Global Health Workforce Alliance The challenge of HRH brain drain in Africa Ms. Sandra Kiapi Executive Director, Executive Director of Action Group for Health, Human Rights and HIV/AIDS 25 February 2009, Kampala, Uganda

The heart of the matter – the people Health workers are the cornerstone and drivers of health systems Who are health workers? –Health workers are all people whose main activities are aimed at enhancing health: – Doctors – Nurses – Pharmacists – Laboratory technicians – Financial officers – Cooks – Drivers – Cleaners

Global health workforce crisis Shortfall of 4.3 million globally –2.4 million health service providers and 1.9 million management support workers One billion people without access to health workers Rates of training and education too low Sub-Saharan Africa: 25% of global burden of disease but only 3% of world's health workers 1 in 4 doctors and 1 nurse in 20 trained in Africa is working in developed countries (Source: World Health Report 2006)

Migration - Figures tell the story… Estimates suggest 20% of Malawian nurses and 60% of Malawian doctors work abroad. One of the country’s central hospitals has just 30 nurses, 26 of whom have plans to leave the country. In Swaziland, 90 nurses graduate from Swazi schools each year – an estimated 60 to 80 of these then migrate to the United Kingdom. Nearly 30% of Ghana’s physicians are working abroad; roughly half of all doctors and a third of nurses leave the country after training. Conversely, Save the Children UK estimates that the United Kingdom saved £65 million in training costs between 1998 and 2005 by recruiting Ghanaian health workers.

57 Critical shortage countries (doctors, nurses & midwives) Source: World Health Report 2006

Why do health workers migrate? Workers tend to go where the working conditions are best Reasons to migrate include: – Income – Better working conditions – More job satisfaction – Career opportunities – Quality of management – Governance – Political instability – War – Threat of violence in the workplace

Migration is a stepwise process Migration is a stepwise process Within a country: Poorest regionsRicher cities Public sectorPrivate sector Between countries: Developing countries Developed countries

Impact of migration Positive features: 1.Billions of US$ in remittances (the money sent back to home countries by migrants) 2.When health workers return, significant skills and expertise back to their home countries Negative features: 1.Financial loss on investment of education of health workers 2.Risk of collapse of a fragile health system

Tackling migration: What is needed –Exporting countries: Protection and fairer treatment of health workers Training of health workers specifically for rural postings –Importing countries: Reduced dependency on migrant health workers in industrialized countries. Bilateral agreements with exporting countries Responsible recruitment policies by industrialized countries.

Tackling migration: What is needed –International agreements: Joint investment in research and information systems critical for enhancing the performance of the health workforce. Agreements on ethical recruitment of and working conditions for migrant health workers, and international planning of the health workforce for humanitarian emergencies and global health threats such as an influenza pandemic Commitment from donor countries to assist crisis countries with their efforts to improve and support the health workforce. Of all new donor funds for health, 50 percent should be dedicated to strengthening health systems, and 50 percent of those funds dedicated specifically to the health workforce.

Some examples: 1. Africa Health Strategy Human resources for health (the health workforce) is a pillar for the provision of quality health care. Due to the inadequate numbers because of inadequate production, migration (internal and international), attrition and other challenges, Africa has to implement strategies to rectify this shortage. Curricula development for other cadres like midlevel health workers and retention strategies need to be enhanced, funded and implemented at country level. Development of country Human Resources Plans is of primary importance. Emphasis on Healthy Lifestyles, Nutrition and other risk reduction awareness programmes need to be promoted in order to prevent the escalation of non-communicable diseases and improve the quality of life

2. Code of practice on the international recruitment of health workers Specific action points include that: –Governments will monitor health workforce flows in and out of countries, making such data transparently available and using this information to inform policy and management decisions –All countries will work collectively to address current and anticipated global health workforce shortages. Richer countries will give high priority and adequate funding to train and recruit sufficient health personnel from within their own country –National governments will be supported to develop coherent policies and build capacity to analyze the implications of trade agreements on the mobility of the health workforce. This effort will be informed by stakeholder consultation mechanisms within and outside government –Stakeholders will test and evaluate innovative interventions in the international health workforce market to assist retention

2. Code of practice on the international recruitment of health workers –GHWA particularly notes the need to ensure the capacity and commitment in both source and destination countries to collect essential data to enable the implementation of the Code and to support monitoring and evaluation of actions taken. –The Alliance underlines that if the issue of migration is not adequately addressed, countries will not be able to provide the health care needed for their populations.

Global Health Workforce Alliance and migration First Global Forum on Human Resources for Health endorsed the Kampala Declaration and Agenda for Global Action – the roadmap for next decade for coordinated, collective international and national efforts to resolve the global health workforce crisis. Within these documents, 'managing the pressures of the international health workforce market and its impact on migration' is specified among the necessary fundamental action strategies. The roadmap: Kampala Declaration and Agenda for Global Action

The roadmap: Kampala Declaration and Agenda for Global Action "While acknowledging that migration of health workers is a reality and has both positive and negative impact, countries [are called] to put appropriate mechanisms in place to shape the health workforce market in favour of retention. The World Health Organization will accelerate negotiations for a code of practice on the international recruitment of health personnel." As one of its key elements, the declaration states:

Monitoring health workforce flows in and out of countries, making such data transparently available and using this information to inform policy and management decisions. WHO will accelerate negotiations for a code of practice on the international recruitment of health workers. Address current and anticipated global health workforce shortages. Develop coherent policies and build capacity to analyze the implications of trade agreements on the mobility of the health workforce. Stakeholders will test and evaluate innovative interventions in the international health workforce market to assist retention. Migration: Kampala Declaration priority points

HWMI is a partnership of GHWA, WHO and Realizing Rights Established in 2007, co-chairs are Mary Robinson (President of Realizing Rights) and Dr Francis Omaswa (former GHWA Executive Director) The HWMI focus is on: –conducting assessments of bilaterals, codes and agreements underway; and –supporting countries in the development of policy to address health worker migration as needed. HWMI also supports the WHO in development, negotiation and implementation of the draft code of practice. Health Worker Migration Policy Initiative (HWMI)

Positive Practice Environments campaign Positive practice environments are settings that ensure the health, safety and personal well- being of staff, support the provision of quality patient care and improve the motivation, productivity and performance of individuals and organisations. First-ever guidelines on incentives for health professionals Multi-stakeholder collaboration: –World's leading health and hospital professional associations (including the International Council of Nurses (ICN), International Hospital Federation (IHF), International Pharmaceutical Federation (FIP), World Confederation for Physical Therapy (WCPT), World Dental Federation (FDI), and World Medical Association (WMA)

Positive Practice Environments campaign Over the course of five years, the campaign aims to: 1.Raise the awareness, understanding and support of all relevant stakeholders about the positive impact healthy and supportive work environments have on the recruitment and retention of health professionals, patient outcomes and the health sector as a whole. 2.Apply the principles of positive practice environments in workplace design and management practices and facilitate their establishment in the health sector. 3.Offer a global platform to share information, good practices and lessons learned in relation to healthy and supportive workplaces in general and retention incentives in particular. 4.Stimulate a sustained trend toward the establishment of positive practice environments across the health sector. 5.Recognise those settings that meet the criteria of PPE.

Progress in countries: some examples Ghana Salary levels have been improved and makes Ghanaian health workers one of the best paid in West Africa Stemming down brain drain Ensured health workers' satisfaction Mixed plan of incentives and coercion has been operating for years, but without significant success Rural/deprived area incentive scheme implemented (including faster promotion, faster post-basic training, rural monetary incentives and better accommodation) but dropped The country cannot compete in the global health labour market to retain higher-lever professional staff (source: GHWA country case study, 2008)

Progress in countries: some examples Malawi Emergency Human Resources Plan (EHRP): 52% taxed salary top-up for 11 priority cadres Comparison between 2003 – % more doctors 50% more clinical officers 30% more nurses Small decrease of migration to the UK of nurses and midwives, but migration within Africa and out of the public sector remains a problem Work on developing further policy for staffing underserved areas has begun 138 hardship health facilities identified, incentives including housing, communication and transportation have been developed (source: GHWA country case study, 2008)

Health Workers for All and All for Health Workers