Addressing the Global Health Workforce Crisis

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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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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