What about health system strengthening and the internal brain drain?
Identifieur interne : 004402 ( Istex/Corpus ); précédent : 004401; suivant : 004403What about health system strengthening and the internal brain drain?
Auteurs : Elin C. Larsson ; Salla Atkins ; Mickey Chopra ; Anna Mia EkströmSource :
- Transactions of The Royal Society of Tropical Medicine and Hygiene [ 0035-9203 ] ; 2009-05.
Url:
DOI: 10.1016/j.trstmh.2008.12.015
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E-mail address: elin.larsson@ki.se</affiliation></author><author xml:id="author-0001"><persName><forename type="first">Salla</forename><surname>Atkins</surname></persName><affiliation>Division of International Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Sweden</affiliation><affiliation>Health Systems Research Unit, Medical Research Council of South Africa</affiliation></author><author xml:id="author-0002"><persName><forename type="first">Mickey</forename><surname>Chopra</surname></persName><affiliation>Health Systems Research Unit, Medical Research Council of South Africa</affiliation></author><author xml:id="author-0003"><persName><forename type="first">Anna Mia</forename><surname>Ekström</surname></persName><affiliation>Division of International Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Sweden</affiliation></author><idno type="istex">D0BBD219E7AE5D10C5278A78589492194F3C86B2</idno><idno type="ark">ark:/67375/HXZ-ZQ1GFHZ9-X</idno><idno type="DOI">10.1016/j.trstmh.2008.12.015</idno></analytic><monogr><title level="j">Transactions of The Royal Society of Tropical Medicine and Hygiene</title><title level="j" type="abbrev">Trans R Soc Trop Med Hyg</title><idno type="pISSN">0035-9203</idno><idno type="eISSN">1878-3503</idno><idno type="publisher-id">trstmh</idno><idno type="PublisherID-hwp">trstmh</idno><imprint><publisher>Royal Society of Tropical Medicine and Hygiene</publisher><date type="published" when="2009-05"></date><biblScope unit="volume">103</biblScope><biblScope unit="issue">5</biblScope><biblScope unit="page" from="533">533</biblScope><biblScope unit="page" to="534">534</biblScope></imprint></monogr></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>2009</date></creation></profileDesc><revisionDesc><change when="2009-05">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/document/D0BBD219E7AE5D10C5278A78589492194F3C86B2/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="corpus oup, element #text not found" wicri:toSee="no header"><istex:xmlDeclaration>version="1.0"</istex:xmlDeclaration><istex:docType PUBLIC="-//NLM//DTD Journal Publishing DTD v2.3 20070202//EN" URI="journalpublishing.dtd" name="istex:docType"></istex:docType><istex:document><article article-type="other">
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<issn pub-type="ppub">0035-9203</issn>
<issn pub-type="epub">1878-3503</issn>
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<subject>Correspondence</subject>
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</article-categories>
<title-group>
<article-title>What about health system strengthening and the internal brain drain?</article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author" corresp="yes">
<name><surname>Larsson</surname><given-names>Elin C.</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref><xref ref-type="corresp" rid="cor1"><sup>*</sup></xref>
</contrib>
<contrib contrib-type="author">
<name><surname>Atkins</surname><given-names>Salla</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref><xref ref-type="aff" rid="aff2"><sup>b</sup></xref>
</contrib>
<contrib contrib-type="author">
<name><surname>Chopra</surname><given-names>Mickey</given-names></name><xref ref-type="aff" rid="aff2"><sup>b</sup></xref>
</contrib>
<contrib contrib-type="author">
<name><surname>Ekström</surname><given-names>Anna Mia</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref>
</contrib>
<aff id="aff1">
<label>a</label>Division of International Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Sweden</aff>
<aff id="aff2">
<label>b</label>Health Systems Research Unit, Medical Research Council of South Africa</aff>
</contrib-group>
<author-notes>
<corresp id="cor1">
<label>*</label>Corresponding author. <italic>E-mail address</italic>: <email>elin.larsson@ki.se</email> (E.C. Larsson)</corresp>
</author-notes>
<pub-date pub-type="ppub">
<month>5</month>
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</pub-date>
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<issue>5</issue>
<fpage>533</fpage>
<lpage>534</lpage>
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<date date-type="received">
<day>14</day>
<month>12</month>
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<copyright-year>2009</copyright-year>
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<p>The article by Zachariah et al.<xref ref-type="bibr" rid="bib1"><sup>1</sup></xref> gave an interesting overview of the challenges and possible solutions to the shortage of human resources for health (HRH) in sub-Saharan Africa. We acknowledge the authors for bringing up the unintended, but well-known, harmful impact of sit-in allowances and for suggesting feasible ways of delegating tasks between staff categories. However, we feel that two important aspects were lacking; to what extent non-governmental organizations (NGOs), international research initiatives and multiple private providers contribute to internal brain drain, and the more general, but crucial, aspect of health system strengthening. How should these issues be addressed in low- and middle-income settings?<xref ref-type="bibr" rid="bib2"><sup>2</sup></xref></p>
<p>It is important to take into account the broader health system strengthening issues when considering the human resource crisis in sub-Saharan Africa. The WHO emphasizes health system strengthening and integration of care, rather than the vertical programme approach that many, especially NGOs, use for the provision of care. Health systems include service delivery, information, medical products, vaccines and technologies, financing systems, and leadership and governance, but when considering the health workforce only this also includes responsible stewardship, appropriate training and supervision of health workers, and ensuring integration and comprehensive implementation.<xref ref-type="bibr" rid="bib3"><sup>3</sup></xref> At the International AIDS Conference in Mexico City in August 2008, both the integration of HIV care into health systems as well as the strengthening of health systems were highlighted and described as key factors for controlling the HIV epidemic.<xref ref-type="bibr" rid="bib4"><sup>4</sup></xref></p>
<p>The HRH shortage in sub-Saharan Africa is a crisis, and requires different types of task shifting to create new cadres of mid-level health workers to ensure healthcare to those in need, as mentioned by the authors. We agree that the brain drain from the new cadres of HRH is less than from other HRH. However, when the authors discuss the challenges of motivation, retention and performance of HRH it is important to note that brain drain does not only concern movement from low-income to high-income countries. Internal brain drain within countries, often from the public sector to research, NGOs or the private sector, which offer salaries many times higher than the government, also has a large, if not larger, impact on the health system and HRH shortage in general.<xref ref-type="bibr" rid="bib2"><sup>2</sup></xref>,<xref ref-type="bibr" rid="bib5"><sup>5</sup></xref> Van Rensburg et al. note that in the Free State, South Africa 80% of new posts created by the antiretroviral programme were filled by nurses from other programmes in the same facility or from other facilities in the province.<xref ref-type="bibr" rid="bib5"><sup>5</sup></xref> It is unlikely that the pattern of movement in other sub-Saharan countries will be different when a new programme with a more attractive work environment and higher salaries is introduced. In order to start solving the issues around human resources for health and start evaluating the effectiveness of task shifting as a response, we need to consider human resources for health in relation to all aspects of the health system.</p>
<sec>
<title>Funding</title>
<p>None.</p>
</sec>
<sec>
<title>Conflicts of interest</title>
<p>None declared.</p>
</sec>
<sec>
<title>Ethical approval</title>
<p>Not required.</p>
</sec>
</body>
<back>
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