36 countries of Latin America and the Caribbean c. 2001 Nurses Doctors More than 50 nurses 2000 patients per doctor 20-49 nurses per Fewer than 5 physicians per per 10,000: 2% 10,000: 0.4% 10,000: 0.1% Less than 5 nurses per 10,000: 17% 5-14 physicians per 10,000: More than 30 physicians per 10,000: 9.6% 27.6% More than 2000 patients per nurse Nurses 15-29 physicians per 10,000: 62.6% 5-19 nurses per Between 526 & 2000 patients per nurse 10,000: 81% Between 667 & 345 patients per doctor A Call to Action TOWARD A DECADE OF Human Resources for Helath in the Americas (2006-2015) VII Regional Meeting of HR Observatories in Toronto, 4-7 Oct 2005

The Toronto Call to Action Five Challenges: Develop HHR plans and policies that respond to health needs of population Place the right people in the right places Regulate migration (internal and external) of health workers Generate labor relationships that promote safe and healthy work environments and foster institutional commitment Develop links between health services and academia I would now like to present the main elements that make up the theoretical framework on which our project is based. There are 5 elements; which are: The five challenges that were identified in the Toronto Call to Action The values on which these challenges are based The 10-year plans that have been developed by the countries The concept of leadership which we are using for our analysis The country context Although the challenges and problems to solve in the area of human resources for health are many, the countries agreed to group them into five critical challenges and to focus their efforts over the next decade on them. The challenges are: -----

In the Region of the Americas In 2000, over 163 million people in the Americas resided in areas where the human resources density was below the minimum target of 25 per 10,000 In the 15 countries where the health human resources density ratio is below 25, it would take approximately 128,000 additional doctors and nurses to reach that level

In the Region of the Americas With respect to the 6 countries with the lowest densities, it would require almost 23,000 doctors and nurses to raise the ratio to the mid-point between the current 8,3 and the target of 25 Physician supply in urban areas is 8 to 10 times higher than it is in rural areas Nurses outnumber doctors 3 to 1 in North America, but doctors outnumber nurses 3 to 1 in many Latin American countries

In the Region of the Americas Roughly three quarters of the countries and territories of the Americas have experienced a net loss with respect to migration of their health human resources Haiti, with the lowest physician to population ratio in the Americas, has a physician migration rate almost 12 times higher than Cuba, with one of the highest ratios in the world The gap between countries with high and low densities of health workers continues to grow

Exit Routes from the Health Workforce Source: WHO World Health Report 2006

Migration Not just brain drain… Migration takes place within countries (rural to urban) Within regions (From poorer to better off countries) However… When large of numbers of doctors and nurses leave the countries that finance their education, they lose a return on their investment and end-up providing wealthy countries with a “perverse subsidy” When a country has a fragile health system, the loss of its health workforce can bring the whole system close to collapse and the consequences can be measured in lives lost. Each year migration generates billions of dollars in remittances and has therefore been associated with a decline in poverty in low income countries. If the health workers return, they bring significant skills and expertise to their home countries In this context the calculus of international migration shifts from “brain drain” to “fatal flows”

“The Call to Action aims to mobilize institutional actors, both national and international, of the health sector and other relevant sectors and civil society, to collectively strengthen the human resources for health through policies and interventions, in order to achieve the Millennium Development Goals and according to the national health priorities to provide access to quality health services for all the peoples of the Americas by the year 2015”

Human Resources for Health: a global public health issue