Addressing the Global Health Workforce Crisis

After I went to Uganda for the Global Forum on Human Resources for Health, I spent a week in Kenya, meeting with our partner group, the Kenya Health Rights Advocacy Forum. As many of you know, Kenya was just coming out of a tragic post election period during which violence killed over 1200 people and displaced almost 300,000. While a peace agreement has been signed, there remain deep divides and challenges to be met in Kenya—especially around health and health workers. During the turmoil in January and February, health workers were displaced, and some faced violence and ethnic discrimination, weakening the health system and scattering doctors and nurses across the country—including to IDP camps. HERAF is deeply concerned about the effect of post-election violence on health workers, and therefore, on the entire health system. During the crisis, HERAF stood with civil society to urge an end to violence and attention to health rights, especially for those with HIV/AIDS. In the coming months, they will document the effects of the violence on health workers while advocating for health and human rights for all during this difficult recovery period in Kenya’s history.

Indeed, while challenges remain in Kenya and across the continent, the Forum gave the world renewed energy to fight for health systems that work—and renewed anger at the promises made and not kept by policy makers world wide.

Please find attached HWAI’s new Platform on Adequate and Sustained Health Workforce Financing, one way PHR will continue to fight to health systems and human rights around the world. We’ve heard plenty of rhetoric about the need for improved health workforce worldwide—but have yet to see anything near the estimated $70 billion needed to make this happen. Donors, national governments and international financial institutions all have obligations–and HWAI demands they meet them in order to ensure health rights for all. Read our platform and stay tuned for what you can do to help build health systems in Africa.

HWAI Platform on Adequate and Sustained Health Workforce Financing (PDF)

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After an inspiring week spent talking about and drawing attention to the dire human resources for health crisis in Africa, I traveled to Mozambique to see how these formidable challenges are being faced on the ground.

The Kampala conference was historic, with Africans and especially high-ranking representatives from Ministries of Health and Finance taking center stage and focusing unprecedented world attention for the first time on the crisis. The results were impressive, with coverage from CNN on the brain drain in Malawi, the BBC and even my hometown paper, the Seattle PI.

The fact that the conference was dominated by African governments and civil society signals a new level of political engagement and commitment to creative, indigenous solutions. The final declaration will hopefully be only the start to an ongoing dialogue between donors, international institutions, governments of developed and developing countries, NGOS, and health workers themselves to implement these ideas. PHR’s workshops on advocacy and human rights will provide stakeholders with important tools to ensure that community voices are heard.

In Mozambique, I was able to see first hand how funds for vertical, disease-specific programs like PEPFAR can be used for health system strengthening. Sophia, a woman I met three years ago when working on a film for Health Alliance International, has gone from being desperately ill and hopeless, to accessing life-saving treatment, to working as an peer-counselor and now recently to serving as a treatment counselor in one of the HIV clinics in the city of Beira. With over 35% of adults living with HIV, Beira has one of the highest infection rates in the world. The huge disease burden threatens to overwhelm the already debilitated health care system. Sophia has gone from patient to provider, helping others with HIV overcome their fears of stigma and understand the importance of treatment adherence by drawing on her own experience. She helps take some of the burden off the nurses and doctors as they attend to an ever-growing patient population. As treatment has become more and more accessible, Sophia says she sees more hope and less fears about stigma in recent months. Even though she’s come very far, Sophia has still further ambitions. After working a full day in the clinic, she attends night school every evening and hopes to complete her high school degree in the next few years and eventually study to become a nurse.

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Like the other hospitals we visited during the week, the “theatre” (operating room) at Jinja Regional Referral Hospital was missing necessary instruments, equipment and supplies. Their limited budget could only pay for a small autoclave (machine that sterilizes equipment before and after surgery) that was not big enough to fit some of the larger, over-sized instruments that are often used during surgery. The drug bottles were only 10% full and the rusted surgery beds were ripped and covered with black trash bags.

Outside the theatre I found the MOTH Data Book used to keep record of all the surgeries with simple remarks such as “good,” “fair” and “poor.” The maternity ward—essentially a room with 30 beds and more than 30 patients—was busy as ever and attended by a single nurse with a huge smile.

Time and time again, we met health workers who were over-burdened but never without hope. Overwhelmed by all there is to witness, one can easily feel hopeless that a stronger, more efficient health system would ever be possible. Talking to those health workers though, I felt invigorated and recommitted to the importance of the work that PHR is doing to strengthen health systems and ensuring the right to health.

Throughout the week, I interviewed many health workers who told me about their struggles, their challenges and their hopes. Among them were Nurse Ruth who works at the Infectious Disease Institute at Mekerere University.

I also interviewed Nixon Niyonzima, a 4th year medical student at the Medical School of Mekerere University in Kampala, who works with the PHR affiliated student chapter called Students for Equity in health Care.

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A little over a year ago Time Magazine highlighted people they called “angels”—individuals praised for making a difference in the world of global health. I remember reading the stories of physicians, researchers and scientists and of their contributions and extraordinary efforts. I was, however, saddened that the invaluable work of the professional nurse went unrecognized.

Here in Uganda at the First Forum on Human Resources for Health, where the focus is on the development of a Global Action Plan—a guide to make a lasting impact on the human resources crisis in developing countries—I have had the opportunity to attend a number of sessions that actually acknowledge the essential role of the nurse. In many African countries nurses comprise up to 70% of the health work force: if you don’t include the voice of the nurse a successful HR plan would be hard to come by!

Eager to get first hand input from nurses attending the conference I collaborated with a nurse member of our partnership organization here in Uganda, AGHA. Together we arranged for an impromptu meeting over lunch with nurses interested in sharing their perspectives: what issues need to be addressed in order to retain skilled, motivated nurses able to provide quality, accessible health care.

To my amazement what I had thought would be a handful of nurses turned out to be over 20, all eager to share their personal experiences. They talked about the need to be recognized and respected as “professionals,” to have access to ongoing educational opportunities that led to professional growth; to work in a safe and secure work environment free from harassment and attack; to care for patients in facilities that had electricity and running water; to know that if they suffered from an occupational exposure to HIV or Hepatitis that they could receive confidential and free care.

Their requests were straight forward—but seemingly out of reach. Patrick, Secretariat of the Uganda Nurses Association, shared with me that policies to address many of these issues were in place, but nothing has been implemented. His fear was we would leave the forum with yet another plan—but no action. “How can we be motivated when we are not respected and our voices seem to be ignored?”

As one nurse, Lucy, said “I am proud to be a nurse but I am not happy.” She told stories of having to care for 30-40 critically ill patients on a hospital ward with no supplies, not even a BP cuff that worked, and one O2 tank that frequently was non-operational. Most of those admitted for care died simply because of the lack of adequate equipment and too few nurses to provide care. “I am not going to stop trying to care but it is difficult,” she said.

As I shared the mission of the Health Action AIDS campaign and AGHA with the group and the role that our joint advocacy efforts could play in strengthening their voices, interest peaked, and the energy and enthusiasm of the discussion grew. Participation in the demand for accountability was enticing. Our session ended with 20 new members of PHR and AGHA—a promise to continue the dialogue and pursue the rights that all health professionals, especially nurses, deserve.

Among the many successes of this forum I think we can count the fact that we have a contingent of nurses who perhaps for the first time feel a sense of support and hope. My goal is that sometime in the near future nurses in the forefront of the AIDS battle are given the acknowledgment they have long deserved and are finally recognized among the “angels” for their invaluable contributions to health rights.

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At the first session of the forum, in a room with well over 1000 attendees, I discovered that sitting next to me was a 4th year medical student who is from Case-Western and a member of our PHR Chapter there. He saw my PHR button and leaned over and said, “I’m a member of PHR.” David Beversluis has been in Uganda since January working to review two clinical outcome projects regarding women and HIV. Additionally, he had extensive rotation in adult and pediatric wards. His desire is to finish his studies in the field of emergency medicine and return to Africa to work and perhaps become involved public health policy. He gave me example after example of the failure of health systems, health worker training and what is often a clear failure in the most basic care.

PHR CEO Frank Donaghue and PHR Student Member David Beversluis

David is here in Africa because he is committed to change. As he told me, “Here I can make a large difference. This is an amazing education. The chance to work in a place like this provides a clinical situation you will never get at home.” PHR helped peak David’s passion for this work. As David explained: “human rights is the common ground for dialogue with students across a variety of interests. It begins the dialogue where interest and action can follow.”

At Case, when David was in his first year, he joined 15 other students with PHR and other organizations focused on human rights. David commented that although sometimes in an environment like this, “the difference you can make is deferred,” there is still a powerful impact.

Since coming to PHR, I have heard over and over again how important it is that we maximize the involvement of students; David is a great example of the power that comes with student action.

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Hello from Kampala! At the First Global Forum on Human Resources for Health, hosted by the World Health Organization I’ve been completely immersed in a wide range of health workforce issues. It’s hard to capture the “fierce urgency” with which the right to health is discussed here.

Although more than a thousand people from around the world have joined in this forum, the real motivation for all of us is in the faces of the health care workers, nurses and doctors that face the workforce problems everyday. In small groups, we learned a lot from the health workers who know so much more than statistics. They understand the real nature of the problem and need for radical and innovative solutions.

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International Women’s Day is a national holiday in Uganda. (Almost) everyone has the day off—wonderful for office workers but ironic for village women who really can’t ever take a day off. The president held a major event in the city center and discussed the epidemic of domestic violence in the country—a horrific indicator of the status of women in Uganda.

The PHR team spent much of the day at Jinja Regional Referral Hospital, which serves 5 million people. For me, it was the most moving International Women’s Day I’ve ever had. One of the doctors showed us around the grounds, which are spacious, with buildings constructed a half century ago and slowly crumbling around us. We entered the labor ward which had two long rows of beds up against the walls, with mothers and babies and grandmothers and aunts and friends all gathered, with no privacy at all but a wonderful sense of camaraderie—and a real sense of the power of women. One woman had just given birth to twin girls, who would join her older daughter as soon as they were strong enough. I was so happy for her, and also just a little sad—as in so many countries across the world, boys can be seen as more of a blessing in Uganda than girls, and I only hoped her husband was as happy as she was, and would embrace the women in his life with wonder and love. Another tiny little girl, dressed in a blue onesie with a giraffe on it, was ill with fever, but her mother was confident with the nurses’ care, she would get better. The room was amazing—bright, full of windows, with blankets and pillows of all different colors and patterns (because you have to bring your own linens to the hospital), and quiet laughter and talking and tiny cries. I could have stayed all day with these women and their beautiful babies, celebrating the incredible power of women to bring life into the world and protect their children at all cost.

The team then toured a different ward, for those with severe injuries. Outside, we could hear a kind of moaning that sounded like a wounded animal—and when we entered, we saw a little boy, with a horribly injured leg, being rebandaged. But there was not enough gauze. The sense of hopelessness here was palpable and sick and sad, and I could not stay there. A tiny boy lay with both legs in traction—the traction being rope tied to an old and wilting IV pole, very makeshift, very uncomfortable. No books, no TV, nothing to do but lay down in a large room surrounded by people in misery and pain. A young woman from Congo had been in the same bed for more than a year: while in Uganda, she had been in a horrific car accident, breaking bones and sustaining burns all over her body. Her family had abandoned her, and the hospital was her home. Another young girl sat silent, with a metal rod extending from her knee to a severely swollen foot. I showed her the scars on my knee from an ACL reconstruction when I was 14, trying to find some common ground with her, but our health outcomes will not be remotely parallel. Eight months after my surgery, I was back on the playing field. I’m not sure where she’ll be in 8 months. I only hope she will be able to walk at all, but I cannot imagine she will run, bike, ski, swim and everything I’ve been able to do. The doctors were working hard to help these patients, but it was hard to imagine anyone coming out of that clinic healthy and whole, or even alive—while the health workers were dedicated and skilled, they did not have the equipment they needed to really heal these horrible injuries.

As the tour ended, the first quintuplets ever successfully delivered in Uganda arrived to say hello to their doctor and nurses. One of the babies has died, but the remaining 4 are adorable and strong, all of them wrapped in blankets that read “I love my mummy”—very fitting in a country where women provide most of the child care and on whom the lives of children truly depend. Their mother, Dorothy, came with two helpers, and looked radiant and tired and proud as people from across the hospital grounds gathered around her and blessed the children and shared the love and hope four little ones create in even the saddest of situations. All I could think of was how powerful are women—and how powerful is hope—and how much we owe to the developing world to ensure women live and their children thrive.

You can help make women’s health rights a reality by signing on to HAA’s Women’s platform, Health Rights=Healthy Women. Act now to send a strong message for women’s health and human rights and support all the women we met at Jinja hospital, whose strength is amazing, but whose future is uncertain.

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The Health Workforce Advocacy Initiative (HWAI) held our second strategy meeting during the opening two days of the Forum. PHR chairs and helped to found this international advocacy coalition affiliated with the Global Health Workforce Alliance. We’re a coalition of 14 institutions from Africa, the United States, Europe and Asia, with a loosely affiliated network. Building on plans from our first strategy discussion, we have decided to launch a Campaign on Sustained Health Workforce Financing.

The choice seemed fairly self-evident. So many of the things we’re talking about in the health workforce arena—retaining health workers, training new ones, improving their working conditions, ensuring that they receive health care, providing health workers to serve in rural areas—cost money. That money simply hasn’t been forthcoming. Since health workforce came onto the international agenda three, four years ago, we have all had one example of significant donor investments in health workforce—the United Kingdom (along with the Global Fund) in Malawi. The attention is now there, but not the money. Moreover, if there was one area where civil society had to be speaking out, it would be evident that governments—even those genuinely interested in strengthening the health workforce—and I think many are—weren’t going to be doing it on their own.

Well, this isn’t exactly our first launch. We decided upon this campaign back in July. But our work quickly moved elsewhere—rights-based national guidelines on developing health workforce plans, an advocacy toolkit for health workers, preparing for this Forum and more.

But that’s going to change. Over the past days, we strategized on how to re-energize the campaign, and I think we’re off to a good start. We still have to finalize our plans, but the opportunities are there, including bringing more international voices to PEPFAR reauthorization and doing what we can to encourage countries to apply for funds for health system strengthening from the Global Fund. And we will push on the International Health Partnership—a new effort by most donors other than the United States to focus their aid on national health strategies. This effort misses the important element of new money to fund these strategies. We’ve developed a platform, and are holding a press conference tomorrow about the launch of the campaign.

So be on the lookout for this exciting effort to start to turn the tide of funding! I hope through our growing coalition, and by taking advantage of our potential for reaching deep into the health workforce in Africa—our coalition members includes the International Council of Nurses, which has member organizations in 130 countries—we can make a difference, can help governments respond to the fact that there simply is no excuse for not making life-saving investments in the health workforce.

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In Uganda, we have been preparing for the Global Health Workforce Alliance Forum for many months. Because the forum is here in Kampala, it has provided health professionals and civil society organizations the opportunity to reflect on the situation here in Uganda. Like many countries in Sub-Saharan Africa, Uganda is experiencing a health workforce crisis. In a country of 27 million people, there are only about 2200 doctors and 19,000 nurses and midwives. That’s about 3 times fewer than the minimum number of doctors, nurses, and midwives recommended by the World Health Organization. A large proportion of the doctors, nurses, and midwives are located in Kampala, leaving the rural areas of the country with even fewer health professionals to serve the majority of the population.

At the Action Group for Health, Human Rights, and HIV/AIDS (AGHA), we have convened a group of health professional associations, trade associations, health rights organizations, and health service organizations to develop an advocacy strategy for addressing the health workforce crisis in Uganda. Called the Health Workforce Advocacy Forum—Uganda (HWAF), this coalition has been meeting for the last few months to identify issues and agree on solutions. The goal of HWAF is to advocate for investments, concrete policy changes and improved implementation of existing policies that will lead to enhanced training, recruitment, and retention of health workers in Uganda.

To reach this goal, HWAF is first focusing on three objectives that we believe will help increase both the numbers of health workers and the quality of health services provided in Uganda:

• Ensuring that all approved posts are filled with trained health workers by the end of 2009.
• Improving infection prevention and control mechanisms in clinics and hospitals country-wide.
• Implementing a national policy mandating effective and high quality community-based education as a part of all health professional pre-service training programs.

The HWAF members will all be at the forum—listening, learning, exchanging ideas, and sharing our agenda with others. We are excited to be a part of this important event, and we look forward to sharing more of our experiences on this blog over the coming week.

Emily Bancroft is a Leland Policy Fellow in the Health Action AIDS Africa Program.

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Next week, a team of Physicians for Human Rights staff members, including Frank Donaghue, Pat Daoust, Sarah Kalloch, Eric Friedman and I, will travel to Uganda for the First Global Forum on Human Resources for Health in Kampala. We will also be joined by our colleagues in Uganda, including Emily Bancroft, Winnie Ngabiirwe, Pam Babirukamu Kamujuni, from the Action Group for Health, Human Rights and HIV/AIDS (AGHA). The Forum is being convened by the Global Health Workforce Alliance (a global partnership hosted by World Health Organization) and will bring together up to 1000 participants, including ministers of health, civic leaders, civil society members, health workers, academics and health professional leaders from around the world.

The Forum will provide an extraordinary opportunity for PHR to share and explore solutions with the global movement that is emerging to respond to the critical lack of human resources in health systems. In partnership with our colleagues, including Action Group for Health, Human Rights and HIV/AIDS (AGHA), we will run two workshops on human rights and advocacy training and also attend strategy meetings for the Health Workforce Advocacy Initiative (HWAI). As some of you may know, HWAI is the civil society-led network of the Global Health Workforce Alliance, which PHR currently chairs. HWAI advocates for the needed financing, a rights-based approach and other actions to enable countries to develop the health workforces they need to achieve universal access to essential health services.

As this year marks the 60th anniversary of the Universal Declaration of Human Rights, the Kampala Forum can direct international attention towards a rights-based approach to the crisis in human resources for healthcare. As members of the global come together for the forum, the wider global community can unite to achieve global goals and to secure the highest available standard of health for all. Please stay close by as we bring you updates from the exciting developments in Kampala throughout the coming week.

Jirair Ratevosian, MPH, is the National Field Organizer for PHR’s Health Action AIDS Campaign. 

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