Human resources in health: an analysis of costs of training, certification requirements & migration issues in Belize

INTRODUCTION: The terms of reference required, inter alia, an analysis of the dynamics of the formation of health professionals in Belize, including available information on the immigration and emigration of these personnel into Belize and the resultant impact on HRH production, deployment, absorption, retention, performance and motivation. METHODS: To undertake the study, it was initially required to focus on the existing clinical science training institutions locally to obtain completion rates for health care professionals, the costs of training, the systems for certification of these professionals and issues regarding migration as a prime determinant of the existing stock of these health care professionals. Acknowledging that there are multiple categories of health care workers, the study focused mainly on nurses and doctors. The former are trained locally at the University of Belize in Belmopan, where after a four year course of study conservatively costing some $20,000 and sitting a regional examination, a student qualifies to practice as a nurse in Belize. Being a national university in receipt of a government subsidy that forms the single largest component of its budget, UB's student fees are deliberately maintained at below market costs. These costs exclude ancillary costs related to academia, such as boarding and lodging, which are substantially more market determined, and when included, costs are easily doubledthe various school fees. Doctors are not trained at UB, though Government does provide scholarships for locals to study medicine at the University of the West Indies, a regional institution also supported by GOB due to its membership in CARICOM. Globally, the market for health professionals is fluid, unregulated and largely undocumented, and Belize is impacted by its fluidity. Belizeans have a long history of emigrating mainly to the USA and while it is believed that health professionals have been among the migrants, there is a paucity of data in this regard. For these professionals immigrating into Belize though, a CSME Skills Certificate must be sought if the person is from any CSME country and if not, then a work permit must be sought. CONCLUSIONS: Most recent data from the Labour Department indicate that various categories of health professionals from as many as twelve countries spanning four continents are an integral component of Belize's existing health workforce. The reasons for the migration of health professionals continue to be many and varied, and there is an active and targeted recruitment programme in the USA. While the migration of these professionals must be regarded as a loss of much needed and scarce human resources in health, there are some positives. Capacity strengthening canoccur as the local health system can be enhanced by partnerships that contribute in specific areas, for example the DangrigaCancer Centre is owned and operated by a Belizean doctor who practices in the USA and occasionally brings fellow specialists to provide treatment services at minimal costs. Acknowledging though that health workers have an inherent right to migrate, the Government of Belize is advised to adopt the WHO's 2010 Code of Practice on the International Recruitment of Health Personnel. The Code of Practice seeks to regulate the migration of health personnel in a way that mitigates the damage to developing countries such as Belize. Other main recommendations focus on increasing the production of HRH. This can be accomplished via the provision of bursaries to students in these areas. Retention strategies are also required to provide pathways for these health professionals. Also being recommended is technical assistance to the Ministry of Health, the Belize Medical and Dental Council and the Nurses and Midwives Council to strengthen the regulatory framework so that they are all able to better keep abreast in tracking their members. At the present time, should a nurse or a doctor leave public employment, the Ministry of Health is not mandated to inform the respective council. Under a strengthened regulatory framework, this would be mandatory. Also mandatory would be the health professional informing in writing the respective council of any changes to his/her employment status or location of employment. This would greatly assist in tracking private doctors and nurses as they relocate to other areas of the country as well as if they migrate abroad. Finally, given Belize's focus on a primary health care model as the basis of its health care system, some consideration ought to be given to further strengthening of the Community Health Workers. These health volunteers are at the base of the local health system and are the most widely dispersed health worker. Consideration is justified because these unheralded workers are most unlikely to migrate since destination countries are selective in their recruitment efforts and exclusively require credentialed professionals as migrants. (AU)

Instrument N° 2. HRH Program Evaluation Questionnaire: Expanded version

This instrument serves as the core document for evaluation and description of the HRH program selected. In order to complete the information requested, use the documents, reports, evaluations, budgets and HRH data available for program evaluation. Attached is a sample (fictional) of a rural health physician program from Canada. This document should be completed by the Director of HRH or the equivalent person in the Health Authority who has access to national information and is in consultation with the national institutions. (AU)

Status report on indicators. 20 goals for a decade in HRH

The Terms of Reference required, inter alia, updating the 20 Regional Goals for Human Resources for Health. These 20 Regional Goals are indicators developed by PAHO to measure a country's progress in meeting the development of its health related human resources, since the development of human resources is particularly critical for health care delivery. The methodology involved detailed discussions with a broad variety of stakeholders since the majority of the goals have a qualitative component. A comparative few of the goals do feature a quantitative component, such as goals 1, 2 and 3, which seek to ascertain the ratio of physicians and health personnel per population. These 20 goals were first measured in Belize in 2009. This updated 2012 measurement found some areas of improvement since 2009 but also noted that there were some areas where there was regression. More specifically, improvements were noted in the areas of human resources density ratio, public health & intercultural competencies of PHC workers, the HRH Unit and public health & management competencies of health services and program managers, while regression was noted in the areas of qualified nurses to physician ratio, urban rural disparity in the distribution of health personnel, and the proportion of precarious employment among health services providers. While indicators are often necessary to measure progress and to facilitate comparison across countries, some lessons learnt are that a wholesale adoption of indicators sans localized modification may often not provide a true picture of on the ground realities. With specific reference to Belize, given its population density as one of the lowest in the region, major health facilities such as regional hospitals are geographically distant and rural populations are generally served via a series of health centers, health posts and mobile clinics. Hence while it may be ideal that health professionals recruited from rural communities serve those communities, the reality is that by these professionals remaining in the rural health facilities, their professional growth and development remains stunted due to the limited opportunities at a rural facility. It is also worthy to mention that no study has been done in Belize to ascertain the impact of employment status on staff morale vis-à-vis service delivery. Belize relies on contractual employment to legally secure the services of certain highly qualified health specialists. Given the indicator as currently defined in the Handbook, this is regarded as "precarious employment." The reality however is substantially different, and seeking modifications in their contractual status may not be feasible and would not necessarily translate to enhanced productivity. Other developments external to Belize are likely to impact Belize's human resources in health. In the United States of America, the passage of the Patient Protection and Affordable Care Act ­ more popularized as "Obamacare" in 2010 - and the requirement of universal coverage starting in 2014 will result in a huge demand for primary health care physicians in that country. Enhanced remuneration and what may be regarded as better employment prospects may orient Belize's health professionals towards migration, given that a certain percentage of Belize's workforce in health are nonnationals. This will likely aggravate the human resources deficits in health across the country. In preparing for this looming challenge, Belize may wish to consider upgrading the skills set of its Community Health Workers and the nurses who are first point of contact with the health system. This will be cost effective since training for these categories of health professionals is offered locally and it costs substantially less to train a CHW and a nurse, as opposed to a doctor. Via this approach, more effective and efficient use will also be made of the country's comparatively scarce primary health care physician and contribute towards the Ministry of Health's goal of Equal Health for All.

Health policy and eye care services in Jamaica

PURPOSE: To test the hypothesis that access to and amount of eye care services in Jamaica are inadequate and that this is related to insufficient eye care personnel and legal limitations on optometric practice in Jamaica. METHODS: An eye care provider survey, a consumer survey, and a literature search were used for data collection. The consumer sample consisted of 500 subjects (aged 16 to 84 years or older) recruited from a stratified random sample of food markets in Jamaica. The provider sample consisted of 10 opthalmologists and 10 optometrists, randomly selected from licensing rosters. Adequacy of amount of eye care services was measured by comparing the frequency of eye examinations in Jamaica with professinal practice guidelines. Access was measured by the eye provider to population ratio compared with calculated need for adequate care. RESULTS: Only 38.6 percent of the study population had received an eye examination within 3 years and only 23.4 percent reported having eye examinations at least once every 3 years. Over 43 percent had never received an eye examination. The total eye care provider/population ratio was only 2.04/100,000 and only 1.32/100,000 when optometrists are excluded. CONCLUSION: Access to and amount of eye care professionals services are severely inadequate in Jamaica. Outdated optometric laws governing the activities of eye care professionals compound the problem. (AU)

Medicine and its alternatives: health care priorities in the Caribbean

In the Caribbean as as in many other areas costly biomedical resources and personnel are limited, and more and more people are turning to alternative medicine and folk practitioners for health care. To meet the goal of providing health care for all, research on nonbiomedical therapies is needed, along with legal recognition of folk practitioners to establish standards of practice.(Au)

Community participation as seen by primary health care workers in the parish of St. Catherine, Jamaica

Primary health care workers in the parish of St. Catherine were studied over a six week period (February 2nd to March 18th) to access their knowledge, attitudes and perceptions towards community participation. The categories of workers in the sample were doctors; nurses; community health aides; dental staff; public health inspectors; pharmacist; others, comprising contact investigators, orderlies, nutritionist and laboratory technicians. A questionnaire instrument was administered among 13 health centres in zones 2 and 3 for a total of 80 workers. The majority of workers were female (85 percent), and the significant age distribution was between 20 years and 49 years. While most of the workers said they heard of community participation only 54 percent described their understanding of the concept as clear. There was clearer understanding of the concept among community health aides (CHA's) as compared to nurses. Overall the attitude of the workers towards community participation was high (66 percent). Most workers felt that health workers and communities should share decision-making, but only 54 percent of the workers studied thought that they had the skills needed for community participation. It is evident that there is potential for participation, but primary health care workers need the tools and the necessary skills to be effective in carrying out the bridging role between the health services and the community. There is need for training in community participation in primary health care; better utilization of the expertise of workers who have some training in community participation and more care in the choice of workers so that they work in the areas in which they live (AU)

Risks of HIV transmission to health care workers

A brief look at the risks of transmission of the HIV virus to health care workers and what preventative measures should be employed to lower these risks. The article mentions briefly the use of protective barriers and emphasizes the importance of the implementation of recommendations such as initial orientation and training about the epidemiology, modes of transmission and prevention of transmission of HIV and other blood borne infections. Provision of equipment and supplies necessary to minimize the risk of infection

Health For All by the Year 2000 and primary health care. How are we doing?

Twelve years after the historic Alma-Ata Conference and with ten years to go to the year 2000, this study looks at how these concepts have penetrated health and sectors impacting on health as well as knowledge of them by patients using the health services in the Counties of St. George West and Central in Trinidad and Tobago. Data collection was through questionnaires and interviews. Most of the workers had heard of the concepts but for most, this knowledge was described as hazy or incomplete. The majority of patients had never heard of Health For All by the Year 2000 (AU)

A proposed protocol and case report of the anaesthetic management of an HIV-positive patient

This report describes the anaesthetic mangement of an HIV-positive patient and proposes a protocol for the management that is suitable for the present working conditions in Jamaica (AU)

Caribbean Cooperation in health (CCH); Trinidad and Tobago. Meeting of Donors

Comments on the effect of the world economic crisis on the social sector in the Caribbean and the concern about the potential of long term effect on the health and other social sectors. The limited available resources devoted to services and the rising expectations of the population have emphasised the need to rationalize the use of scarce resources while attempting to satisfy basic health needs. Looks at the institutions within the Caribbean which will make for the success of the initiative. Outlines the seven priority areas around which the CCH was organised such as: environmental protection, human resources development, chronic diseases control and accidents prevention, strengthening of health systems, food and nutrition, maternal and child health and population and AIDS. Presents a brief review of the socio-economic situation in Trinidad and Tobago and gives an epidemiological analysis of the country. Discusses the general health status of the country, the birth and mortality rates, special health problems and communicable and non-communicable diseases. Presents an overview of the priority areas mentioned and outlines the policies, strategies, plans and programmes adopted by Trinidad and Tobago. Presents a project profile of each priority area in which the following are outlined: problem description, project objectives, project components, budget, associated institutions and duration(AU)

Pattern of health activity study

Activities performed by the staff of Edna Manly Health Centre, Kingston, Jamaica were studied (Summary)

Attitudes, practices and knowledge of health professionals on breast feeding in Kingston, Jamaica

In order to assess attitudes practices and knowledge of different categories of health professionals towards breast feeding, 30 doctors, 76 nurses and 22 community health aides (CHAs) answered a self-administered questionnaire. The results indicated that the health workers, in general, have positive views on breast feeding even though some practices interfering with breast feeding still continue. In contrast, knowledge about breast feeding physiology, management, and contraindications was generally poor, suggesting that training on the subject may not be adequate. Doctors had better knowledge than other health professionals, indicating that they are not sharing their knowledge with those who have closer contact with breast feeding mothers. Some actions are suggested to maintain the health workers' positive attitudes to breast feeding, and improve popular practices and knowledge. (AU)