Berkeley Global Health Workforce Conference - World Health ...

Berkeley Global Health Workforce Conference: From Evidence-Based Research to Policy

April 4-5, 2008 School of Public Health University of California, Berkeley Berkeley, California, United States

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elcome to the 2008 Berkeley Conference on the Global Health Workforce. We are honored to have many of the health leaders in policy, economics, education, research, and implementation from around the world. More than twenty countries are represented among us. We are very grateful to the funders and sponsors who made this gathering possible through their generous support. We also must thank the Advisory Committee and the Scientific Committee (page 12) for many months of hard work. We are all here because lives depend on us making a difference. We know that the burden of disease is unfairly spread out across the world, and that access to appropriate care means the difference between despair and hope for individuals, families, and whole communities and regions. As we have witnessed over the last several decades, the health of millions of people has suffered in many developing countries. The interrelated causes involve lack of resources, deteriorating infrastructure, lack of training and sufficient pay, diminishing quality of care, and migration of workers to developed countries. It is a convoluted problem, but recent global efforts have identified the health workforce as a particularly promising lever for improving access to quality care. Many of us recently attended the first Global Forum on Human Resources for Health in Kampala, Uganda, organized by the World Health Organization’s Global Health Workforce Alliance. Nearly 1,500 participants endorsed the “Kampala Declaration and Agenda for Global Action” (page 4). At its core is the vision that “all people, everywhere, shall have access to a skilled, motivated, and facilitated health worker within a robust health system.” We see the next two days at Berkeley as a significant step in such an agenda. Because of the quantity of new research to be presented, we have a busy schedule. I want to draw your attention to the final plenary session: The Global Health Workforce Policy Implementation Roundtable. Lord Nigel Crisp, co-chair of the Global Health Workforce Alliance’s Scaling Up Education & Training Task Force in developing countries, will anchor a remarkable panel of experts on these issues. Their job will be to help translate the proceedings of this two-day conference into workable solutions on the ground. When we depart for our home countries and institutions, we will be armed with a host of new research, insights, contacts, and tools to move forward. As we all know, the barriers are high and the stakes are higher still. Nevertheless, I am convinced that, if anyone can move the ball forward, it is the people gathered here. And that is what we expect to happen. Sincerely,

Richard M. Scheffler, PhD Director, The Global Center for Health Economics and Policy Research Distinguished Professor of Health Economics & Public Policy, University of California, Berkeley

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Table of Contents



Kampala Declaration & Agenda for Global Action Program Overview Panel Sessions Posters Advisory Board & Scientific Committee Profiles of Advisory Board & Scientific Committee Members Profiles of Participants Profiles of Poster Participants Panel Session #1 Abstracts Panel Session #2 Abstracts Panel Session #3 Abstracts Panel Session #4a Abstracts Panel Session #4b Abstracts Panel Session #5 Abstract Panel Session #6 Abstracts Poster Abstracts Delegates Contacts Campus Map

4 5 6-10 11 12 13-16 17-21 22-24 25-28 29-33 34-37 38-40 41-43 44 45-47 48-56 57 58 59

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Health Workers for All and All for Health Workers The Kampala Declaration and Agenda for Global Action Declaration We, the participants at the first Global Forum on Human Resources for Health in Kampala, 2-7 March 2008, and representing a diverse group of governments, multilateral, bilateral and academic institutions, civil society, the private sector, and health workers’ professional associations and unions; Recognizing the devastating impact that HIV/AIDS has on health systems and the health workforce, which has compounded the effects of the already heavy global burden of communicable and non-communicable diseases, accidents and injuries and other health problems, and delayed progress in achieving the health-related Millennium Development Goals; Recognizing that in addition to the effective health system, there are other determinants to health; Acknowledging that the enjoyment of the highest attainable standard of health is one of the fundamental human rights; Further recognizing the need for immediate action to resolve the accelerating crisis in the global health workforce, including the global shortage of over 4 million health workers needed to deliver essential health care; Aware that we are building on existing commitments made by global and national leaders to address this crisis, and desirous and committed to see immediate and urgent actions taken; Now call upon: 1. Government leaders to provide the stewardship to resolve the health worker crisis, involving all relevant stakeholders and providing political momentum to the process. 2. Leaders of bilateral and multilateral development partners to provide coordinated and coherent support to formulate and implement comprehensive country health workforce strategies and plans. 3. Governments to determine the appropriate health workforce skill mix and to institute coordinated policies, including through public private partnerships, for an immediate, massive scale-up of community and mid-level health workers, while also addressing the need for more highly trained and specialized staff. 4. Governments to devise rigorous accreditation systems for health worker education and training, complemented by stringent regulatory frameworks developed in close cooperation with health workers and their professional organizations. 5. Governments, civil society, private sector, and professional organizations to strengthen leadership and management capacity at all levels. 6. Governments to assure adequate incentives and an enabling and safe working environment for effective retention and equitable distribution of the health workforce. 7. While acknowledging that migration of health workers is a reality and has both positive and negative impact, countries to put appropriate mechanisms in place to shape the health workforce market in favour of retention. The World Health Organization will accelerate negotiations for a code of practice on the international recruitment of health personnel. 8. All countries will work collectively to address current and anticipated global health workforce shortages. Richer countries will give high priority and adequate funding to train and recruit sufficient health personnel from within their own country. 9. Governments to increase their own financing of the health workforce, with international institutions relaxing the macro-economic constraints on their doing so. 10. Multilateral and bilateral development partners to provide dependable, sustained and adequate financial support and immediately to fulfill existing pledges concerning health and development. 11. Countries to create health workforce information systems, to improve research and to develop capacity for data management in order to institutionalize evidencebased decision-making and enhance shared learning. 12. The Global Health Workforce Alliance to monitor the implementation of this Kampala Declaration and Agenda for Global Action and to re-convene this Forum in two years’ time to report and evaluate progress.

Source: http://www.who.int/workforcealliance/forum/2_declaration_final.pdf

4 The kampala Declaration





Berkeley City Club 2315 Durant Avenue Thursday, April 3rd

Program Overview

6:00 – 10:00 pm Welcome Reception

Drawing Room (1st Floor)

Friday, April 4th

8:00 – 8:45 am

Registration and Breakfast

Terrace (2nd Floor)



8:45 – 9:00 am

Opening Session

Member’s Lounge Library (2nd Floor)



9:00 – 11:00 am Panel Session #1: Global Health Workforce Supply-Demand Balance

Member’s Lounge Library (2nd Floor)



11:00 – 12:00 pm Poster Session (refreshments served)

Julia Morgan Room (2nd Floor)



12:00 – 1:30 pm Lunch

Terrace (2nd Floor)

1:30 – 4:00 pm (Concurrent Panels)

Panel Session #2: Tools for Monitoring and Projecting Health Workforce Supply and Dynamics

Member’s Lounge Library (2nd Floor)

Panel Session #3: Linkages Between Health Workforce Mix and Health Outcomes

Julia Morgan Room (2nd Floor)



4:00 – 5:00 pm

Break (refreshments served)

Terrace (2nd Floor)



6:30 – 9:00 pm

Dinner

Adagia Restaurant, 2700 Bancroft Way

Breakfast

Terrace (2nd Floor)

Saturday, April 5th

8:00 – 9:00 am

9:00 – 11:00 am Panel Session #4A: Health Worker Mobility and Incentives (Concurrent Panels) Panel Session #4B: Health Worker Mobility and Incentives

Member’s Lounge Library (2nd Floor)



11:00 – 11:45 am Poster Session (refreshments served)

Venetian Room (2nd Floor)

11:45 – 1:00 pm Lunch

Terrace (2nd Floor)



1:00 – 2:00 pm Panel Session #5: Human Resources for Health Policy: Country Perspectives

Member’s Lounge Library (2nd Floor)



2:00 – 2:30 pm

Break (refreshments served)

Terrace (2nd Floor)



2:30 – 4:45 pm

Panel Session #6: Global Health Workforce Policy Implementation Roundtable Member’s Lounge Library (2nd Floor)



4:45 – 5:00 pm Closing Remarks

Julia Morgan Room (2nd Floor)

Member’s Lounge Library (2nd Floor)

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Friday, April 4th, 8:45 - 11:00 am

Opening Session Friday, April 4th, 8:45-9:00 am Member’s Lounge Library Welcome and Conference Overview: Richard M. Scheffler, PhD Director, The Global Center for Health Economics and Policy Research Distinguished Professor of Health Economics & Public Policy, University of California, Berkeley



Panel Session #1: Global Health Workforce Supply-Demand Balance Friday, April 4th, 9:00-11:00 am Member’s Lounge Library



Chair: Haile T. Debas, MD Director, Global Health Sciences Maurice Galante Distinguished Professor of Surgery, University of California, San Francisco Discussant: Neeru Gupta, PhD Demographer-Statistician, Department of Human Resources for Health, World Health Organization, Geneva, Switzerland “Estimating Health Worker Shortages: What Can Africa Afford and What Else Can Be Done?” Richard M. Scheffler, PhD, Director, The Global Center for Health Economics and Policy Research; Distinguished Professor of Health Economics & Public Policy, University of California, Berkeley “Spatial Distribution of Health Workforce and Health Care Services An Inter- and Intra-Country Analysis” Sailabala Debi, PhD, MPhil, MA, Economist, Former Director and Professor, Centre for Multidisciplinary Development Research (CMDR), Karnataka, India “Scaling Up Health Education Opportunities and Challenges for Africa” Alexander S. Preker, MD, PhD, Lead Economist, Health, Nutrition, and Population AFTH2 Africa Region, The World Bank, Washington DC “Scaling-Up Interventions to Meet Shortages of Health Workers” Gilles Dussault, PhD, Professor and Director, Health Systems Unit, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Portugal

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Friday, April 4th, 1:30-4:00 pm Member’s Lounge Library



Chair: Mario Dal Poz, MD, PhD Coordinator, Human Resources for Health, World Health Organization, Geneva, Switzerland Discussant: Marko Vujicic, PhD Economist, Human Development Network, The World Bank, Washington DC “Measuring and Monitoring the Health Workforce Using Open Source Tools” Pamela McQuide, PhD, RN, Workforce Planning and Policy Advisor, The Capacity Project, IntraHealth International, Chapel Hill, North Carolina “The State of Human Resources for Health in Zambia: Results of the Public Expenditure Tracking and Quality of Service Delivery Survey (PET/QSDS), 2005/2006” Oscar F. Picazo, MA, Senior Economist, South Africa Country Office, The World Bank, Pretoria, South Africa “Ensuring Workforce Capacity to Meet Healthcare Demands Equitably in a Public System” Basu Ghosh, PhD, Professor, Advisor, Human Resources, Ministry of Health, Sultanate of Oman, Muscat, Oman

Friday, April 4th, 1:30 - 4:00 pm



Panel Session #2: Tools for Monitoring and Projecting Health Workforce Supply and Dynamics (Concurrent Panel)

“Understanding the Dynamics of the Medical Workforce: The MABEL Longitudinal Survey of Doctors” Anthony Scott, PhD, Professor, Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Victoria, Australia “Explaining Health Worker Career Paths” Pieter Serneels, MD, The World Bank, Washington DC

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Friday, April 4th, 1:30 - 9:00 pm

Panel Session #3: Linkages Between Health Workforce Mix and Health Outcomes (Concurrent Panel) Friday, April 4th, 1:30-4:00 pm Julia Morgan Room



Chair: Murray N. Ross, PhD Vice President, Kaiser Foundation Health Plan, Inc. Director, Kaiser Permanente Institute for Health Policy, Oakland, California Discussant: Brent D. Fulton, PhD Health Services Researcher The Global Center for Health Economics and Policy Research, University of California, Berkeley “Do More Health Workers Mean Higher Immunization Coverage? Evidence from Turkey” Andrew D. Mitchell, SM, Doctoral Student, Harvard School of Public Health, Harvard University, Cambridge, Massachusetts “The Workforce and Cost Implications of Substituting Nurses and Pharmacists for Doctors in the Follow-up of Patients with AIDS on Antiretroviral Therapy in Uganda” Joseph B. Babigumira, MBChB, MS, Graduate Student, Pharmaceutical Outcomes Research and Policy Program, University of Washington, Seattle, Washington “Monitoring Health Workforce Skills Mix and Productivity to Support Decision Making for Health Policy and Planning: Insights from Survey Data in Six Low- and Middle-Income Countries” Neeru Gupta, PhD, Demographer-Statistician, Department of Human Resources for Health, World Health Organization, Geneva, Switzerland “Effects of Health Labour Migration on Low- and Mid-Level Health Personnel for Infectious Disease Control at the Periphery in the Volta Region of Ghana” Caroline Jehu-Appiah, MD, MSc, Deputy Director Policy Planning Monitoring and Evaluation Division Ghana Health Service, Accra, Ghana

Conference Dinner Friday, April 4th, 6:30-9:00 pm Adagia Restaurant, 2700 Bancroft Way, Berkeley

Introduction: Alexander S. Preker, MD, PhD Lead Economist, Health, Nutrition, and Population AFTH2 Africa Region, The World Bank, Washington DC Guest Speaker: Soccoh Alex Kabia, MD Minister of Health and Sanitation, Sierra Leone

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Saturday, April 5th, 9:00-11:00 am Concurrent Panel Session 4A: Member’s Lounge Library Chair: Gilles Dussault, PhD Professor and Director, Health Systems Unit Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Portugal “Human Resources in Health Labor Markets: The Role of Incentives” Agnes Soucat, MD, PhD, Lead Economist, Health, Nutrition, and Population AFTHD Africa Region, The World Bank, Washington DC “Health Workers’ Attitudes to Market Incentives and Privatisation in Central and Eastern Europe” Helena Schweiger, Economist, Office of the Chief Economist, European Bank for Reconstruction and Development, London, United Kingdom “Toward a Northern Metric: Tracking Global Citizenship in an Epoch of Health Globalization” Fitzhugh Mullan, MD, Murdock Head Professor of Medicine and Health Policy, Department of Health Policy, The George Washington University, Washington DC “Health Labor Market Institutions and Incentives in Ethiopia” William Jack, DPhil, MPhil, BSc, Department of Economics, Georgetown University

Concurrent Panel Session 4B: Julia Morgan Room

Saturday, April 5th, 9:00 - 11:00 am



Panel Session #4: Health Worker Mobility and Incentives (Concurrent Panel)



Chair: Dr. Belgacem Sabri Director Health Systems and Services Development, World Health Organization, Eastern Mediterranean Region Office, Cairo, Egypt “How Wage Bill Policies Affect the Evolution of the Health Workforce in the Public Sector” Marko Vujicic, PhD, Economist, Human Development Network, The World Bank, Washington DC “Obligatory Service Requirement and Physician Distribution in Turkey” Burcay Erus, PhD, MA, Assistant Professor of Economics, Department of Economics, Bogazici University, Istanbul, Turkey “Immigrant Health Workers in OECD Countries in the Broader Context of Highly Skilled Migration” Jean-Christophe Dumont, PhD, OECD Principal Administrator, Directorate of Employment, Labour, and Social Affairs, Division of Non-member Economies and International Migration, Paris, France

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Saturday, April 5th, 1:00 - 5:00 pm

Panel Session #5: Human Resources for Health Policy: Country Perspectives Saturday, April 5th, 1:00 - 2:00 pm Member’s Lounge Library Introduction: Chair:

Stephen M. Shortell, PhD, MPH Dean and Professor, School of Public Health Blue Cross of California Distinguished Professor Health Policy and Management Professor of Organization Behavior, University of California, Berkeley

Soccoh Alex Kabia, MD Minister of Health and Sanitation, Sierra Leone

Anthony A. Sandi, MD, Manager, Human Resources for Health, Minister of Health and Sanitation, Sierra Leone Francisco Eduardo de Campos, MD, Secretary of Human Resources Development for Health, Brazilian Ministry of Health Stephen Tomlin, BA, Vice President, Program, Policy & Planning, International Medical Corps

Panel Session #6: Global Health Workforce Policy Implementation Roundtable Saturday, April 5th, 2:30-4:45 pm Member’s Lounge Library Chair:

Sir Richard Feachem, KBE, FREng, DSc(Med), PhD Professor of Global Health, University of California, San Francisco and University of California, Berkeley Director of the Global Health Group at the University of California, San Francisco’s Global Health Sciences

Co-Chair: Mario Dal Poz, MD, PhD Coordinator, Human Resources for Health, World Health Organization, Geneva, Switzerland “Scaling Up the Education and Training of Health Workers in Developing Countries” Lord Nigel Crisp, KCB, Co-Chair, Scaling Up Education & Training Task Force, Global Health Workforce Alliance Sally Stansfield, MD, Executive Secretary, Health Metrics Network, WHO Kathy Cahill, MPH, Deputy Director, Global Health Strategies, Global Health Program, Bill & Melinda Gates Foundation Ariel Pablos-Mendez, MD, Director, The Rockefeller Foundation Karen J. Hofman MD, Director of the Division of International Science Policy, Planning and Evaluation, Fogarty International Center Lois A. Schaefer, BSN, MPH, Senior Technical Advisor, Human Capacity Development and Training, United States Agency for International Development

Closing Remarks Saturday, April 5th, 4:45-5:00 pm Member’s Lounge Library Richard M. Scheffler, PhD Director, The Global Center for Health Economics and Policy Research Distinguished Professor of Health Economics & Public Policy, University of California, Berkeley

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Friday, April 4th, 11:00 - 12:00 pm, Julia Morgan Room Saturday, April 5th, 11:00 - 11:45 Am, Venetian Room

Posters

Global Health Workforce Supply-Demand Balance “Forecasting Health Workforce Supply and Demand: From Surveys to Models” Joanne Spetz, PhD, Associate Adjunct Professor of Community Health Systems, School of Nursing, University of California, San Francisco* “Comparing the Influence of the Global Context on How Internationally Educated Health Workers Fit into HHR Planning: Lessons from Canada, the US, the UK, and Australia” Ivy Lynn Bourgeault, PhD, MSc, Canada Research Chair in Comparative Health Labour Policy, McMaster University, Ontario, Canada*

Health Worker Mobility and Incentives “Primary Care Workers: Mobility, Retention and Turnover in Rural Thailand” Nonglak Pagaiya, Sirindhorn College of Public Health, Muang, Khon Kaen, Thailand* “Health Spending, Human Resources and Development: A Multivariate Time Series Analysis for Pakistan” Faisal Abbas, MSc, PhD Candidate, Junior Researcher, Centre for Development Research (ZEF), University of Bonn, Bonn, Germany*

Health Workforce Characteristics, Development, and Training “Preventing Child Deaths in Resource Poor Settings: Options When there Are No Doctors and Nurses” Julia Walsh, MD, DTPH, Adjunct Professor, Community Health and Human Development, School of Public Health, University of California, Berkeley* “A Systematic Approach to Workforce Development: Primary Health Care and Human Resources Lessons from the Balkans” Orvill Adams, MD, Project Director, Balkans Primary Health Care Project; Djenana Jalovic, Country Manager, Balkans Primary Health Care Project; Dr. Zlatko Vucina, Director, Institute of Public Health, Federation of Bosnia and Herzegovina, BiH; Dr. Dragana Stojisavljevic, Director, Institute of Public Health, Republic of Srpska, BiH; and Vern Hicks, MA, Principal Health Workforce Planning Advisor, Balkans Primary Health Care Policy Project, Bosnia and Herzegovina “From Surgeons to Shamans! The Characteristics of Private Health Sector Providers in One of India’s Largest Provinces – Madhya Pradesh” Ayesha De Costa, MD, Division of International Health, Stockholm, Sweden* “How Many Health Workers, Who Are They and Where Are They? – Using Multiple Sources of Information to Estimate the Health Workforce in India” Aarushi Bhatnagar, Public Health Foundation of India, New Delhi, India; Krishna D. Rao, Public Health Foundation of India, New Delhi, India; Shomikho Raha, World Bank, New Delhi, India “Educational Level of Nurse Anesthetists: Impact on Competence and Labor Supply Choices in The Netherlands” Vera Meeusen MA, (PhD candidate), Department of Anaesthesiology, Catharina Hospital - Brabant Medical School, Eindhoven, The Netherlands. Chris Brown Mahoney, PhD, NIMH Scholar, Petris Center, University of California, Berkeley *Note: Only first author is listed.

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Advisory Board & Scientific Committee Richard M. Scheffler, PhD - Chair

Director, The Global Center for Health Economics and Policy Research Distinguished Professor of Health Economics & Public Policy University of California, Berkeley Email: [email protected]

Timothy T. Brown, PhD

Associate Director of Research and Training The Global Center for Health Economics and Policy Research University of California, Berkeley Email: [email protected]

Haile T. Debas, MD

Executive Director, UCSF Global Health Sciences University of California, San Francisco Email: [email protected] [email protected]

Brent D. Fulton, PhD

Health Services Researcher The Global Center for Health Economics and Policy Research University of California, Berkeley Email: [email protected]

Sharon Levine, MD

Associate Executive Medical Director The Permanente Medical Group, Inc.

Coordinator Human Resources for Health World Health Organization Email: [email protected]

Gilles Dussault, PhD

Professor Catedrático Director, Unidade de Sistemas de Saúde Instituto de Higiene e Medicina Tropical Universidade Nova de Lisboa Email: [email protected]

Neeru Gupta, PhD

Demographer-Statistician Department of Human Resources for Health Health Systems and Services World Health Organization Email: [email protected]

Fitzhugh Mullan, MD

Murdock Head Professor of Medicine and Health Policy The George Washington University Department of Health Policy Email: [email protected]

Alexander S. Preker, MD, PhD

Murray N. Ross, PhD

Stephen M. Shortell, PhD, MPH

Marko Vujicic, PhD

Lead Economist, Health, Nutrition, and Population AFTH2 Africa Region The World Bank Email: [email protected]

Dean and Professor, School of Public Health Blue Cross of California Distinguished Professor Health Policy and Management Professor of Organization Behavior University of California Berkeley Email: [email protected]

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Mario R. Dal Poz, MD, PhP

Vice President, Kaiser Foundation Health Plan, Inc. Diretor, Kaiser Permanente Institute for Health Policy Email: [email protected]

Economist Human Development Network The World Bank Email: [email protected]





Advisory Board & Scientific Committee Richard M. Scheffler, PhD

Richard Scheffler is Director of the Global Center for Health Economics and Policy Research. He is the Distinguished Professor of Health Economics and Public Policy at the University of California, Berkeley, and holds the Chair in Health Care Markets & Consumer Welfare. He holds tenured faculty positions in the Graduate School of Public Health and the Goldman School of Public Policy, where he teaches health economics. Dr. Scheffler has been a World Bank Visiting Scholar, Human Resources Advisor to the World Health Organization, a Fulbright Scholar, a Scholar in Residence at the Institute of Medicine-National Academy of Sciences, a Resident at the Rockefeller Bellagio Center in Italy, a Visiting Professor at the University of Barcelona and University of Pompeu Fabr in Spain, and a Visiting Professor at the London School of Economics. In 2003, Dr. Scheffler served as President for the International Health Economics Association’s (iHEA). In 2004, he received the Carl A. Taube Award from the American Public Health Association for distinguished contributions to the field of mental health services research. He has published more than 150 papers and has edited and written six books. Dr. Scheffler’s book, Is There a Doctor in the House? Market Signals and Tomorrow’s Supply of Doctors, is forthcoming from Stanford University Press, September 2008.

Timothy T. Brown, PhD

Tim Brown is Associate Director of the Global Center for Health Economics and Policy Research. He is also Assistant Adjunct Professor of Health Economics in the School of Public Health at the University of California at Berkeley. He received his doctorate in Health Services and Policy Analysis, with a specialization in health economics, from the University of California at Berkeley, where he was an Agency for Healthcare Research and Quality Scholar. His current research focuses on health care labor markets (physicians, advanced practice nurses, dental hygienists, and dental assistants), child behavioral health, oral health, and the connection between social capital and health. Dr. Brown has both hosted sessions and presented his research at numerous international meetings, most recently at the Sixth World Congress of the International Health Economics Association in Copenhagen, Denmark; the ICMPE Eighth Workshop on Costs and Assessment in Psychiatry in Venice, Italy; and the Sixth European Conference on Health Economics in Budapest, Hungary.

Mario R. Dal Poz, MD, PhD

Mario Dal Poz is a pediatrician with a passion for public health. He has been working in the area of health systems for over 25 years and has built up a great deal of experience in the development of human resources at regional, national and international levels. He holds a MSc in Social Medicine and has discussed health delivery models in the context of the growing urbanization in Brazil. Later on he received a PhD in Public Health defending a new methodology for the policy analysis of human resources for health development. Dr. Dal Poz joined WHO in 2000 to work at the Department of Human Resources for Health. His work has led him to travel to several countries in Latin America, Africa, Middle East, Europe and Asia, mostly assisting countries to develop their human resources for health, providing health workforce information, discussing health performance indicators, and HRH policy and planning implementation at national and sub-national levels. He published over 40 papers in specialized journals. He has published six books and has contributed to more than 10 chapters of books in the area of human resources for health. Today, he is Coordinator of the Tools, Evidence and Policy Unit within the Department of Human Resources for Health at WHO, Geneva.

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Advisory Board and Scientific Committee Haile T. Debas, MD

Haile Debas received his MD from McGill University and completed his surgical training at the University of British Columbia. Prior to becoming dean he served as chair of surgery at UCSF for six years. Under Dr. Debas’ stewardship, the UCSF School of Medicine became a national model for medical education, an achievement for which he was recognized with the 2004 Abraham Flexner Award of the AAMC. Dr. Debas also spearheaded the formation of several interdepartmental and interdisciplinary centers of excellence and was instrumental in developing UCSF’s new campus at Mission Bay. He has held leadership positions with numerous membership organizations and professional associations. One of the few surgeons to be elected a fellow of the American Academy of Arts and Sciences, he is also a member of the Institute of Medicine. He currently serves on the United Nations Commission on HIV/AIDS and Governance in Africa and on the Committee on Science, Engineering, and Public Policy of the National Academy of Sciences.

Gilles Dussault, PhD

Gilles Dussault is Professor and Head of the Health Systems Unit, at the Institute of Hygiene and Tropical Medicine, Lisbon, Portugal. Before joining the Institute in August 2006, he worked as a Senior Health Specialist with the World Bank Institute in Washington D.C. He was responsible for the regional activities of the Flagship Program on “Health Sector Reform and Sustainable Financing” in French, Portuguese, and Spanish speaking countries where the World Bank was active. His work focused on health sector financing and workforce policies. Between 1985 and 2000, he was Professor and Director of the Department of Health Administration, University of Montreal. He has taught in a number of countries, including one year at the national School of Public Health of Brazil in 1991-92. He has published principally on topics related to the regulation and management of the health workforce. He collaborates with various editorial boards and international working groups and has served as a consultant for various multi- and bilateral aid agencies. He has been a member of the Joint Learning Initiative on Human Resources for Health, a landscape and advocacy major international initiative created by the Rockefeller Foundation in 2002.

Brent D. Fulton, PhD, MBA

Brent Fulton received his doctorate in public policy analysis from the Pardee RAND Graduate School, where his studies focused on microeconomics and econometrics. While at RAND, his health research included health insurance reform and health care financing. His current research includes studying health insurance reform (including California’s proposed reform), binational health insurance between the United States and Mexico, global health workforce supplydemand dynamics, the economics of attention-deficit/hyperactivity disorder (ADHD) and its treatments, and oral health care disparities. Brent’s MBA is from The Anderson School at UCLA and his B.S. is from the U.S. Air Force Academy.

Neeru Gupta, PhD

Neeru Gupta is a Demographer-Statistician with the World Health Organization’s Department of Human Resources for Health. She has over 15 years of professional experience in planning, implementation and management of activities to collect, analyze, use and disseminate demographic and health data at the national and international levels. She has extensive experience in providing technical assistance to countries and partners to support strengthening of health information systems, including HRH information systems, to support decision-making for policies and programmes. Dr. Gupta has work experience in a number of developed countries and developing countries of the African, Asian, and Latin American and Caribbean regions. She holds a PhD in Demography from the Université de Montréal (Canada). Among her publications are research papers on the global health workforce in the journals, Human Resources for Health and International Journal for Equity in Health, as well as in the forthcoming joint WHO-World Bank-USAID book, Handbook on Monitoring and Evaluation of Human Resources for Health.

14 Profiles





Advisory Board and Scientific Committee Sharon Levine, MD

Sharon Levine is a nationally respected expert and frequent speaker on issues of health policy, drug use management, and the design and delivery of health care services. As associate executive director for The Permanente Medical Group of Northern California since 1991- the largest medical group in the country – she has responsibility for the recruitment, compensation, clinical education, management training, and leadership development for the group’s physicians; government and community relations; health policy and external affairs; and pharmacy policy and drug use management. A board-certified pediatrician, Dr. Levine has practiced with The Permanente Medical Group since 1977. During that time she has held multiple leadership roles, including chief of Pediatrics, chief of Quality, and physician-in-charge of the Fremont Medical Center. She began her medical career at the Montgomery-Georgetown Pediatric Comprehensive Care Clinic and Georgetown University Community Health Plan. In addition, she has held academic appointments at Tufts University School of Medicine and Georgetown University School of Medicine, and spent two years as a clinical associate at the National Institutes of Health, Institute of Child Health and Human Development, doing research on infant nutrition. A native of Boston, she received her undergraduate degree from Radcliffe College at Harvard University, and her MD degree from Tufts University School of Medicine.

Fitzhugh Mullan, MD

Fitzhugh Mullan is the Murdock Head Professor of Medicine and Health Policy at the George Washington University School of Public Health and a Professor of Pediatrics at the George Washington University School of Medicine. Dr. Mullan graduated from Harvard University and the University of Chicago Medical School. He served as one of the first physicians in the National Health Service Corps and subsequently directed the NHSC for 23 years as a Commissioned Officer in the USPHS. Since 1996, he has been a Contributing Editor of the journal Health Affairs and the Editor of its Narrative Matters section. Dr. Mullan is an expert on human resources for health with a long record of research and publication on the issues of US and global health workforce. His recent work includes studies of the metrics of global physician migration, workforce retention strategies in Ghana, an inventory of mid-level providers in Sub-Saharan Africa, Indian physician emigration, and reverse flows of health professionals from developed to lesser developed settings. Dr. Mullan has written widely for both professional and general audiences on medical and health policy topics. His books include White Coat Clenched Fist: The Political Education of an American Physician (Macmillan, 1977); Vital Signs: A Young Doctor’s Struggle with Cancer (Farrar, Straus and Giroux, 1983); Plagues and Politics: The Story of the United States Public Health Service (Basic Books, 1989); Big Doctoring in America: Profiles in Primary Care (University of California Press/Milbank Fund, 2002). He is the senior editor of Healers Abroad: Americans Responding to Human Resource Crisis in HIV/AIDS (National Academy Press, 2005) and Narrative Matters: The Power of the Personal Essay in Health Policy (Johns Hopkins Press, 2006.) He is a member of the Institute of Medicine of the National Academy of Sciences.

Alexander S. Preker, MD, PhD

Alexander Preker, Lead Economist for Health, Nutrition, and Population in the World Bank, is responsible for overseeing the Bank’s analytical work on health financing and provision. He coordinated the team that prepared the Bank’s 1997 Sector Strategy on health care in developing countries and was on the World Health Organization team that completed the World Health Report 2000 on health systems. In collaboration with UNICEF, the ILO and several bilateral donors, he recently helped the WHO Regional Office in Brazzaville prepare a Health Financing Strategy for the Africa Region which was adopted by the 56th Regional Council of Health Ministers in August 2006. He is currently a member of the Task Force on Scaling up Health Education of the Global Health Workforce Alliance and is leading a team of technical experts that is preparing a report on the financial sustainability of scaling up health education in developing countries. He teaches regularly at Columbia University and McGill University. His training includes a PhD in Economics from the London School of Economics and Political Science, a Fellowship in Medicine from University College London, a Diploma in Medical Law and Ethics from Kings College London, and a MD from the University of British Columbia/McGill.

Profiles 15

Advisory Board and Scientific Committee Murray N. Ross, PhD

Murray Ross is Vice President, Kaiser Foundation Health Plan, and Director of the Kaiser Permanente Institute for Health Policy in Oakland, California. The Institute for Health Policy supports research, expert roundtables, and conferences intended to increase understanding of policy issues and help identify solutions. Dr. Ross explains the practical implications of market developments and public policies to government leaders and health care industry decision-makers. He advises KP’s leadership on business and public policy issues arising from ongoing changes in that program. His current policy research focuses on how the US health system can make more effective use of new drugs, devices, and medical procedures and how to encourage greater integration of care delivery to improve quality. Before joining Kaiser Permanente in 2002, Dr. Ross served almost five years as the executive director of the Medicare Payment Advisory Commission, an influential nonpartisan agency charged with making recommendations on Medicare policy issues to the Congress. Previously, he spent nine years at the Congressional Budget Office, lastly heading up the group charged with assessing the budgetary impact of legislative proposals affecting the Medicare and Medicaid programs. Dr. Ross earned his doctorate in economics from the University of Maryland, College Park, and completed his undergraduate work in economics at Arizona State University.

Stephen M. Shortell, PhD, MPH

Stephen Shortell is the Dean of the School of Public Health at the University of California, Berkeley. He also holds appointments in the Department of Sociology at UC Berkeley and at the Institute for Health Policy Research, UC San Francisco. A leading health care scholar, Prof. Shortell has done extensive research identifying the organizational and managerial correlates of quality of care and of high-performing health care organizations. He has been the recipient of many awards including the distinguished Baxter-Allegiance Prize for his contributions to health services research; the Distinguished Investigator Award from Academy Health; the Gold Medal Award from the American College of HealthCare Executives; and the Honorary Lifetime Membership Award from the American Hospital Association. Prof. Shortell received a commendation by the California State Senate for his contribution to health through leadership of the technical committee on “Pay for Performance.” He is an elected member of the Institute of Medicine of the National Academy of Sciences and past editor of Health Services Research. He serves on many boards and advisory groups. He is currently conducting research on the evaluation of quality improvement initiatives and on the implementation of evidence-based medicine practices in physician organizations.

Marko Vujicic, PhD

Marko Vujicic is an economist specializing in issues related to the health care sector. He is currently working in the Health, Nutrition and Population unit of the Human Development Network at The World Bank. Specific topics of interest include provider responses to incentives, migration of health care professionals, labor market dynamics in the health care sector, health financing and fiscal space issues in developing countries. He worked in several developing countries including Ghana, Ethiopia, Tanzania, Barbados, South Africa. Prior to joining the Bank in 2004, he held the position of Labor Economist in the Human Resources for Health Department at the World Health Organization in Geneva. Mr. Vujicic completed his PhD in Economics at the University of British Columbia in Canada in 2003. Parallel to his studies he worked as an associate consultant with the National Health Care Practice at IBM Business Consulting Services and has carried out independent consulting work for the Canadian Health Services Research Foundation. He also worked as a research analyst for the Centre for Health Services and Policy Research at the University of British Columbia. He is a Canadian national.

16 Profiles





Participants Joseph B. Babigumira, MBChB, MS

Joseph Babigumira is a doctoral student in the Pharmaceutical Outcomes Research and Policy Program at University of Washington in Seattle. He studied medicine and surgery at Mbarara University in Uganda. He spent two and half years practicing at Mbarara Regional Referral hospital. During this time he also worked part time for the medical charity Medecins Sans Frontieres (MSF) in their epidemiology group Epicentre, where he led a team of clinicians performing a trial of the antimalarial Coartem. He was also a part time lecturer in Microbiology at Mbarara University Medical School during the same period. In August 2004, he enrolled in Case Western Reserve University where he completed a master’s degree in Health Services Research before joining the University of Washington.

Kathy Cahill, MPH

Kathy Cahill joined the Bill & Melinda Gates Foundation in January 2005, and is the Deputy Director in Global Health Strategies of the Global Health Program. Her portfolio includes leadership development, community based delivery and demand programs, and emergency relief. She is responsible for shaping country-based leadership programs for the developing world that will improve national decision-making for public health. Prior to coming to the Bill and Melinda Gates Foundation, she was Associate Director for Policy, Planning and Evaluation for the Centers for Disease Control and Prevention (CDC). In this position, she advised the Director of CDC on public health policy issues and led the agency’s major restructuring effort in 2003. She was director of planning and evaluation for over eight years and advised three CDC directors during her tenure. Her professional experience at the CDC ranges from programs addressing immunization to managed care, HIV/AIDS, and bioterrorism. She led the transformation process across CDC to restructure the agency’s science and public health programs to better serve stakeholders and the public. She received her Master of Public Health degree in 1994 at the School of Public Health, University of North Carolina at Chapel Hill.

Francisco Eduardo de Campos, MD

Francisco Campos is the current Secretary of the Secretariat of Work and Education Management in Heath at the Ministry of Health in Brazil. With an MD degree, a master’s degree in Social Medicine, and a doctoral degree in Public Health, Dr. Campos has a permanent position as Professor in the Medical College of the Federal University of Minas Gerais. Dr. Campos has devoted his life to the improvement of medical education. He coordinated the first massive rural internship for a medical school in Brazil 30 years ago. He has served as a staff member for PAHO/WHO, both in Washington DC and Geneva. He founded and served as the Director of the Nucleus of Research in Public Health at the Federal University of Minas Gerais. He holds a position on the Board of the Global Health Workforce Alliance.

Nigel Crisp, KCB

Currently, Nigel Crisp is supported by the Bill and Melinda Gates Foundation to chair an International Task Force on scaling up the training and education of health workers in developing countries as part of the Global Health Workforce Alliance. He published a report for the Prime Minister in February 2007 on Global Health Partnerships: the UK contribution to health in developing countries. Previously, he was Chief Executive of the NHS and Permanent Secretary of the Department of Health from 2000 to 2006. He joined the NHS in 1986 and has managed mental health and acute services. He was Chief Executive of the Oxford Radcliffe Hospital NHS Trust, one of the country’s leading academic centres. He worked in community development and in industry prior to joining the NHS. He is a Cambridge philosophy graduate, an Honorary Professor at the London School of Hygiene and Tropical Medicine, a Senior Fellow at the Institute for Healthcare Improvement in Cambridge, Massachusetts, and Chair of Sightsavers International. He became a member of the House of Lords in 2006.

Sailabala Debi, PhD, MPhil, MA

Sailabala Debi, is Professor in Economics at the Centre for Multi Disciplinary Development Research, Dharwad, Karnataka, India and served as Director of the same institute. She had earlier taught in the Department of Economics, Utkal University. Her areas of specialization are Economics of Education, Health and Statistics. She was a Visiting Fellow at UNESCO, Paris. She is a member of the International Health Economics Association, the Indian Econometric Society and the Indian Economic Association. She has published more than 50 papers in the areas of economics, development economics, education and health in reputed research journals. She has been associated with more than 20 major research projects sponsored by national and international funding agencies. She published the book Economics of Higher Education and edited the book Sustainable Development and The Indian Economy: Issues and Challenges.

Profiles 17

Participants Jean-Christophe Dumont, PhD

Jean-Christophe Dumont is an economist and principal administrator in the Direction for Employment, Labour and Social Affairs (Division for Non-Member Economies and International Migration) at the OECD, Paris. He joined the OECD Secretariat in 2000 to work on international migration issues. He is co-author of the annual publication of the OECD on international migration (International Migration Outlook, OECD, Paris). He has several publications on the economics of international mobility of persons, including labour market integration of immigrants and on the management of migration flows. He holds a PhD in development economics from the University Paris IX-Dauphine and has been working as a research fellow in Laval University, Quebec Canada. Previously he was a research assistant at DIAL, a European center for research on development economics in Paris.

Burcay Erus, PhD, MA

Burcay Erus is an Assistant Professor at Bogazici University, Turkey. He holds a PhD in Economics from the Department of Economics, Northwestern University, US (2005). His dissertation analyzed the impact of medical malpractice regulations on location choice of physicians in US. His current research focuses on applied microeconomics and particularly health economics.

Sir Richard Feachem, KBE, CBE, BSc, PhD, DSc(Med), FREng, HonFFPHM, HonDEng

Richard Feachem is Professor of Global Health at both the University of California, San Francisco and the University of California, Berkeley, and Director of the Global Health Group at UCSF Global Health Sciences. He is also a Visiting Professor at London University and an Honorary Professor at the University of Queensland. From 2002 to 2007, Sir Richard served as founding Executive Director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. During this time, the Global Fund became the world’s largest health financing institution for developing countries, with assets of $11 billion, supporting 450 programmes in 136 countries. From 1999 to 2002, Dr. Feachem was the founding Director of the Institute for Global Health at UCSF and UC Berkeley. From 1995 until 1999, he was Director for Health, Nutrition and Population at the World Bank. Previously (1989-1995), he was Dean of the London School of Hygiene and Tropical Medicine. Dr. Feachem served as Chairman of the Foundation Council of the Global Forum for Health Research; Treasurer of the International AIDS Vaccine Initiative; Council Member of Voluntary Service Overseas; and on numerous other boards and committees. He was a member of the Commission on Macroeconomics and Health, and the Commission on HIV and Governance in Africa. He worked in international health and development for 35 years and published extensively on public health and health policy. Dr. Feachem holds a Doctor of Science degree in Medicine from the University of London, and a PhD in Environmental Health from the University of New South Wales. In 2007, he was awarded an Honorary Doctorate in Engineering by the University of Birmingham. He is a Fellow of the Royal Academy of Engineering and an Honorary Fellow of the Faculty of Public Health Medicine of the Royal College of Physicians and of the American Society of Tropical Medicine and Hygiene. In 2002, he was elected to membership of the Institute of Medicine of the US National Academy of Sciences. He was knighted by Queen Elizabeth II in 2007.

Basu Ghosh, PhD

Basu Ghosh is Advisor to HE the Minister of Health, Oman. Formerly, he was Professor & Chairman of the Health Management Center at the Indian Institute of Management Bangalore (1976-94). Dr. Ghosh has undertaken numerous WHO assignments in Asia and Africa. He served as honorary member on WHO Global Advisory Panel on HRH (1987-2005) and WHO-EMRO Regional Advisory Panel on Health Systems Development (2002-06). He published numerous research papers in various journals and edited / authored numerous books, monographs, and reports. Some of his significant activities include: assisting Ford Foundation to strengthen evaluation and information in West Bengal (1970), preparing teaching cases distributed through ICCH Boston (1978), leading ICMR research project on specialty manpower planning (1978), conducting first inter-regional consultation on strengthening health manpower management systems (1983), drafting background document for first WHO expert committee meeting on health manpower management (1987), conducting first inter-country symposium on implications of public policy on health status and quality of life (1989), HRD strategic planning for Oman (1990), and leading a USAID project on integrated child development services management (1994). Dr. Ghosh has since been engaged in intense change initiatives in Oman on HRH planning, infrastructure development, policy / management reforms and hospital autonomy.

Karen J. Hofman, MD

Karen Hofman came to Fogarty International Center in March 1999 as a Science Policy Analyst. She has been director of the Division of International Science Policy, Planning and Evaluation since December 2002. She is a board certified pediatrician and geneticist. After completing postdoctoral studies at the Kennedy Krieger Institute and the Johns Hopkins School of Medicine, she joined the faculty and served as Acting Clinical Director at the Center for Medical Genetics. Dr. Hofman has consulted for the Pan American Health Organization on Non Communicable Disease, NIH (NICHD and NHGRI) and the Child Health Policy Unit at the University of Cape Town. As Director of DISPPE, Dr. Hofman is responsible for analyzing social, economic and public health polices related to international biomedical research with an emphasis on disparities in global health. DISPPE is responsible for developing the FIC congressional justification. In addition this office generally takes the lead in providing strategic guidance for new initiatives, organizing workshops and colloquia that inform FIC and potential funding partners regarding key research gaps and training needs.

18 Profiles





Participants William Jack, DPhil, MPhil, BSc

William Jack is an Associate Professor in the Economics Department at Georgetown University. His research interests include public economics, health economics, and development economics. He has held academic appointments at the Australian National University and Sydney University, has worked at the US Congress Joint Committee on Taxation and the International Monetary Fund, and was a member of the GAVI Alliance financing task force. Professor Jack is author of “Principles of Health Economics for Developing Countries.” Many of his current research projects are based in Kenya, and include studies of the use of cell phone technology in improving adherence to HIV/AIDS treatment, the spread and impact of cell phone banking, and the evaluation of a randomized road safety intervention. He earned his DPhil and MPhil in economics at Oxford as a Rhodes Scholar, and his BSc in mathematics and physics at the University of Western Australia.

Caroline Jehu-Appiah, MD, MSc

Caroline Jehu-Appiah obtained her MD degree from the Friendship University in Moscow and an MSc in Health Economics from University of York, UK. Currently she is the Deputy Director of Policy in the Policy, Planning, Monitoring and Evaluation division of the Ghana Health Service where she is responsible for broad level strategic planning, policy analysis and development. She has extensive experience in public health, applied research and health systems. She provided technical leadership for the implementation of National Health Insurance in the GHS and is actively involved in research to strengthen the health systems.

Soccoh Alex Kabia, MD

Soccoh Alex Kabia is Minister of Health and Sanitation in Sierra Leone. He is a trained medical doctor with over 30 years experience in the US.

Pamela McQuide, PhD, RN

Pamela McQuide is a Workforce Planning and Policy Advisor with the Capacity Project, IntraHealth International, Chapel Hill, North Carolina, USA. Dr. McQuide is a health services researcher with over 12 years of international experience and extensive expertise in Human Resources Management. A registered nurse and PhD in Social Policy, Dr. McQuide brings health policy leaders together facilitating Stakeholder Leadership Groups to identify key issues and needs for countries across the developing world. Her dedicated and participatory approach engages local leaders in every step of the process, promoting ownership and creating an atmosphere of respect and trust that enables better implementation and quicker mobilization of appropriate technologies and services. In addition, Dr. McQuide’s work with health care leaders emphasizes skill development in the use of data for decision-making and promotes sustainability by encouraging responsiveness to stakeholder feedback as country needs change. Prior to her work with IntraHealth she served as the principal investigator/project director for the Kenya Nursing Workforce Project, a collaborative agreement between Emory University and the Centers for Disease Control and Prevention. She has worked as a senior research associate at Family Health International, a research fellow for Massachusetts General and Harvard Medical School, a prenatal care consultant to the European Union, a nurse manager at Colombia Hospital and a technical monitor for USAID, Care International and the United Nations Population Fund.

Andrew D. Mitchell, SM

Andrew Mitchell is a doctoral candidate in health economics at the Harvard School of Public Health. His current research focuses on effects of payment system change on hospital behavior. As a researcher and consultant to multinational agencies, he has examined a variety of health systems issues including human resources strategic planning and decentralization of health services. He has also conducted research in social determinants of health with publications on social capital and health. Mr. Mitchell holds a Master of Science degree from the School of Public Health.

Ariel Pablos-Mendez, MD, PhD

Ariel Pablos-Méndez joined the Rockefeller Foundation as Managing Director on April 2, 2007. Previously, since 2004, he served as the Director of Knowledge Management & Sharing at the World Health Organization (WHO) in Geneva. There he worked on establishing the principles and practice of knowledge management as a core competence of public health to help bridge the gap between research and implementation. Dr. Pablos-Méndez’s appointment to Rockefeller in April of 2007 marked his return to the Rockefeller Foundation, where he was from 1998 to 2004. During his previous tenure, he worked with international agencies and donors to spearhead the creation of the Global Alliance for TB Drug Development, which shortens and facilitates the treatment of the disease in poor countries. He also led a re-thinking of the Foundation’s program in AIDS, which brought about an initiative for the treatment of mothers with AIDS and their families. Dr. Pablos-Méndez was Acting Director for Health Equity when he left the Rockefeller Foundation in 2004. Dr. Pablos-Méndez received his MD from the University of Guadalajara’s School of Medicine (Mexico) and his MPH from Columbia University’s School of Public Health.

Profiles 19

Participants Oscar F. Picazo, MA

Oscar Picazo is a senior health economist of The World Bank. He works primarily on East and Southern African countries. He is based in Pretoria, South Africa.

Belgacem Sabri, MD

Belgacem Sabri, is a Tunisian with a medical background and concentration on public health and holds a Master’s of Public Administration from the Kennedy School of Government at Harvard University and a Master’s of Economics from Boston University. After a career as a GP and medical inspector at various levels of the health care system including director of planning and research in the MOH of Tunisia, he joined WHO EMRO in 1991. He served nine years as regional adviser in health policy and management and health economics. Since 2000, he is the director of the division of health systems and services development. His areas of interest include public health, health policy and financing and human resource development.

Anthony A. Sandi, MD

Anthony Sandi is the Human Resources Director in the Health Ministry in Sierra Leone.

Lois A. Schaefer, BSN, MPH

Lois Schaefer has served as the Senior Technical Advisor for Human Capacity Development and Training in the Global Health Bureau’s Office of Population and Reproductive Health at the United States Agency for International Development (USAID) since January 2004. In addition to providing technical guidance to the Agency in its efforts to address issues of human resources for health, she manages the Capacity Project, a 5-year global project to build the capacity of health workers in developing countries. Prior to joining USAID, she was at JHPIEGO for 12 years where she was the Senior Clinical Training Advisor and Chief of the Clinical Services Division. She has experience in developing countries throughout the world as a clinician and trainer/ teacher with a focus on family planning and reproductive health. She has particular expertise in strengthening pre-service education. Ms. Schaefer holds a Bachelor of Science in Nursing from The University of Virginia and a MPH from the Johns Hopkins School of Hygiene and Public Health.

Helena Schweiger, PhD

Helena Schweiger is an Economist in the Office of the Chief Economist at the European Bank for Reconstruction and Development, London. She works on the Business Environment and Enterprise Performance Survey and Management, Organisation and Innovation Survey. She received her PhD from the University of Maryland, College Park in August 2006. She is interested in how institutional frameworks (broadly defined) affect micro and macroeconomic outcomes. These interests lie at the cross-section of a number of economic fields, including macroeconomics, labor economics and institutional economics.

Anthony Scott, PhD

Anthony Scott is a Professorial Fellow at the Melbourne Institute of Applied Economic and Social Research at the University of Melbourne. He leads the Health Economics Research Program. He is also an Honorary Professorial Fellow in the School of Population Health at the University of Melbourne, and an Honorary Professor in the Health Economics Research Unit at the University of Aberdeen. Previously, he has worked at the Universities of Aberdeen, Newcastle, Sydney, and York. Dr. Scott is known for his work on the economics of primary care, general practice and health workforce and has published widely in the area, and in other areas of health economics. He has 250 publications and presentations, including 60 peer-reviewed journal articles, 50 working papers and reports, five keynote presentations, 40 peer-reviewed conference presentations, and 40 invited presentations and seminars. He is currently conducting research examining the impact of blended payments schemes in general practice, examining a number of workforce issues in nursing, and is principal investigator on an NHMRC Health Services Research Grant establishing Australia’s first large-scale longitudinal survey of doctors (MABEL: Medicine in Australia: Balancing Employment and Life), with the first wave to be conducted in May 2008.

20 Profiles





Participants Pieter Serneels, MD

Pieter Serneels joined the University of East Anglia in September 2007 as a Lecturer in Development Economics. He teaches micro development economics and food and rural development. His research is on behavioral and labour economics in low-income countries, political economy, micro-economics and applied micro-econometrics. He is a Research Associate at the Centre for the Study of African Economies, Economics Department, University of Oxford, and carried out research consultancy for a number of organizations on a regular basis. Dr. Serneels is currently engaged in a research project on service delivery with The World Bank. Prior to working at East Anglia, he worked at the Universities of Oxford, Copenhagen and Ghent; Serneels held posts at The World Bank and the International Labour Organization and gave advice to governments in developing countries. He holds a MSc in Economics from Warwick University and a PhD in Economics from Oxford University, and an MBA from De Vlerick School for Management. He published in peer-reviewed journals and contributed to books, especially on issues related to labour and behavioral economics, and service delivery in low-income countries.

Agnes Soucat, MD, PhD

Agnes Soucat holds an MS and MD from the University of Nancy, and an MPH and PhD from John Hopkins University. She is a Lead Economist at The World Bank. Prior to joining the Bank, she worked in numerous national and international organizations, including UNICEF Benin, the International Children’s Center, the WHO, and the European Union. She joined the Bank in 2000 as lead health, nutrition and education economist for the Africa Region. She has extensive public health experience in Africa and much of her work revolves around strengthening health systems on the continent.

Sally Stansfield, MD

Sally Stansfield is the Executive Secretary of the Health Metrics Network (HMN), responsible for managing the technical and financial contributions of HMN partners to accelerate reform of health information systems for improved health outcomes on behalf of the Network and its host, the WHO. Prior to 2006, Dr. Stansfield was the Associate Director for Global Health Strategies of the Bill & Melinda Gates Foundation. She draws upon more than 30 years of clinical and public health practice, experience in research agencies, universities, governments, non-governmental organizations, and multilateral agencies. Dr. Stansfield’s areas of expertise include public health research, policy, strategic planning, program design and development, evaluation, and the development of health information systems. She has designed and managed programs for the US Centers for Disease Control and Prevention, the US Agency for International Development and Canada’s International Development Research Centre. She has advised governments in Bangladesh, Cambodia, Democratic Republic of the Congo, Ethiopia, Malawi, many other countries, primarily in Asia and Africa. Her many awards include the Alpha Omega Alpha medical honorary, the International College of Surgeons Award for Scholarship, the Public Health Service Distinguished Service Commendation, a Fulbright Fellowship, and the Yale Tercentennial Medal.

Stephen Tomlin, BA

Stephen Tomlin has long experience on four continents managing emergency relief, training and development operations for the International Medical Corps. As Vice President for Program, Policy & Planning, he has helped mobilize and direct International Medical Corps’ response to crises, including those in Kosovo, East Timor, Iraq, Darfur, Lebanon and the tsunami-affected areas of Indonesia and Sri Lanka. After the fall of the Taliban regime in late 2001, he spent six months in Afghanistan, supervising the scale-up of International Medical Corps programs to expand health care training. He has directed capacity-building programs ranging from the training of trauma surgeons in war zones to the development of local practitioners who have integrated mental health services into primary care delivery. He co-chairs the WHO-led Humanitarian Health Cluster working group for capacity building. He was educated at Oxford Brookes University in Oxford, England.

Profiles 21

Poster Presenters Faisal Abbas, MSc

Faisal Abbas is a Junior Researcher at the Centre for Development Research (ZEF), University of Bonn, Germany. Currently, he is a PhD candidate doing research on Health Economics issues related to developing countries including Pakistan. He was awarded the German Academic Exchange Service (DAAD) research scholarship relevant to developing countries for PhD studies. He has completed his MSc (Hons.) in Agricultural Economics and wrote his thesis on rural poverty issues. He has been a Researcher for a DFID-funded project related to urban health issues in Faisalabad, Pakistan. He also worked on land and rural development issues related to Pakistan. He is a member of the Macroeconomic and Poverty group based at ZEF. He is presenting his PhD work in recognized conferences, in the winter of 2008; he is accepted as a presenter in the German Economic Institute conference at Berlin. He has written on issues related to rural poverty, micro-credit, education and health economics in journals of national repute and in the popular press on topics concerning economic development of Pakistan. Currently he is in his final stages of his PhD degree.

Orvill Adams, MD

Orvill Adams is the Director of Orvill Adams & Associates. The Consultancy specializes in working with policy makers and senior managers to formulate policies and to implement innovative and sustainable solutions to the complex health systems and health workforce challenges they face. The Consultancy works in developed, developing, and countries in transition in the public and private sector. He is currently the Project Director of the Balkans Primary Health Care Policy Project working in Bosnia, Herzegovina, and in Serbia. Dr. Adams has more than 25 years of experience in senior positions in the public and private health sector. In the private sector he was the Director of Medical Economics with the Canadian Medical Association for 10 years. He then managed his own firm as a Principal in the Consulting Firm Curry Adams & Associates which focused on health, education and social services issues. In the public sector he worked for 10 years at the World Health Organization, more than five as Director, initially of the Department of Health Services Provision and after, of the Department of Human Resources for Health. He has managed and developed health systems and health workforce tools and policies, and has worked in and with countries to implement them. He has interacted with Development Partners, both bilateral and multilateral, at global levels and within countries. He is an adjunct lecturer at the University of Helsinki Department of General Practice in Primary Health Care, Quality and Management of Human Resources. He is widely published in the area of health workforce development, management, policy and planning. He holds postgraduate degrees in Economics and International Affairs.

Aarushi Bhatnagar

Aarushi Bhatnagar is a Research Fellow at the Public Health Foundation of India, New Delhi. She is a part of the PHFI-World Bank initiative for research on human resources for health in India. Her work includes estimating the size, composition, and distribution of India’s health workforce; the impact of the workforce on health and service delivery outcomes; and determinants of employment choice in rural areas among graduating medical and nursing students. Her other research interests include measuring the association between income, income inequality, and health in India. She has been trained in economics at the University of Cambridge and Delhi University. She has worked with UNICEF on the impact and cost-effectiveness of integrated management of neonatal and childhood illnesses and with the World Health Organization on breastfeeding and HIV transmission.

22 Profiles





Poster Presenters Ivy Lynn Bourgeault, PhD, MSc

Ivy Lynn Bourgeault is an Associate Professor in Sociology/Health, Aging & Society and Canada Research Chair in Comparative Health Labour Policy at McMaster University. She has published widely in national and international journals and edited volumes on midwifery and maternity care, health professions and health policy, complementary and alternative medicine, and rural women’s health. Her recent research focuses on the migration of health professionals, with a particular focus on the policy contexts in Canada, the US, the UK, and Australia, and the experiences of internationally educated health professionals in Canada. She is affiliated with the Centre for Health Economics & Policy Analysis, the Nursing Health Services Research Unit, and the Institute for Globalization and the Human Condition at McMaster University.

Ayesha De Costa, MD

Ayesha De Costa is a medical doctor who trained at the All India Institute of Medical Sciences in New Delhi. She has worked with public health, human resources, international development aid in India, and has published on these topics. She is now a doctoral researcher at the Division of International Health, Karolinska Institutet in Stockholm. She conduscts research on human resources for health in the private health care sector, and the public-private mix in India.

Djenana Jalovcic, MPA

Djenana Jalovcic is the Director of the International Centre for the Advancement of Community Based Rehabilitation at Queen’s University, Kingston, Canada. For the last 16 years she has been working in international development of health, social, disability and community-based rehabilitation services in Central America, Africa, Asia, and Central and Eastern Europe. Her research interest is the intersection of gender and health. She directs ICACBR international projects which focus on human resource development in education, services and policy sectors. She leads continuing professional development programs for interprofessional teams, and advises governments and conducts program evaluations. She is a guest lecturer in several university programs, including University of North Carolina and Queen’s University. Ms. Jalovcic manages Balkans Primary Health Care Policy Project in Bosnia, Herzegovina, and Serbia. Prior to joining Queen’s, she worked with Doctors without Borders, Italian Public Health Institutes and the World Health Organization.

Christine Brown Mahoney, PhD

Christine Brown Mahoney received her PhD in 1991 from the University of Minnesota, Carlson School of Management. She also holds an AA in nursing, a BS in animal science and genetics, and an MS in quantitative genetics and statistics. She has designed, analyzed, and reported on data in clinical trials, on patients’ surgical outcomes, technology changes and costs, health care workers labor supply, and meta-analyses. She has published over 40 of these in peer-refereed journals and presented them at over 100 conferences internationally. She has consulted extensively with medical device companies, government agencies, and hospitals and clinics. Ms. Mahoney has taught statistics to graduate students for 15 years at the Carlson School of Management, University of Minnesota.

Profiles 23

Poster Presenters Vera Meeusen, MA, RZ, CRNA

Vera Meeusen is a nurse-anesthetist (CRNA) at Catharina Hospital Eindhoven and a PhD candidate in the Department of Anaesthesiology, Brabant Medical School, Eindhoven. She has lectured on technical and medical issues for CRNAs as well as workplace and work environment in the hospital. She has written and published training manuals on several topics for nurse anesthetists and articles in peer-reviewed journals on medical anesthesia. Her PhD work concentrates on educational preparation of nurse anesthetists, the impact of their workload on burnout and satisfaction, and the causes of turnover.

Nonglak Pagaiya, BSc, MPH, MA, PhD

Nonglak Pagaiya is currently working at the Human Resources for Health office as a researcher. Her main research interest is in human resources for health, particularly at the primary care and community level. Her previous work focused on nurse guidelines at rural primary care units, workforce planning of primary care units in Thailand, as well as retention of primary care workers at rural primary care units.

Joanne Spetz, PhD

Joanne Spetz is an Associate Professor in the Departments of Community Health Systems and Social and Behavioral Sciences at the UCSF School of Nursing. She is also the Associate Director of the Center for California Health Workforce Studies. Her areas of expertise include nursing labor markets, hospital industry structure and finance, quality of patient care, information technologies, cost-effectiveness analysis, and econometrics. She has led surveys of California registered nurses and nursing schools, evaluations of programs to expand the supply of nurses, research on the effects of health information technologies in hospitals, studies of hospital industry structure, and analysis of the effects of minimum nurse staffing regulations on patients and hospitals. She was a member of the National Commission on VA Nursing, and is a member of the California Board of Registered Nursing Workforce Advisory Committee. She frequently provides testimony and technical assistance to state and federal agencies and policy-makers. She has taught quantitative research methods for doctoral students, and financial management and health economics for masters students in nursing administration and public health. She received her PhD in Economics from Stanford University after studying economics at the Massachusetts Institute of Technology.

Julia Walsh, MD, DTPH

Julia Walsh is a physician and health planner with a particular interest in cost-effectiveness analysis and priority setting. Her research emphasizes health policy and planning in developing countries, especially financing family planning and reproductive health, and vaccine policies. Dr. Walsh is co-principal investigator for the SHARE project (Study of Hispanic Acculturation, Reproduction, and the Environment), examining 1500 Hispanic pregnant women prospectively over the next three years to assess the causes of the worsening birth outcomes among Hispanic women after migrating to the U.S. She has worked with Ministries of Health in Egypt and Bolivia to analyze priorities for health systems based on cost-effectiveness analysis. She also recently completed an extensive study of the efficiency and costs of 17 Egyptian public sector hospitals and more than 60 outpatient facilities. With the Family Health Outcomes Project at UC San Francisco and UC Berkeley Center for Media and Independent Learning, Dr. Walsh developed a series of internet-based, computer-interactive courses for maternal and child health professionals. She teaches International Health with Professor Malcolm Potts at University of California, Berkeley.

24 Profiles





Panel Session #1 Estimating Health Worker Shortages: What Can Africa Afford and What Else Can Be Done? Richard M. Scheffler, PhD

Director, The Global Center for Health Economics and Policy Research Distinguished Professor of Health Economics & Public Policy, University of California, Berkeley Objective: Critical shortages of health workers are now acknowledged to be a global problem, particularly in Africa, which has the largest per capita workforce shortages. This report provides new forecasts of the need, supply, and shortages of doctors, nurses, and midwives in African countries in 2015, the target date of the U.N. Millennium Development Goals. We analyze health worker wage data and estimate the additional wage expenditures that would be required to fill these shortages. We illustrate how changes in the current workforce mix of doctors, nurses, and midwives can impact the wage expenditures that will be needed. The purpose of the report is to inform policy-makers, providers, governments, and NGOs. Methods: We used Scheffler et al.’s (forthcoming, Bulletin of the World Health Organization) results from their needsbased model that estimated the total number of doctors required to achieve 80% coverage of live births by a skilled health care attendant in 2015. To estimate the number of nurses and midwives needed for each country, we assumed that the current ratios of nurses-to-doctors and midwives-to-doctors would remain constant. We used a similar procedure to estimate supply. We then estimated the total wages that would have to be paid to workers to fill the shortages, based on the doctor, nurse, and midwife wages for each country. Calculations for changes in skill mixes were made based on the assumption that a nurse’s productivity is 0.8 of a doctor’s productivity, and a midwife’s productivity is 0.6 of a doctor’s productivity. Data: Data from numerous sources were combined to conduct the research: Scheffler’s previous estimates derived from World Health Organization (WHO) and World Bank data; WHO Global Atlas of the Health Workforce data on the ratio of nurses-to-doctors and midwives-to-doctors by country, and wage data from the National Bureau of Economic Research (NBER), specifically their published Occupational Wages around the World (OWW) database, derived from the International Labour Office (ILO) October Inquiry. Where wage data were not available, an estimate using regression analysis was employed using the country’s per capita income. Results: We estimate that some 30 African countries will experience shortages of health workers in 2015. The total need for these countries will be 3.9 million workers, whereas they will have only 1.6 million workers—or 41 percent of their need. By profession, we estimate these countries will have 60% of needed doctors, 36% of needed nurses, and 48% of needed midwives. The incremental annual wage bill to eliminate this shortage is estimated to be approximately $7 billion (in 2007 U.S. dollars). The wage bill can be reduced by shifting the workforce mix. Savings vary by country and depend on the country’s nurse-to-doctor and midwife-to-doctor ratios, the relative wage mix, and the relative productivity of workers. Fourteen of Africa’s countries can reduce their annual wage bills by bringing their nurse-to-doctor and midwife-to-doctor ratios to the African median nurse-to-doctor ratio (6.7) and median midwife-to-doctor ratio (1.2). If this were done, the savings could be as large as 20% of the wage bill necessary to eliminate the shortage. Conclusion: We provide new estimates of the number of health care workers and the wage bill that would be required for individual countries to eliminate their shortage. We conclude that this incremental wage bill is unachievable for most African countries because the new total wage bill would approximately double the current wage bill. Therefore other solutions need to be explored, such as improvement in worker productivity, less expensive training, and making good use of community health workers and other new health professionals. These findings and conclusions will be important to policy-makers and other stakeholders who are engaged in improving the health workforce capacity in African countries and all developing countries.

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Panel Session #1 Spatial Distribution of Health Workforce and Health Care Services: An Inter- and Intra- Country Analysis Sailabala Debi

Abstract: It is widely recognized that the health care system in almost all the countries is facing severe crisis. The most important cause of present crisis is attributed to the human resources (health workforce i.e. doctors, nurses, mid wives, Pharmacists, etc) in providing health care services. The unequal distribution of health workers across regions affects the health care to a significant extent. Objectives: • To measure the imbalances in the distribution of health workforce between and within different countries of the world and across different regions in the India union; • To examine the relationship between health workforce and health care services; • To assess the contribution of health workforce in influencing the health status of the population. Data: The study has used the country wide secondary data on health workers density Index (Doctors, Nurses and mid wives per 1000 population), infant mortality rate, maternal mortality rate, birth attended by health staff and life expectancy at birth collected from world indicators of health and Human Development Report (UNDP). The data for India Karnataka was collected from the Health information of India, Human Development Report –II, Annual reports of the Directorate of Health and Family welfare, Government of Karnataka etc. Methods: Using simple average, SD and CV, the imbalances in the distribution of health workforce (HWF) across different countries, different states in India and different districts in a state in India (a medium developed state: Karnataka) were estimated. A total of 152 countries of the world were classified as highly developed, medium developed and less developed on the basis of HDI. The relationship between health workforce and health care was examined through simple correlation and regression. Findings: • The average density of HWF moves in unison with the development status of the countries of the world, i.e. more developed –higher density, less developed - lower density and so on. • The variation (CV) is the lowest in highly developed countries (54.37%) and highest in less developed countries (196.82%). The spatial distribution in the density of HWF among the LD countries is most imbalanced, in MD countries is more imbalanced and in HD countries it is least imbalanced. The variation in the distribution of HWF (CV) in Indian states and in Karnataka state is found be less uneven than HD countries. • The correlation between health workers and (i) Infant mortality rate (IMR), maternal mortality rate (MMR), death due to communicable diseases and prevalence of HIV is negative and statistically significant. (ii) Life expectancy at birth (LEB) and birth attended by health staff and immunization is positive. Most interestingly the value of correlation (r) is found to be the highest for the less developed countries for almost all the indicators. (iii) Similar estimates were made in the context of India (a medium developed country in respect of HDI) and Karnataka (medium developed state in India). The correlation estimates showed similar pattern as in case of country wide analysis. • The impact of these variables on health status was examined by using simple linear regression model. The dependent variable was the index of LEB (proxy for health status) and the independent variables were education index, per capita income and health workers. The results of multiple regression indicated that the variables included in the model explained 70%, 51%, 19%, and 38% variation in health status respectively for all countries, HD, MD and LD countries. The corresponding figures for India and Karnataka explaining variations in the health status were 68% and 53% respectively. • The variable health workforce is found to be statistically significant for the less developed countries, India and Karnataka indicating its significant contribution in influencing the health status of people (LEB) in LD and MD countries/regions. Policy Implications: The imbalances in the distribution of health workers can be corrected by adopting suitable policy by providing more/better incentive measures to the health workers particularly in the less developed and rural areas through public-private partnership and developed-developing country partnership. More investment on human resources in the health sector particularly in less developed regions is urgently needed, as there is a threat of different epidemiological disease all over the world in view of the rapid climatic change. However, no uniform policy can meet the specific needs of a specific region and hence it needs to be target specific and need based.

26 Abstract





Panel Session #1 Scaling Up Health Education Opportunities and Challenges for Africa

Alexander S. Preker, Marko Vujicic, Yohana Dukhan, Caroline Ly, Hortenzia Beciu, and Peter Nicolas Materu Prepared for the Task Force on Scaling up Health Education of the Global Health Workforce Alliance Presented at the Fourth Taskforce Meeting in Kampala, Uganda, Oct 11-12, 2007

Abstract: This report reviews the economics of scaling up education for health workers in the context of the Africa region. It provides an assessment of the likely resource envelope that might be available to the health and education sectors by 2015 using different assumptions about political commitment to spending on economic growth, health care, and institutional development; an estimate of the number of additional staff that could be hired by countries under the different resource envelope scenarios; and an estimate of the cost of scaling up the education of health workers in terms of recurrent and capital costs. All estimates were done on a country-by-country basis. Regional estimates are based on the sum of this detailed country level analysis. Scaling up health education has significant implications for both the health and education sector. The cost of employing new staff falls on the health sector while the cost of educating health workers falls mainly on the education sector. Projecting current economic trends would allow countries in the Africa region to absorb around 300,000 new staff by the year 2015. If, however, there were a skills mix shift to more highly skilled workers the absorptive capacity would be reduced to about 200,000 additional workers; while a skills mix shift to lower skilled workers would increase the absorptive capacity to about 450,000 new workers. A wage increase of about 25 percent over time would partially offset this increase in staffing. Under a best case scenario and skill mix shift toward high skills, a small number of counties could reach the WHO target of 2.5 health workers per 1,000 populations. Most countries, however, are not likely to enjoy the sustained growth, commitment to increasing public spending on the health sector or mobilization of additional resources through health insurance that are needed to achieve this target. In many countries, the binding constraint to scaling up health education was not only the limited absorptive capacity of the health sector to hire the resulting staff but the limited resources in the education sector to train the additional staff and make the needed capital investments to increase the capacity and throughput of training institutions. In a number of countries, the cost of educating the addition health workforce would outstrip the annual higher education budget of the Ministry of Education.

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Panel Session #1 Scaling-up Interventions to Meet Shortages of Health Workers Gilles Dussault, Mario Dal Poz, I. Fronteira, H. Prytherch, and K. Wyss

Theme: Improving the capacity of the health workforce to meet demand and needs for health services. Background: The World Health Report 2006 estimates that fifty-seven countries suffer from severe shortages of health workers; 36 of these countries are in sub-Saharan Africa. According to the World Health Organization, more than four million additional health care workers are needed to fill this gap, which brought the World Health Assembly to adopt a resolution calling for a rapid scaling up of the production of health workers. This paper aims to synthesize data and knowledge in relation to scaling up and their implications for policy development. Objectives: To review the existing literature on: • What is meant by scaling up of human resources for health? • The rationale for scaling-up • Strategies and methods for scaling-up • The costs of scaling-up • Lessons learned from evaluations of experiences • What are the critical factors (obstacles, facilitators) of success? Data: These are derived from published and gray literature Results: A critical overview of policies and practices in relation to scaling-up human resources for health and of the determinants of their success or failure Policy Implications: This paper will inform policy development processes in making available the current state of knowledge on how to conceptualize scaling-up and on lessons learned form country experiences

28 Abstract





Panel Session #2 Measuring and Monitoring the Health Workforce using Open Source Tools Pamela McQuide1, Dykki Settle1, and Rita Matte2 Capacity Project, IntraHealth International Registrar, Nursing Council of Uganda

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Theme: The use of new and existing data sources and tools to measure and monitor the health workforce’s (including public health workers’) capacity to meet a population’s health care demand and needs Background: Doctors, nurses and other health professionals form the backbone of a country’s health system. Although there is growing concern about out-migration and the impact of HIV/AIDS on health workers from developing countries, there are inadequate data available regarding the extent of the problem. This is mainly attributable to the lack of a reliable, current, and easily accessible workforce data system in many of these countries. To ensure the availability of such data, there is an urgent appeal by several international organizations such as the World Health Organization, United Nations, United States Agency for International Development (USAID) and the Eastern, Central, and Southern Africa Health Community (ECSA) to assist in the development of accurate and timely human resource information. In response, USAID’s Capacity Project has been developing a suite of free and Open Source software products (iHRIS) to help countries plan, measure, monitor and manage their health workforce. Implementation of these human resource information systems is underway in eight sub-Saharan African countries. Objectives: • Identify the need for accurate and timely human resource information systems for use in developing countries • Introduce the Capacity Project’s HRIS strengthening process and iHRIS suite of tools using Open Source solutions • Present case studies using data from iHRIS to train, register, manage and plan health workforce needs in three developing countries Data: National data from the Nursing Council of Uganda and the Ministry of Health in Swaziland and Rwanda identify training, registration and deployment information about health workers by demographic variables, districts, categories of health workers and health worker positions. Methods: Based on key policy questions identified by the Ministry of Health, councils and other country-level key stakeholders, univariate and bivariate data are analyzed with iHRIS report functions and geographical mapping tools. Results: Findings indicate the number of nurses and midwives that have been trained and registered across Uganda for the last 30 years according to population statistics, HIV prevalence, and workforce needs. Geographical mapping illustrates disparities across the country. Information from Rwanda and Swaziland demonstrates use of routine administrative data to recruit, deploy, manage and plan for the health workforce needs across the country. Policy Implications: Having reliable, valid, and timely information about the health workforce in developing countries encourages evidence-based decision-making about key policy questions on a wide variety of health workforce issues. Using Open Source software solutions encourages sustainability of human resource information systems beyond the funding cycle of a development partner.

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Panel Session #2 The State of Human Resources for Health in Zambia: Results of the Public Expenditure Tracking and Quality of Service Delivery Survey (PET/QSDS), 2005/2006 Oscar F. Picazo

Senior Economist, The World Bank, South Africa Country Office, Pro-Equity Court, 1250 Pretorius St., Hatfield 0028, Pretoria, South Africa

Theme: Use of new data sources and tools to measure and monitor health workforce’s capacity to meet a population’s health care demands and needs Background: Zambia’s health workforce is in crisis. The Health Workforce component of the Public Expenditure Tracking (PET)/Quality of Service Delivery Survey (QSDS) aimed to quantify various dimensions of the crisis and provide these as inputs into strategic planning activities. The survey supported the larger public expenditure review in the health sector. It was funded by an Institutional Development Fund (IDF) grant from the World Bank, and was implemented in collaboration with the Zambia Ministry of Health, University of Zambia. Objectives: The PET/QSDS’ Health Workforce component examined staffing patterns and availability/vacancy; staff absenteeism and tardiness; staff workload, morale, and dual practice; staff salary and benefits; and salary management issues. Data and Method: PET/QSDS is a nationwide survey of 21 district health management teams (DHMTs), 18 hospitals, 132 urban and rural health centers, and patients in five provinces: Lusaka, Copperbelt, Southern, Western, and Northern. Results: (a) Skewed staffing patterns persist as reflected in the composition of established posts. (b) Health facilities have very high rates of staff vacancy. (c) The rate of staff turnover is worrisome, especially in rural health clinics. (d) Health facilities are increasingly relying on expatriate and volunteer staff. (e) Staff absenteeism is considerable, and self-reported rate of absenteeism is even higher than the rate found in the facility survey. (f ) Staff tardiness is a much bigger problem than absenteeism. (g) Half of the staff surveyed complained of the workload. (h) Very little time is being devoted to direct patient care. (i) About half of the staff surveyed have low morale. (j) A fifth of the staff are engaged in dual practice or other salary-augmenting economic activities. (k) Salary levels of professional and clinical staff are highly compressed, and a variety of allowances are being used to decompress overall payroll. (l)The cash allowances and in-kind benefits are varied but highly fragmented, and cater only to a small proportion of staff. (m) Salary management is a problem and could lead to leakage.

30 Abstract





Panel Session #2 Ensuring Workforce Capacity to Meet Healthcare Demands Equitably in a Public System Basu Ghosh

Advisor, HR, Ministry of Health, Sultanate of Oman. PO Box 393, Muscat 113

Background: This study has been conducted in a middle-income country in the Arabian Gulf viz. Oman, where healthcare system is largely financed and provided by the Government. The public health authority of the country has adopted a rational staffing policy, which entails staffing of health care institutions based on workload-cum-allocation considerations. The requirements are estimated using computer-based requirement planning models. The staffing situation is periodically reviewed and staffing patterns are re-adjusted. Objective: The paper intends to demonstrate an approach towards rational staffing of primary health care institutions based on workload-cum-allocation considerations. Data: The study draws upon secondary sources of information such as utilization figures officially published in annual health reports, and cumulative experience of workforce requirement estimation using locally developed and time-tested user-friendly computer-based models. Methods: The essence of the methodology involves the development of dynamic classification systems separately for ‘health centers’ and small rural hospitals called ‘local hospitals.’ The paper evolves a suitable classification of health centers and local hospitals, and lays down staffing norms for each type. For health centers, the classification is based on catchment area population and expected daily OPD attendance. For the local hospitals, the classification is in terms of expected OPD attendance and effective number of beds (where effective number of beds is calculated as the product of the number of beds and bed occupancy expressed in ratio form). It then assigns a tested staffing plan to each classification type according to the current class of institution based on utilization and catchment area population. Provision is made for periodic up-gradation of class of an institution depending on changes in utilization and /or in population coverage. Results: The newly evolved staffing policy for primary health care institutions based on the above is examined and accepted by HE the Minister as the norm with a view to strengthening the primary health care institutions. Public and/or Health Care Policy Implications: This study demonstrates an evidence-based framework for rational decision-making, which helps to minimize ad-hoc sanctioning of staff to primary health care institutions. Official adoption of such carefully orchestrated locally-evolved methodologies strengthens the desire of public authorities to mobilize additional financial resources whenever necessary. It thus ensures adequate workforce capacity in quantitative terms and appropriateness of the skills mix thus enabling them to respond well to primary healthcare demands in a public system. Furthermore, the approach makes it possible to guarantee equitable geographical distribution of workforce within a given healthcare infrastructure.

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Panel Session #2 Understanding the Dynamics of the Medical Workforce: The MABEL Longitudinal Survey of Doctors Anthony Scott1, John Humphreys2, Catherine Joyce3, and Guyonne Kalb3

Melbourne Institute of Applied Economic and Social Research, The University of Melbourne School of Rural Health, Monash University 3 Department of General Practice, Monash University 1 2

Theme: The use of new and innovative data sources and tools to measure and monitor the health workforce’s capacity to meet a population’s health care demand and needs. Background: There is very little longitudinal data studying the dynamics of the medical workforce, especially for mid to late career doctors. Datasets need to move beyond just ‘counting and describing’ the health workforce to the analysis of behaviour and productivity. Longitudinal data is necessary to examine the effects of changes in family circumstances, working conditions, and incentives on changes in physicians’ labour supply, productivity, and attitudes to work. Objective: The aim of this paper is to describe the methods of the MABEL survey (Medicine in Australia: Balancing Employment and Life) and present some results from the pilot survey. Methods: MABEL is a survey of a random sample of 30,000 doctors in Australia, stratified by doctor type and geographic location. The sample contains doctors from intern year through to those who are close to retirement, and includes general practitioners, specialists, specialists in vocational training programs, and hospital junior doctors not enrolled in specialist training. Doctors are posted a personal invite letter and asked to log on to www.mabel.org.au where they can fill out the survey online, download a paper copy, or request a paper copy to be posted to them. Data are collected on training and registration status, workplaces and job characteristics, job satisfaction, family circumstances, and individual and household earnings. The survey also includes a discrete choice experiment to examine doctors’ preferences and trade-offs for different types of jobs. The data will be used to estimate a structural labour supply model of factors influencing hours worked. Microsimulation models will also be estimated and both pecuniary and non-pecuniary factors will be examined. Other types of decisions will also be examined, including retirement, changing jobs, specialty choice, and movements between urban and rural areas. Results: The paper will present the results of the main pilot surveys and will focus on our experiences with sampling methods, response rates and recruitment, in addition to presenting some baseline data. The future opportunities for the use of MABEL data will also be outlined.

32 Abstract





Panel Session #2 Explaining Health Worker Career Paths

Pieter Serneels, Magnus Lindelow, and Jose Montalvo Abstract: Like other professionals, health workers tend to have strong career preferences. Some jobs are more popular than others. Most health workers prefer, for instance, a posting in an urban area or a position in a hospital. Some health workers also aspire to a job abroad. This often leads to an understaffing in certain postions and an overstaffing in others. What drives these outcomes and (how) can they be shifted? Using unique panel data for health workers in Ethiopia, this paper investigates the determinants of career outcomes and the role of preferences and motivation. Since the data contains information on the health workers both when they were at school and after they entered the labor market, we focus on the early stage of their career path, which typically has a strong effect on their remaining career.

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Panel Session #3 Do More Health Workers Mean Higher Immunization Coverage? Evidence from Turkey Andrew D. Mitchell1, Thomas J. Bossert1, Winnie Yip1, and Salih Mollahaliloglu2

Harvard School of Public Health School of Public Health, Ministry of Health, Turkey; Takemi Fellow in International Health, Harvard School of Public Health

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Theme: The use of new and existing data sources and tools to measure and monitor the health workforce’s (including public health workers’) capacity to meet a population’s health care demand and needs Background: Understanding a country’s health production function is central to efficient and effective use of health sector resources. While the macro-level link between provision of services and health outcomes is still not well-established on many fronts, recent international research on densities of human resources for health (HRH) has begun to fill this gap. Previous research has linked, for example, the size of countries’ health workforces to reductions in maternal mortality and increased vaccination coverage. While such research can inform HRH planning for policymakers, it is still in its infancy and can benefit from methodological development. Objectives: This study seeks to answer the question: Have HRH densities contributed to increasing vaccination rates in Turkey and what implications do findings hold for raising future vaccination coverage? It furthers previous research by focusing on relationships between HRH and vaccination coverage over time within a single country. Data: The analysis draws upon the following data from Turkey’s 81 provinces and spanning the period 2000 to 2006: provincial coverage of publicly provided vaccines included in Turkey’s Expanded Program of Immunizations (EPI); deployment levels of public sector/primary care-level general practitioners (GPs), nurses and midwives, and health officers; and provincial socio-economic and demographic characteristics (i.e., population levels, per capita GDP, land area and female adult illiteracy). Methods: Panel data regression methodologies are used to estimate fixed- and random-effects models relating provincial vaccination coverage to HRH densities. Results: Four main findings emerge: First, combined GP, nurse/midwife and health officer density is associated with vaccination rates — independent of provincial-level characteristics — characterized by an initially positive association that diminishes over time. Second, HRH-vaccination relationships differ by cadre of health worker, with strongest associations found between GP/health officer densities. Third, HRH densities bear stronger relationships with vaccination coverage among Turkey’s more rural provinces compared to provinces with higher population densities. Finally, HRH during the period 2001 to 2006 in which Turkey underwent significant macroeconomic changes and new health sector policies, HRH density-vaccination rate relationships are markedly stronger. These patterns of associations are robust to model specification as random- or fixed-effects. Policy Implications: We draw three main policy conclusions: First, densities of health personnel can be relevant for health service delivery at a level of development well-above that of the world’s poorest countries. Second, relationships between HRH densities and EPI vaccination coverage appear to be affected by many other factors; this suggests that a focus on per capita levels of health personnel to determine adequate workforce levels may not be sufficient to achieve health outcomes. Third, differing relationships by health worker cadre suggests a team-based approach may be important to future immunization efforts in Turkey.

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Panel Session #3 The Workforce and Cost Implications of Substituting Nurses and Pharmacists for Doctors in the Follow-up of Patients with AIDS on Antiretroviral Therapy in Uganda Joseph B. Babigumira1, B. Castelnuovo2, M. Lamorde2, A. Muwanga2, A. Kambugu2, P. Easterbrook2, and L.P. Garrison1 Pharmaceutical Outcomes Research and Policy Program, School of Pharmacy, University of Washington, Seattle, WA Infectious Diseases Institute, Kampala, Uganda.

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Theme: The use of new and existing data sources and tools to measure and monitor the health workforce’s (including public health workers’) capacity to meet a population’s health care demand and needs Background: Uganda faces acute health worker shortages, partly due to the HIV epidemic, which affects 1 million people of whom 300,000 need antiretroviral therapy (ART). The Infectious Diseases Institute (IDI) at Makerere University in Uganda is a regional center of excellence in HIV treatment, prevention, training and research in Africa. Its clinic provides free ART to almost 5000 patients. ART follow-up is implemented using three algorithms: 1) doctor-intensive (DI), the routine follow-up method, 2) nurse-intensive (NI), an innovation where specially trained nurses substitute for doctors and 3) pharmacist-intensive (PI) another innovation where patients utilize a pharmacy-only refill program (PRP) between 6-monthly doctor visits. Objective: To quantify the workforce and cost implications of ART follow-up algorithms at IDI for HIV/AIDS treatment in Uganda. Data: Primary data from a time-motion survey performed to estimate median health worker utilization (HWU) and patient waiting (PW) times for different services at IDI. Methods: We performed a societal perspective cost analysis including health resource utilization (HRU) and opportunity cost of patient waiting time. Non-health worker aspects of HRU such as overhead costs, and patient transport costs are identical for algorithms and were excluded. Unique personnel requirements for algorithms were identified and used to determine hourly HWU per patient, which was multiplied by hourly wages for different cadres, provided by IDI human resources department. PW times for different services were multiplied by mean hourly wage for Ugandans, estimated from 2007 per capita GDP. National projections were made to quantify workforce and cost implications. Results: Median HWU and PW times per visit (hours) were 0.20 and 0.24 for triage nurse, 0.12 and 1.10 for doctors, 0.08 and 0.27 for pharmacists, and 0.13 and 0.05 for nurses. HWU time for PRP pharmacists was 0.03 with no waiting. IDI hourly wages were nurses $4.6, doctors $8.3, and pharmacists $3.3. The average Ugandan hourly wage was $0.99. Total annual societal per-patient cost of follow-up was $45.2 for DI, $28.3 for NI and $16.3 for PI. Total projected national annual follow-up cost was $13.5 million for PI, $8.5 million for NI and $4.9 million for PI. Therefore, total annual resource savings were $5.0 million for NI and $8.6 million for PI. Direct patient care (DPC) time for doctors was 1.4 hours per patient per year or 420,000 hours per year nationally. Assuming doctors work 2080 hours a year of which 1040 (50%) are DPC, substitution of doctors with nurses or pharmacists would save 404 full-time-equivalent (FTE) doctors per year, 18.4% of the current number practicing in Uganda. Health Policy Implications: The use of NI and PI innovations as substitutes for DI follow-up results in substantial reductions in doctor demand and substantial societal resource savings. Since prior research suggests no adverse impact on adherence to drugs and follow-up of these innovations, serious consideration should be given to policy changes to adopt and optimize them as a way to reduce health spending. However, additional research into the effect of innovations on quality of care and other outcomes is needed before definitive policies are recommended.

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Panel Session #3 Monitoring Health Workforce Skills Mix and Productivity to Support Decision Making for Health Policy and Planning: Insights from Survey Data in Six Low and Middle Income Countries Neeru Gupta and Mario R. Dal Poz

World Health Organization, Department of Human Resources for Health, 20 avenue Appia, Geneva 1211, Switzerland

Background: The link between human resources for health (HRH) and population health outcomes is not well understood. Data on resource profiles and investments in health systems are inadequate in many countries despite the importance of such data for policy decisions. It is important for countries to understand their health systems workforce, especially the different elements of planning, production, recruitment and management of health personnel. The appropriate and timely delivery of health services depends strongly on a workforce that is sufficient in numbers, well educated and trained, and adequately deployed, managed and motivated. Objectives: In recognition that national capacities for planning, implementing, monitoring and evaluating appropriate HRH policies are in many countries inadequate, the World Health Organization coordinated a series of detailed HRH assessments in six developing countries. The objectives were two-fold: to inform the development of HRH policy within the countries; and to test and validate reliable methods of data collection and how they can best be used for short- and long-term planning. Data and Methods: Data for this analysis are primarily drawn from the Assessment of Human Resources for Health, a multi-component data collection approach developed by WHO and fielded in six low and middle income countries: Chad, Côte d’Ivoire, Jamaica, Mozambique, Sri Lanka and Zimbabwe. Data on health workforce skills mix and provider productivity are extracted from the health care providers component of the survey. Basic statistical analysis techniques are used to measure, assess and compare health workforce metrics across countries. Results: Survey results reveal a large diversity in both the organization of health services delivery and, in particular, the mix, distribution and activities of HRH across the sampled countries. Despite efforts to reduce survey variances by means of standardized data collection tools and approaches, consideration variations did occur in fieldwork implementation due to specificities of national health systems as well as logistic, technical and political reasons. While the use of standardized questionnaires across all countries offered the advantage of enhancing cross-national comparability of the research findings, some limitations were noted especially in relation to the categories used for occupation and qualifications, which did not necessarily conform to the country situation. Policy Implications: The results presented here are part of larger technical cooperation efforts initiated by WHO in collaboration with countries and partners to measure and assess health workforce metrics. The findings help contribute to improving the knowledge base to enable decision makers to have a better understanding of health systems performance, linking evidence to actions to improve performance, and developing greater capacity to monitor and improve performance at the international, regional, and national levels.

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Panel Session #3 Effects of Health Labour Migration on Low and Mid-Level Health Personnel for Infectious Disease Control at the Periphery in the Volta Region of Ghana Dr. Frank Nyonator, Dr. Caroline Jehu-Appiah, Charles Acquah, and Theresa Akuoko Ghana Health Service

Theme: The effect of health workforce skills mix, geographical distribution, mobility, and workforce/population demographics on health care delivery, access to care, and quality. Background: A situational analysis of mid-level health cadres in the control and prevention of malaria, tuberculosis and schistosomiasis in the Volta Region of Ghana in order to inform future policy on the production, deployment, and retention of mid-level cadre in the health sector. The results presented are part of the first phase of the 3 phase study. Objective: To conduct a situational analysis on low- and mid-level cadres involved in the control and prevention of infectious diseases, specifically, malaria, tuberculosis and schistosomiasis in the Volta Region of Ghana in order to inform policy on the production, deployment and retention of mid-level cadre1 in the health sector. Methods: Qualitative and quantitative data on human resources at national, regional, and district levels were gathered over a period of five years (2000-2005). A document review as well as key informant questionnaires were administered in all fifteen districts of the Volta Region and analyzed for trends in numbers, deployment, distribution and magnitude of internal and external migration in the Volta Region. Key informant interviews were conducted to validate data on training and educational pre-qualifications. The results are presented in descriptive statistics, charts, and tables. Results: The Volta region lost 8% of its mid-level cadre workforce in the six years under review. Transfers and study leave accounted for 42% of all attrition. Retirement accounted for 8%, death 3%, vacation of post 2%, while sick leave and end of contract accounted for 1%. Among the various mid-level staff, community health nurses (50%), technical officers (45%) and enrolled nurses (41%) were the most likely to go on study leave. Analysis of results show an ever increasing ageing mid-level cadre workforce with a mean age of 44yrs. The implication is that not only are we loosing our trained health professionals but also the mid-level cadres to different forms of attrition. Validation of the task list revealed mid-level cadres often have to perform and take on additional tasks outside their areas of training. Mid-level cadres are often left out in favour of professional workers and only 8% benefited from deprived area incentives. Policy Implications: The policy response to address the inadequate numbers of mid-level cadres in Ghana may be geared towards increasing intake and reducing the rigid barriers to professional practice. In addition, these cadres should be enabled to take on additional roles. This can be achieved by redefining functions, reforms in staffing standards, and refocusing on in-service training. A firm decision by policy makers on the most efficient skill mix and numbers of health workers to train to achieve the desired coverage of health interventions cannot be overemphasized. Lastly, the current strategies/incentives to rectify geographic imbalances have not had the desired results. More innovative strategies are thus needed to achieve an equitable distribution of health workers within and between regions in Ghana. Midlevel health care cadres are defined as cadres of health workers who support highly skilled professionals such as doctors, nurses and pharmacists. Examples of these cadres identified at the forum include Medical Assistants, Enrolled Nurses, Community Health Nurses, Field Technical Assistants and a range of Allied Health Care Assistants. 1

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Panel Session #4A Health Workers’ Attitudes to Market Incentives and Privatisation in Central and Eastern Europe Libor Krkoska and Helena Schweiger

European Bank for Reconstruction and Development, London, U.K.

Theme: The use of new and existing data sources and tools to measure and monitor the health workforce’s (including public health workers’) capacity to meet a population’s health care demand and needs Background: Policy-makers in transition countries in Central and Eastern Europe face difficult choices as they respond to the pressure to improve the quality and efficiency of their health sectors. Many governments are considering involvement of the private sector to alleviate strains on limited government resources and provide the level of health services that responds to people’s needs. Health workers are among the key stakeholders whose views on increased role of the private sector in the provision of health care have to be taken into account in proposed health reforms relying on public private partnerships. Objective: This paper analyses the attitudes of health workers to the introduction of market incentives and greater involvement of the private sector during transition from central planning to the market in Central and Eastern Europe. Data: The empirical analysis is based on a unique household survey, Life in Transition, undertaken by the EBRD/ World Bank in 29 countries in Central and Eastern Europe in 2006. The main objective of this survey was to assess the impact of transition on people and to help understand how their attitudes towards market reforms and political changes relate to individual and household circumstances. Methods: Econometric analysis of household survey data linking views of the respondents to their individual and household characteristics, including income, age, education, location, and labour market path in the past fifteen years. Cross-country differences are corrected for by the use of country fixed effects as well as selected country level health care input / output variables. Results: Empirical results based on the household survey show that health workers have relatively favourable views on greater use of market incentives and private sector involvement, even though they would like to see substantial extra public investments in the health sector. Indeed, health workers are significantly less likely, compared to average households, to say that the state should guarantee employment opportunities or re-nationalise privatised companies. However, a significant part of health workers’ attitudes is driven by their education and labour market experiences during the transition period. Health workers are substantially more likely to have seen improvements in living standards compared to average households, have easier access to public services, and are less likely to rely on informal payments in their use of public services. Policy Implications: The health sector has been identified as the top priority by households in transition countries. The views of health workers on the need for further public investments in the health sector, and potential for introduction of market incentives / greater private sector involvement to alleviate some of the fiscal constraints which prevent higher public investments are therefore important for the design of health reforms.

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Panel Session #4A Toward a Northern Metric: Tracking Global Citizenship in an Epoch of Health Globalization Fitzhugh Mullan

Murdock Head Professor of Medicine and Health Policy, The George Washington University

Context: Recent research suggests that 20% of African physicians and 10% of African nurses reside in northern countries. In the United States alone there are predictions of a shortfall of 800,000 nurses and 200,000 physicians by 2020. These trends and the absence of formal policies in northern countries that promote health workforce self-sufficiency promise increasing levels of health worker migration from the south to the north. Objectives: 1. To document the importance of under-training in the north as a driver of migration from the South. 2. To discuss vehicles for raising public awareness in northern countries about HRH inequities. 3. To propose actions that could be taken by Northern countries to mitigate the brain drain. Methods: 1. Literature review 2. Review of research findings 3. Presentation of data in regard to migration, reverse flows, and capacity development support. New Findings: In addition to codes of ethics it will be proposed that northern nations engage in: 1. HRH tracking to determine the levels of southern health workers entering Northern workforces on an annual basis 2. The establishment of Northern goals for HRH self-sufficiency including guidelines and targets. 3. HRH capacity support targets in which Northern nations would set goals for financial assistance for capacity development in Southern countries. 4. Reverse flow tracking in which Northern nations would promote the mobilization of increased numbers of health workers, including “Diasporics” to assist in health system development in the south. Policy Implications: Absent heightened awareness in the North and more rigorous metrics related to Northern immigration and Southern capacity development, the best efforts of Southern nations to improve the management of HRH will not offset the pull from the north. It will be proposed that a Responsible HRH Capacity Index be developed for northern countries based on the tracking factors above.

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Panel Session #4A Health Labor Market Institutions and Incentives in Ethiopia Joost de Laat1, Kara Hanson2, and William Jack3 Université du Québec à Montré al London School of Hygeine and Tropical Medicine 3 Georgetown University 1 2

Abstract: This presentation summarizes the results of a survey of over 800 health workers in Addis Ababa and two remote rural regions of Ethiopia. We report results of a discrete choice experiment, in which we assessed the valuation of a range of job attributes, and use this information to determine the impact of policy changes on rural health worker labor supply. We also examine the functioning of the physician labor market, including the short-term determinants of job assignments upon graduation, and the long-term impacts of those assignments on the future evolution of physicians’ careers. We find evidence that the labor market consisting of those whose first jobs were assigned by lottery (about 60 percent) is characterized by adverse selection and attrition of high-quality doctors, in comparison with the market for physicians who did not participate.

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Panel Session #4B How Wage Bill Policies Affect the Evolution of the Health Workforce in the Public Sector Marko Vujicic The World Bank

Theme: The use of innovative measures and predictive models to analyze health workforce supply-demand dynamics, as well as wage levels (especially for low-skilled workers) Abstract: There have been persistent claims that wage bill ceilings in developing countries – often thought to be influenced by the IMF – are a key constraint to scaling up the health workforce, and therefore, the principle barrier to improving health service delivery. A recent mapping by the IMF has indicated that of the 30 countries that have a PRGF-supported program, 14 have some form of public sector wage bill conditionality as part of the program. This includes 11 out of 18 African countries. However, there is little analysis on how aggregate wage bill policies have influenced the resource envelope (and therefore the demand) available for hiring health workers in the public sector. Has the health sector been exempt from public sector downsizing, has it been targeted, what determines the share of health spending that goes to salaries, how does this differ across countries and what are the policy implications? This study examines the relationship between overall public sector wage bill policies and wage bill and employment levels in the health sector. Information is drawn from four country cases: Zambia, Kenya, Rwanda and the Dominican Republic. In addition, econometric analysis is carried out on a cross country dataset compiled from data sources at WHO, the IMF the World Bank and ILO. The main results are that overall wage bill constraints do not influence the health workforce in consistent ways. Some countries deliberately budget and spend wage bill resources preferentially to the health sector while in others, the budgeted and the actual expenditures differ greatly, so that the rhetoric is not supported by evidence. In addition, besides constraints on the overall resource envelope for salaries in the health sector, there are incredible inefficiencies in the management of human resources that need to be dealt with before additional resources can be absorbed.

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Panel Session #4B Obligatory Service Requirement and Physician Distribution in Turkey Burcay Erus and Ayca Bilir

Bogazici University, Istanbul, Turkey

Theme: The use of innovative measures and predictive models to analyze health workforce supply-demand dynamics, as well as wage levels (especially for low-skilled workers) Background: Equitable distribution of physicians across geographic locations has been a major concern for governments in various countries including Turkey. Both monetary incentives (like pay differences) and nonmonetary policies (like obligatory service requirements) have been used to attract physicians to locations that are considered rather unattractive based on socio-economic conditions. In Turkey, from 1981 to 1995, the obligatory service requirement was in place and all the new graduates had to work for 2 to 4 years in a location specified by the government. In 1995 the requirement was lifted. Objective: The objective of this study is to identify the effect of the physician obligatory service requirement on location choice of physician workforce in public sector in Turkey. We also investigate the impact of differential in physician distribution, on the workload of the physicians, and the impact of the obligatory service requirement on the admissions to medical schools in Turkey. Data and Methods: To identify the impact of the regulation we make use of a change in the regulation in 1995. We compare the determinants of physician distribution across 70 districts before and after the change in regulation. Data on the number of physicians and socio-economic conditions is obtained from the Turkish Ministry of Health and Turkish Statistics Institution respectively. We run separate regressions using ‘Seemingly Unrelated Regressions’ for the periods before and after 1995. The change in the number of physicians per capita is the dependent variable and an index measuring the socio-economic development of the region is the independent variable of interest. We test whether the importance of the socio-economic index differs across regressions. We also analyze the number of hospital cases per physician in these two periods in order to assess the burden on the physicians of the unequal distribution. Finally we look into the medical school admissions. Results: Preliminary analysis found the coefficient for the socio-economic development index to differ significantly between before and after 1995. In 2000 physicians are more likely to go to locations with better socioeconomic conditions compared to 1990 when the obligatory service requirement was in practice. Public and/or health care industry policy implications: Preliminary results show that obligatory service requirements have been effective in directing physician workforce to less developed parts of Turkey. When the requirement was lifted socio economic conditions of a region determined the access to physician resources. The inequality problem between east-west and urban-rural Turkey has been worsened. Considering the unpopularity of the requirement among the physicians, new policies may directly focus on several wage policies, such as differentiated wages, with higher promotions to physicians who agree to work in areas with physician shortages.

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Panel Session #4B Immigrant Health Workers in OECD Countries in the Broader Context of Highly Skilled Migration Jean-Christophe Dumont

Administrateur Principal OCDE / OECD Princpal Administrator, Direction de l’emploi, du travail et des affaires sociales, Division des économies non membres et des migrations internationales, Directorate of Employment, Labour and Social Affairs

Background: In recent years, concerns about growing shortages of doctors and nurses, have emerged in OECD countries. In this context, there is increasing competition between OECD countries to attract and retain highly skilled workers in general, and health professionals in particular. This raises concerns in both sending and receiving countries. In the case of developing countries, these concerns were set out in the 2006 World Health Report. Several international initiatives have been set up with the aim of formulating policy recommendations to overcome the global health workforce crisis, including through the elaboration of codes of conduct governing the international recruitment of health workers. Despite this, evidence on the international mobility of health professionals remains limited, if not anecdotal. This lack of evidence has given rise to much misunderstanding of a complex phenomenon and has hindered the development of effective policy responses. Objectives: To present a comprehensive and relevant picture of immigrants in the health sector in OECD countries, in order to better inform the policy dialogue at national and international levels. Census and professional register data as well as migration statistics have been collected. Results: On average, we find that 11% of employed nurses and 18% of employed doctors in the OECD were foreign-born Circa 2000; there are large variations in the size of the foreign-born health workforce across OECD countries, partly reflecting general migration patterns, notably of the highly skilled. While there is a legitimate concern about the consequences of migration on origin countries the results show that the global health workforce crisis goes far beyond the migration issue. In particular, the health sector needs for human resources in developing countries, as estimated by the WHO at the regional level, largely exceed the numbers of immigrant health workers in the OECD, implying that international migration is neither the main cause nor would its reduction be the solution to the worldwide health human resources crisis. However, two key qualifying arguments should be taken into consideration. The first relates to the fact that international migration contributes to exacerbate the acuteness of the problems in some particular countries, notably in Caribbean countries and a number of African countries. Second, since 2000, migration flows of health professionals have increased. If they seem to have mainly affected the main source countries like Philippines and India, they have also involved some African countries as well as central and eastern European countries. Public and/or health care industry policy implications: There are very few specific migration programmes targeting health professionals in OECD countries. In this context, the short-term question may become “should receiving countries explicitly exclude health professionals from international recruitments of the highly skilled in order to avoid potential perverse impacts on the health systems of developing countries”? Would it be efficient? Would it be fair? In the long run, it is however necessary to recognise that active international recruitment is a quick fix and/or a distraction from other home-built solutions to health resources management such as increasing domestic training, improving retention, developing skill mix, and increasing productivity.

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Panel Session #5 Human Resources for Health Policy: Country Perspectives Objectives: Will focus on human resource issues that health ministries face in developing countries. It will include lessons learned from previously implemented workforce policies, including which policies worked well and which didn’t. For policies that worked well, the panelists will discuss whether they could be successfully implemented in other countries. The panelists will also share policy innovations that they are considering. The panel will discuss what types of research are needed to better inform their policy decisions.

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Panel Session #6 Scaling Up Health Education Opportunities and Challenges for Africa

Alexander S. Preker, Marko Vujicic, Yohana Dukhan, Caroline Ly, Hortenzia Beciu, and Peter Nicolas Materu Prepared for the Task Force on Scaling up Health Education of the Global Health Workforce Alliance Presented at the Fourth Taskforce Meeting in Kampala, Uganda, Oct 11-12, 2007

Abstract: This report reviews the economics of scaling up education for health workers in the context of the Africa region. It provides an assessment of the likely resource envelope that might be available to the health and education sectors by 2015 using different assumptions about economic growth, political commitment to spending on, health care, and institutional development; an estimate of the number of additional staff that could be hired by countries under the different resource envelope scenarios; and an estimate of the costs of scaling up the education of health workers in terms of recurrent and capital costs. All estimates were done on a country-by-country basis. Regional estimates are based on the sum of this detailed country level analysis. Scaling up health education has significant implications for both the health and education sectors. The cost of employing new staff falls on the health sector while the cost of educating health workers falls mainly on the education sector. Projecting economic trends based on the past ten years would allow countries in the Africa region to absorb around 648,000 new staff by the year 2015. If, however, there were a skills mix shift to more highly skilled workers the absorptive capacity would be reduced to about 412,000 additional workers; while a skills mix shift to lower skilled workers would increase the absorptive capacity to about 959,000 new workers. A wage increase of about 25 percent over time would partially offset this increase in staffing. Under a best case scenario and skill mix shift toward high skills, a number of countries could reach the WHO target of 2.5 health workers per 1,000 populations. Most countries, however, are not likely to enjoy the sustained growth, commitment to increasing public spending on the health sector or mobilization of additional resources through health insurance that are needed to achieve this target. In many countries, the binding constraint to scaling up health education is not only the limited absorptive capacity of the health sector to hire the resulting staff but the limited resources in the education sector to train the additional staff and make the needed capital investments to increase the capacity and throughput of training institutions. In a number of countries, the cost of educating the addition health workforce would outstrip the annual higher education budgets of the Ministries of Education. Furthermore, many countries trying to scale up health education also need to consider parallel measures to ensure that the secondary education system is producing a sufficient supply of graduates to feed a scaling up of health education. Although additional donor aid to both the health and education sectors is a possible solution, it is worth noting that the expenditure analysis used under the various scenarios already included current and projected levels of donor assistance. The analysis showed that increasing donor assistance by 100 percent improves the situation but still does not allow the region to attain the one million additional health workers under a projection of past trends scenario. There is considerable scope, however, for better earmarking of some ODA to scale up health education, especially in the case of some of the larger international funds devoted to addressing major public health priorities.

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Panel Session #6 Scaling Up, Saving Lives Nigel Crisp

The Task Force report is expected to be published in May 2008.

Nigel Crisp will set out the work of the Global Health Workforce Alliance Task Force on scaling up the education and training of health workers and pose challenges for international organisations about how its findings and recommendations can be implemented. The Task Force has focused on countries with a health workforce crisis, particularly in Africa, and has found that current policies and plans are failing. The number of people being educated and trained is too small to make a difference. This is compounded by the fact that there is little international coordination of effort and, all too often, international organisations recruit scarce local staff in developing countries and drive up costs, the working conditions in many countries are very poor, and too many health workers emigrate to richer countries. Yet, many leaders in developing countries know what needs to be done. Scaling Up, Saving Lives draws together evidence from countries such as Brazil, Ethiopia and India of what can and has been done practically and effectively to increase the education and training of health workers quickly and on a national scale, by national governments as well as education and training bodies. It sets out the critical success factors, and effective strategies for scaling up education and training, based on a review of the evidence. This is a global problem. Scaling Up, Saving Lives sets out proposals for concerted action on a massive scale – with the international community fully supporting national leaders – to make sure everyone has access to a suitably trained and motivated health worker as part of a functioning health system and that: • National governments draw up 10-year ‘scale up’ plans and implement an immediate and huge increase in community and mid-level health workers – trained, paid, supervised and able to refer on to more skilled workers – alongside the expansion of education and training for all groups of health workers. • Education and training curricula are focussed on the health needs of the country, are community and team-based, draw on the resources of the public and private sectors and the skills of international partners and make greater use of innovative means to increase training capacity, such as information and communication technologies and regional approaches. • Development partners and international organisations give strong backing to national ‘scale up’ plans, with a big increase in dedicated long-term funding for education and training and much better coordination and cooperation.

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Panel Session #6 Scaling Up, Saving Lives (cont.) Nigel Crisp

Challenges: The Task Force makes 10 recommendations for a concerted programme of change involving national governments and leaders in health and education as well as international organisations. It challenges international organisations – such as those at the Berkeley meeting – to: Align their planning and their actions with country plans. How will international organisations: • • • •

Throw their weight behind country plans and align their activities to country priorities and plans? Coordinate their own activities better, reducing fragmentation and duplication? Adopt a cross-sectoral approach to their support for developing countries? Support the use of the critical success factors for national scale up and the principles and strategies for education and training as a common framework for action?

Invest globally for local outcomes. How will international organisations: • Invest in country scale up plans; particularly through pre-service training and achieving a better balance between pre-service and in-service training? • Ensure that international economic frameworks and donor grant and monitoring arrangements allow sufficient flexibility for countries to develop appropriate local solutions? Support education, training and development. How will international organisations: • • • •

Promote, support and develop leadership at all levels in countries? Support innovative curricula – appropriate to country needs – and innovative ways of delivering education and training? Develop partnerships which will help build up the scientific, clinical, logistical and managerial strength and knowledge base of developing countries and help create centres of excellence? Help develop appropriate frameworks both for assuring the quality of education and of service, linked to systematic methods for quality improvement and monitoring?

Learn and share mutually. How will international organisations: • Create opportunities for real time collaborative learning about how to scale-up and share and disseminate research findings and good practice? • Identify the lessons which can be learned for policy and practice in developed countries?

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Poster Forecasting Health Workforce Supply and Demand: From Surveys to Models Joanne Spetz

Associate Professor, University of California, San Francisco

Theme: The use of new and existing data sources and tools to measure and monitor the health workforce’s (including public health workers’) capacity to meet a population’s health care demand and needs Background: Many nations are facing shortages of Registered Nurses (RNs) and other health professionals. Within the United States, the U.S. Bureau of the Health Professions has conducted surveys of RNs since 1977, and has periodically published forecasts of the supply, demand, and shortage of RNs. The state of California also has conducted surveys of RNs and developed its own shortages. The ability of statistically-based surveys, and econometric and stock-flow forecasting models to predict future health workforce supply and demand needs close examination. Objective: This paper critically assesses strategies to forecast supply and demand for health professionals, using the RN workforce as an example. Data: National Sample Surveys of Registered Nursing (US), California Board of Registered Nursing Surveys of RNs, California Office of Statewide Health Planning and Development data. Methods: First, we review methods for obtaining data about the RN workforce, from surveys and administrative data. We compare the patterns of employment and demographics identified in different datasets and identify potential causes for discrepancies. Second, we review methods for forecasting the supply of RNs. Most approaches to estimating future supply focus on stock-and-flow models. Third, we review methods for forecasting the demand for RNs. Here, there is substantial divergence in the literature. Some researchers use RN-per-capita ratios as a proxy for demand. Others create simple forecasts from current RN-per-patient ratios and forecasts of future hospitalization rates. A third approach involves developing econometric models. The results of these three strategies will be compared using California as a case study. We then will examine how forecasting strategies can be applied to regions within a nation or other jurisdiction, again using California as an example. Finally, we will compare forecasts that have been published over time, to learn how accurate these forecasts have been. The findings of this assessment will be discussed in the context of general development of health workforce forecasting models. Results: Each method of forecasting the demand for nurses has benefits and drawbacks. Most methods produce similar forecasts in the short-run, with greater divergence in the long-term. California’s Board of Registered Nursing published a report of nursing forecasts (the example in this paper) in September, 2007, which presented two alternate demand forecasts; the response of policymakers to this report will be discussed in this presentation. If the US Bureau of Health Professions forecasts are released before this conference, they will be compared with the California forecasts. Public/Health Policy Implications: A careful examination of health workforce forecasting strategies, with a focus on the economic factors that affect supply and demand, will help states, provinces, cities, and nations better assess whether and how to plan for future health workforce needs.

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Poster Comparing the Influence of the Global Context on How Internationally Educated Health Workers fit into HHR Planning: Lessons from Canada, the U.S., the U.K., and Australia Ivy Lynn Bourgeault

Canada Research Chair in Comparative Health Labour Policy, McMaster University, Canada

Background: Health care workers have long been nationally and internationally mobile, but the speed and extensiveness of recent migratory patterns has become cause for concern. The role of internationally educated health workers (IEHWs) is increasingly a critical part of recruitment strategies in many Western countries – not the least of which has been Canada, the U.S., the U.K., and Australia – in response to existing or predicted shortages of health human resources. The consequences of this increased reliance on IEHWs on the countries they come from, however, raise important ethical issues. Until most recently there has been relatively little comparative analysis of the policy influences and responses to IEHWs and the role they play in destination countries in light of this changing global debate. Objective: The objective of this presentation is to discuss based on comparative data from Canada, the U.S., the U.K., and Australia of how IEHWs fit into their HHR planning schemes. Data and Methods: For each of the four countries, data have been collected through: 1) the acquisition of key public domain policy documents primarily from 2000 onwards from the various provider/stakeholder groups; and 2) interviews with 186 key informants involved in or influenced by the policy decision-making process conducted in 2007. These data are analysed thematically using the constant comparative technique of qualitative health policy analysis. Results: What we have found thus far is that IEHWs represent a similar policy problem and potential policy solution in each of the four countries – safety/quality, ethical issues, underserviced areas – but the emphasis on these problems and solutions differ. All countries exhibit evidence of the use of IEHWs as an element of potential solutions to underserviced areas through the use of a range of policy instruments – from Visa Waivers (U.S.) to Temporary Licences (Australia), to direct recruitment (in some Canadian cases) – despite all sharing the position that this is at best a temporary solution. The recent shift away from active international recruitment in the U.K. is illustrative of where each of the other three countries might be in a few years time with important consequences for IEHWs. The Canadian case also reveals increasing public and policy concern with the ‘brain waste’ issue of IEHWs in the country not being able to practice to their highest skill level. Policy Implications: These findings are of key importance to the development of informed health and social/ migration policy both at the national and international level uncovering where institutional adjustments are needed to best respond to changes in the supply and demand of health care providers understanding the consequences on a global scale.

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Poster Primary Care Workers: Mobility, Retention and Turn Over in Rural Thailand Nonglak Pagaiya, Ekachai Danchanchai, Yolrudee Tantasit, and Polsap Polsing Sirindhorn College of Public Health, 90/1 Anamai road, Muang, Khon Kaen, 40000, THAILAND

Theme: Health workforce mobility and policy recommendation Abstract: Provision of health prevention and promotion is the most cost-effective health services, particularly in the middle and low-income countries, where vast areas are rural. Retention of primary care workers (PCWs) who play important roles in providing health prevention and promotion is the vital aspects for the rural health system in Thailand. The study therefore aims to examine the mobility, intention to stay or to leave and factors associate with intention to stay or leave rural primary care units (PCU) of the PCWs. 1820 PCWs working in 8 provinces were included into the sample size. Self-administered questionnaire was used for data collection as well as focus group discussion with 70 PCWs. Statistics used were %, means, SD, and logistic regression. The results showed that, of 1482 respondents, the average years in services at PCU is 15.6 years (SD=8.4) and their average mobility is 2.8 (SD=2.0) per person. On average, mobility was high during the first 5 years in service. Survival analysis showed trend to stay at PCUs shorter for descendant batches, though retention in PCUs was high, on average. 66.9% of PCWs currently working at PCUs stated their intention to stay whilst 33.1% stated their intention to leave. Reasons attracting them to stay were: social recognition, work security, relationship with co-workers, and professional is well accepted by the society. On the contrary, those who intended to leave stated: high workload in relation to existing staff, insufficient financial support, low salary, and lack of career advancement were driving force for them to leave. Logistic regression found that factors significantly associate with intention to stay of PCWs were: years in services, income, opportunity to find other job, hardship areas, appropriate management, social recognition, relationship with co-workers, safety at work place, and work place environment. Base on the survey and focus group discussion, appropriate measures to retain PCWs in rural areas needs to be implemented in the areas of: appropriate managerial support, career ladders development, recognition the important roles of PCWs by policy-makers and society, appropriate salary in relation to workload, as well as re-orientation of PCWs curriculum and teaching methods in the direction of community approach.

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Poster Health Spending, Human Resources and Development: A Multivariate Time Series Analysis for Pakistan Faisal Abbas

Centre for Development Research Bonn, Germany

Theme: The effect of health workforce skill mix, geographical distribution, mobility and workforce/population demographics on health care delivery, access to care, and quality. Abstract: Health is one of the capabilities that generate economic freedom and constitutes a basic human right. It is widely recognized that improved health not only lowers mortality, and level of fertility, but also contributes to productivity. In spite of economic improvement, social and demographic indicators in Pakistan present a dismal picture. A snapshot view indicates that the health sector has expanded considerably in terms of physical infrastructure and manpower. Nevertheless, Pakistan still has one of the highest infant, child, and maternal mortality rates compared with the developing countries of the region. In addition, there is also significant inequality in the distribution of financial and human resources in health sector between the urban and rural areas. Almost 80 % of the resources spent on the heath sector are allocated to urban areas and rural areas lacking necessary health infrastructure hence doctors, nurses and paramedical staff are reluctant to work there. According to World Bank poor governance, weak health sector management and low levels of public spending are the key factors behind poor health outcomes. Keeping in view the likely role that health sector can play in economic development; this study using time series data on economic, demographic, social and political variables, spanning from 1972 to 2005, aims at answering the following questions: what are the determinants (economic, demographic, social and political) of health sector spending in Pakistan? Whether the allocation over time shows an urban or a rural bias? And how health work force like doctors, nurses and auxiliaries are helpful in increasing access to health care (especially in rural areas)? The study uses the cointegration approach to test the time series properties and 2SLS methodology to determine the likely role of public spending and health care personnel availability in determining the health status of population and hence the effect of improved health on development. By applying Augmented Dickey Fuller (ADF) and Philip Perron tests we find that all data series are non-stationary in their level form and become stationary after first differencing and therefore integrated of order one. A Granger causality test reveals unidirectional causality running from health care spending towards per capita income implying the importance of investing in the health sector for generating social returns. Impulse response function is estimated to see the shocks to health sector and its likely impact on GDP per capita. The results support the hypothesis of increasing investments in health and providing skilled health manpower for easy access and better health for all.

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Poster Preventing Child Deaths in Resource Poor Settings: Options When there are No Doctors and Nurses. Julia A. Walsh1, Bhupendra Sheoran2, Scott Chu1 and Malcolm Potts1 1 2

UC Berkeley School of Public Health Asian Pacific AIDS Alliance

Theme: The effect of health workforce skills mix, geographical distribution, mobility, and workforce/population demographics on health care delivery, access to care, and quality. Abstract: More than 90% of infant and child deaths occur in lower income countries and among the poorest, especially in rural areas. They have meagre access to quality health services. For most of the causes of deaths, there exist interventions that can prevent them. The gap is in delivering the interventions to the community. Several of these interventions involve households learning to use items available in or close to the home (e.g., salt and sugar solutions and rice water for prevention of dehydration from diarrhea; soap for washing hands and clothes; prolonging breast feeding). Other require commodities such as antibiotics, pesticide impregnated bed nets, efficient household stoves, vitamin A supplements, vaccines, among others. In the absence of formally trained health workers, these interventions can be accessible to the poor and save lives. There are many successful examples of private sector advertising and market systems providing behavior change communication campaigns that increase breast feeding, oral rehydration use, complementary feed, and hygiene and decrease child deaths. If 90% of all household with children used these, then child deaths would decrease more than 30%. Even if only 15% of families adopted these healthy behaviors, more than one million child deaths can be averted. For commodities that need to be purchased, social marketing networks using private market channels are a cost-effective and efficient method for providing these at subsidized prices. These can prevent an additional 35% of infant and child deaths. The presentation will review private social market distribution programs in poor countries, their success, and estimates of infant and child lives salvageable using these methods in locations where formally trained health workers are not available.

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Poster A Systematic Approach to Workforce Development Primary Health Care and Human Resources Lessons from the Balkans

Orvill Adams1, Djenana Jalovic2, Dr. Zlatko Vucina3, and Dr. Dragana Stojisavljevic4 Project Director, Balkans Primary Health Care Project Country Manager, Balkans Primary Health Care Project 3 Director, Institute of Public Health, Federation of Bosnia and Herzegovina, BiH 4 Director, Institute of Public Health, Republic of Srpska, BiH 1 2

Theme: The use of new and existing data sources and tools to measure and monitor the health workforce (including public health workers) Background: The different political jurisdictions in Bosnia and Herzegovina have embarked on human resources for health project that is comprehensive in its application. The three year project is supported by the Canadian Government through the Canadian Agency for International Development. The approach brings together policy makers, regulators, planners and providers. It is also multi-sector in its engagement of the education, and social sector ministries. Objectives: The prime objective of the Project is better alignment of human resources planning with the health policies of Bosnia and Herzegovina. The focus in the Republic of Srpska and the District of Brcko is on Primary Care and in the Federation of Bosnia and Herzegovina it is on both primary and secondary care. The second objective is the building of institutional and individual capacities to undertake HR planning and to promote its benefits. Data: Qualitative and quantitative original data collection and existing data sources are used to compile data and information about employed and unemployed health care professionals. The network of public health institutes work closely with the health provider institutions and the respective ministries of health to agree on the data to be collected, the method of collection, the future use of the data and the approach to analysis. The capture of data from the private sector required a different approach from that of the public sector. Methods: The approach combines planning with the strengthening of competencies for planning, the reorganization of work (changes in methods of service delivery), improvement of quality of providers and in accountability mechanism (strengthening of licensing and certification bodies). Results: Data have been collected and an approach to planning has been agreed by all stakeholders. There is an increased understanding of the relationship between planning, management of health personnel and mechanisms for the improvement of practice. The different jurisdictions have new tools and methods and processes for HR planning and development. Public health Institutes are being strengthened and nine persons are undertaking an international masters program in human resources for health. Policy Implications: The respective ministries have been full and active partners in this work and have a plan to use the results of the planning and capacity development to support policy initiatives to implement the already agreed Primary Health Care Policy.

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Poster From Surgeons to Shamans! The Characteristics of Private Health Sector Providers in One of India’s Largest Provinces – Madhya Pradesh Ayesha De Costa1, 2, M. Jhalani3, V. Saraf4, and V. K. Diwan1,2

Division of International Health, Karolinska Institutet, Stockholm, Sweden Dept. of Community Health, RD Gardi Medical College, Ujjain, Madhya Pradesh, India 3 Department of Health, Government of Madhya Pradesh 4 National Center for Human Settlements and Environment, Bhopal, Madhya Pradesh 1 2

Theme: The effect of health workforce skills mix, geographical distribution, mobility, and workforce/population demographics on health care delivery, access to care, and quality Background: India has one of the most highly privatised health care systems in the world. National health accounts show that 77.4% of all healthcare expenses are made in the private health sector, mostly out-of-pocket. The heterogeneous private sector provides 75% of all out patient care and a third of inpatient care across socioeconomic groups. Providers are variously qualified, practice different systems of medicine in diverse organizational set-ups, at primary, secondary or tertiary levels. Madhya Pradesh (MP) is one of India’s largest provinces with a population of 60.4 million in its 52117 villages and 394 towns. Spread over an area of 304000 km2, the province lies in the geographic heart of India. Objectives: This paper describes the characteristics and distribution of healthcare providers in the 45 districts of MP with an emphasis on the private sector. While qualification has been used as the main categorization variable, gender, system of medicine practiced, institutional arrangements and commercial orientation are described. Distribution of providers between the highly urban districts and others is considered. Policy implications are discussed in the manuscript. Data: Qualitative and quantitative original data collection and existing data sources are used to compile data and information about employed and unemployed health care professionals. The network of public health institutes work closely with the health provider institutions and the respective ministries of health to agree on the data to be collected, the method of collection, the future use of the data and the approach to analysis. The capture of data from the private sector required a different approach from that of the public sector. Methods: A primary survey of all healthcare providers (public and private) in the province (all villages and towns) serving the 60.4 million population was undertaken in collaboration with the Department of Health and the medical university. The survey was undertaken between April and December 2004 as part of an activity to develop a geographic health information system for the province on which these providers would be mapped. Results: Of the 24,807 qualified doctors mapped in the survey, 18,757 (75.6%) work in the private sector. Fifteen thousand one hundred forty-two (80%) of these private physicians work in urban areas. 75% of private doctors had solo practices; 59% were qualified in allopathy (western medicine), 41% in Indian Systems. A little over 10% were female. 72.1% (67793) of all qualified paramedical staff work in the private sector, mostly in rural areas. 87% of 110.5 qualified private paramedical staff /100,000 were solo providers, mostly rural (3.4%female). These included barefoot doctors, pharmacists, lab-technicians and others qualified in Indian systems. There were 92.5 trained traditional birth attendants/ 100,000 largely rural, mostly female. There were 147.5 unqualified providers/100,000, mostly males, practicing as rural ‘solo doctors’. Policy Implications: The study empirically demonstrates the dominant heterogeneous private health sector and the overall the disparity in healthcare provision in rural and urban areas. It argues for a new role for the public health sector, one of constructive oversight over the entire health sector (public and private) balanced with direct provision of services where necessary. It emphasizes the need to build strong public private partnerships to ensure equitable access to healthcare for all. Our study shows a shortfall of qualified care not in terms of absolute numbers, but more in terms of distribution. A factor contributing to gender barriers to access to care include the very low numbers of qualified female providers. Roles for different provider groups are discussed in the manuscript keeping in view the health care demand in the province. The scope for demand side financing in such a private healthcare dominated setting needs to be seriously considered.

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Poster How Many Health Workers, Who Are They and Where Are They? – Using Multiple Sources of Information to Estimate the Health Workforce in India Aarushi Bhatnagar1, Krishna D. Rao1, Peter Berman2, Indrani Saran1, and Shomikho Raha2 1 2

The Public Health Foundation of India (PHFI) The World Bank, New Delhi

Theme: The use of new and existing data sources and tools to measure and monitor the health workforce’s (including public health workers’) capacity to meet a population’s health care demand and needs Background: Health workers are critical for delivering health services and studies indicate that population health and service utilization is associated with the size, composition and distribution of the health workforce. Information about the health workforce is important for planning and in addressing labor market failures which result in the geographic and compositional mal-distribution of health workers. Yet, in many developing countries like India, information on the health workforce is typically inaccurate, fragmented and unreliable. Objectives: This study has the following objectives. First, to estimate the size, composition and distribution of the health workforce across states in India using a variety of data sources to produce a set of ‘preferred estimates’. The second part of the study explores the association between availability of health workers and key service utilization and health outcomes. Data and Methods: The study uses data from the 2001 Census of India, the National Sample Survey 200405 on Employment and Unemployment, and the Government of India. Health workforce estimates from the different sources are triangulated to generate a set of ‘preferred’ estimates. The association between health outcomes and health worker density is estimated using median splines. Results and Implications: Preliminary results indicate that there are substantial differences between officially reported statistics and estimates from the Census and household surveys. Importantly, there is better agreement between the latter two sources. Moreover, the health workforce density in India is below the 2.5/1000 population norm, though there is considerable inter-state variation. Further, doctors, female doctors, and nurses are concentrated in urban areas. Alarmingly, the density of female health workers is very low in India, especially in the rural areas. Moreover, the majority of the health workforce works in the private sector in both urban and rural areas. Higher worker density improves performance on measles immunization, infant mortality and attended deliveries. Overall, this study shows that a variety of routinely available data sources available in many developing countries can provide useful information on the health workforce and can be used to cross-check the accuracy of the workforce estimates.

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Poster Current Issues Impacting the Labor Supply of Nurse Anesthetists in The Netherlands Vera Meeusen1, Chris Brown Mahoney2, Karen van Dam3, J.T.A. Knape4, and Andre van Zundert5

Department of Anaesthesiology, Catharina Hospital - Brabant Medical School, Eindhoven, Michelangelolaan 2, the Netherlands Petris Center on Health Markets & Consumer Welfare, Berkeley, California 3 Work & Organizational Psychology, Tilburg University / FSW, the Netherlands 4 Chair Department of Anaesthesiology, Division of Perioperative and Emergency Care, University Medical Center Utrecht, the Netherlands 5 Professor of anaesthesiology, Catharina Hospital - Brabant Medical School, Eindhoven, Michelangelolaan 2, the Netherlands 1 2

Theme: This study addresses current issues that impact the labor supply of nurse anesthetists in the Netherlands and the skills mix in this professional group. The skills mix of nurse anesthetists is unique to the Netherlands. Background: In the Dutch Health Care System a “nurse anesthetist” is not always a nurse. One can choose to go directly from high school to do a three year study to become an “anesthesia-assistant” or first become a nurse and then do the same three year study. This professional group is getting older, while the demand for nurse anesthetists continues to increase, resulting in an increased age limit for retirement in Europe. This means older nurse anesthetists must be retained to meet the demand; they may need particular accommodations. The shortage of staff at some hospital departments was so high that several operating rooms were closed due to lack of personnel. Retention of nurse anesthetists that are already trained is an effective solution. One possible solution is the (re)design of work, keeping in mind the organizational limitations. Objectives: To assess the impact of work load, work climate, individual physical and psychological health, and work satisfaction, as well as individual demographic characteristics, on turnover intentions. To compare burnout rates and competence levels between the two differently educationally prepared types of nurse anesthetists in the Netherlands. Data and Methods: All anesthesia-nurses and anesthesia-assistants in The Netherlands were asked to complete an online questionnaire containing 168 multiple choice questions. We used the TOMO-questionnaire1 to measure workload; one of the most complete and objective lists, combining different models on motivation and workload. The TOMO exists of: competence-scale, autonomy, social relations and environmental conditions. The survey also addresses physical and psychological health, work satisfaction, absenteeism and intent to leave the organization (turnover). For measuring psychological health we used the Maslach Burnout Inventory General Survey (MBI-GS)2, which consists of 16 items with three subscales measuring emotional exhaustion, depersonalization and professional accomplishment. By combining the burnout dimensions, overall effects of burnout become more visible. Responses of 882 nurse anesthetists, who filled in the survey completely, compose the sample. This is a 50% response rate of all those surveyed. Results: There were no statistically significant differences in burnout levels and competence between nurse-based and non-nurse-based “anesthesia-assistant”. A high workload among anesthesia-nurses results in more personnel who have physical complaints, less satisfaction, lower mood status and a higher burnout rate. Mental and physical stress result in work overload and illnesses like overstrain, burnout, depression, musculoskeletal and cardiovascular disorders3. Implications: Short term demand for nurse anesthetists requires solutions that retain currently trained professionals in the work force. Data reported in this study suggest that the redesign of the work performed by anesthesia-nurses and anesthesia-assistants may decrease experienced burnout and therefore increase retention. Long term, educational preparation of nurse anesthetists appears to be flexible regarding whether these professionals must first be trained as nurses. Further research on specific patient healthcare outcomes is necessary to support the long term findings. TOMO: toetsingslijst Mens & Organisatie. Zeist: Kerkebosch (1994). Journal of Applied Biobehavioral Research, 1999;4:65-78. 3 Bongers PM, Kremer AM, Ter Laak J. (2002). Are psychosocial factors, risk factors for symptoms and signs of shoulder, elbow, or hand/wrist?: A review of the epidemiological literature. Am J Ind Med. 2002;41(5):315-42 1 2

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Delegates Howard Adelman, PhD Research Professor at the Key Centre for Ethics, Law, Justice and Governance, Griffith University, Brisbane, Australia

Annika Frohloff Visiting Scholar, PhD candidate, Institute for Research on Labor and Employment, Berkeley, CA

Kevin Barnett, DrPH, MCP Senior Investigator, Public Health Institute

Lou Garrison, PhD Professor, Pharmaceutical Outcomes Research & Policy Program, Department of Pharmacy, Health Sciences Building, University of Washington

Nickie Bazell, BA MPH candidate, Health and Social Behavior Program, UC Berkeley Hortenzia Beciu, MD, MPH Consultant, Human Development II (AFTH2), The World Bank Group-Africa Region Eran Bendavid, MD CHP/PCOR Trainee in the Agency for Healthcare Research and Quality’s Fellowship in Health Care Research and Policy, Stanford University Sara Bennett, PhD Manager, Alliance for Health Policy and Systems Research, Geneva Andy Bindman, MD Professor Medicine, Health Policy, Epidemiology & Biostatistics, University of California San Francisco Mickey Chopra, MD Head, Health Systems research unit, Medical Research Council of South Africa Dessi Dimitrova Program Officer, Results for Development Institute, Washington, DC Norman H. Edelman, MD Professor, Preventive Medicine, Internal Medicine, Physiology & Biophysics, Stony Brook University Fadi El-Jardali, PhD Professor, Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut Neelam Sekhri Feachem, MHA Chief Executive Officer, The Healthcare Redesign Group Sean Flannery, MD Senior Economist, Center for Global Health Massachusetts General Hospital Danielle Frechette, MPA Senior Advisor, Governance & Policy Development, Royal College of Physicians & Surgeons of Canada

Pape Amadou Gaye, MBA President and CEO, IntraHealth International, Inc., Chapel Hill, NC Rosemary Goodyear, EdD, FAANP INP/APN Network, International Council of Nurses Karen Grepin, SM, BSc PhD Candidate, Health Policy, 0Harvard University Kevin Grumbach, MD Chair, UCSF Department of Family and Community Medicine Ali S. Hassan Abadi, MD Regional Adviser, Educational Develeopment/ Fellowships, EDT/EMRO/WHO William Holzemer, RN, PhD, FAAN Professor and Associate Dean, International Programs, Lillian & Dudley Aldous Endowed Chair in Nursing Science, School of Nursing, University of California, San Francisco Roderick Hooker, PhD Department of Veterans Affairs, Dallas VA Medical Center, Rheumatology Research Meg Kellogg, MA Health Care Consultant; Program Director, Global Health Leadership Forum Suzanne N. Kiwanuka, PhD Review Coordinator, Centre for Systematic Reviews on Human Resources for Health, Makerere University School of Public Health Julie Klein-Geltink, MHSc Epidemiologist, Institute for Clinical Evaluative Sciences (I.C.E.S.), Toronto ON, Canada Rebecca Kohler, MA VP of External Affairs, IntraHealth International, Inc., Chapel Hill, NC

Dr. Mensah Kwadwo Public Health Researcher, Institut de Recherche en Science de la Santé, Burkina Faso Merle Mahabir Senior Workforce Planner, Workforce Policy and Planning Branch, Alberta Health and Wellness, Alberta, Canada Marly Norris Senior Associate Director, Corporate and Foundation Relations, UC Berkeley E.C. Okorochukwu Executive Director of Center for Public Health in Nigeria Paige Passano, MPH Research Coordinator, Bixby Program, UC Berkeley Gary Pekeles, MD, MSc, FRCP Associate Professor, Pediatrics, Epidemiology and Biostats, McGill Hospital Center, Montreal QC, Canada Kent M. Ranson, MD Consultant, Alliance for Health Policy and Systems Research, Geneva Evan Rawstron Graduate student, International Health Policy, London School of Economics and Political Science Dykki Settle Director of Informatics, Intrahealth International, Inc., Chapel Hill, NC Miriam Shuchman, MD Canadian Medical Association Journal Sue Skillman, MS Deputy Director, Center for Health Workforce Studies and Rural Health Research Center, University of Washington Ellen Switkes Assistant Vice President, UC Office of the President, University of California School of Global Health Marcia Thomas, MS, MPH, RD Administrative Director, NYU Master’s Program in Global Public Health Shirley Williams Consultant, Alliance for Health Policy and Systems Research, Geneva

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