Health Workforce for Integrated Primary Health Care | Prof James Avoka Asamani, WHO Africa

And I apologize up front for those who in the family meeting because what I'm going to share here is not fundamentally different from what we discussed on Tuesday. So if you are bought by it, please can attend your emails. [laughter] >> But it's great to be with you and I would like to share with you maybe four things. First I will not definition of primary health care and how it relates to primary care. I would like to only highlight what we count when we say course and I will give you a broad overview of the health course in Africa and I will try to zoom in into family medicine and I'm [clears throat] having questions for you not questions I crafted but questions that I got from everyone I spoke to and told them I'm coming for family doctor's meeting and the questions are these Who are they? [laughter] What do they do? Where are they? And how do you do it? You got the questions? Who are they? What do they do? Where are they? And how do we actually live of those doctors? I don't have all the answers to these ones but I will attempt to provide for those that there is some glimpse of data. So as you saw the definition for primary healthcare is very well uh founded and professor Karen already took this up. The key thing I want to mention here is that primary healthcare is an approach and that approach has the how. The how to give universal coverage to everybody is to focus on the needs of people as early as possible and along that continuum of care from health promotion, disease prevention and detection, treatment and the disease management, rehabilitation and palative care that you already do and that [clears throat] it should be done for the people as close as close to their environment. So from a health workforce perspective we look at this as saying if you want to tell which kind of health worker do you need for this population and how many of them first you need to understand what are the population's own health needs that is plan from the people's need then the second is that the health workers we should we have we should avoid dealing with one occupation as if that occupation will be a partial to everything. Also look at the rate of skills that are required in a team and then you can define the roles appropriately and then they work as a cohesive team. And finally they should be physically stationed as close as possible to where the people who need the services are like profess is working and I was very impressed from the back. I said this cannot be Australia it's probably Africa if I were to see that picture randomly. So there are six basic elements when we're looking at who is a health worker that we count as the PHC workforce. So when we say PC workforce what we actually mean is that we are looking at people when I say people here I'm talking health workers who are contributing to some of the basic functions of the primary health care not just primary care primary health care and those functions there are at least six of them that are fundamental you need to contribute to at least one and these are the six at least any worker contributing to one or more of these functions and they are stationed at the primary level of care then we come as a peace workforce. They can sometimes be stationed at tertiary or quinary levels of care but through a network of service that they can provide when they are referrals and counter referrals or tele consultations here and there but we try to quantify those that contribution a bit differently. Now having said that I'm now coming to look at what is the state of workforce in Africa. Professor Karen already mentioned this. The graph to my left is life expectancy. As doctors sitting here, I believe all that you are trying to do is to make sure people live longer and in good health. True or yes? >> It's both true and it's right. [laughter] Sir, >> in Africa, your effort has been recognized. You've added 11 more years to Africans since 2000. But the reality is that Africans are still expected to live 8 years shorter than their counterparts born at the same time in any other place in the world. So we are 11 more years better living longer but we are still 8 years below how many years people expected to live if they born any other in any other part of the world not in Africa. That means we are not healthy enough or living long enough. I have always said that if you have a car that is not performing you take it to where? >> To the shop to fix it. to have a better health. The shop to fix it is to get health services. The measure for health services, the what we have come to live with as the single metric that summarizes access to health services is called the universal health coverage index. It's measured between zero and 100. The higher the better. In Africa, our current average is 51. the global average is around um 70 71 or so. What this means is that Africa is about 20 points less than the global average. For an ordinary man walking the street, I would tell the person that in Africa only 51% of your health needs can be met reasonably by the services we provide. Only 51 that mean 41 can be met. And if you're in Africa, the differential between you and someone in any other part of the world is 20 points in how much services you can access. So the car is not performing. We are not performing well on life expectancy. Where to get the servicesing? We are also not performing enough. But don't forget you have we have made good progress thanks to your effort cuz we have made at least 11 years of gains in that respect. All of this is not a fl many factors account for it. Financing deficits, infrastructure deficits, medicines deficit as well as fake and uh counterfeit medicines that are all over the place. All of this account but one thing has been standing up. How many health workers are there to provide services? And this map you see is the density of doctors, nurses, midwives, pharmacies and dentists per 10,000 people across the world. The more blue a country is, the better density they have. The less blue or the more red a country is, the less density they have. And if you look at this map, Africa looks like a continent without health workers. Same for a few countries like Botswana, Algeria and others that are showing a bit of and then maybe South Africa showing a bit of um some blue coloring at some point otherwise Africa is like a continent with that kind of so fundamental issue is that there are no enough workers in Africa. Whatever the challenges are, they are there but they are not enough. So I don't want us to get the message later on because of count to me unemployment to say oh we have more than we need. Look no we don't have but we don't have enough. How many do we actually have? 5.7 million as of our last count. Of those almost 1.2 million are community health workers train at variable degree of training. Some train for just 5 days, some maybe two weeks, some maybe 6 months, some two years. All of the those are in the mix. What we have is only 46% of what Africa requires to put the population on the good path to universal health Africa and that translate to needing additional 5.85 million health workers. It's not uniform across the sub regions. For example, southern part of Africa has 60% of their requirement. West Africa 51, east and then central Africa uh 34 and 35 respectively. The educators here, please thank you very much. You have increased capacity in training and we now training nearly to 326,000 health workers per year for more than 4,000 institutions across Africa. This is fantastic. But the effort to create job to absorb these health workers who are trained is not matching the training capacity. [clears throat] Hence about 27% of health workers are currently unemployed or still looking for better jobs. But I want to tell you all the numbers what whichever institution that has done an analysis on the return on investment for health workers from the World Bank or the IMF or the UN Commission WH Africa CDC all point to one thing. When you put $1 in investing in the health doctor as a very minimum you expect $9 back in the economy. And if you take into account the full social value of what health workers do, the health they give to the population and the work they do, the catalytic employment. If you doctors work, you use uh um medicines, you use logistics like gloves among others. Those are manufactured in another industry, transported, stored and when you finish using them, they disposed of. People do all of these jobs and they are jobs that are being created by the working. If you put everything together, investing in health worker can return 33 times the value of invested in But the reality is we have getting close to a million workers who are not employed and there are no exceptions anymore. For young graduates we are seeing even doctors 58% of young graduate doctors struggle to find jobs in the first year of their graduation. And last uh last Tuesday I was telling the the meeting that I had a very unpleasant surprise of being driven by a doctor who was as a taxi driver and he had been doing so for at least 2 years. Yeah. is no longer interested to say that we put public resources to train a doctor for six or seven years only for the person to finish and spend two years of their lives driving taxi and not working in the uh front lines of service delivery when we know that for every year they don't practice their knowledge they lose roughly 10% of what they have learned. But there's another animal in the room. That animal in the room is about competences and our ability [clears throat] to provide services according to national guidelines. There has been so many attempts to research on this and there's been a lot of debate about whether the evidence will reverse or not. What we can tell you is that we have now taken our time to look at the evidence across 25 studies big and small from all contexts in Africa limited to Africa alone. Our conclusion is that it may vary for your country but on average 62% of cases that present at health facilities predominantly at the primary care level do get the correct diagnosis. The flip side is that if we all walk to the health faces today, for every 10 people sitting there, four of us will come back without the correct diagnosis. And for those who get the correct diagnosis, 40% are likely to get the right treatment according to this guidelines. That means if we have 10 people going to the clinic, we will come back with six people not having the right treatment. Even if they got the right diagnosis, don't forget it. But when the cases are more complex, think of somebody with hypertension, HIV with diabetes in at the same time. For those ones, they tend to get up to 27% of the treatment [clears throat] correct. This is not just a statistic. What this means is that the health system is bleeding financially or some of these are wasted resources and the health system sometimes do not have the resources to make the right decisions for diagnosis and treatment. So instead of blaming the health for not being competent, let's look at what are the enablers that we need the health perform. So that these are some of the things and when we go a bit further you would notice that a lot of governments and decision makers recognize this and what they try to do is to provide inservice training workshops in hotels here and there try to uh patch up the gap but it has created a new reality also that in some context we have seen up to 35% health worker absentism because of some of those frequent workshops. >> So the solution is not just add more workshops only. We have to tackle it from the foundation. Across several occupations between 19 and 70% of them are deployed at the level of the health system that is considered the primary care level. And if you were to look at uh since um I'm speaking with doctors uh where the interest might be more only 32% of doctors are deployed at this level but we heard from profaring that up to 90% of the population health needs could be addressed at the primary care level. So there's a complete mismatch between where the need is and where our doctors are deployed. And it's not only doctors. You can [clears throat] one would expect more nurses at the primary care level, but it's not the case. It's only almost 48%. It's only midwives and um the clinical process of physician assistants that will have more than half of them deployed. I just focus on the uh these four top clinical patients. Then as I head towards conclusion, I want to now begin on who are they and where are they and how many are needed. First, who [clears throat] are they? Since yesterday, I have been listening carefully to speakers to understand what they understanding, their conceptualization of who a family doctor is, cuz that is key in what we count as family doctor and what we don't count as family doctor. Internationally, occupations are classified through the international standard classification of occupations. This is a comprehensive tool that tells the names of occupations and the different variants of naming what they do and how to become one. It is done under the opices of the IO the international labor organization and is revised at least in the last ones approximately every 20 years. The current version was done in 2008. The next one will be released in 2028. Hopefully you can count 28 years from there when the next one will be. This classification that we call it the ISC OA for short founding um doctors as part of general practitioners but general practitioners are defined as people who have the first level qualification from a medical school. So what it means is that the recognition about the value of what family doctors do is there because at least it's mentioned but the appropriate placement of what they do as a specialized services at that level is what is lacking as a result. This is how countries report on their doctors to the rest of the world. It's called the national health force account system. It's freely online and you can go to you can just check it out to see how many people are in how many doctors in the country. You can see that 1.1 is general medical practitioners including family medicine practitioners. So this is where the issue is. If you pick a phone and call a random health policy maker and ask the person how many family doctors do you have in your country? First is it's impossible for them to keep the number in their head. But second, there's no way they can just click to find and tell you this the number because of how the reporting structure is. So the question of who they are, we need to now better define who the funding medicine doctor is based on based on what we have received in this conference. Even with shaky definitions, we have tried to understand how many there are in Africa. From 24 countries, we found 5,075 family doctors who represent just 2% of the doctors in those countries. 2%. [snorts] and approximately 0.59 doctor if you like one doctor for 200,000 people but how do they actually need in Africa and in those countries the way we do need analysis for health workers follow what we call the epidemiology based need analysis and that approach takes the population the disease burden at least 90 we normally go up to 99%. So for Africa we do 98.1% of the disease burden in any country and then we combine that to estimate how many people actually require care for different diseases risk factors and conditions and we come and look at what services or interventions are proven and known to address these diseases and risk factors. So there is a tool online called the UNHC compendium. It has that list also. And we now come and look at which health worker is best placed to deliver these interventions. How much time do they require to do it? And how often should that intervention be delivered for those affected. Put all of that together, we are able to quantify how many health workers of a particular kind is needed in which country and across Africa. So uh this is our approach to this analysis and uh with the we have we have a tool for it which is publicly available. they call the heavy river market analysis of two and we have published this in across a number of journals on this methodology and the estimates. So all of the estimates you see are based on this approach for fun doctors using this approach our estimation is that today 2026 Africa require at least 41,000 doctors and this will rise by at least 8,000 or if you like 19.5% in 10 years. So by tuning for the 35 we expect Africa to need at least 49,000 family doctors. This translates into having four family doctors per 100,000 people or if you like for simplicity one for 25,000 as a minimum because context vary it can also vary but this is the best scenario. uh please this should not be puted yet as according to the law we need 400 per 100,000 because we haven't published it put it publicly yet so when we put it publicly you are free to code but we are very confident in this process the methodology and record for all other health workers you can use as your working scenario for the countries that have shown data for found doctors all across those countries they only have 21% of what they require 21%. So if someone asked me today to say what proportion of the required family doctors do we have in Africa I will say that 24 countries have family doctors present and amongst them we have 21% of what they need but Africa as a whole we need between now and 10 years time between 41,000 and 49,000 family doctors. So as I summarize who are family doctors these are experts providing comprehensive care we have just 5,000 plus in Africa but we need 49,000 more doctors in Africa face a recognition issue 30% of countries we have spoken to do not officially yet recognize or at least have the mechanism to recognize them as a special as a specialist area. There are issues around lack of standardization in curriculum and what we call a family doctor. The one from Tanzania and the one from Nigeria are they the same as the one from South Africa and also there are also the BL career pathways. uh if you become a family doctor would you be disadvantaged compared to one who has done obstet and when they are looking for appointment to appoint the CEO of something later in the future would you be advantage or disadvantage all of these things are not clear would you earn the same salary all of these are not clear so some of these things need clarity as I conclude what do we propose Bob Marc spoke about this yesterday let's count better the family buttons have a road map for scenario farm doctors for Africa. Develop a model scheme of service and career pathway for family doctors and work towards properly classified family medicine as a specialist area. Let's I'm not too ambitious but it's workable. The next may be in 20 years but 20 years is still a short amount of time for the evolution of a professional field. [laughter] We have a number of curriculum we have done around um health workers and countries the uptake is quite impressive and I believe you do a similar family medicine it will have a good uptake as I conclude I want to tell you don't give up keep pushing and do the work we are doing and tell everyone to plan train and attain at least 3 million health workers to Africa but in that they must Prioritize communism. Thank you. [applause]