Health Systems: Goals, Functions, Actors Health workforce...25 September 2019 Health workforce 10 Availability Sufficient supply of health workers, with competencies and skill mix

Health Systems: Goals, Functions, ActorsHealth workforce

Daniel OpokuDepartment of Health Care Management, Technische Universität Berlin

(WHO Collaborating Centre for Health Systems Research and Management)European Observatory on Health Systems and Policies

WHO 2007

25 Sept

25 Sept

26 Sept

26 Sept

27 Sept

01 Oct

02 Oct

02 Oct

03 Oct

03 Oct

2

Guiding framework for the module

24 September 2019 Frameworks 1

01 Oct

Summary: 27 Sept Performance assessment: 03 Oct

& other frameworks: 24/25 Sept

25 Sept

325 September 2019 Health workforce

Outline of the course

1st Semester – Week 1

1W1 Monday (23.09.) Tuesday (24.09.) Wednesday (25.09.) Thursday (26.09.) Friday (27.09.)

08:00 -

10:00

Public Holiday

+

Arrival of non-KNUST

student participants

Frameworks 2/Financing (triangle) Service delivery

10:30 -

12:30

Campus tour for

exchange students/short

course participants

FinancingMedical products and

technologies

13:00 -

15:00

Introduction, expectations,

groupsHealth workforce

Group work (triangle Ghana

health system)

Leadership, governance,

stewardship

15:30 -

17:30Frameworks 1 Information

Optional supervised group

workPreliminary summary

1st Semester – Week 2

1W2 Monday (30.09.) Tuesday (01.10.) Wednesday (02.10.) Thursday (03.10.) Friday (04.10.)

08:00 -

10:00Improved health

Efficiency and

responsiveness

10:30 -

12:30Access and coverage

Financial protection and equity in

financing

Health system performance

assessment (summary)

13:00 -

15:00

Group work (access,

coverage – Ghana health

system in cube)

Group work (health system goals,

ranking, weighting)Revision

Departure of non-KNUST

student participants15:30 -

17:30

Group work presentation

(graded)Quality and safety Self-study for mid-Sem Exam

Mid-term exam (30 min) +

final questions

NB: Lecturer (by colour) = PD Dr. Wilm Quentin Dr. Daniel Opoku W. Quentin + D. Opoku

4

Agenda


• Importance, definition and indicators of health workforce

• Distribution of health workforce & health staff shortage

• Shifting demands and rising pressures on health workers

• International mobility of health workforce


High-income countries: Growth in health & social sector outpaces general employment growth, 1990-2014


WHO 2016 OECD 2016

High on the international agenda (2016)


High on the international agenda (2017)


“Health workers are all people primarily engaged in actions with the primary intent of enhancing health.” (World Health Report 2006)

“A well-performing health workforce is one that works in ways that are responsive, fair and efficient, to achieve the best health outcomes possible, given available resources and circumstances.” (WHO, 2007)

Health workforce includes different occupations: • Physicians, nurses and midwifery personnel• Dentistry & pharmaceutical personnel• Laboratory health workers• Environmental and public health workers• Community and traditional health workers• Other health service providers• Health management and support workers

… working in curative, preventive and rehabilitative care services as well as health education, promotion and research.

Health workforce: definitions


Source: A Universal Truth: No Health Without a Workforce

Third Global Forum on Human Resources for Health Report

Four critical dimensions of Human Resources for Health I


Availability Sufficient supply of health workers, with competencies and skill mix that correspond to population needs

Accessibility Equitable distribution of health workers in terms of travel time and transport (spatial), opening hours (temporal), referral mechanisms (organizational); direct and indirect cost of services (formal & informal)

Acceptability Characteristics and ability of the workforce to treat all patients with dignity, create trust and enable/promote demand for services (age/religion/social & cultural values etc.)

QualityCompetencies, skills, knowledge and behaviour of health worker as assessed according to professional norms and as perceived by users

Can these dimensions

be influenced and how?

- Governance! Based on data/evidence

- E.g. health workforce policies- Legislation & regulation,

e.g. incentives/ disincentives, education;

- non-legislative governance mechanisms

Four critical dimensions of Human Resources for Health II


Key indicators

Health worker density• measured by physician/nurse/

midwife/dentist or pharmacistrate per 1000 population

Distribution of health workers• health workers by occupation,

geographical region, facility type, country-of-birth, age and sex/the total number of health workers

Annual number of graduates • N° of graduates from health

profession educational institutions /total population

Skill mix/composition of workforce• nurse/physician ratio,

GP/physician ratio

Employment characteristics • Total annual number of working

hours/number of active health workers, defined in headcounts



Nursing and physician density in EU countries

3 : 1

2 : 1


Why health workforce is important

Source: World Health Report 2006


Ebola outbreak in West Africa in 2014

Source: https://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html


Healthcare systems were too weak to control the outbreak

• Inadequate services and workforce to control the outbreak – cases other than Ebola were often not treated (malaria etc.)

• Problems with adequate and timely payment of health workers for their services as well as appropriate training and education

Source: http://allafrica.com/view/group/main/main/id/00032734.html

WHO defines minimum threshold of 2.3 doctors, nurses and midwives per 1 000 population that are necessary to deliver essential maternal and child health services (MDG 4).

Shortage of health workforce was a major challenge in controlling Ebola during the West African outbreak but workforce itself was also severely affected by the outbreak.


• Mortality: Ebola deaths among health workers? • Are health workers (more) at risk?

Ebola: Health workers essential, but too few andat risk

0.02 0.11 0.06

1.45

8.07

6.85

0

1

2

3

4

5

6

7

8

9

10

Ginea Liberia Sierra Leone

% mortality (caused by Ebola) among total population compared to health workforce

% mortality due to Ebola among total population

% mortality among doctor, nurse/midwive workforce

Source: Evans et al., Lancet 2015

x 70

x 80

x 100


Density of physicians (per 1000 population, 2014)

Liberia: 0.014Sierra Leone: 0.024Guinea: 0.097

Source: http://apps.who.int/gho/data/node.main.A1444?lang=en&showonly=HWF

Russia: 3.3

Australia: 3.4

Germany: 4.1

Norway: 4.4

USA: 2.6

Brazil: 1.8

Argentina 3.8

South Africa: 0.8

Libya: 2.1

India:0.7

China: 1.5

Canada: 2.5


Density of nurses & midwives (per 1000, 2014)

Liberia: 0.266Sierra Leone: 0.319Guinea: 0.466


USA: 9.9

Canada: 9.5

Brazil: 7.4Peru: 1.5

South Africa: 5.1

Libya 6.9

Turkey:2.5

Russia: 4.6

China: 1.7

Australia: 12.3

Norway: 17.4

Germany:13.5

India: 2.1


Health professionals in Africa and globally

WH

O/ O

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In Ghana?

WHO (2017). Africa Health Workforce Observatory. HRH Observatory.

Ghana http://www.hrh-observatory.afro.who.int/countries/ghana-2/

0.11

0.98

0.010.07

0.190.22

1.17

0.04 0.06

0.45

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Physicians Nurses andMidwives

Dentists andtechnicians

Pharmacists andtechnicians

Community health

Den

sity

per

1,0

00

po

pu

lati

on

Density of health workforce in Ghana and WHO African region in 2008

Ghana

Africa


Source: WHO (2016) Health workforce requirements for universal health coverage and the

sustainable development goals.

Uneven distribution of health workers

10x

10x 6x

9x12x

6x


The uneven distribution of health workers …

… multiplies if burden of diseaseis taken into account

Source: WHO. 2006. The World Health Report 2006 -Working

Together for Health, page 9

3% vs.

25%

37% vs. 9%


Density levels also differ significantly within countries

Geographical variation in physician density per 100,000 population by countries’ national, highest and lowest physician density region (NUTS 2 level), 2014


316276

529

302

487

321

414 404

519

439

695

441

551

473

419464

604

501

588

529

689

867

95

160148

227 224

300

240275

129

286240

215

273300 313 328

351

298254

376 378

299

00

100

200

300

400

500

600

700

800

900

1,000

Highest density region lowest region 2014 national

25

Density levels also differ significantly within countries

Geographical variation in physician density per 100,000 population by countries’ national, highest and lowest physician density region (NUTS 2 level), 2014

Source: Maier 2017, based

on Eurostat database 2016

→ Maldistribution leads to both under- and over-served areas2.9x

2.9x

3.6x

3.3x

4.0x

1.1x

1.4x

1.4x

1.7x

1.3x

1.4x


x 2.6

x 2.3

x 1.0

x 1.2x 1.2

Urban-rural discrepancies:a different way to look at intra-country variation

x 2.5


Ghana? What data on urban/rural divide?


902

2346

990

551

2338

1564

5 18

236

0

500

1000

1500

2000

2500

Physicians Midwives Dentists Radiographers Medical assistants

Tota

l nu

mb

ers

of

hea

lth

wo

rkfo

rce

Total numbers of health workforce by geographic distribution in Ghana in 2004

Rural

Urban

-> Only absolute numbers and from 2004


Rising numbers of doctors in OECD countries

Source: OECD (2016) Health Workforce Policies in OECD Countries - Right Jobs, Right Skills, Right Places

http://www.oecd.org/health/health-systems/health-workforce-policies-in-oecd-countries-9789264239517-en.htm


Source: WHO (2016) Health workforce requirements for universal health coverage and the

sustainable development goals.

… but numbers should rise in low-income countries,especially in Africa, not in Europe


Ghana over time? Density of pysicians andnurses/midwives in Ghana 2004, 2007-10


0.160.07

0.11 0.09 0.10

0.950.99

1.05

0.93

0.00

0.20

0.40

0.60

0.80

1.00

1.20

2004 2007 2008 2009 2010

Den

sity

per

1,0

00

po

pu

lati

on

if no bars shown, no data available

Physicians Nurses and midwives



Global health workforce deficit

Driving forces are:

▪ population growth

▪ demographic and

epidemiological transitions

▪ ageing of the existing

health workforce

▪ international migration and

recruitment of health

personnel from low- and

middle-income countries

Global demand for health workers still far outstrips supply, and the gap

is growing every year.


International mobility & migration of health workforce

Since 2000, the number and share has increased in many OECD countries

incoming


WHO Global Code of Practice on the International Recruitment of Health Personnel (2010)

➢ adopted by all 193 WHO member states➢ Aim: to stem the brain drain from poor to rich countries➢ establishes and promotes voluntary principles and practices

for the ethical international recruitment of health personnel

Global care chains’ impacts on health systems

incoming


outgoing

35

A closer look at Ghana

24 September 2019 Frameworks 1


• Physicians: annual registrations in the UK of from selected African countries: 1.1 % (Ghana), 2.0 % (South Africa), and 0.7 % (Zimbabwe) of the total number of doctors registering in the UK.

• Nurses: the number of nurses: 1% from Ghana, 0.6% (SA) and 2.6% (Zimbabwe) registering annually in the UK as a proportion of the total number of nurses registering in the UK; yearly increasing trend (Ghana)

(Source: Stilwell, Human Resources for Health 2003, Buchan & Dovlo for DFID 2004)

Source: Anarfi et al. 2010 Key Determinants of Migration among Health Professionals in Ghana https://www.researchgate.net/profile/John_Anarfi/publication/242579161_Key_Determinants_of_Migration_among_Health_Professionals_in_Ghana/links/5425841c0cf238c6ea7411cf.pdf

Ghana: migration of physicians and nurses

outgoing

incoming


Shifting demands on health professionals


Population growth

& ageing, epidemiological

transition

Retirement, supply ofgraduates

3825 September 2019 Health workforce12 September 2018 Health workforce 38

Public policy levers to shape health labour markets

Source: WHO (2016) Working for health and growth: investingin the health workforce. Report of the High-Level Commission on Health Employment and Economic Growth.


Take-home messages

• Health workers are the backbone of strong, resilient health systems.

• Demand for health workforce expected to increase (e.g. demographic and epidemiological transitions, technology, changing patients expectations) -> access to safe & quality health services

• Health workforce shortages widen inequities in access to & quality of health services -> economic consequences and development (HIV/AIDS / Ebola in West Africa)

• Equity? International health worker mobility affects low resource countries that already have shortages –> but mobility of health workers may also bring benefits to source nations (brain drain to brain gain/circular migration?)

Health Systems: Goals, Functions, Actors Health workforce...25 September 2019 Health workforce 10 Availability Sufficient supply of health workers, with competencies and skill mix

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