PHR Student Blog

The World Health Organization has published new guidelines meant to address the health worker shortage that plague rural and impoverished regions. In a July 2010 policy recommendation paper, the WHO offers recommendations to aid worker retention and attract new health workers to overlooked areas. Strategies include altering the ways in which students are selected and trained, as well as improvements in working and living conditions.

The WHO explains that “a shortage of qualified health workers in remote and rural areas impedes access to health-care services for a significant percentage of the population, slows progress towards attaining the Millennium Development Goals and challenges the aspirations of achieving health for all.” The WHO’s recommendations come at the request of global leaders, civil society groups, and Member States. WHO recommendations fall into four categories, with greater detail and context available within the body of the Report:

1. EDUCATION RECOMMENDATIONS
   Recommendations include targeted admission policies to enroll students with a rural background (who are statistically more likely to then practice in rural areas), exposing students to greater rural field work, and locating schools and residency programs outside of major cities.
2. REGULATORY RECOMMENDATIONS
   Recommendations include the creation of compulsory service requirements in rural and remote areas, educational subsidies offered with enforceable agreements of return service work in rural areas, and a focus on increasing the scope of medical practice in remote regions to increase job satisfaction.
3. FINANCIAL INCENTIVES RECOMMENDATIONS
   The WHO suggests “a combination of fiscally sustainable financial incentives, such as hardship allowances, grants for housing, free transportation, paid vacations, etc., sufficient enough to outweigh the opportunity costs associated with working in rural areas, as perceived by health workers, to improve rural retention.”
4. PERSONAL AND PROFESSIONAL SUPPORT RECOMMENDATIONS
   Recommendations include improved living conditions for health workers and their families in remote locales, career development programs to help rural workers progress in their careers, and the creation and promotion of senior posts in rural areas so that advancing workers are not forced to leave their communities.

The WHO suggests policies should be implemented in conjunction with the country’s national health plan and should be guided by the concept of health equity. The Report states that some countries, the Lao People’s Democratic Republic and Mali among them, are already considering using WHO recommendations to inform their retention policy.

As WHO guidelines have been disseminated, an August 14 article in The Lancet registered a first critique, underlining the roles of NGOs and INGOs in the internal brain drain within struggling countries. As an addendum to the WHO report, the article offers further policy recommendations, to be implemented in conjunction with WHO strategies.

Only 37% of Ugandan physicians are satisfied with their jobs and nearly half are at risk of either exiting the health sector or leaving Uganda entirely, according to a study published this year by the International Journal of Health Planning and Management. The study, “Satisfaction, Motivation, and Intent to Stay Among Ugandan Physicians,” is co-authored by Emily Bancroft, a former Leland Fellow with PHR in the US and AGHA in Uganda. Dovetailing with PHR’s previous works on health worker shortages in Africa, the study’s results come from a sample group of physicians working in 18 public and private health facilities in Uganda representing approximately 3% of Ugandan physicians. This study came about at the behest of Uganda’s Ministry of Health, which hopes to analyze how to implement effective policy reforms to strengthen and expand their health workforce. Bancroft’s team, headed by long time PHR advisor Professor Amy Hagopian of the University of Washington, urges Ugandan policy-makers to intervene to stem the “brain drain” that is heightened by factors such as low wages, poor infrastructure and materials, few opportunities to progress within the medical field, and regional isolation for doctors outside large cities.

14% of Ugandan physicians emigrate abroad, largely to four English-speaking countries—the US, Canada, the UK, and Australia. This number is significantly lower than that of some other countries in peril. For example, it is frequently said that more Malawian doctors practice in Manchester, England, than in the entire country of Malawi. Although Uganda’s health workforce shortage seems less drastic than Malawi’s, the crisis is no less dire: in 2008, the study’s authors estimated that there are only 2,500 physicians for Uganda’s 31 million inhabitants. Physicians, far more so than other Ugandan health professionals, were seen by Bancroft and colleagues as dissatisfied with their work and both ready and capable of vacating their posts if the opportunity should arise. Along with nurses, physicians are the group most heavily courted by international recruiters, which means many of the physicians Bancroft spoke with may already have found an opportunity to leave Uganda.

The World Bank and International Monetary Fund have exacerbated the “brain drain” seen in Uganda and throughout Africa with “structural adjustment” policies that cap domestic health expenditures. Wealthy countries can offer doctors higher salaries, greater career advancement opportunities, and, in many cases, a more stable political environment in which to work.

The Global HEALTH Act, introduced by Rep. Barbara Lee in March 2010, would assist Uganda’s efforts and help curtail health workforce shortages in countries facing similar crises by providing $2 billion over five years to increase the number of physicians, nurses, and other health workers in developing countries—and to help retain those health workers already there. The bill not only authorizes new resources, it also calls for the creation of a US Global Health Strategy to complement the goals of countries like Uganda and ensure US aid money goes where it can make a difference. This study will help foreign aid innovations like the Global HEALTH Act to better tackle complex problems like brain drain and to work with communities to solve these challenges—something PHR is dedicated to helping support.

On May 10th, The New York Times published a heartrending story on the faltering fight against AIDS in Uganda — a story that has sparked a firestorm of controversy and criticism of the Obama Administration’s global AIDS strategy.

The Times identified a deep funding gap for combating AIDS in Uganda, including a freeze on new funds from the United States and a lack of commitment to AIDS spending by the Ugandan government (which evidently has no problem finding $300 million to spend on Russian fighter jets). The Times also outlined the devastating human toll this funding gap is taking on people living with — and dying of — AIDS.

Sadly, this news is not new. In March 2009, PHR invited Dr. Peter Myugenyi, Founder and Director of the PEPFAR-supported Joint Clinical Research Centre in Uganda, to Washington, DC to talk about the emerging funding gap for AIDS in Uganda. Said Dr. Mugyenyi:

After urging people to get tested and enter care, we now have to tell them there is no treatment available when they need it. We created hope and now we are returning to the days when one member of a family can get treatment and the others cannot.

It is a recipe for chaos as patients start to share doses or skip treatment altogether. I fear that we will soon start to see more drug-resistant strains of HIV and rising death rates.

As The Times notes, one year later, Dr. Myugenyi remains fearful:

Dr. Peter Mugyenyi, the hospital’s founder, helped the Bush administration form its AIDS plan and sat beside Laura Bush during the State of the Union address as it was announced.

The loss of donor interest “makes me frantic with worry,” Dr. Mugyenyi said.

He offers copies of e-mail messages he exchanged with American aid officials. One reminds him that he has been instructed to stop enrolling new patients and asks for an explanation of reports that he is treating 37,000 when only 32,000 are authorized. Another asks him not to announce publicly that his funds have been frozen.

He admits slipping pregnant women and young mothers like Ms. Kamukama into treatment slots “contrary to instructions.”

“Morally, I can’t turn them away,” he said.

This story gained traction worldwide, and was followed by a New York Times editorial, The Wavering War on AIDS, which outlined a $13 billion deficit in AIDS spending, and a series of letters to the editor, including one by PHR Global Health Action Campaign advisor Pat Daoust.

Dr. Mugyenyi won’t turn away patients. And we won’t turn away from this issue.

PHR, in conjuction with other global health groups, sent a letter to Secretary of State Clinton last week, urging her to end the AIDS funding freeze and ensure Ugandans have access to life-saving AIDS treatment.

PHR members have spent years advocating for more global AIDS funding and health programming based on science and human rights. We will continue to fight for greater global health funding, a strong US global health strategy, and to ensure people living with AIDS worldwide have access to drugs and quality care.

Want to help? Encourage your Representative to co-sponsor the Global HEALTH Act, which will provide $2 billion for health system strengthening and support a comprehensive US global health strategy, both of which will help in the fight against AIDS.

Today, as we celebrate International Nurses Day, the health workforce crisis remains one of the greatest hurdles to realizing the right to health for all in developing countries.

The Global HEALTH Act can help. The GHA, introduced in Congress by Representative Barbara Lee on March 24, would provide $2 billion over five years to increase the number of doctors, nurses, pharmacists and other health workers in developing countries, and to improve primary health care for all. The bill not only authorizes new resources, it also calls for the creation of a US Global Health Strategy that will complement the goals of developing countries and ensure our aid money is effectively used to save the lives of hundreds of thousands of people.

That is why PHR is uniting with more than 15 other US organizations to hold a national Call-in Day TODAY to support the Global HEALTH Act. Be part of the movement. Tell your Representative to support Global Health by co-sponsoring this bill.

It’s easy. Call the Congressional Switchboard at (202) 224-3121 and ask to be connected to your Representative’s office (if you don’t know who your Rep. is, find out). Then, make your case. Use the script below, and/or bring your own experiences into the call:

Hi, my name is XXX and I live in Town, State. I am calling to encourage Representative XXX to co-sponsor HR 4933, The Global HEALTH Act, which will help fix broken health systems in developing countries. The Global HEALTH Act calls for the development of a US Global Health Strategy to harmonize aid, and provides $2 billion over 5 years to help countries in Africa hire, train and retain more doctors, nurses and other health workers. The Global HEALTH Act will save lives: I hope Rep. XXX will consider co-sponsoring this bill today.

As of today, the global health community has secured nine co-sponsors: Reps. John Conyers (MI), Lynn Woolsey (CA), Raul Grijalva (AZ), Keith Ellison (MN), John Garamendi (CA), Fortney Pete Stark (CA), Diane Watson (CA), Jesse Jackson, Jr. (IL) and Eleanor Holmes Norton (DC). Help us secure more. Commemorate International Nurses Day by taking action. Join thousands around the country today who are making a difference. Call your Representative and encourage them to co-sponsor the Global HEALTH Act today.

UPDATE, May 17: The Global HEALTH Act has garnered six new co-sponsors: Jesse Jackson, Jr. (IL), Eleanor Holmes Norton (DC), Sam Farr (CA), Maxine Waters (CA), Bobby Rush (IL) and James McGovern (MA).

You are not the only one encouraging your Congressperson to co-sponsor the Global HEALTH Act. Representative Barbara Lee sent a letter to all her Congressional colleagues last week, urging them to support the bill. Check out her letter below. It outlines the four ways that the Global HEALTH Act will assist with the development and implementation of Obama’s landmark Global Health Initiative. The Act will provide strategy, consistency and a greater emphasis on health workforce and health systems — all key to making foreign health policy that supports the right to health.

Her letter includes a list of organizations from across the globe that support the Global HEALTH Act — including PHR. Organizations are continually being added to this list, and we encourage you all to contact your Congressperson and urge them to co-sponsor this bill, which will revolutionize foreign health aid and save lives.

The health workforce crisis in Uganda is immense. Uganda is reportedly losing at least 1,400 skilled professionals each year, and there are only 29,000 medical personnel in a country of 31 million people. Consequently, the health system is suffering, and most often the blame falls on health workers, as they are on the frontline and seemingly represent the health sector. In the past eight months, since I’ve been in Uganda, media coverage of the health system has almost always focused on the negative aspects of health workers, further demonizing a field that is made up largely of hard working people.

Recent Ugandan headlines include:

Rioters attack Mityana hospital” (New Vision, Aug 21, 2009)

12 Health workers held over drug theft” (New Vision, Jan 11, 2010)

Health officials remanded over theft of government drugs” (Daily Monitor, Mar 11, 2010)

These news stories reflect the public’s negative perception of health workers, who are almost always associated with being unqualified, incompetent, rude, corrupt, and thieves. Furthermore, personal stories shared with me about using the health system are most often about being ignored and mistreated — not about receiving good care by caring health workers.

For those of us advocating for health workforce development, the negative image of health workers makes it more difficult to garner support and foster dialogue. We should honor the truth of people’s experiences with health workers and the health system, but the problem is complex and there are many underlying factors that need to be addressed. Health workers are overworked, underpaid, and lack proper resources and equipment. Yet the majority of health workers still show up to work and perform their duties. If they didn’t, the health system would completely collapse. At the same time, we should expect and demand a standard of care from our health workers.

Ugandan nurse Mitterand Kiirya (Physicians for Human Rights)

Given the complexity of the issue and the lack of easy answers, I wanted to highlight one health worker who I feel exemplifies the notion of a dedicated and ethical health worker. Mitterand Kiirya is a research nurse for the Antiretrovirals for Kaposi’s Sarcoma (ARKS) study at the Infectious Disease Institute (IDI) at Mulago Hospital, the largest national referral hospital in Kampala, Uganda. For the past 2½ years, he has been working with HIV-positive patients who have Kaposi’s Sarcoma. Previously, Mitterand worked at Uganda Cares, an antiretroviral access initiative in Masaka.

I first heard about Mitterand through my roommate, a U.S. medical student working with him at IDI. She would often talk about his dedication, and how he would invite her to join him on visits to the countryside 6–7 hours away from Kampala to check in on his patients in their homes. This was not part of his duties, but something he did on his own time. But most of all, she would always talk about how he inspired her to be a good doctor, because he always put the patient first. And, despite all the challenges he faced, he always remained positive and managed to smile and make people laugh everyday.

Here are some highlights from a recent conversation I had with Mitterand:

Why did you want to become a nurse?

It was from watching my mother. She is a mid-wife in my village, Namugong, Kaliro [in the Eastern part of Uganda]. I watched her passion for her patients. How she cared for them, wanting to alleviate their pain. What I saw was that she tried to understand the patient, and I wanted to do the same thing.

What does it mean to understand your patient?

Well…before seeing the doctor, the patient has a lot of anxiety, especially when they are referred from place to place. So I try to sit and talk to them before they see the doctor, prepare them to receive what the doctor will tell them.

What do you see as the role of the nurse?

As a nurse, I try to reverse what was impossible, and make it possible. I try to bring a message of hope and new life, especially with my patients who are HIV-positive. If you haven’t even given the message of assurance, then it’s the equivalent of not having come to work that day.

People have encouraged me to further my studies, and become a doctor. I have thought about it a lot, but I don’t want to lose the contact with my patients, which I think happens sometimes with doctors. So, right now, I’m staying a nurse, staying with my patients.

You often see that nurses, or health workers in general, get discouraged by their work environment. What do you think about this?

Yes, I do see some of my colleagues who are not working. But what I try to do is motivate them. Remind them about the ethical requirements of our profession, but also try to serve as an example for them too. But, I tell them that “ we are here to serve our profession, give the service and think about the quality of your services, the quality of your service should determine your cost”. But you must work hard.

I know the system is broken. Infrastructure is inadequate, and the environment is making it difficult. We are losing the confidentiality of the patient, because we are sharing spaces with only curtains to divide, and sometimes not even that. I am always trying to improvise to keep the patients alive.

How do you stay motivated?

I have love for the patients. That is what motivates me. Be their friend, we need to be there first for the patients.

Tell me about the award you received from Alicia Keys.

When I was working at Uganda Cares in Masaka, she contributed ARVs and general support for HIV-positive children. She found me at Masaka, working as a nurse, she was told through my director, my medical director, Dr. Bernard Okongo. He introduced me as a hardworking nurse, who was dedicated with total love for his profession. I received an award and took a picture with her. It was a big ceremony held in Masaka.

I felt very…actually felt humbled really, for the public to appreciate my contribution and my profession, I felt humbled. I felt so humbled. In this country, what de-motivates people, you can serve, but failure to appreciate your service is another big issue. If the services we are offering are appreciated, the level of our service would be so high.

Thanks Mitterand for speaking with me.

No, I say ‘thank you’ to you, because you are listening to me. Everyday, I am here for others, listening to them, and having to hold back my pain. But it’s nice that I can talk and you listen to me.

Speaking with Mitterand is always inspiring, and I know he is not the exception. From my experience in Uganda, I have witnessed the dedication of health workers throughout the country, ranging from district health officials to field doctors and nurses and community health workers. Further, I have seen administrators, Ministry of Health officials and policymakers who are also working tirelessly to improve the health of the population. I think it’s important for us in advocacy to re-frame the issue of health workers, by highlighting the positive aspects of their work and recognizing them for it, so that the media and general public can better understand them and the complexities of the Human Resources for Health issue. And we need health workers to also speak out and show their commitment and concern for the health of the population, because in the end, we are all working towards a collective goal to ensure the right to health for all.