Human Resources Human Resources for Health: for Health: A ResponseA Response

Jack A. DeHovitz, MD, MPHJack A. DeHovitz, MD, MPHDirector, New York International Training and Director, New York International Training and

Research ProgramResearch ProgramProfessor of MedicineProfessor of Medicine

SUNY Downstate Medical CenterSUNY Downstate Medical Center

Georgian Health Care Georgian Health Care 2020: MEDEA 20112020: MEDEA 2011

February 1, 2011February 1, 2011

Physicians High levels of medical staffing even compared to

FSU Only one medical faculty prior to 1991 (~700

students) Four state and 69 private faculties IN 2004

(~15,000 students) decreasing to 34 in 2006 Responsive to demand but not need Fragmentation of training, MoE responsible for

undergraduate, MoLHSA responsible for postgraduate and CME

Flux between private and public employers

Source: WHO European Health for All Database (6)

Georgia Health System Performance Assessment 2009

Ratio of number of patients hospitalized annually per hospital full-time-equivalent doctor working in hospitals, Georgia and selected countries, 2007

Source: WHO European Health for All Database (6)

Georgia Health System Performance Assessment 2009

Source: National Centre for Disease Control

Georgia Health System Performance Assessment 2009

Challenges in Nursing Challenges in Nursing WorkforceWorkforce

Nurse training focuses on technical Nurse training focuses on technical skills rather than theoretical and skills rather than theoretical and critical thinkingcritical thinking

Historically two paths-technical Historically two paths-technical education and medical studentseducation and medical students

No national licensing, specialization No national licensing, specialization or continuing educationor continuing education

No national registryNo national registry

Nursing competencies

Only allowed to obtain vital signs and distribute medications

Do not do patient assessments Do not engage in nursing care plans No health education No knowledge of evidence based

practice

Source: National Centre for Disease Control

Georgia Health System Performance Assessment 2009

Nurses per 100 000 population in Georgia and other selected countries from 1990 to latest available year

Source: Who Regional Office for Europe 2009Georgia Health System Review

Nursing Supply

21,000 Physicians and 19,000 nurses Ratio=0.9 nurses: physicians Greece and China: 0.7 Bangladesh: 1.0 US: 4

Positive Trends in NursingPositive Trends in Nursing

Law recently passed (December, 2010) to Law recently passed (December, 2010) to allow for the development of a baccalaureate allow for the development of a baccalaureate nursing programnursing program

Emory University funded by USAID to initiate Emory University funded by USAID to initiate program beginning in Fall, 2012program beginning in Fall, 2012

Georgian Nurses Association has increasing Georgian Nurses Association has increasing presence and has a plan to initiate a nursing presence and has a plan to initiate a nursing registryregistry

Demand will be created by anticipated opening Demand will be created by anticipated opening of over 40 new hospitals and clinics.of over 40 new hospitals and clinics.

Public Health Workforce Public Health Workforce ChallengesChallenges

Elements remain of Russian Sanitarian (“San-epid”) Elements remain of Russian Sanitarian (“San-epid”) modelmodel

Achievements included high immunization rates and Achievements included high immunization rates and communicable disease controlcommunicable disease control

Numerator focused assessment-case counting-Numerator focused assessment-case counting-current staff have little or no competence in current staff have little or no competence in designing and conducting epidemiologic studiesdesigning and conducting epidemiologic studies

Following independence =>DecentralizationFollowing independence =>Decentralization Subsequent rise in STI’s, substance use, CV disease Subsequent rise in STI’s, substance use, CV disease

and smokingand smoking Decline in its share of total allocation for health Decline in its share of total allocation for health

(8.1% ->2.3%)(8.1% ->2.3%)

Role of Public Health System

Policy makers and managers must use analyzed data to make informed public health decisions.

Accurate data is necessary in order to make these decisions

Comparison of infant, under-five and maternal mortality rates reported by National Centre for Disease Control (routine health information source) and two population-based surveys, 2000-2004.

Source: National Centre for Disease Control; Women’s Reproductive Health Survey (9); Multiple Indicator Cluster Survey (7)

Georgia Health System Performance Assessment 2009

Source: National Health AccountsGeorgia Health System Performance Assessment 2009

Public expenditures on outpatient care, inpatient care and public health

and prevention services as % of total public health expenditures, 2001 –

2007.

Public Health Workforce Challenges

Until last month, not one staff member at Until last month, not one staff member at NCDC had a Master’s degree in Public HeaNCDC had a Master’s degree in Public Healthlth

While US and others have made serious While US and others have made serious investment in public health training most investment in public health training most return to work for NGOsreturn to work for NGOs

Challenges in intersectoral collaborationChallenges in intersectoral collaboration Unequal distribution of public health workers Unequal distribution of public health workers

with lack of professional staffing in rural with lack of professional staffing in rural centers and overstaffing in urban centers*centers and overstaffing in urban centers*

Poor coordination between district level public Poor coordination between district level public health programs and health facilitieshealth programs and health facilities

*Djibuti et al. Human resources for health challenges of public health system reform in Georgia; Human Resources for Health 2008

Positive trends in public health Positive trends in public health workforceworkforce

MPH programs being MPH programs being developed in Georgia with developed in Georgia with assistance of US and assistance of US and European institutionsEuropean institutions

New public health law passed New public health law passed in 2007 which defines in 2007 which defines MoLHSA roleMoLHSA role

Effective functioning of Effective functioning of Country Coordinating Country Coordinating Mechanism (CCM) to fight Mechanism (CCM) to fight HIV/TB/MalariaHIV/TB/Malaria

Recent appointment of US Recent appointment of US trained specialists to direct trained specialists to direct NCDCNCDC

Documented improvement in Documented improvement in immunization deliveryimmunization delivery

Substantial and ongoing Substantial and ongoing support for epidemiology and support for epidemiology and laboratory training by USGlaboratory training by USG

Issues for discussion How do we move beyond ad hoc planning? Who will take responsibility for addressing

the nexus between training and provision of services?

How do we revitalize and evolve public health services?

How do we integrate the alphabet soup of international partners into rational health planning?

How do we balance decentralization and centralization?

Stakeholders to consider including

Government at National and Regional level

Sectors: Education, health, finance Under and postgraduate education Training organizations Employers of health workers Representatives of healthworkers Representatives of users Donor community Parliament

With thanks to:SUNY Downstate Medical Center (Brooklyn, NY)SUNY Downstate Medical Center (Brooklyn, NY)

David Odegaard, MPHDavid Odegaard, MPH Dana TurnerDana Turner Susan Holman, RN, MSSusan Holman, RN, MS

University at Albany School of Public HealthUniversity at Albany School of Public Health

Louise-Anne McNutt, PhDLouise-Anne McNutt, PhD

New York State Department of Health (Albany, NY)New York State Department of Health (Albany, NY)

Dale Morse, MD, MSDale Morse, MD, MS

Emory University (Atlanta, GAEmory University (Atlanta, GA Carlos del Rio, MDCarlos del Rio, MD Henry Blumberg, MDHenry Blumberg, MD J.L. Wold, PhD, RNJ.L. Wold, PhD, RN

Georgian National Centers for Disease ControlGeorgian National Centers for Disease Control Maia Butsashvili, MD, MSMaia Butsashvili, MD, MS

Infectious Diseases, AIDS and Clinical Immunology Research CenterInfectious Diseases, AIDS and Clinical Immunology Research Center Tengiz Tsertsvadze, MD, Ph.D.Tengiz Tsertsvadze, MD, Ph.D.