The Global Crisis Global shortage of nurses & other health professionals Migration of nurses & doctors to developed countries Impact on delivery of care & health outcomes Undermines Africa’s effort to achieve Millennium Development Goals

Major Studies & Publications Joint Learning Initiative (JLI) World Health Report 2006 –Extended the JLI report –Additional data

The Glue of the Health System

The Health Worker Density Index (HRH index) 1. A composite index 2. A density of 2.5 workers per 1, a threshold to cover essential health interventions & core MDG-related health services. 3. Sub-Saharan Africa need 1 million additional health workers.

Association between Mortality & Health Worker Density

Health Worker Density Comparisons by World’s Regions From: JLI 2004.

Numerical Approach  Valuable for advocacy  Prompted debate & discussion  Stimulated policy review

Systematic Analysis: Back to basics 1. Task analysis –Identify needed skills & competence –Design training & apprenticeship –Review job descriptions / deployment 2, Managing migration –Dimensions & determinants –Amelioration 3. Balanced investment in health systems

HOME / COMMUNITY Home based care Community based care Information exchange Technology transfer. PRIMARY CARE FACILITY Basic health care Referral.... FIRST REFERRAL HOSPITAL Complicated cases:  Emergency Obstetric care  Severe malaria  Life-threatening illnesses SECOND / THIRD REFERRAL HOSPITALS Specialist care:  Internal Medicine  Paediatrcis  Surgery  Obstetrics

PUSH PULL

Higher income Better working environment Security Low income Unpaid salaries Shortage of drugs, etc Poor logistic support Loyalty to nation Family ties Social & other interests

Managing Migration  Realistic national human resource policy  Gather data & monitor trends  Tackle ‘push’ factors  Negotiate managed migration  Make most effective use of health workers  Note: the large amount of funds repatriated by African workers

Amelioration of PUSH factors Financial incentives –Realistic salaries in terms of local realities –Regular payment of salaries. Allowances & pensions Non-financial incentives –Improving working environment –More efficient management of services Consultations accredited representatives of: –Health workers –Civil society

Balanced investment in the health system Mismanaged, malfunctioning health systems ‘Sick System Syndrome’ Staff salaries - high percentage of recurrent budget (60-80%) Infrastructure, supplies, logistics, etc. inadequate Vertical programmes fragment health systems

Strengthening Health Care Units PHYSICAL Infrastructure Equipment Maintenance MANAGEMENT Evidence Procurement/Distribution Human resources Financing RELATIONSHIPS Stewardship Development partners Health education Community mobilisation Dare & Reeler, 2005

Training Obstetricians in Ghana PeriodTrained Working in Ghana To 1989 UK Ghana 3837 Can other nations adopt lessons learnt?

Training manual Developed in Ghana Translated to French, Spanish, Vietnamese, Russian, etc. Used in 30 countries