(Photo Credit: World Health Organization)

One of the topcis I have spent quite a bit of time of late thinking about is the question of how to build and sustain an effective health workforce in sub-Saharan Africa. I had actually hoped to devote my dissertation to this topic, however, severe data shortages prevented me from looking at most of the questions I was really interested in. However, one of the things that would drive me crazy about this topic was that whenever I told someone about my research interests in health workforce issues in Africa, I would always get: “oh, you mean like brain drain?”. To this, I would reply: “No, I don’t.”

It is not that I think brain drain is not an important issue, it is just that I really think it is a second order problem. The first order problems related to health workforce have much more to do with the barriers to demand and supply of health workers. In general, on the demand side, it is not like there are thousands of unfilled posts and no one to fill them because everyone has migrated (sometimes there are unfilled posts, true, but it is usually due to some bureaucratic inefficiency that prevents the position from being filled), it is that there is a big difference between the true “need” for health workers and the actual “demand”, that is spots for them in the public service or elsewhere. On the supply side, pre-service training is a severe constraint. Even if there were more jobs, which might induce more people to want to become a health worker, it is likely that there would not be enough training spots in medical and nursing schools for them to get training.

Finally, there is now some good research out there that makes this point quite clearly. Kinfu, Dal Poz, Mercer, and Evans from the WHO has recently published a nice piece in the Bulletin of the WHO that makes the best use of the spotty data out there and logic to make an important point. Even under relatively conservative assumptions about natural rates of outflow from the health work force (death, retirement, etc), current pre-service output is barely above average replacement rates in 12 sub-Saharan African countries (half above average and half below). If you then factor in population growth, no country will keep pace. If you then also expect it to try to acheive any of the major new global health initiatives we donors so hope to implement, forget it. The output of health workers in Africa is far, far to low, and everything else is a second order issue.

Some of my research in Ghana has also identified this constraint. Ghana is a country that gets a lot of airplay about how bad outward migration has been, but in reality, Ghana’s real problems have very little to do with migration. In the 50 years since Ghana gained independencance from the UK, it has only ever had 2 medical schools, one started soon after independence and the other during the 1990s. Combined, these medical schools have only ever produced roughly 3000 doctors…IN 50 YEARS. Even if every single one of these doctors were alive and working today, a completely unrealistic assumption, Ghana would still be an order of magnitude below health density levels advocated by the WHO (ignore for the moment whether one believes in these ratios or not). Ghana probably has somewhere over 2000 doctors currently practicing in the country today, reasonably good levels, considering, but this point never gets any attention. I was at one point trying to see if Ghana was actually a net importer of doctors trained outside of Ghana, but the data was a bit too messy to allow me to show this, but I suspect it might be close in recent years.

So I am really happy to see this new article. The authors get my highest level of priase for making the most of the paucity of data available on this topic.

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Stuff on the net

On March 5, 2009, in links, stuff on the net, by Karen Grepin

Here is a roundup of good stuff to read on the net these days:

1. Can you justify buying fine wine when children are dying in Africa? Peter Singer’s new book argues that you cannot, Bill Easterly disagrees.

2. IntraHealth teams up with Youssou N’Dour to promote their “OPEN” iniative to get open source solutions to improve health care into clinics in Africa.

3. Sanjay Gupta is reportedly out of the running to become Surgeon General. There goes my best chance of ever getting to meet Anderson Cooper (thanks to Alana for the update on Twitter).

4. Yesterday I posted about the ICC decision to arrest al-Bashir of Sudan. I am happy to know that I am not the only one who does not have a clue what this will mean for the future of the people of Sudan. Alex de Waal has an excellent analysis of the situation that is a must read for anyone interested in this topic.

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(Photo credit: REUTERS)

The big news story of the day is clearly the issuance of an arrest warrant for Omar al-Bashir, the current President of Sudan, by the International Criminal Court on on charges of war crimes and crimes against humanity in Darfur. For now, he appears to have escaped an accusation of the big G word, but charges of Genocide may be added at a later date. This is a historical moment for international law as this is the first time the ICC has issued the arrest of a sitting head of state.

What will all this mean for the people of the Darfur? In some ways, likely not all that much. The arrest warrant will be given to the Government of the Sudan and it will be up to them to decide whether to hand him over or not. I am going to take a stab in the dark on this one and say that in all likelihood they won’t respect it, and perhaps aside from taking less international trips, not much may change for President al-Bashir. al-Bashir told the ICC earlier today that they could “eat” their warrant.

There has been a lot of speculation as to how Sudan may respond in retaliation to this arrest warrant. One of the first things they did, however, was to expel the Dutch portion of the Non-Governmental Organization MSF. It is no coincidence that they kicked the Dutch out as the ICC is headquartered in the Hague. The organization is currently delivering health services to hundreds of thousands of people and it is not clear if anything will be able to come in and fill in. Other international health organizations and aid agencies are likely to follow.

To read more about the expulsion of MSF, click here.

Update: It appears as though Oxfam, CARE, and Mercy Corps have also been expelled.

Click here to read the NYTimes coverage.

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It is only over the past few years, perhaps since the birth of the DALY, that we have given the idea of mental illness in developing countries much thought. The reason is not likely to be a surprise to many, which just don’t have the data systems in place to properly measure the burden from mental illness in these countries. Most of what we know about health in low-income settings come from household surveys, which tend to focus more on reproductive health and infectious diseases – the stuff we consider to only be problems in those countries.

Therefore the new publication by Jishnu Das, Quy-Toan Do, Jed Friedman, and David McKenzie (all from the World Bank) is very welcome and makes an important contribution to what we know about mental health in lower income countries.

They summarize the burden of mental illness as follows:

“According to widely circulated estimates, unipolar depressive disorders are the leading cause of loss of disability adjusted life-years (DALYs) in the Americas and the third leading cause in Europe, but they also rank highly in lower income countries. They are the second leading cause in the Western Pacific, the fourth in South-East Asia, and the fifth in the Eastern Mediterranean. While depression is not in the top 10 in Africa, it is recognized as a major source of disability, particularly in conjunction with HIV/AIDS epidemic.”

And:

“The few low-income country estimates of poor psychological health suggest that prevalence is not systematically lower than it is in wealthier countries.”

So basically, the overall prevalence of mental illness is probably comparable in low and high income countries, but since other conditions are so much more prevalent in developing countries, it does not rank as high as it does in developed countries.

Their work finds two major finidngs. First, unlike in richer countries, there is no strong positive relationship between measures of income or consumption and mental illness. Mental illness is not a disease of “affluence” or “poverty” in developing countries. Second, they also find that shocks (e.g. illness or crisis) can have a greater impact on measures of mental illness than on measures of illness or poverty, suggesting that classical economists measures of well-being may neglect to consider the mental impact of such shocks in developing countries.

If you want to read more, click here. Subscription, I believe is required.

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Peter Hotez has done it again. When does this guy sleep? In addition to being the editor of the PLoS NTD journal, Professor at George Washington University, President of the Sabin Institute, the inventor of the hookworm vaccine, and a the tireless campaigner for raising awareness about Neglected Tropical Diseases, he has now released a book devoted to the topic of NTDs. This may not be on the top of everyone’s reading list for sure, but it will probably be on mine. Good thing I have trips to Ghana, Ethiopia, and Vegas coming up.

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High risk of polio spread in Eastern Africa

On March 3, 2009, in epidemiology, polio, by Karen Grepin

The WHO and others have reported that polio may be spreading in Eastern Africa. There have been isolated cases of polio in Sudan and Ethiopia, however, it appears as though polio may have surfaced in other parts of Sudan and may have spread to surrounding countries in Uganda and Kenya.

In Uganda, the cases of polio are the first reported cases in nearly 13 years. In Sudan, a case has been reported in one of the port cities leading epidemiologist to worry that the disease may spread quickly. If these stories are in fact true, this is very troubling news. The Gates Foundation and others have recently renewed efforts to eliminate polio and this could only make things more challenging. Lets hope we get our act together and respond.

You can read more about polio eradication here.

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One less person in the running to head PEPFAR

On March 3, 2009, in Obama, PEPFAR, politics, by Karen Grepin

(photo credit: Harvard School of Public Health)

Dr. Jim Yong Kim has been named the next president of Dartmouth College. Dr. Kim’s name has been circulating in recent years to become the next US Global AIDS Coordinator, but clearly he is no longer in the running that job.

According to the NYTimes article, Dr. Kim is:

“…an unusual choice for a university president. He is known less for his academic achievements than for his groundbreaking work as co-founder of Partners in Health, and then at the World Health Organization, bringing effective medical treatment for H.I.V. and AIDS and for drug-resistant tuberculosis to the poor.”

This certainly is an interesting turn of events…

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All indicators seem to suggest that the Obama administration will maintain US government spending on global health initiatives in the coming years, despite the financial crisis that is causing havoc across the country and around the world. An analysis by the NYTimes of the foreign assistance allocation in the budget announced by Obama last week suggests that overall foreign assistance will receive a small increase over previous years and that global health remain a priority. The article also suggests that the global health priorities of the government may broaden in the coming year to focus more on other health conditions not just HIV/AIDS.

Update: For another analysis on how the international affairs budget in the new Obama budget breaks down, see the CGD blog entry by John Simon.

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