2. 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

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

4. The Glue of the Health System

5. The Health Worker Density Index (HRH index) 1. A composite index 2. A density of 2.5 workers per 1,000 -- a threshold to cover essential health interventions & core MDG-related health services. 3. Sub-Saharan Africa need 1 million additional health workers.

6. Association between Mortality & Health Worker Density

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

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

12. 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

13. 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

14. PUSH PULL

15. 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

16. 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

17. 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

18. 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

19. 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

20. Training Obstetricians in Ghana PeriodTrained Working in Ghana To 1989 UK 303 1989-2006 Ghana 3837 Can other nations adopt lessons learnt?

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