1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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?

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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,

20. 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

21. 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

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

23. 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

24. 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

25. 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.
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