Migration and Human Resources for Health:Migration and Human Resources for Health:From Awareness to ActionFrom Awareness to Action

Health Care SystemsHealth Care Systems

SRI LANKASRI LANKA

23-24 March 2006, Geneva

ILO/IOM/WHO

Dr. Sarath SamarageM.B.,B.S.,M.P.H.(USA), M.Sc., M.D.(Com.Med)

Director-Organisation Development, Ministry of Health, SRI LANKA.

OverviewOverview

• The current situation,

• The challenges and effects on the Sri Lankan health system and

• How the migration of health care workers is currently managed.

Sri LankaSri Lanka

Total Population 20.064 m (2004)

GDP per capita 947 USD (2003)

GDP per capita (PPP US$) 4,300

Human Development Index (HDI) 0.74

Sri Lanka is ranked 93rd in the 2005 Human Development Report,with an HDI value of 0.751.

Net Migration Rate -1.27 migrant(s)/1,000 pop

•• Life expectancy at birth (years) Life expectancy at birth (years) 7373•• Adult literacy rate Adult literacy rate 92.392.3•• Infant Mortality Rate 14.35 / 1000 LBInfant Mortality Rate 14.35 / 1000 LB• Hospital beds: 3.6 per 1,000 persons• Doctors: 2,300 persons per doctor• Nurses: 12.1 per 10,000 persons

Sri LankaSri Lanka

ProblemsProblems•• MalnutritionMalnutrition•• rapid increase in rapid increase in noncommunicablenoncommunicable

diseasesdiseases•• violence and injuries (intentional and violence and injuries (intentional and

unintentional)unintentional)•• malaria, TB, dengue and malaria, TB, dengue and filariasisfilariasis•• the abovethe above--mentioned problems are mentioned problems are

compounded for the poor population, with compounded for the poor population, with an estimated 25% of the population below an estimated 25% of the population below the the ‘‘nationalnational’’ poverty line and 7% on less poverty line and 7% on less than one dollar/day.than one dollar/day.

8.0 6.0 4.0 2.0 0.0 2.0 4.0 6.0 8.0

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

Over 75

Age

grou

p (y

ears

)

Percentage of population

Male Female

Age Pyramid 1981 and 2001

8.0 6.0 4.0 2.0 0.0 2.0 4.0 6.0 8.0

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

Over 75

Age

gro

up (y

ears

)

Percentage of population

Male Female

3.1

3.3

3.8

3.9

4.0

5.6

6.3

6.4

9.7

14.5

0 2 4 6 8 10 12 14 16

Diseases of the sk in and subcutaneous tissue

Diseases of the m usculoskele tal system and connective tissue

Diseases of the urinary system

Intestinal infectious diseases

Direct and indirect obstetric causes

Diseases of the gastro-intestinal tract

Sym ptom s, s igns and abnorm al clinical and laboratory findings

Viral diseases

Diseases of the respiratory system excluding diseases of upper respiratory tract, pneum onia and influenza

Traum atic injuries

Percentage

Ten Leading Causes of Hospitalization - 2002

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

1965 1970 1975 1980 1985 1990 1995 1998 1999 2000 2001 2002

Year

New

Cas

es o

f TB

0

10

20

30

40

50

60

70

Rat

e pe

r 100

,000

pop

ulat

ion

New Cases Rate

New Cases of Tuberculosis 1965 - 2002TB Cases per 100,000 Population

0 - 20

20 - 40

40 - 60

60 - 80

80 - 100

Legend

Ampara

Anuradhapura

Moneragala

Kurunegala

Badulla

Puttalam

Ratnapura

Matale

Galle

Kandy

Polonnaruwa

Mullaitivu

Mannar

Batticaloa

Kegalle

Hambantota

Trincomalee

Kalutara

Matara

GampahaNuwara

Eliya

Kilinochchi

Jaffna

Colombo

37.6

26.6

47.6

50.7

48.1

52.3

21.5

27.8

36.5

30.0

22.1

36.3

44.4

43.0

14.8

20.9

64.2

43.3

39.2

38.4

28.4

25.4

70.5

19.0

84.6Vavuniya

New Cases of Tuberculosis by District - 2002

0.0

1.6

2.1

8.5

9.9

10.7

10.7

15.4

34.7

42.5

46.8

51.9

138.4

165.6

181.8

184.2

184.7

187.7

258.1

263.2

349.0

571.9

1307.9

4802.9

9094.0

421.6

0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

Galle

Nuwara-Eliya

Colombo

Gampaha

Kalutara

Kandy

Matara

Kegalle

Badulla

Mannar

Matale

Puttalam

Trincomalee

Ratnapura

Jaffna

Kurunegala

Moneragala

Hambantota

Ampara

Polonnaruwa

Anuradhapura

Sri Lanka

Vavuniya

Batticaloa

Mullaitivu

Kilinochchi

Incidence per 100 000 population

Ampara

Anuradhapura

Moneragala

Kurunegala

Badulla

Puttalam

Galle

Ratnapura

Matale

Kandy

Mullaitivu

Polonnaruwa

Mannar

Batticaloa

Kegalle

Hambantota

Vavuniya

Trincomalee

Kalutara

Matara

GampahaNuwara

Eliya

Kilinochchi

Jaffna

Colombo

349

185

184

258

52 263

35

166

188

138

4803

47

1308

10

42

2

11

572

158

11

9094

2

182

0

Incidence per 10,000 population0

1 - 500

501 - 1000

1001 - 2000

2001 - 4000

> 4000

Legend

Malaria Incidence by District - 2002

Sri Lanka Disaster Prone Areas

IDP Population by District as at 30 September 2004

Health Facilities Destroyed by TsunamiHealth Facilities Destroyed by Tsunami

SECTORSSECTORS

++OthersOthers

++++IndigenousIndigenous

++++WesternWestern

PrivatePrivateGovernmentGovernment

0

0.5

1

1.5

2

2.5

1940 1943 1946 1949 1952 1955 1958 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000

Year

% S

hare

of G

DP

M OH Health Share of GDP Nominal (R+C) Exp.

* MOH Health Expenditure combines Recurrent & Capital Expenditures , 2003 is based on Estimates

Figure 01

Sri Lanka MOH Health Expenditure Share of GDP, 1939 to 2003

0.00

1.00

2.00

3.00

4.00

5.00

6.0019

73

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

Y earHealth Share of Nominal GDP Educat ion Share of Nominal GDPDefense Share of Nominal GDP

Trends in Sri Lanka Public Expenditure Shares of GDPfor Health, Education and Defence, 1972-2003

Figure 02

49%44%

4%

1% 2%

Taxes

Employers

Out of pocket

Insurance

NGOs

Who Pays?

Source: Annual Health Accounts, Ministry of Health 2002

Human ResourcesHuman Resources

•• Policy & PlanningPolicy & Planning

Human Resource StrategyHuman Resource Strategy•• There have been several initiatives to develop There have been several initiatives to develop

human resources for health. human resources for health.

•• In the 60s, a task force set up by the Ministry In the 60s, a task force set up by the Ministry of Health designed a national health plan. of Health designed a national health plan.

•• In 1975, a health manpower study was In 1975, a health manpower study was undertaken. undertaken.

•• In the late 1970s and early 1980s, two In the late 1970s and early 1980s, two studies, one on cadre determination of all studies, one on cadre determination of all medical, nursing and paramedical personnel medical, nursing and paramedical personnel (Report of staffing study 1981) and the other (Report of staffing study 1981) and the other on nursing (1977), were undertaken. on nursing (1977), were undertaken.

•• In 1992, a National Health Policy was In 1992, a National Health Policy was initiated. initiated.

•• In 1993, a study was undertaken by the Human In 1993, a study was undertaken by the Human Resource Development Council on Human Resource Development Council on Human Resource Development in the Health Sector.Resource Development in the Health Sector.

•• In 1994, a Perspective Plan for Health In 1994, a Perspective Plan for Health Development in Sri Lanka (1995Development in Sri Lanka (1995--2004) was 2004) was formulated. Their impacts on policy and the formulated. Their impacts on policy and the implemented plan on Human Resource implemented plan on Human Resource Development are not known. Development are not known.

•• The 1993 study found that health manpower The 1993 study found that health manpower planning in Sri Lanka has been episodic and, to a planning in Sri Lanka has been episodic and, to a large extent, limited in scope; health manpower large extent, limited in scope; health manpower development in the private sector has not been development in the private sector has not been given due consideration and the demand pattern given due consideration and the demand pattern for services and the technological changes have for services and the technological changes have not been taken into account.not been taken into account.

•• In addition, there have been some studies that In addition, there have been some studies that examined issues of human resource policy and examined issues of human resource policy and management in the public sector health system, such management in the public sector health system, such as the as the

•• draft Strategic Human Resource Plan 1999draft Strategic Human Resource Plan 1999--2009 and 2009 and

•• the Health Manpower Development Plan for Sri Lanka the Health Manpower Development Plan for Sri Lanka 19971997--2006. In the Health Manpower Development 2006. In the Health Manpower Development Plan 1997Plan 1997--2006 for Sri Lanka report, recommended 2006 for Sri Lanka report, recommended actions for health manpower plan precisely described actions for health manpower plan precisely described what should be done in the area of HRD policy what should be done in the area of HRD policy formulation and plan formulation, production, formulation and plan formulation, production, manpower management and others; however, none of manpower management and others; however, none of them have been implemented.them have been implemented.

Human Resource Strategy Human Resource Strategy contdcontd……

Strategic Framework for Health DevelopmentStrategic Framework for Health Development

Improve Health Services Delivery and Health Actions

StrengthenStewardship

& Management

Functions

ImproveHuman

Resource Development

&Management

Improve HealthFinancing,Resource Allocation

and Utilization

Strengthen individual, household and community actions for health

Health WorkforceHealth Workforce

•• 276 categories of health personnel in 276 categories of health personnel in public sector in Sri Lanka. public sector in Sri Lanka.

•• 21 categories within paramedical 21 categories within paramedical

Cadre Projection of Key Health Personnel in 2010 (Public Sector)

223.8%472168Food and Drugs Inspectors

224.8%7873501,137School Dental Therapists

487.5%39847Radiotherapists

0%044Opthologist

120.0%1,0148451,859Field Assistants

51.4%4248251,249Dispensers

300.0%12416Perfusionists

-15015Audiology Scientist

250.0%10542147Health Education Officers

147.4%8457141Ophthalmic Technologists

72.7%81119Dental Technician

246.0%15563218Entomology Assistants

151.5%397262659Public Health Nursing Sisters

1,450.0%29231Speech Therapists

336.8%641983EEG Recordist

-9610961Community Health Nurses

263.3%345131476ECG Recordist

167.4%1,7981,0742,872Public Health Inspectors

747.7%32944373Occupational Therapists

562.9%1,1542051,359Physiotherapists

345.8%2,5697433,312Medical Laboratory Technologists

323.8%2,6138073,420Pharmacists

241.0%653271924Radiographers

282.7%8483001,148Microscopists

100.4%7,4437,40914,852Public Health Midwives

258.9%34,27713,24047,517Nursing Officers

124.0%.89867,24816,234Medical Officers

Growth rateBalanceExisting in 1999

Cadre in 2010Categories

Source: Department of Health Services

Private SectorPrivate Sector Human Resources in Private Hospitals (a)

51,6231,550Other (labourers etc)

6475450Administrative staff

6526495Technical staff

52,6242,4953. Other staff

0748749Attendants

5563535Trainees

41,4071,356Qualified

41,9701,891Nurses

32,7182,6402. Nursing staff

5117111Part-time

7906847Visiting

6193182Permanent

71,2161,1401. Doctors

Change (%)2001(b)2000

Note: (a) Based on information reported by 34 private hospitals located in the Western Province (22), Southern Province (6), Central Province (2), North Western Province (2), Eastern Province (1) and Uva Province (1).

(b) ProvisionalSource: Central Bank of Sri Lanka Annual Report – 2001

Number of Physicians Registered under the Ayurvedic Medical Council, Sri Lanka.

16,13016,221Total 1 + 2

6,4916,646Total (2 specialists)

658676Others

767Vidum Pilissum (Burning andpenetrating skin with special tools)

259262Skin

8384Mental

159166Rabies

482499Boils and Carbuncles

3530Burns

561573Ophthalmology

1,4151,420Fractures & dislocations

2,8322,869Snake Bites

Special Traditional Physicians

9,6399,575Total (1)

526486Diploma in Ayurveda Shastri

3,6023,607Diploma Holders

9789BUMS

209189BSMS

395349BAMS

4,7074,855Traditional (General) Graduates

As of 31st Dec. 2001As of 31st Dec. 2000

Notes: BAMS – Bachelor of Ayurvedic Medical Science; BSMS – Bachelor of Siddha Medical Science; BUMS – Bachelor of Unani Medical Science.

Human Resource Planning & Human Resource Planning & Information SystemInformation System

•• One of the big issues in human resources is that One of the big issues in human resources is that there is there is no overall human resources policy and no overall human resources policy and development plandevelopment plan existing in this country mainly existing in this country mainly due to a lack of an due to a lack of an organisationorganisation at the national at the national level to take the initiative and the lead. level to take the initiative and the lead.

•• the absence of a central the absence of a central human resources unit human resources unit or departmentor department or or

•• that of a durable mechanism to link functions of that of a durable mechanism to link functions of several units within the Ministry might serve as a several units within the Ministry might serve as a handicap because handicap because decisiondecision--making might be making might be segmented. segmented.

•• M.I.S. M.I.S. being developedbeing developed

Cadre VacanciesCadre Vacancies

•• Medical Officers Medical Officers –– Limiting factor cadre Limiting factor cadre creationcreation

•• Nurses & ParaNurses & Para--medics medics –– Problems of Problems of productionproduction

Staff LossStaff Loss

•• International migration International migration ++•• MovtMovt. to other sectors . to other sectors •• Internal migration Pub. Internal migration Pub. PrvtPrvt ++•• Internal migration Internal migration RurRur. Urban . Urban ++++++•• Attrition for other reason Attrition for other reason ++

Ampara

Anuradhapura

Moneragala

Kurunegala

Badulla

Puttalam

Ratnapura

Matale

Galle

Kandy

Polonnaruwa

Mullaitivu

Mannar

Batticaloa

Kegalle

Vavuniya

Hambantota

Trincomalee

Kalutara

Matara

GampahaNuwara

Eliya

Kilinochchi

Jaffna

Colombo

53.2

26.9

30.1

19.0

53.7

32.9

30.6

38.0

26.3

23.6

21.3

45.8

25.3

95.1

13.3

17.7

30.9

38.5

57.1

33.8

35.5

2.2

113.1

23.5

Medical Offcers0

1 - 25

25 - 35

35 - 55

55 - 115

Legend

Distribution of Medical Officers - 2002

Note : The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptanceby the United Nations.

Source : Annual Health Bulletin 2002 Department of Health Services - Sri Lanka

Ampara

Anuradhapura

Moneragala

Kurunegala

Badulla

Puttalam

Ratnapura

Galle

Matale

Kandy

Mullaitivu

Polonnaruwa

Mannar

Batticaloa

Kegalle

Vavuniya

Hambantota

Trincomalee

Kalutara

Matara

GampahaNuwara

Eliya

Kilinochchi

Jaffna

Colombo

128.4

47.9

81.5

34.2

55.1

68.0

45.0

80.6

38.8

44.4

65.9

66.1

49.337.8

28.4

151.8

66.7

55.5

109.4

54.2

68.6

8.2

172.1

60.7

Distribution of Nurses - 2002

Nurses per 100,000 population0

1 - 50

50 - 100

100 - 150

150 - 200

Legend

Source : Annual Health Bulletin 2002 Department of Health Services - Sri Lanka

Note : The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptanceby the United Nations.

StudiesStudies

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

ColomboGampaha

Kalutara

Kandy

Matale

Nuw ara Eliy a

Galle

Matara

Hambantota

Jaffna

Kiliinochchi

MannarVav unijaMullaitiv u

Batticaloa

Ampara

Trincomalee

Kurunegala

Puttalam

Anuradhapura

Polonnaruw a

Badulla

Moneragala

RatnapuraKegalle

Nurses

Medical Off icers

Midw ives

Other Paramedics

Distribution of Health Personnel by District (per 100,000 population)Source: Department of Health Services (2001) Annual Health Bulletin 2000

Distribution of Health Personnel by District Distribution of Health Personnel by District (per 100,000 population)(per 100,000 population)

•• Source: Department of Health Services (2001) Annual Health BulleSource: Department of Health Services (2001) Annual Health Bulletin 2000tin 2000

0.0 50.0 100.0 150.0 200.0 250.0 300.0 350.0

Jaffna

Kiliinochchi

Mannar

Vavunija

Mullaitivu

Batticaloa

Ampara

Trincomalee

Kurunegala

Puttalam

Anuradhapura

Polonnaruw a

Badulla

Moneragala

Ratnapura

Kegalle

Galle

Matara

Hambantota

Kandy

Matale

Nuw ara Eliya

Colombo

Gampaha

Kalutara

(Per 100,000 persons)

Medical Officer Nurse Midwife Specialist

North & East Province

North Western Province

North Central Province

Uva Province

Sabaragamuwa Province

Southern Province

Central Province

Western Province

Current Problems in Human Current Problems in Human Resources ManagementResources Management•• The Working Group on Human Resources for the The Working Group on Human Resources for the

MoHMoH--JICA Study identified the key managerial JICA Study identified the key managerial problems as follows:problems as follows:

•• Insufficient quality control caused by:Insufficient quality control caused by:•• Lack of specialists adapted to the change of Lack of specialists adapted to the change of

disease patterndisease pattern•• Low responsiveness to patients caused by workLow responsiveness to patients caused by work--

load, concentration in certain facilities, partload, concentration in certain facilities, part--time time working after duty hoursworking after duty hours

•• Increasing underIncreasing under--trained intern stafftrained intern staff

•• Unsystematic continuing trainingUnsystematic continuing training•• Low motivation in government facilities due to Low motivation in government facilities due to

partpart--time working after duty hourstime working after duty hours•• Lack of Monitoring and Evaluation, lack of Lack of Monitoring and Evaluation, lack of

performanceperformance--based wage systembased wage system•• Brain drain overseas due to low compensation, Brain drain overseas due to low compensation,

low incentives, and (only for doctors) shortage of low incentives, and (only for doctors) shortage of good postsgood posts

•• Mismanagement of personnel / concentration in Mismanagement of personnel / concentration in urban area due to lack of incentive for work in urban area due to lack of incentive for work in rural areas, proportional distribution not rural areas, proportional distribution not according to disease pattern / care needs.according to disease pattern / care needs.

Current Problems in Human Current Problems in Human Resources Management (2)Resources Management (2)

•• Low social status of paramedical/coLow social status of paramedical/co--medical personnelmedical personnel

•• Low management / planning ability of Low management / planning ability of health service sections at local levelhealth service sections at local level

•• Insufficient devolution, e.g., deployment Insufficient devolution, e.g., deployment of doctors by central of doctors by central MoHMoH

•• Lack of planning skill due to shortage of Lack of planning skill due to shortage of experience in the pastexperience in the past

•• Discretionary administration due to Discretionary administration due to budgetary constraintsbudgetary constraints

Current Problems in Human Current Problems in Human Resources Management (3)Resources Management (3)

Recruitment from outsideRecruitment from outside

•• Medical OfficersMedical Officers–– NEP (Conflict areas) INGONEP (Conflict areas) INGO–– Private Sector Private Sector ––Nurses from IndiaNurses from India

•• Registration at the SLMC is essential Registration at the SLMC is essential

MIGRATIONMIGRATION

External MigrationExternal Migration

•• Medical Officers Medical Officers –– UK, Australia, USAUK, Australia, USA•• Nurses Nurses –– UK, MUK, M--EE•• Other categories Other categories –– no ext. migrationno ext. migration

Table 6. : The training programmes with highest percentage losses of postgraduate trainees who qualified MD/MS from 1997 to 2000.

56503728292834

PsychiatryDental SurgeryAnaesthesiologyMedicineMicrobiologyPaediatricsSurgery

Percentage of postgraduates migrated

Training Programme

14816%

78384%

Left the country after boardcertificationServing in Sri Lanka

Fig. 4 percentage of board certified specialists migrated during 1993-2004

Rationalization of human Rationalization of human resource developmentresource development

The issue of migration of health care The issue of migration of health care workers has been a very relevant issue workers has been a very relevant issue for Sri Lankafor Sri Lanka

•• The Hon. Minister of Health of Sri Lanka in The Hon. Minister of Health of Sri Lanka in his address to the World Health Assembly his address to the World Health Assembly in May 2005 raised this issue.in May 2005 raised this issue.

“ Sri Lanka is a country that has seen the adverse effects of the health sector” brain drain”, and we still witness many of our exceedingly talented, best qualified doctors and nurses taking wing to the developed world. I would like to propose to this august Assembly that we collectively develop a set of guiding principles for management of migration of health personnel, and to obtain some compensatory payment for developing countries. Mr. Director General, I would recommend this for your kind consideration as a useful and practical project under next year’s WHO theme of Human Resource Development”Hon.Nimal Siripala De Silva, WHA 2004