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 1,000

-- 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.

COUNTRY HRHINDEX

MATERNALMORTALITY

UNDER 5MORTALITY

Niger 0.30 920 265Togo 0.30 980 141Benin 0.34 880 158Cameroun 0.45 720 155Ivory Coast 0.55 1200 175Ghana 0.93 590 100

Nigeria 1.45 1100 183

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 careCommunity based careInformation exchangeTechnology transfer

.

PRIMARY CARE FACILITY

Basic health careReferral

.

.

FIRST REFERRAL HOSPITAL

Complicated cases:Emergency Obstetric careSevere malariaLife-threatening illnesses

.

.

.

SECOND / THIRDREFERRAL HOSPITALS

Specialist care:Internal MedicinePaediatrcisSurgeryObstetrics

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 MigrationRealistic national human resource policyGather data & monitor trendsTackle ‘push’ factorsNegotiate managed migration Make most effective use of health

workersNote: 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

Period Trained Working in Ghana

To 1989 UK 30 31989-2006 Ghana 38 37

Can other nations adopt lessons learnt?

Training manual • Developed in Ghana

• Translated to French, Spanish, Vietnamese, Russian, etc.

• Used in 30 countries