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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.

This month, PHR is examining the health workers shortage in Africa ahead of the introduction of the Global HEALTH Act, which would provide $2 billion over five years to strengthen the health workforce in developing countries.

Today, we want to highlight an organization that is working right now to fill health worker vacancies in rural areas in Southern Africa. If you are a doctor or nurse, Africa Health Placements (AHP) needs your skills to support rural health in South Africa, Lesotho, and Swaziland—contact them today for more information.

Africa Health Placements originated in South Africa and now works in several other countries in the region to increase the public sector health workforce through recruitment from the private sector and through recruiting foreign health workers who are looking for the excellent work experience and unrivalled lifestyle that is offered through such an opportunity. AHP’s support is aimed specifically at those provinces and areas where there are major shortages of doctors, nurses, and other health professionals.

AHP’s focus is on patients and equity in healthcare for rural and disadvantaged communities—communities that are suffering high burdens of AIDS and other diseases, including malaria and TB.

These efforts are having far-reaching results. In 2009, their foreign recruitment efforts placed approximately seven times more doctors in rural South Africa than the long-term rural placements of all 8 South African medical schools combined. Learn more about their work by watching the film Bush Doctors.

AHP delivers support to health workers by offering a way of smoothing the application and registration process, matching interested health workers with available opportunities, and by providing clinical, cultural and logistical orientation and ongoing support throughout a recruit’s placement. AHP also supports the strengthening of human resources in health in the region through consulting, advocacy and knowledge-sharing with relevant partners and government bodies.

AHP recruits into rural areas, where health workers are asked to commit to at least 12 months of services. Many renew their term of service—for one year, two years, even longer. Since its founding in 2005, AHP has placed more than 1,500 health professionals in Southern Africa, half of whom are from abroad.

Check out AHP’s website, and consider working with them to deliver health care to the rural poor in Africa. If you have friends or colleagues who might be interested in this critically important opportunity, please spread the word!

Yesterday, Representative Barbara Lee (D-CA) introduced the Global HEALTH Act (House Resolution 4933) in Congress. We are thrilled at this opportunity to transform America’s global health policy and provide billions more in aid to develop health systems in poor countries.

Take 10 minutes to read the bill (pdf)—there is a lot to learn:

• What the HEALTH in Global HEALTH Act really stands for (This one I’ll give you: Global Health Expansion, Access to Labor, Transparency, and Harmonization Act of 2010).
• The overall goal of the bill (This one you get too—the rest you have to look up: To establish a strategy to coordinate all health-related United States foreign assistance, to assist developing countries in improving delivery of health services, and to establish an initiative to assist developing countries in strengthening their indigenous health workforces).
• The GHA’s vision for a new United States Global Health Strategy (page 2).
• Which Millennium Development Goals the new Strategy would target (page 4).
• The ration of health workers to population the Strategy will aim for (page 12).
• How the Global Health Strategy will really work—what it will support, what it can do (page 8).
• How the US Global Health Strategy will support National Health Strategies in developing countries (page 30).
• How the new Global Health Workforce Initiative  fits in to the Global Health Strategy (page 39).
• How many countries the GHWI will target (page 40).
• The criteria for selecting these countries (page 40).
• What the GHWI will do to support health workers in developing countries (page 43).
• How much money the Global HEALTH Act will provide for all these critical global health capacity building programs (this one I have to tell you—$2 Billion over 5 years. Amazing. See the yearly breakdown on pages 64-65).

Read the bill, and get ready to take action. On April 7th, World Health Day, we’ll ask you to email your Congressperson and urge them to co-sponsor the Global HEALTH Act. And spread the word—this is a transformative bill, and you can make a difference.

Over the past month, PHR’s Health Rights Advocate blog has highlighted the health workforce crisis in Africa, and how the about-to-be-released Global HEALTH Act can help.

Now, we want to hear from you.

What is your experience with the health workforce crisis in Africa? If you are from Africa or another developing country with a health workforce shortage, tell us about your experience in giving or receiving health care in your country. If you are a health professional who has left your country to practice in the US or elsewhere, we’d love to hear your story: your experience in the health system at home, why you left, and what it is like where you are now.

For those of you not from a developing country, have you visited or worked in Africa and seen the impacts of the health workforce crisis first hand? Have you met doctors and nurses from developing countries who are working in the US or going to school and plan to stay here? What have you learned from their experience?

Some African health workers have already offered their own insights into the health workforce crisis, its impact on themselves and on their patients, and their advice to policymakers.

The hospital where I work, which serves 100,000 people in the district, averages 2-3 maternal deaths per week due to delayed operations. The two medical officers cannot adequately cope since they have to attend to other emergencies and referrals from the neighbouring districts.” – Nurse, Homa Bay, Kenya

The shortage of doctors and nurses in our hospital has led to one nurse attending to 40 patients at time, a nightmare for those suffering acute conditions. This had led to the loss of patients who would otherwise be stabilised. The quality of service is highly compromised and bordering on unethical practice. This is inhuman treatment of fellow human beings.” – Medical Laboratory Technologist, Nairobi, Kenya

I have a situation at the moment where about 200 patients have to travel for up to six hours to get their ARVs [antiretrovirals] and access related services. Most antiretroviral treatment (ART) centres are in the cities and there are no qualified healthcare professionals in the towns and villages. ARVs are even expiring in some centres because the inconvenience involved is just too much for patients.”– Pharmacist, Abuja, Nigeria

PEPFAR is focused on urban areas. The rural areas are left behind. Patients can’t afford transit. I’ve had five patients die quietly in the last six months because they didn’t have access to AIDS treatment…There’s no electricity where I work, the roads are bad, there’s no equipment. If I get a needle puncture, there’s no prophylaxis. I’m on my own. I’m on call 24 hours; this leads to fatal errors. This is a classic case of marginalization.” – Physician, Niger State, Nigeria

Communities in rural Uganda have a difficult time accessing a health care worker. For example, at outpatient facilities upcountry, there may be 200 people per day who show up seeking care, but only one health worker and one clinic for 25 km. You may see a doctor or a nurse, but quality of care is unsure. It’s different seeing a patient first thing in the morning versus after many, many patients – my judgment may be impaired after so many consultations.” – Medical Student, Makerere University, Kampala, Uganda

There is nothing more demotivating to a worker than being in an office without any resources to do the work. Many of us have worked in hospitals where we were recycling gloves in this era of HIV. We have worked in labour wards and operating theatres where autoclaves could be broken for days, yet we are expected to provide safe motherhood services.” – Physician, Kenya

African Health Workers’ Prescriptions for Policymakers:

Policymakers at country and global levels have to make a deliberate move to recruit and retain health workers in the right numbers based on needs assessments.

Our capacity to deliver health services would be improved by a conducive working environment with adequate basic infrastructure, proper medical supply management, better and regular remuneration and opportunities for continuing education and training.

Donors need to scale up investments in human resources for health, especially in health care workers. Most donors do not fund salaries, which I find self-defeating. For example, a donor will choose to fund only medical supplies without considering how the supplies will be dispensed and by whom.

Western countries recruit health workers and have made it very easy to acquire entry visas and work permits, especially for nurses. This is like picking from the poor man’s pocket.

A healthy nation is a strong nation politically, economically and socially. Investing in health is not only right but a necessity!

We want to hear from you. Use the comment form below to tell your story.

We are just three weeks away from World Health Day (April 7) and the official launch of advocacy for the Global HEALTH Act of 2010. And we have now heard that Representative Barbara Lee will be introducing the bill in the coming days! Now more than ever we need you to be ready on April 7 to email or call your Congressperson urging him or her to co-sponsor this bill.

Since the beginning of March, though this blog you’ve learned about the purpose of the Global HEALTH Act , garnered some great facts about the health workforce crisis, seen one of the many ways in which health systems can be measured and watched four health workers at Mbagathi Hospital talk about the challenges they face on a daily basis.

Today’s post takes a closer look at some very important components of the Global HEALTH Act. But first, it is important to congratulate Representative Lee on the development of a bill that heralds a new way of working to strengthen and improve the health systems of developing countries, and the delivery of health services to the whole of the population in those countries. The bill calls on President Obama to develop a comprehensive US Global Health Strategy (the Strategy) that harmonizes and aligns all health-related US foreign assistance, and seeks to ensure that equity, non-discrimination, participation and accountability are embedded in the Strategy and, to the greatest extent possible, in the national health strategy of each country receiving direct assistance.

This is a comprehensive bill, and it is not possible to review it here completely. Hence we have selected a few specific examples for you of how the bill advances the right of everyone to the enjoyment of the highest attainable standard of health:

Equity and non-discrimination: An objective of the Strategy is to ensure that there is access to quality health services for poor, vulnerable or marginalized populations. Equity and non-discrimination permeate the bill. These issues are to be principal considerations in the construction or rehabilitation of health facilities, in the distribution of health services and health workers, and in the provision and distribution of medical, pharmaceutical and laboratory supplies. The ability of women and youth to use health services without fear, violence, discrimination or other mistreatment is one of the many principles that the President is called upon to encourage countries to include in their national health strategies.

Participation: There is a concern with participation throughout the bill. First, the Strategy itself is to be developed in consultation with all manner of individuals, groups and organizationsfrom executive agencies administering US foreign assistance, to US embassies and country missions, to civil society and nongovernmental organizations in developing countries, to international organizationsand other donor nations. At the developing country level, the bill calls on the President to encourage countries receiving direct assistance to ensure meaningful participation in developing their national health strategies. This participation is to include the poor, vulnerable, or marginalized populations, as well as nongovernmental organizations, in program and budget decisions as well as in the implementation, monitoring and evaluation of the country’s national health strategy. Hence, the bill makes a direct link between equity, non-discrimination, participation and accountability.

Accountability: The accountability process enables the government to identify what is working and what is not – to explain what it has been done and why – and to provide to individuals and communities the opportunity to understand how the government has discharged its obligations. Where mistakes have been made, accountability requires redress. It is a process that includes monitoring, mechanisms, remedies, and participation. The bill makes clear that the Strategy should have each of these components. The Strategy itself is to be monitored and evaluated for effectiveness. To allow this to take place, the Administration is to establish indicators to monitor the Strategy and provide annual reports to Congress. The bill authorizes the President to provide assistance to developing countries to improve the delivery of health services in those countries. The activities that have been authorized include direct support to civil society and nongovernmental organizations to monitor and evaluate their country’s health system. The President is also called upon to encourage countries to include in their national health strategies the development and implementation of sustainable legal frameworks that engage the whole of the population to monitor and enforce policies related to health. Ensuring there is a legal requirement to enable people to participate in monitoring and to enforce policies is essential for government accountability.

The bill’s consistent focus on equity, non-discrimination, participation and accountability indirectly promotes the incorporation of a human rights approach to health into the Strategy. If the Strategy is developed and implemented, it will provide – in time – the proof that adoption of this approach improves health outcomes and the processes to achieve those health outcomes. This bill is to be applauded. It is essential that it obtain a large number of co-sponsors to demonstrate significant support for this legislation, which will help move this bill towards final passage. This is not only for the benefit of the populations in the countries receiving direct assistance but also for the benefit of the US. This bill has the potential to do more for the credibility of the US in the arena of human rights and global health than anything that has gone before.

On April 7 BE READY to email your representative – PLEASE!

We’re just a month away from World Health Day (April 7th) and the official launch of advocacy for the Global HEALTH Act of 2010. So far this month, through this blog you’ve learned about the Global HEALTH Act and gotten some great facts about the health workforce crisis (and how many people are waiting in line for an I-Pad — impressive!). Today’s post includes a few more resources that highlight the impact of Africa’s health workforce shortage. Check them out and share with colleagues.

PHR made the following video in collaboration with our Kenyan partner group, the Health Rights Advocacy Forum. In this 6-minute video, four health workers at Mbagathi Hospital talk about  the challenges they face every day — and why they stay and practice medicine in their home country. This moving video can be shown on campus or at your workplace to stimulate discussion and urge people to take action.

For more personal stories, check out Africa’s Health Care Worker Crisis: Views from the Ground, a PowerPoint presentation that outlines six main drivers of the health workforce crisis in Africa and explores these challenges through the eyes of four Ugandan medical student leaders. Feel free to use this to make a presentation on campus or in your community, or use facts from it to drive home the need for action.

And watch our slideshows of Dr. Fred Katumba and Clinical Officer Jane Byarugaba following them through a typical day as they provide health care to the rural poor in Southwestern Uganda. Dr. Katumba’s work has propelled Lyantonde District to #2 out of more than 90 districts in terms of health outcomes — a phenomenal accomplishment and testament to Dr. Katumba, his staff, and the millions of hard-working health professionals who help communities realize the right to health every day.