this study was funded by human resources for health, world health organization (hqhrh0801824), and...

This study was funded by Human Resources for Health, World Health Organization (HQHRH0801824), and by the Global Center for Health Economics and Policy Research, a WHO/PAHO Collaborating Center on Health Workforce Economics Research, at the University of California, Berkeley.

Human Resources for Mental Health: Workforce Shortages in Lower and

Middle Income Countries

Richard M. Scheffler, Ph.D.University of California, Berkeley

Tim Bruckner, Ph.D.University of California, Irvine

Draft – Not for Distribution

Collaborators

World Health Organization

Shekhar Saxena, M.D.Programme Manager, Department of Mental Health and

Substance Abuse Coordinator, Evidence, Research and Action on Mental

and Brain Disorders

Mario Dal Poz, M.D., M.Sc., Ph.D.Coordinator, Information and Governance, Department of

Human Resources for Health

Dan Chisholm, Ph.D.Technical Officer, Costs, Effectiveness and Expenditure

and Priority Setting Unit, Department of Health Systems Financing

Jodi Morris, Ph.D.Technical Officer, Mental Health: Evidence and Research

Team, Department of Mental Health and Substance Abuse

University of California, Berkeley

Tim-Allen Bruckner, Ph.D.Assistant ProfessorProgram in Public HealthUniversity of California, Irvine

Jangho Yoon, Ph.D.Assistant Professor Health Policy and Management Jiann-Ping Hsu College of Public Health Georgia Southern University

Gordon Shen, M.Sc.Graduate StudentHealth Services and Policy Analysis Ph.D. ProgramUniversity of California, Berkeley

Brent D. Fulton, Ph.D.Assistant Research EconomistGlobal Center for Health Economics and Policy ResearchUniversity of California, Berkeley

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Learning Objectives

Understand the steps to estimate target workforce levels

Locate appropriate data sources to arrive at (1) the population in need and (2) target service delivery models

Identify the assumptions built into the models

Describe the magnitude of the mental health workforce shortage


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Presentation Outline

Introduction Methods and Data Results Discussion


Introduction

Mental health is critical to overall health

– Depression was the third leading cause of disability (based on DALYs) in 2004, ahead of heart disease and HIV/AIDS

An estimated 14% of the global burden of disease involves mental, neurological, and substance use (MNS) disorders

Costs – direct economic costs of mental healthcare – indirect economic costs of lost productivity, impaired functioning,

and premature death

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Treatment Gap

In low- and middle-income countries (LAMICs), 50-65% with mental disorders are not treated

LAMICs spend only 2% of the government health budget on mental health

Several reports have called on governments to scale-up the mental health workforce in LAMICs

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Workforce Research Questions

What is the needed number of mental health workers required to treat mental, neurological, and substance use (MNS) disorders in low- and middle-income countries (LAMICs)?

What is the supply of mental health workers in LAMICs?

What is the shortage of mental health workers in LAMICs?

How much are the wage bill costs to scale-up the mental health workforce in LAMICs?

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Method to estimate mental health workforce shortage by country

Needed number of mental health workers– Based on disorder prevalence, treatment rates,

and treatment modalitySupply

– Number of psychiatrists, nurses working in mental health settings, and psychosocial care providers

Shortage = Need – Supply

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Draft – Not for DistributionStep-by-step process to calculate persons with a mental disorder requiring treatment: epilepsy in Ethiopia

Step 1: Estimate prevalence

10.38 cases per 1,000 persons Source: WHO Global Burden of Disease, 2004

Step 2: Multiply prevalence by the population of adults

Step 3: Multiply number of persons by target coverage rate

438,057 X 80% coverage = 350,445

10.38 cases per 1,000 persons X 42million = 438,057 Source: United Nations Population Reference Bureau, 2008 Revision

Source: Ding D et al., Epilepsia. 2008 49(3):535-9.

350,445Target number of persons needing treatment


Notes on Population in Need

Population (not clinic) based prevalence

Population age structure important– ex: dementia is 1 of the 8 disorders covered

Target coverage depends on – severity of disorder – the ability to detect cases– probability cases will seek care

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Draft – Not for DistributionBaseline workforce need for mental health: epilepsy in Ethiopia

Step 4: Begin with persons needing treatment

350,445 persons

Step 5: Assign treatment models

Step 6: Calculate FTE needed per setting

= 991.15 outpatient FTEs

hospital outpatient services

Psychiatrists: 32Nurses: 334

Psychosocial care providers: 832

350,445 PHC outpatient services

(11 consults / day X 225 working days / yr)

2,453,115 outpatient visits / yr

87,611 bed-days / yr

= 208.72 beds (365 days in yr X 1.15 rotation factor)

Step 7: Assign staffing proportions based on setting needs

community residential inpatient services


Method to estimate needed number of mental health workers

Step 1: Estimate prevalence of the 8 priority MNS disorders by country

Step 2: Set treatment rate goals for each disorder– Depression (33%)– Schizophrenia, other psychotic disorders (80%)– Suicidal ideation (80%)– Epilepsy (80%)– Dementia (80%)– Disorders due to use of alcohol (25%)– Disorders due to use of illicit drugs (50%)– Mental disorders in children (20%)

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Method to estimate needed number of mental health workers (cont’d)

Step 3: Estimate needed treatment: number of outpatient visits and inpatient bed days – cost-effective interventions

Step 4: Estimate number of psychiatrists, nurses, and psychosocial workers needed to deliver treatment

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Example: estimate needed number of mental health workers required to treat epilepsy in Ethiopia

Epilepsy cases: 438,000 – Based on prevalence of 10.38 per 1,000

Epilepsy cases to treat: 350,000– Assumes 80% treatment rate

Treatment modalities– 100% use primary care outpatient services (4 visits/year)– 50% use hospital outpatient services (5 visits/year)– 5% use community residential inpatient services (5

bed-days/year)

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Example: estimate needed number of mental health workers required to treat epilepsy in Ethiopia (cont’d)

Worker productivity– 2,475 outpatient visits per worker per year (11

visits per day x 225 days)– inpatient beds: various ratios by specialty and setting

for example: 1 psychiatrist needed per 34.5 inpatient beds for residential care

Workers needed: 1,198– Psychiatrists/specialist: 32– Nurses: 334– Psychosocial care provider: 832

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Supply of Workers

WHO-AIMS– Assessment tool at all levels of organization

National, provincial, local, level

2005-2009: 58 LAMICs participated– Work closely with WHO to administer WHO-AIMS

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Ethiopia workforce results for 8 priority MNS disorders

Psychiatrists Nurses

Psychosocial Care

Providers TotalTotal

Need 772 7,335 7,948 16,054Supply 15 200 667 882 Shortage 757 7,135 7,281 15,173 Supply as percent of need 2% 3% 8% 5%

Per 100,000 populationNeed 1.02 9.69 10.50 21.22Supply 0.02 0.26 0.88 1.17 Shortage 1.00 9.43 9.62 20.05

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Data

MNS Prevalence– 2004 Global Burden of Disease Project– Comparative Risk Assessment (CRA)

Population– United Nations Population Database

Treatment modalities and number of workers per modality– Chisholm et al., 2007; Chisholm & WHO-CHOICE, 2005

Mental health workforce supply– 2005-2009 World Health Organization Assessment Instrument for Mental Health

Systems (WHO-AIMS) Version 2.2

Workforce wages– Occupational Wages around the World (OWW) Database

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Draft – Not for DistributionData Sources: search for Chisholm D or Lund C.

Step 4: Begin with persons needing treatment

Step 5: Assign treatment models

Step 6: Calculate FTE needed per setting

Step 7: Assign staffing proportions based on setting needs

Chisholm D et al., 2004. J Stud Alcohol 65: 782-93; Chisholm et al, 2004; Br J Psych 184: 393-403; Chisholm et al., 2007. Bull WHO 2008 Jul;86(7):542-51; Hyman et al., 2007. Mental Disorders. In Disease Control Priorities in Developing Countries pp. 605-25; Chisholm et al., Br J Psych 2007 v191, 528-35; (Lund et al., 2000. S African Med J 90:1019-24; Lund and Fleisher, 2006. Soc Psychiatry and Psychiatric Epidemiology 41:587-94

Source: Rispel, Price, and Cabral, 1996. Confronting Need and Affordability:

Guidelines for Primary Health Care Services in South Africa. Johannesburg: Centre for Health Policy.

Source: Chisholm D, Lund C, Saxena S. Br J Psychiatry. 2007 Dec;191:528-35.


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Supply represents 22% of need, resulting in a 282,000 worker shortage in 57 of 58 LAMICs

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Workers (thousands) Psychiatrists Nurses

Psychosocial Care

Providers TotalNeed 17 190 156 362Supply 4 48 29 81

Shortage 13 142 127 282Supply (% of need) 24% 25% 18% 22%

Totals may not add due to rounding.


Countries with the largest shortages

Country ShortageBangladesh 39,492 26 2%Nigeria 27,912 20 15%Vietnam 27,098 32 12%Philippines 22,871 27 11%Pakistan 18,261 11 83%Egypt 15,185 20 21%Ethiopia 15,173 20 5%Thailand 13,728 21 26%Sudan 8,692 22 4%Morocco 7,985 26 16%

Shortage per 100,000

population

Supply as a Percent of

Need

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A few caveats

Point estimates vs. confidence intervals (need for sensitivity analyses)

Specified target coverage level exerts strongest influence on staffing need

We assumed no transferability of staff across specialty (or across country)


Sensitivity Results

-50

-40

-30

-20

-10

0

10

20

30

40

50

Dif

fere

nce

bet

wee

n C

urr

ent

and

T

arg

et F

TE

(p

er 1

00,0

00 p

op

n)

Maximum FTE Shortage -32.4 -21.365 -40.319 -24.48 -32.119 -34.764 -30.825

Maximum FTE Surplus 37.43 44.163 33.729 41.134 37.496 35.196 38.922

Average FTE Difference -11.588 -4.37 -15.675 -7.5 -11.397 -13.61 -10.24

Baseline Coverage (1) Resource (1) Resource (2) Resource (3) Efficiency (1) Efficiency (2)


282,000 worker shortage grows to 1.4 million if include all MNS disorders and LAMICs

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0

200

400

600

800

1,000

1,200

1,400

58 LAMICs,8 MNS Disorders

58 LAMICs,All MNS Disorders


Workers (thousands)


Annual wage bill to remove shortages approaches $700 million (USD 2005)

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$0

$100

$200

$300

$400

$500

$600

$700

Psychiatrists Nurses PsychosocialCare Providers

Total

U.S. dollars (2005, millions)


Annual wage bill to remove shortages in countries with largest shortages

Country ShortageBangladesh 39,492 26 2% $54Nigeria 27,912 20 15% $66Vietnam 27,098 32 12% $43Philippines 22,871 27 11% $48Pakistan 18,261 11 83% $33Egypt 15,185 20 21% $35Ethiopia 15,173 20 5% $15Thailand 13,728 21 26% $80Sudan 8,692 22 4% $56Morocco 7,985 26 16% $25

Shortage per 100,000

population

Supply as a Percent of

Need

Wage Bill (millions,

$U.S. 2005)

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Annual wage bill to remove shortages for all MNS disorders in 144 LAMICs approaches $3.5 billion (USD 2005)

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$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

58 LAMICs,8 MNS Disorders



U.S. dollars (2005, millions)


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Discussion – Ways to Mitigate Shortage

Productivity improvements

Skill mix

Worker incentives, both monetary and non-monetary

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this study was funded by human resources for health, world health organization (hqhrh0801824), and...

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