Human Resources for Health: A Response

1. Human Resources for Health: A Response Georgian Health Care 2020: MEDEA 2011 February 1, 2011 Jack A. DeHovitz, MD, MPH Director, New York International Training and Research Program Professor of Medicine SUNY Downstate Medical Center

2. 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

3. Source: WHO European Health for All Database (6) Georgia Health System Performance Assessment 2009

4. 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

5. Source: National Centre for Disease Control Georgia Health System Performance Assessment 2009

6. Challenges in Nursing Workforce Nurse training focuses on technical skills rather than theoretical and critical thinking Historically two paths-technical education and medical students No national licensing, specialization or continuing education No national registry

7. 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

8. Source: National Centre for Disease Control Georgia Health System Performance Assessment 2009

9. Nurses per 100 000 population in Georgia and other selected countries from 1990 to latest available year Source: Who Regional Office for Europe 2009 Georgia Health System Review

10. Nursing Supply • 21,000 Physicians and 19,000 nurses • Ratio=0.9 nurses: physicians • Greece and China: 0.7 • Bangladesh: 1.0 • US: 4

11. Positive Trends in Nursing Law recently passed (December, 2010) to allow for the development of a baccalaureate nursing program Emory University funded by USAID to initiate program beginning in Fall, 2012 Georgian Nurses Association has increasing presence and has a plan to initiate a nursing registry Demand will be created by anticipated opening of over 40 new hospitals and clinics.

12. Public Health Workforce Challenges Elements remain of Russian Sanitarian (“San-epid”) model Achievements included high immunization rates and communicable disease control Numerator focused assessment-case counting-current staff have little or no competence in designing and conducting epidemiologic studies Following independence =>Decentralization Subsequent rise in STI’s, substance use, CV disease and smoking Decline in its share of total allocation for health (8.1% ->2.3%)

13. 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

14. 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

15. 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.

16. Public Health Workforce Challenges • Until last month, not one staff member at NCDC had a Master’s degree in Public Health • While US and others have made serious investment in public health training most return to work for NGOs • Challenges in intersectoral collaboration • Unequal distribution of public health workers with lack of professional staffing in rural centers and overstaffing in urban centers* • Poor coordination between district level public health programs and health facilities *Djibuti et al. Human resources for health challenges of public health system reform in Georgia; Human Resources for Health 2008

17. Positive trends in public health workforce • MPH programs being developed in Georgia with assistance of US and European institutions • New public health law passed in 2007 which defines MoLHSA role • Effective functioning of Country Coordinating Mechanism (CCM) to fight HIV/TB/Malaria • Recent appointment of US trained specialists to direct NCDC • Documented improvement in immunization delivery • Substantial and ongoing support for epidemiology and laboratory training by USG

18. 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?

19. 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

20. With thanks to: SUNY Downstate Medical Center (Brooklyn, NY) • David Odegaard, MPH • Dana Turner • Susan Holman, RN, MS University at Albany School of Public Health • Louise-Anne McNutt, PhD New York State Department of Health (Albany, NY) • Dale Morse, MD, MS Emory University (Atlanta, GA • Carlos del Rio, MD • Henry Blumberg, MD • J.L. Wold, PhD, RN Georgian National Centers for Disease Control • Maia Butsashvili, MD, MS Infectious Diseases, AIDS and Clinical Immunology Research Center • TengizTsertsvadze, MD, Ph.D.