INCENTIVES TO SUPPORT HUMAN RESOURCES FOR HEALTH (HRH), RETENTION, PRODUCTIVITY, AND EQUITABLE DISTRIBUTION Lalitha Mendis, Indika Karunathilaka, and Hiranthi de Silva AAAH Conference, Bangkok, October

Sri Lanka Surface area62,7 million sq km KM Surface area62,7 million sq km KM Population19.2M Population19.2M Health Budget3.8% GDP Health Budget3.8% GDP Health Indices Health Indices Life Expectancy 73 years Life Expectancy 73 years Infant Mortality/1000 live births 11.2 Infant Mortality/1000 live births 11.2 Maternal Mortality /10,000 live births1.9 Maternal Mortality /10,000 live births1.9 Under 5 yr mortality/1000 live births 16.3 Under 5 yr mortality/1000 live births 16.3 Health Work force 100,000

MAIN PROBLEMS RELATING TO HRH Insufficient numbers in some categories Insufficient numbers in some categories Maldistribution Maldistribution Migration Migration International International Rural to urban Rural to urban Public to private sector Public to private sector Lack of clear health policy Lack of clear health policy Lack of proper management information system Lack of proper management information system Lack of modern management system Lack of modern management system

As at 2006 & 2010 projection 55.2 Drs per 100,000 population i.e. one Dr per 1811 people Drs per 100,000 population i.e. one Dr per 1811 people. (By 2010 it should increase to 90.5 Drs per 100,000 i.e. I Dr per 1100 persons) (By 2010 it should increase to 90.5 Drs per 100,000 i.e. I Dr per 1100 persons) 4.3 specialists per 100,000 population i.e. One Sp per 23,000 persons 4.3 specialists per 100,000 population i.e. One Sp per 23,000 persons (By 2010 we should have 10.8 sp per 100,000; i.e. 1 sp per 9000 persons) (By 2010 we should have 10.8 sp per 100,000; i.e. 1 sp per 9000 persons) 2.8 GPs per 100,000 population i.e. GP per 35,000 persons. 2.8 GPs per 100,000 population i.e. GP per 35,000 persons. 6.2 dentists per 100,000 pop. i.e. 1 dentist per 16,000 persons. 6.2 dentists per 100,000 pop. i.e. 1 dentist per 16,000 persons.

DOCTORS PER 100,000 POPULATION DOCTORS PER 100,000 POPULATION Drs per 100, Drs per 100, Sri lanka Sri lanka Global average 170 / 100,000 population Global average 170 / 100,000 population South Asian average 40 + South Asian average 40 + Sri Lanka55.2 Sri Lanka55.2 Bangladesh23 Bangladesh23 India51 India51 Nepal05 Nepal05 Pakistan66 Pakistan66 Malaysia67.2 Malaysia67.2

Medical Laboratory Technologists RadiographersPhysiotherapistsECG RecordistsEEG Recordists No.RateNo.RateNo.RateNo.RateNo.Rate Rate per 100,000 population Source : Annual Health Bulletin 2002 Medical Statistics Unit Allied Health Professionals in SL, September 2002

NURSES NURSES Cadre 36,000 Cadre 36,000 Available Available In Training 8000 In Training 8000

Province Non specialst Dr /100,000 Pop Dr /100,000 PopSpecialist DR/ 100,000 pop Number of GPs Population density (persons per sq. KM 2002) Rural & Estate Doctors per 100,000 Population Western (79.6%)1,51568%71.3 Southern %43.8 Sabara’ Central %52.4 N.West (6.5%)29195%37.4 Uva %35.5 N.Centr %40.4 North %30.7 East Sri lanka ??55.2

Undergraduate Medical Education Undergraduate Medical Education Free Free 8 medical Schools 8 medical Schools ? Impending glut of doctors ? Impending glut of doctors Postgraduate Medical Education (PGIM) Postgraduate Medical Education (PGIM) Compulsory year of overseas Training Both undergraduate and postgraduate medical education by Ministry of Higher Education

Loss of Postgraduate Trainees who Qualified MD/MS from 1993 to 2000 Loss of Postgraduate Trainees who Qualified MD/MS from 1993 to 2000 Time Period Number who qualified with MD/MS Number who left Sri Lanka after MD/MS Percentage Loss 13%28% Highest Losses Psychiatry33%56% Dental Surgery 33%50% Anesthesiology26%37% Opthalmology25%- Medicine28% Microbiology-29% Paediatrics-28% Surgery-34%

Training of Nurses and AHP Training of Nurses and AHP By Ministry of Health By Ministry of Health Recently Recently 4 universities have begun BSc courses 4 universities have begun BSc courses

What Non Financial Incentives are possible to populate the provinces with HCWs that they need Improve living conditions of housing, and accommodation Improve living conditions of housing, and accommodation Schooling for children by ensuring places for children in closest & good urban schools (army has this arrangement) Schooling for children by ensuring places for children in closest & good urban schools (army has this arrangement) Provide car loans and housing loans Provide car loans and housing loans Provide good working conditions that satisfy their professional conscious & good job satisfaction and enable them to use the skills that they have learned Provide good working conditions that satisfy their professional conscious & good job satisfaction and enable them to use the skills that they have learned Work out a credit and reward system for working in difficult areas Work out a credit and reward system for working in difficult areas

What Non Financial Incentives are possible to populate the provinces with HCWs that they need Limit the period spent in difficult areas to a minimum Limit the period spent in difficult areas to a minimum Offer the incentives of recruitment in services to those in different areas as the understanding they will serve in that area for a specific period of time Offer the incentives of recruitment in services to those in different areas as the understanding they will serve in that area for a specific period of time The ministry could inspire more confidence in the system – that is worker friendly, efficient, non-political, fair and firm. The ministry could inspire more confidence in the system – that is worker friendly, efficient, non-political, fair and firm. For this the ministry needs a good management information system. For lack of this and due to political manouvering some remain in urban areas for long period of time. For this the ministry needs a good management information system. For lack of this and due to political manouvering some remain in urban areas for long period of time.

INCREASING MOTIVATION AND PERFORMANCE Performance based salary increments and promotions Performance based salary increments and promotions Improve social prestige & image Improve social prestige & image Reward good work e.g. opportunities for post- basic training in country or overseas Reward good work e.g. opportunities for post- basic training in country or overseas

ADDRESSING THE HRH PROBLEM ROLE OF MINISTRY OF HEALTH ROLE OF MINISTRY OF HEALTH Human Resource Unit in Ministry of health Human Resource Unit in Ministry of health Research the problem Research the problem Evidence based solutions Evidence based solutions Clear and transparent policies Clear and transparent policies POSSIBLE ROLE OF WHO AND GHWA Advocacy Fund Research

Thank you