Brain Drain: Africa’s Health Workforce Crisis Doug Menuez Allafrica.com Leslie Reti Allafrica.com

Crisis in Africa’s Health Workforce  Africa has 25% of the world’s disease burden, 13.8% of the world’s population, but only 1.3 % of the world’s health workforce (Source: WHO)  Joint Learning Initiative estimate: 600,000 doctors, nurses, and midwives now; 1 million more needed to achieve Millennium Development Goals  This is needed to achieve a health worker density of 250 doctors, nurses, and midwives per 100,000 population  In contrast, the U.S. and Europe have more than 1,000 doctors, nurses, and midwives per 100,000 population (Source: WHO)

Crisis In Africa’s Health Workforce  Rural and poorest areas are worst off  Ghana’s Greater Accra Region has 120 nurses and 30 physicians per 1,000 population. By contrast, Ghana’s Northern Region has only 34 nurses and 1 physician per 100,000 population (Source: Ghana’s MoH)  More auxiliary and community health workers are key  No ideal health worker density or skills set, but magnitude of challenge immense  Personal/Local experience

World Workforce & Health Status: The Global Picture From: JLI 2004.

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

Why It Matters: The Cost of Our Inaction  Major constraint to increasing coverage of essential health interventions in Africa (where money is available). Without addressing the shortage, the Millennium Development Goals and Abuja Declaration cannot be achieved.  AIDS treatment cannot be successfully and sustainably scaled up without more health workers  Studies in Cote d’Ivoire, Ethiopia, and Zambia indicate that without more health workers these countries cannot achieve AIDS targets while maintaining current (woefully inadequate) level of health services  “Putting in place the health workforce needed for scaling up maternal, newborn, and child health services towards universal access is the first and most pressing task.” (Source: WHO)

More Health Workers – Fewer Deaths From: JLI 2004.

Health Care Workers: The Glue of the Health System From: JLI 2004.

Causes and Solutions to the Health Workforce Crisis

Shortage of Health Workers and HIV/AIDS  HIV prevalence among health care workers is similar to general adult population  HIV/AIDS and health care workers’ care obligations  Attrition due to death from HIV/AIDS  Stigma discourages many health workers from learning their HIV status  HIV/AIDS causes significantly increased workload  Deterrent to new entrants into healthcare- perceived risk of occupational infection  Paradox-higher demand for health care workers but lower supply

Causes: Massive Under- Investment in Health Sector  Massive underspending in health sector  Least-developed countries spend an average of US$11/capita on health (1997), including US$6/capita in public spending. A minimum health package costs US$34/capita. (Source: Commission on Macroeconomic and Health [2001])  To contrast, the U.S. spent $4,178/capita on health in (Source: OECD)  Economic policies place ceilings on government spending and wage bills, limiting the public sector’s ability to employ additional health workers.  Many countries cannot even afford to hire nurses and other health workers who are already trained.  Health workforce has not been prioritized  Insufficient/irrelevant training capacity

Causes: Health System and Non-Health System  Health system-related causes:  Health professionals unable to meet their own goals  Health professionals unable to meet their patients’ needs  Non-health system-related causes:  Corruption, crime, instability, lack of development, poor human rights practices, etc.

Causes: Unmet Health Worker Needs; Unmet Patient Needs  Health professionals own needs: unmet  Low salaries  Dangers of occupational infection: HIV, other diseases  Stress from high workloads  Inadequate training, supervision, and management  Lack of opportunities for research and continuing education  Pre-service training often poor preparation for actual practice  Needs of patients: unmet  Lack of medicines, supplies, equipment, and other support required to be healers

Workers Want More than Money

Brain Drain of Health Professionals Out of Africa  Significant numbers of nurses and other health professionals migrate to wealthy countries, including the United Kingdom, United States, Canada, and Australia.  In 2002/2003, more than 3,000 nurses from South Africa, Zimbabwe, Nigeria, Ghana, Zambia, and Kenya registered in the United Kingdom. (Source: James Buchan and Delanyo Dolvo)  Only 360 of 1,200 doctors trained in Zimbabwe in the 1990s were still practicing in the country by (Source: EQUINET/HealthSystemsTrust/MEDACT)  Brain Circulation  Rural to urban, public to private and NGOs, intra- Africa

Migration Intentions- Proportion of Health Workers Who Intend to Migrate, (6 African Countries: 2002) Source: WHO AFRO 2002

Causes: Health Professionals Shortages in Wealthy Countries  Shortages of health professionals in wealthy countries  US nursing shortage: 111,000 short in 2001, 275,000 by 2010, and 808,000 short by 2020 (Source: US Department of Health and Human Services)  US physician shortage: 85,000 to 200,000 by 2020 (Source: USA Today)  Active recruitment (amount unknown)

Projected Nursing Shortfalls in Rich Countries – A Danger for Poor Source Countries?. COUNTRIESPROJECTED NURSE SHORTFALLS & YEAR. United States500,000 – 2015 Canada113,000 – 2011 United Kingdom35,0000 – 2008 Australia31,000 – 2006 Derived from data at - (October 2004)

Huge Regional Disparities in Medical Schools and Graduates

Foreign-Trained Doctors can Make up a Third of the Total Number of Doctors

What Should Be Done?

Solutions: Investments and Policy Changes  Investments (salaries and incentives, health workforce management, safe workplaces, pre-service training capacity, continuous learning opportunities, overall health systems improvements)  Policy changes (integration of community and auxiliary health workers into health systems, advanced practice roles for nurses, respect for all cadres of health workers)  End World Bank/ International Monetary Fund mandated policies that restrict health budgets

Solutions: Self-Sufficiency; “Do No Harm” in Recruitment  Wealthy countries should increase their own training capacity and ability to recruit and retain health professionals, especially in rural areas  End active recruitment of health professionals from developing countries or form mutually beneficial agreement with those countries  UK has a code of practice covering National Health Service; independent sector also encouraged to comply—code can’t succeed otherwise

Commitments and Responses Underway

EXAMPLES OF COUNTRY STRATEGIES  WORKFORCE SUPPLY Expansion in numbers – Professionals/Mid-Level cadres mix? Enrolled Nurses/AMOs in Tanzania External Recruitment – Cuba, ODCs  WORKFORCE PRODUCTIVITY Decentralization, Delinkage – Outcomes mixed (eg; Ghana, Zambia,) New CB, PB curricula. Utilizing Community Resources – Ghana CHPS, Ethiopia HEWs  RETENTION AND MIGRATION MANAGEMENT Income enhancement – Ghana-ADHA Botswana-30% Nurses enhancement, SA – Rural and Rare Skills; Comm. Service  INCENTIVES AND MOTIVATION IMPACT Non financial Incentives? Huge variation in migration intent not always related to PPP differential.  RESTRUCTURING AND GOVERNANCE Leadership & HW Frustrations  HIV/AIDS – Zambia – ARV for Health Workers

Multilateral Commitments  G8 commitment (July 2005): commitment to: “investing in improved health systems in partnership with African governments, by helping Africa train and retain doctors, nurses, and community health workers  UN World Summit (September 2005): commitment to: “increase investment…to improve health systems in developing countries…with the aim of providing sufficient health workers, infrastructure, management systems and supplies to achieve the health related Millennium Development Goals.”  African Union health ministers conference (October 2005): commitment to: “prepare and implement costed human resources for health development plans”

Sources of Funds  Global Fund to Fight AIDS, Tuberculosis, and Malaria  Permits funding for health systems strengthening, including health workforce strengthening  Has funded proposals to pay for salaries, incentives, pre- service training, universal precautions  Global Alliance for Vaccines and Immunization (GAVI)  Expected to approve health system strengthening as a new major area of investment  United Kingdom  In December 2004, the UK committed $100 million over 6 years to support Malawi’s Emergency Human Resource Program (are receiving significant support from the Global Fund, Malawi’s own budget)  Other donors  Some support from other donors (e.g., Dutch, Swedes, Norwegians) as well

US Support  Scattered through increasing responses, primarily through President’s Emergency Plan for AIDS Relief (PEPFAR)(rural incentives for Zambian physicians, salaries for Namibian health professionals providing AIDS treatment, Kenyan nursing database)  New requirement that US develop health workforce strategy in 15 PEPFAR focus countries

What You Can Do

Support US Investments Abroad  Write to and call the President and your Members of Congress to encourage them to include $650 million in global health workforce strengthening in fiscal year 2007  Urge the Administration and Congress to support full funding for the Global Fund to Fight AIDS, Tuberculosis, and Malaria (needs $1.2 billion from the U.S. in the next (2007) budget cycle)  Join the AIDS Advocacy Network (

Support US Strategy on Health Workforce Self-Sufficiency  Support development of explicit U.S. strategy to meet health workforce needs through reduced reliance on foreign health workers  Support investments that will increase the total number of U.S. health professionals and the number serving in areas suffering shortages of health professions (such as through expanding the National Health Service Corps and fully funding the Nurse Reinvestment Act)  Oppose efforts to ease recruitment of foreign health professionals  American Hospital Association and 10 other organizations seeking to speed the flow of foreign nurses in to the U.S.  Wrong solution  Support ethical recruitment principles at your health facility  Convince your colleagues that health workforce strengthening at home and abroad is not zero sum

AIDS Advocacy Network-AAN Mobilize! Chance to network with local and national AIDS activists. Speak at schools in your area Plan events for World AIDS day: Dec 1st Help coordinate Global AIDS Week of Action in February