Advanced Health Care Management Insights

International Health Care Management II Part 2.1-2 Steffen Fle a Institute of Health Care Management University of Greifswald 1

Supply of Health Services: Structure 1. Demand for Health Services 2. Supply of Health Services 1. Factors of Production 1. Buildings and Equipment 2. Staff 3. Problems of Donations 2. Spatial Structure of Supply 3. Levels of Care 4. Provider Portfolio 3. Health Care Systems and Reforms 2

2.1.2 Staff Medical Training in the USA High School: 12 Years 3

Medical Training in the USA Bachelor Studies (i.e. Human Biology): 4 Years High School: 12 Years 4

Medical Training in the USA Medical Studies (MD): 4 Years Bachelor Studies : 4 Years High School: 12 Years 5

Medical Training in the USA Specialist 4 Years Medical Studies (MD): 4 Years Bachelor Studies : 4 Years High School: 12 Years 6

Medical Training in the USA Specialist 4 Years PhD 3 Years Medical Studies (MD): 4 Years Bachelor Studies: 4 Years High School: 12 Years 7

Medical Training in Tanzania Time of Study (Years) Primary School: 7 Years 8

Medical Training in Tanzania Time of Study (Years) Secondary School (O-Level): 4 Years Primary School: 7 Years 9

Medical Training in Tanzania Time of Study (Years) 20 Secondary School (A-Level): 2 Years Secondary School (O-Level): 4 Years Primary School: 7 Years 10

Medical Training in Tanzania Time of Study (Years) Military Service Secondary School (A-Level): 2 Years Secondary School (O-Level): 4 Years Primary School: 7 Years 11

Medical Training in Tanzania Time of Study (Years) Medical Officer Studies: 6 Years Military Service Secondary School (A-Level): 2 Years Secondary School (O-Level): 4 Years Primary School: 7 Years 12

Medical Training in Tanzania Time of Study (Years) Medical Officer Studies: 6 Years Military Service Medical Assistant Training: 3 Years Secondary School (A-Level): 2 Years Secondary School (O-Level): 4 Years Primary School: 7 Years 13

Medical Training in Tanzania Time of Study (Years) Ass. Med. Off. 2 Years 20 Medical Officer Studies: 6 Years Professional Experience Medical Assistant Training: 3 Years Military Service Secondary School (A-Level): 2 Years 10 Secondary School (O-Level): 4 Years Primary School: 7 Years 14

Medical Training in Tanzania Time of Study (Years) Ass. Med. Off. 2 Years 20 Medical Officer Studies: 6 Years Professional Experience Military Service Medical Assistant Training: 3 Years Secondary School (A-Level): 2 Years 10 Secondary School (O-Level): 4 Years Rural Medical Aid: 3 Years Primary School: 7 Years 15

Medical Training in Tanzania Time of Study (Years) Ass. Med. Off. 2 Years 20 Medical Officer Studies: 6 Years Professional Experience MA-Training Military Service Medical Assistant Training: 3 Years Secondary School (A-Level): 2 Years Professional Experience Rural Medical Aid: 10 Secondary School (O-Level): 4 Years Rural Medical Aid: 3 Jahre 3 Years Primary School: 7 Years 16

Medical Training in Tanzania Time of Study (Years) Ass. Med. Off. 2 Years 20 Medical Officer Studies: 6 Years Professional Experience Professional Experience MA-Training Military Service Medical Assistant Training: 3 Years Secondary School (A-Level): 2 Years Professional Experience Rural Medical Aid: 3 Years 10 Secondary School (O-Level): 4 Years Primary School: 7 Years 17

Training in Nursing Care in the USA Length of study (years) 1 Training work bedside-nursing with supervision Practical Nurse hospital 18

Training in Nursing Care in the USA Length of study (years) 1 Training work bedside-nursing with supervision bedside nursing Practical Nurse hospital Diploma in Nursing 2 hospital 19

Training in Nursing Care in the USA Length of study (years) 1 Training work bedside-nursing with supervision bedside nursing Practical Nurse hospital Diploma in Nursing 2 hospital college + hospital Associate Degree 2 bedside nursing 20

Training in Nursing Care in the USA Length of study (years) 1 Training work bedside-nursing with supervision bedside nursing Practical Nurse hospital Diploma in Nursing 2 hospital college + hospital university or college + hospital Associate Degree 2 bedside nursing 4 (basic) or Diploma/ Assosciate +2 BA for Registered Nursing bedside nursing 21

Training in Nursing Care in the USA Length of study (years) 1 Training work bedside-nursing with supervision bedside nursing Practical Nurse hospital Diploma in Nursing 2 hospital college + hospital university or college + hospital university Associate Degree 2 bedside nursing 4 (basic) or Diploma/ Assosciate +2 BA+2 BA for Registered Nursing bedside nursing Master s Degree in Nursing specialist nurse 22

Training in Nursing Care in the USA Length of study (years) 1 Training work bedside-nursing with supervision bedside nursing Practical Nurse hospital Diploma in Nursing 2 hospital college + hospital university or college + hospital university Associate Degree 2 bedside nursing 4 (basic) or Diploma/ Assosciate +2 BA+2 BA for Registered Nursing bedside nursing Master s Degree in Nursing Doctoral Degree in Nursing specialist nurse BA + >3 university div. 23

Training in Nursing Care in Tanzania Time of Study (Years) 15 10 Primary School: 7 Years 24

Training in Nursing Care in Tanzania Time of Study (Years) 15 Secondary School (O-Level):4 Years 10 Primary School: 7 Years 25

Training in Nursing Care in Tanzania Time of Study (Years) Nursing Training A-Nurse: 4 Years 15 Secondary School (O-Level):4 Years 10 Primary School: 7 Years 26

Training in Nursing Care in Tanzania Time of Study (Years) Nursing Training A-Nurse: 4 Years 15 Secondary School (O-Level):4 Years 10 Pre-Nursing Course Primary School: 7 Years 27

Training in Nursing Care in Tanzania Time of Study (Years) Nursing Training A-Nurse: 4 Years 15 Nursing Training B-Nurse: 3 Y. Secondary School (O-Level):4 Years 10 Pre-Nursing Course Primary School: 7 Years 28

Training in Nursing Care in Tanzania Time of Study (Years) Nursing Training A-Nurse: 4 Years 15 Mid-Wifery 1 Y. Nursing Training B-Nurse: 3 Y. Secondary School (O-Level):4 Years 10 Pre-Nursing Course Primary School: 7 Years 29

Training in Nursing Care in Tanzania Time of Study (Years) A-Nurse 1 Y. Professional Experience Nursing Training A-Nurse: 4 Years 15 Midwifery 1 Y. Nursing Training B-Nurse: 3 Y. Secondary School (O-Level):4 Years 10 Pre-Nursing Course Primary School: 7 Years 30

Training in Nursing Care in Tanzania Time of Study (Years) A-Nurse 1 Y. Professional Experience Nursing Training A-Nurse: 4 Years 15 Nursing Assis- tants Midwifery 1 Y. Nursing Training B-Nurse: 3 Y. Secondary School (O-Level):4 Years 10 Pre-Nursing Course Primary School: 7 Years 31

Training in Nursing Care in Tanzania Time of Study (Years) A-Nurse 1 Y. Professional Experience Nursing Training A-Nurse: 4 Years 15 Nursing Assis- tants Nursing Atten- dants (semi- skilled) Midwifery 1 Y. Nursing Training B-Nurse: 3 Y. Secondary School (O-Level):4 Years 10 Pre-Nursing Course Primary School: 7 Years 32

Training in Nursing Care in Tanzania Time of Study (Years) A-Nurse 1 Y. Professional Experience Nursing Training A-Nurse: 4 Years 15 Nursing Assis- tants Nursing Atten- dants (semi- skilled) Midwifery 1 Y. Nursing Training B-Nurse: 3 Y. Secondary School (O-Level):4 Years 10 Pre-Nursing Course Primary School: 7 Years 33

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Staff Ratios: Physicians per 1,000 Inhabitants Latest available data (access 2014) http://www.who.int/gho/health_workforce/physicians_density/en/ 35

Country latest Country Niger South Sudan Malawi Liberia Tanzania Chad Benin Papua New Guinea Burundi Central African Republic Sierra Leone Eritrea Gambia, The Togo Mozambique Senegal Burkina Faso Congo, Rep. Ethiopia Zambia Rwanda Mali Cameroon Eswatini Uganda Kenya Cote d'Ivoire latest 0,0345 0,0374 0,0501 0,0510 0,0512 0,0611 0,0647 0,0661 0,0717 0,0718 0,0740 0,0821 0,0823 0,0827 0,0850 0,0881 0,0940 0,1037 0,1059 0,1168 0,1182 0,1286 0,1292 0,1422 0,1537 0,1565 0,1623 Italy Argentina Kazakhstan Netherlands Euro area Australia Iceland Czechia Bulgaria Denmark Switzerland Sweden Germany Spain Trinidad and Tobago Belarus Lithuania Finland Uruguay Norway Georgia Austria Portugal Greece Cuba 3,9477 4,0596 4,0712 4,0794 4,1249 4,1292 4,1416 4,1533 4,2071 4,2247 4,3804 4,4055 4,4348 4,4411 4,4760 4,5382 4,6268 4,6404 4,9398 5,0470 5,1085 5,2933 5,4837 6,3072 8,4199 Physicians per 1000 pop. 36 https://databank.worldbank.org/reports.aspx?source=world-development-indicators#

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Staff Ratios: Nurses and midwives per 1,000 Inhabitants Latest available data (access 2014) http://http://gamapserver.who.int/gho/interactive_charts/health_workforce/NursingMidwiferyDensity/atlas.html/ 38

Country Latest Country Chad Niger Central African Republic Madagascar Benin Equatorial Guinea South Sudan Cameroon Haiti Angola Mali Afghanistan Papua New Guinea Pakistan Mozambique Bangladesh Togo Senegal Tanzania Guinea Burundi Cote d'Ivoire Malawi Honduras Paraguay Sierra Leone Ethiopia latest Nurses/midwives per 1000 pop. 0,2029 0,2234 0,2561 0,2980 0,3029 0,3102 0,3395 0,3631 0,3977 0,4075 0,4408 0,4461 0,4529 0,4832 0,4849 0,4891 0,5071 0,5404 0,5672 0,5796 0,6487 0,6556 0,7090 0,7287 0,7387 0,7525 0,7844 Slovenia Denmark Canada High income Netherlands Belgium Post-demographic dividend New Zealand France Sweden Japan Luxembourg Ireland Australia Germany North America United States Iceland Switzerland Norway Finland 10,4570 10,5355 11,0730 11,2609 11,6429 11,7356 11,7739 11,7764 11,7833 11,8549 11,9480 12,1744 13,0118 13,1388 14,1887 15,2153 15,6850 16,7800 18,2605 18,4218 22,3080 39 https://databank.worldbank.org/reports.aspx?source=world-development-indicators#

Foreign Staff Reasons: Training in Foreign Country E.g. Germans studying medicine in Italy E.g. students from developing countries studying in former SU Collaboration in Countries in High Need E.g. German physicians in Scandinavia E.g. German physicians in UK s NHS Collaboration in Countries with a High Level of Income E.g. nurses from Eastern Europe in Germany E.g. Indian physician in USA E.g. Malawian physician in Sambia Problem: Brain Drain Collaboration for Charitable Reasons (E.g. development aid) 40

Cost of a Development Worker (Physician, 2 Year Period) Cost category Amount Preparation Orientation course 10,000 Language course English 10,000 Language course local language 5,000 Transport 15,000 Running Expenditure Gross salary 157,000 Tuition children 48,000 Insurances etc. 5,000 Repatriation allowance 18,000 Total cost 268,000 41

Cost of a Development Worker (cont.) Cost: 11,166 per months of service on the job. Salary of a local physician: < 500 p. month. Personnel in development assistance can only be justified when no adequate staff is available in the country no adequate staff can be obtained through south-south Accompanying training of local staff 42

Excursus: Internal Brain Drain High salary differentiation within one country Urban - rural Professions (e.g. nurse working as flight attendant) Employer International Health Partnerships Clinton Foundation, Global Fund, : salary = 3 * local average Status (e.g. physicians in administration) 43

Urban / Rural Distribution 44 http://www.who.int/gho/health_workforce/hrh_002.jpg?ua=1

Countries Showing a Deficit in Staff Source: World Health Report 2006, p. xviii 45

Supply of Health Services: Structure 1. Demand for Health Services 2. Supply of Health Services 1. Factors of Production 1. Buildings and Equipment 2. Staff 3. Problems of Donations 2. Spatial Structure of Supply 3. Levels of Care 4. Provider Portfolio 3. Health Care Systems and Reforms 46