http://www.healthallianceinternational.org/index.php Blog Post en deriel@u.washington.edu Copyright 2010 2010-07-26T17:00:03+00:00 http://www.healthallianceinternational.org/blog/post/can-we-afford-fewer-health-workers/ http://www.healthallianceinternational.org/blog/post/can-we-afford-fewer-health-workers/ Two Harvard researchers recently published a paper proposing that the WHO reduce its recommended target for health workers in each country. But we can do better than just telling poor countries to make do with less. Two Harvard researchers (Thomas Bossert and Tomoko Ono) recently published a paper proposing that the World Health Organization reduce its recommended target for health workers in each country, which is 2.3 health workers per 1,000 people. The US, by the way, has about 13 health workers per 1,000. The researchers claim it's "unrealistic as a short- or medium-term goal for many of the low- and middle-income countries" to try to achieve this target, as it would be too costly or just too hard to train and employ so many doctors, nurses and midwives. The 2.3 per 1,000 figure emerged from research conducted by the Joint Learning Initiative, which plotted country performance on two measures: births attended by a midwife or other health professional, and measles immunization by age one year.  Researchers found countries needed at least 2.3 health workers per thousand to get reasonably decent coverage (~80%) on those two measures. By that measure, the WHO estimated a worldwide shortage of more than 4 million health workers.  Others have reported 57 countries have workforce shortages using the 2.3 standard. On average, each of the 57 countries needs another 75,000 health workers.  The WHO also estimated it would cost $136 million a year for each of the 57 countries to train enough people to keep up with the ratio, and another $311 million per country per year to keep those people employed. That's an unrealistic target, say Bossert and Ono. In one way, they are right.  If countries have limited budgets, and they want to achieve a higher health status for their population, spending money on health care may not be the most efficient way to achieve health.  While Bossert and Ono don't suggest this, countries with very scarce dollars could consider focusing those resources on education as a top priority, since education is an important determinant of health. But that's not the authors' point, however. They are instead arguing that if countries can't afford more health workers, they should just make do with less, since external support from donors to pay for or top up salaries is still not likely to be enough, and "relying on donors to cover salaries over the long term is generally not considered prudent." But setting goals based on what countries can afford rather than what they need will never get us to "health for all," or even "health for most." So how do we meet the needs-based WHO recommendation considering the financial limitations of so many countries? It's time we viewed health as a critical worldwide public good for which each country has shared responsibility. There are some things we could do. The US should develop policies that restrict recruiting health workers from shortage countries, in line with the recently passed WHO Code of Practice for the International Recruitment of Health Personnel. Remove harmful macroeconomic policies such as wage caps that restrict how much governments can spend on salaries for health workers and teachers. (To their credit, Bossert and Ono do mention these constraints in their article.) Develop long-term funding streams on which developing country governments can rely so they can budget for more training and salaries for health workers. Many countries may need support for decades, and we should recognize that supporting the health workforce and health system will get us to a point of self-sufficiency more quickly than undercutting them. Explore strategies such as task-shifting that would allow lower-level (and less expensive) cadres of workers to provide certain health services as long as quality is equivalent to what higher-level workers provide. See for instance our own Barrot Lambdin's blog post on health workforce strategies from the International AIDS Conference in Vienna last week. Wouldn't it be great if we could commit to getting all countries to at least 2.3 health workers per 1,000, rather than setting our sights -- and health outcomes -- lower because we don't think the money is there? Primary Health Care, Macroeconomic Policies, Public-Sector Health Systems 2010-07-26T17:00:03+00:00 http://www.healthallianceinternational.org/blog/post/from-vienna-closing-day-and-looking-ahead-to-2012-in-dc/ http://www.healthallianceinternational.org/blog/post/from-vienna-closing-day-and-looking-ahead-to-2012-in-dc/ A lot happened at the conference this week. Secretary of State Clinton reaffirmed the shared responsibility to ensure universal access to HIV/AIDS services -- where will we be on this path by the next conference in 2012?Today was the closing day of the AIDS 2010 conference in Vienna. The next conference will be in Washington, DC in 2012, which was made possible thanks to Obama's retraction of the ban on people with HIV from traveling to the US. A lot of great presentations, demonstrations, discussions and ideas were part of the conference this past week, so there's a lot to digest. The AIDS 2010 web site has great information posted, including webcasts, transcripts and slides, photos, a sign-on to the Vienna Declaration (on the need for science-based policy related to illicit drug use), and more. Both President Obama and Secretary of State Hillary Clinton delivered closing remarks via video message. On the down side, US funding for HIV and global health as a whole is less than what advocates have been asking for, and less than what was reauthorized through PEPFAR in 2008. On a more positive note, Secretary Clinton included an important message in her closing remarks: "And we believe HIV/AIDS prevention, treatment, and care should be a universal, shared responsibility, because health is a human right. As we push to expand access to these resources, the United States will continue to work with our partner countries and with civil society to help empower citizens to lead the charge in their own countries." What will we be talking about in two years at the next AIDS conference? Fewer new infections, more new drugs for prevention and treatment, and progress in expanding health workforces that can support a goal of universal access? Or will we have moved backwards in the fight against AIDS? Let's hope -- and act to ensure -- the former. Primary Health Care, Health Systems Research, HIV/AIDS, Public-Sector Health Systems 2010-07-24T00:06:18+00:00 http://www.healthallianceinternational.org/blog/post/from-vienna-when-does-hiv-funding-strengthen-health-systems/ http://www.healthallianceinternational.org/blog/post/from-vienna-when-does-hiv-funding-strengthen-health-systems/ On Wednesday I attended a symposium on when HIV funding strengthens health systems. Panelists brought up lessons from countries, and talked about the need for HIV to be funded and also part of larger system efforts.On Wednesday I attended a symposium where participants tackled the question: when does HIV funding strengthen health systems? A response to this question came from Ruairi Brugha of the Global HIV/AIDS Initiatives Network (GHIN), who shared the findings of a recent GHIN study on three global health initiatives: PEPFAR, Global Fund to Fight AIDS, TB and Malaria, and the World Bank Multi-Country AIDS Program (MAP). The study looked at Uganda, Malawi and Zambia to see how the HIV-focused funding from these initiatives affected the overall health system. Some of the findings were: The scale-up of global health initiative funding has not translated into significant increases in the health workforce. In all 3 countries, the national health workforce has not grown proportionately to the increasing number of clients seeking care and treatment for HIV/AIDS. (Our own research at HAI suggests that this is leading to poor retention in HIV treatment.) Time set aside for trainings (1- to 2-week courses of already trained health personnel) has stretched an already overburdened workforce, leading to high levels of absenteeism from work. Low salaries for government health workers make it difficult for employers to retain staff who are attracted by the higher wages offered by global health initiative-supported NGOs. (This is something we've also seen in our work, and is one of the reasons for the development of the NGO Code of Conduct for Health Systems Strengthening.) In the panel discussion part of the session, Lesotho Health Minister Mphu Keneiloe Ramatlapeng touched on a subject integral to HAI's mission and values: the need for programs to work directly with governments to achieve results instead of in autonomous parallel systems. Ramatlapeng said that when partners come into the country and set up parallel HIV/AIDS programs outside of the government's services, those do not end up supporting the larger health system. In addition, a sort of catch-22 exists where HIV funding can't be used to develop human resources, yet the government gets criticized for not having the capacity to effectively deliver treatment. To address these problems, she highlighted the importance of supporting health programs and services as well as overall health systems.She complimented the Global Fund and the Irish government for their support of human resources for health. She also mentioned the need for donors to coordinate so that reporting can be more streamlined and efficient. Finally, she called on donors to trust the governments of developing countries if they really want to build capacity. Rather than having a large portion of aid funding return to donor countries through consultant salaries and the like, "build capacity of the people who live in those countries. Empower them with education. Empower them to remain in their countries. (...) What we really would appreciate [is] our nurses and doctors to be assisted to remain home." A number of presenters emphasized the need to have national priorities and plans -- such as for overall health systems strengthening, integration of services and health workforce development -- to better make the case to donors that funding those particular areas will build a stronger system as part of a coordinated plan. Finally, Jean-Paul Moatti, professor of health economics at the University of the Mediterranean in France, made a compelling argument for the need for more funding for all the health MDGs. As he said, greater efficiency is a good goal, but it should not be a pretext for flat or reduced funding. He called for countries to pursue a financial transactions tax, which some organizations in Europe and the US have been working on. There was a lot of good discussion in this session, and a lot of energy around finding ways to make sure HIV programs continue and are funded, and that they are implemented in a way that builds overall health systems for the long term.   You can find the session description and links to slides here (click on "slides with audio" since the PowerPoint links don't seem to be working). A transcript of the session is available here. And you can watch a webcast below, or find it here.   Primary Health Care, HIV/AIDS, Public-Sector Health Systems 2010-07-22T18:49:16+00:00 http://www.healthallianceinternational.org/blog/post/from-vienna-the-health-workforce-crisis-opening-the-bottleneck/ http://www.healthallianceinternational.org/blog/post/from-vienna-the-health-workforce-crisis-opening-the-bottleneck/ A session today ("Human resources: the ultimate bottleneck") included presentations on options for increasing the health workforce in sub-Saharan Africa to better support HIV/AIDS and other health services.The health workforce shortage has been well documented. A number of "push" and "pull" factors result in what one speaker referred to this morning as "The Leaky Bucket" -- 13.9% of the health workforce in sub-Saharan Africa is lost to countries in the North and West. The most obvious, long-term solution includes opening the pipeline by training more providers. One of the speakers advocated for socially accountable educational scale-up which emphasizes work in-country and not emigration as the goal. This will require many investments including monies for classrooms, libraries, computing labs as well as highly trained faculty. In addition, we have to consider building environments which include advanced training opportunities and better working conditions to reduce the "push," and informing policies in the US and other countries to minimize the "pull" in order to retain the providers we currently have. At the same time, we have to become more efficient with our current health workforce. One of the speakers highlighted the need for task-shifting and using lay workers to supplement the workforce. A recent randomized, non-inferiority trial done in South Africa found that nurses and doctors provide similar levels of care quality in managing patients receiving HIV treatment -- findings similar to our research in Mozambique.  However, we need to continue asking how we can better improve the quality of services as approximately 45% of patients in the South African study experienced treatment failure. These are unacceptable failure rates regardless of whether it's a nurse or a doctor providing services. But, perhaps one of the biggest things that we could do to reduce the burden on health workers would be reducing the visit frequency of patients. Quality Improvement methodologies can help us identify where we could bundle services, simplify visit flows and do away with redundant activities. See the session information and presentations, and the webcast provided by the Kaiser Family Foundation. Food for thought from Vienna! Attendees wait to ask questions at one of the sessions (Photo: IAS/Marcus Rose/Workers' Photos) Mozambique, Primary Health Care, Health Systems Research, HIV/AIDS, Public-Sector Health Systems 2010-07-20T23:58:09+00:00 http://www.healthallianceinternational.org/blog/post/from-vienna-a-microbicide-for-women-to-prevent-HIV/ http://www.healthallianceinternational.org/blog/post/from-vienna-a-microbicide-for-women-to-prevent-HIV/ Breaking news here is about a trial of a microbicide gel for women that seems to successfully reduce the chance for HIV infection. Although more studies need to be done, we should start considering how this intervention can fit within the health system.Some big news out of Vienna so far has been the results of a trial of a microbicide gel for women that seems to successfully reduce the chance for HIV infection. A study conducted in South Africa of 889 women randomized to receive either tenofovir or a placebo microbicide found a 39% reduction of HIV incidence among women using tenofovir. When the investigators looked at groups based on their adherence levels, they found a 54% protective effect among high adherers, 38% protective effect among intermediate adherers and 28% protective effect among low adherers. In addition, women randomized to the tenofovir arm also had a 51% reduction of herpes (HSV-2) incidence which will lower the overall prevalence of HSV-2 in the population and can additionally lower the incidence of HIV over the long term. This is very exciting news as it could be a powerful tool for women to utilize in preventing HIV! Even though confirmatory studies need to be done, we should start considering how this intervention can fit within the health system. You can read the full article, published in the magazine Science, here. The New York Times also published an article covering this study, and another one looking at the effect of giving poor women cash payments in reducing HIV infection. One of the study authors, Quarraisha Abdool Karim (Photo: IAS/Marcus Rose/Workers' Photos)   Primary Health Care, Health Systems Research, HIV/AIDS, Public-Sector Health Systems 2010-07-20T23:49:28+00:00 http://www.healthallianceinternational.org/blog/post/not-in-vienna-heres-how-to-stay-on-top-of-the-international-aids-conference/ http://www.healthallianceinternational.org/blog/post/not-in-vienna-heres-how-to-stay-on-top-of-the-international-aids-conference/ In addition to checking here for posts from HAI's Barrot Lambdin, you can also follow some of these sources to keep track of sessions, discussions and commentary on the conference as it progresses.If you aren't in Vienna this week for the International AIDS Conference but want to keep track of sessions, discussions, side events and commentary, here are some resources. We also hope you'll check back with us for posts from Barrot Lambdin, one of our staff who is there presenting on health workforce issues and HIV/AIDS programs. Webcasts: Kaiser Family Foundation web site Blogs: Official AIDS 2010 Conference blog Global AIDS Alliance web site and blogs Global Health Council AIDS Conference blogs Health GAP's blog on actions at the conference to draw attention to inadequate funding for HIV Center for Health and Gender Equity (CHANGE) web page on actions and issues at the conference related to women's health Photos: Official AIDS 2010 Conference photo site   What else are you reading or following to keep track of what's happening at the conference? Vuyiseka Dubula, General Secretary of the Treatment Action Campaign, South Africa (Photo: IAS/Marcus Rose/Workers' Photos) Health Systems Research, HIV/AIDS, Reproductive and Child Health, Public-Sector Health Systems 2010-07-19T19:17:52+00:00 http://www.healthallianceinternational.org/blog/post/sneak-peek-international-aids-conference-2010-next-week-in-vienna/ http://www.healthallianceinternational.org/blog/post/sneak-peek-international-aids-conference-2010-next-week-in-vienna/ At the conference, HAI's Technical Advisor for Implementation Science, Barrot Lambdin, will be presenting research on health workforce levels -- particularly pharmacy staff -- and their impact on HIV programs. He'll also be blogging from Vienna about the latest in HIV/AIDS research and policy.The 18th International AIDS Conference is taking place next week, from July 18-23 in Vienna, Austria. The conference brings together researchers and advocates to share findings and re-energize international collaborations to fight the disease. Some HAI staff will be there, including Barrot Lambdin, our Technical Advisor for Implementation Science. He will be presenting some research from Mozambique that focuses on health workforce levels and their impact on HIV programs ("Human resource levels affect attrition from HIV treatment programs in Mozambique"). This study looked at the impact of patient volume, clinical staff burden and pharmacy staff burden (number of pharmacy visits per pharmacy staffperson) on patient attrition from HIV treatment programs in central Mozambique.  Interestingly, although doctors and nurses are both in short supply in Mozambique -- only 3 doctors and 21 nurses per 100,000 people -- this study revealed that the pharmacy staff burden is the bigger bottleneck for patients to remain on treatment. In other words, patients attending clinics with a higher pharmacy staff burden were more likely to leave HIV treatment programs. Mozambique has only 3 pharmacy staff per 100,000 people, and per Mozambican treatment standards, patients come in monthly for pharmacy appointments to get more antiretroviral drugs. Thanks to task-shifting of certain HIV care activities from doctors to nurses, and the fact that patients don't typically need monthly clinical visits once they are established on treatment, the burden on doctors and nurses can be less than on pharmacy staff. These results present new areas for further study, such as uncovering ways to improve the flow of patients at pharmaceutical visits thereby reducing waiting times. Also, new policies may be considered to relieve the burden on pharmacy staff, which would hopefully improve the patient experience and result in better treatment outcomes. Barrot will be presenting these findings through a poster session, and will also be blogging from the conference to report on sessions of interest, including: Using Quality Improvement methods to strengthen HIV care Will we achieve universal access to HIV care with the health workforce we have? ART for prevention -- what are the implications? and more.... Check back next week for posts from Vienna on the latest in HIV/AIDS research and policy! Mozambique, USA (Headquarters), Health Systems Research, HIV/AIDS, Public-Sector Health Systems 2010-07-16T22:30:27+00:00 http://www.healthallianceinternational.org/blog/post/what-do-you-think-about-global-health-journalism-in-the-northwest/ http://www.healthallianceinternational.org/blog/post/what-do-you-think-about-global-health-journalism-in-the-northwest/ Where do you find information about global health work coming from or having an impact on the Pacific Northwest? What do you need? Take a survey by July 31 to help inform global health journalism in the Northwest.Where do you find information about global health work coming from or having an impact on the Pacific Northwest? What do you read or watch, and what would you like to be able to find? Journalism That Matters and the global health community are collaborating to improve global health journalism in the Northwest. They have developed a survey to find out what what people who work in global health in this area think about local coverage of global health issues: what exists and what's needed. "Local coverage" includes:1. Global health efforts based in Washington, Oregon, and British Columbia.2. General global health news that has an impact on the Northwest. 3. Northwest residents working around the world. Do you live in the Pacific Northwest and work in global health? If so, please take this survey by July 31, 2010. Responses are anonymous. Journalism That Matters is a diverse community of professional journalists, educators, media innovators, and other stakeholders that focus on convening, connecting, inspiring, and building bridges to a new news ecology. For more information, see http://journalismthatmatters.org/content/about-journalism-matters. If you have questions about the survey, please contact pamkm@comcast.net. USA (Headquarters) 2010-07-15T21:55:11+00:00 http://www.healthallianceinternational.org/blog/post/the-guardian-features-timor-lestes-community-health-efforts/ http://www.healthallianceinternational.org/blog/post/the-guardian-features-timor-lestes-community-health-efforts/ An article in the UK's Guardian talks about Timor-Leste's community health programs, which we help to support. Thanks to this program, people in rural villages get health information and services through monthly events.The government of Timor-Leste is striving to involve communities in planning for and using health services, reports the UK's Guardian newspaper. Facing a health worker shortage and cultural and geographic barriers that prevent people from visiting health facilities, the Ministry of Health developed a program of integrated community health services, or "SISCa" in the local Tetum language. Each of Timor's 442 villages should have a monthly SISCa health event, which brings health workers and the community together. We have been working with the Ministry of Health to support these monthly events, as the article describes: "With three-quarters of Timor-Leste's people living in rural areas, access to healthcare is one of the country's biggest problems, said Health Alliance International's Paul Vasconcelos, who works with the health ministry as a regional SISCa coordinator. "'The motto of SISCa is from the community, with the community, to the community. SISCa is yours, it belongs to you, so they organise it, the people will do everything. The health staff give assistance, but the community organises everything in the village levels,' he said. "'In some villages it's very active. Village leaders know what's happening,' Vasconcelos said." Read the full article here, or read more about our project to support the SISCa program. Photo: Beawiharta/Reuters Timor-Leste, Press Coverage, Primary Health Care 2010-07-14T17:24:14+00:00 http://www.healthallianceinternational.org/blog/post/white-house-to-announce-national-hiv-aids-strategy-on-july-13th/ http://www.healthallianceinternational.org/blog/post/white-house-to-announce-national-hiv-aids-strategy-on-july-13th/ An announcement is expected from the White House tomorrow on the first national strategy for continuing the fight against HIV/AIDS domestically. The New York Times reported that the plan includes a target of reducing new infections by 25% in five years. Other goals include increasing the proportion of infected people who know their status to 90%, and getting 85% of the newly diagnosed into clinical care within 3 months of diagnosis. However, no new federal funds are attached to the plan, according to the New York Times, which saw a final draft of the strategy report. Currently the U.S. government spends $19 billion per year on HIV/AIDS programs. The plan will likely instead emphasize a shift of resources to populations at highest risk of infection. The announcement of this strategy, coming right before the International AIDS Conference in Vienna next week, will highlight the need to continue focusing on HIV/AIDS despite a changed perception in the west that the AIDS epidemic is waning. However, like with international AIDS efforts and funding, the scope of the goals may exceed the resources devoted to them. Health and Human Services Secretary Kathleen Sibelius and Domestic Council Policy Director Melody Barnes will make the announcement tomorrow, July 13th, at 2pm Eastern. President Obama will make a statement at 5:50pm Eastern. Watch the announcements live. USA (Headquarters), HIV/AIDS, Public-Sector Health Systems 2010-07-12T22:41:04+00:00