Human Resources for Health

Human Resources for Health

A Worldwide Crisis

Thomas L. Hall, MD, DrPH Nicole Bores

Univ. of California at San Francisco September 2007

Prepared as part of an education project of the Global Health Education Consortium

Learning objectives

1. Appreciate the importance of the health workforce 2. Understand factors affecting workforce supply and

requirements, and basic methods for their estimation 3. Learn about the variables affecting workforce

distribution and interventions to improve distribution 4. Appreciate management issues that contribute to the

workforce crisis

5. Recognize difficulties in estimating supply,

requirements, and in making workforce changes

6. Understand changing health workforce priorities, and the implications for the future

Frequently used Terms

• Human Resources Development (HRD)

encompasses the planning, training and

management of the health workforce

• Human Resources for Health (HRH) replaces the

earlier term “Health Manpower”

HRH Category ​ Type of Health Workers​ Educational Preparation​ Skills and Tasks​

Researchers, Teachers​ Faculty members, lecturers, laboratoy researchers, pharmaceutical developers​

Post-basic university (Masters, PhD)​

Developing new knowledge, preparing health professionlas and others for entry to the workforce, working with policy makers to implement new knowledge into policy and practice​

Health Professionals ​ Doctors, nurses, dentists, pharmacists, psychologists, physician's assistants​

Tertiary (professional college, university) ​

Diagnosis and treatment of illness, hospital and community care, promotion of health, education about health, dispensing and supervision of medication, public health, monitoring and improvemnet, maternal and child care, mental health and emotional care and support​

Vocational Workforce​ Nursing aids, dental aides, theatre technicians, laboratory technicians, medical

assistants​

Secondary school, college​ Home based care, assisting health professionals, education and support for individuals, families, and communities, technical support​

Traditional Healers​ Curanderas, Shamans​ Varied​ Healing, counseling, use of traditional and natural medicines​

Community Level Workers​

Village health workers, Community health workers​

On the job local training, primary/secondary school ​

Home based care, managment of simple family health problems, sanitation, environmental health, health education and promotion, supervision of daily medication routines​

Informal Workers​ Volunteers, home caregivers (family and non-family)​

Non specific to caring role, informal education and support from health workers ​

Practical care for sick family or community members, supervision of daily medication routines,transporting inddividuals in clinics and hospitals, emotional support, community health promotion ​

Non-Health Workforce in Health Sector​

Drivers, accountants, managers​

Varied​ Many skills to support health workforce​

Why is the health workforce important?

• The workforce is the primary determinant of health system effectiveness. There is….

– No substitute for trained personnel applying skills appropriately, at the right time, in the right place, to address priority national health needs

– Ample evidence of a positive association between

worker quality and numbers with immunization levels,

Why is the health workforce important?

• Health workers are most costly component of health system – Personnel are 50-80% of recurrent public health sector

budget

• As % spent on staff increases, less money is available for drugs, equipment, supplies, etc.

• Managers can delay purchase of drugs, supplies and equipment but can’t delay salaries

Why is the health workforce important?

• In sum, the health workforce…..

– Spearheads and glues together the health system

– Drives health status changes essential for development

Health workforce priorities since 1945*

• Worldwide priorities, as reflected by WHO policies and programs and by efforts in

developing countries, have undergone major changes over the decades, by turns putting emphasis on different qualitative, quantitative and distributional aspects of the health

workforce

Health workforce priorities since 1945

• Increase numbers (1940s – ’60s)

• Attain international quality standards (1950s – ’60s) • Match or exceed HRH ratios of peer countries (1960s) • Expand use of multi-purpose auxiliary personnel (1970s) • Improve geographic coverage (1970s – ’80s)

• Increase training efficiency (1970s – ’80s)

• Strive for more rational HRH planning (1980s – 90s) • Increase training relevance to national needs (1990s) • Increase numbers (and relevance) (2000s…)

Components of an effective workforce

• An effective health workforce is characterized by having: – the ‘right’ number of health workers

– in the ‘right’ mix of different worker categories – with the ‘right’ training

– in the ‘right’ places – at the ‘right’ time

– providing the ‘right’ and ‘effective’ services – to the people who need them

– at an affordable cost

• Creating a workforce that meet these characteristics is extremely difficult, as the rest of this module will show.

Working lifespan approach to

workforce dynamics

*Unless otherwise noted the tables and figures are from ”Working together for health:

Entry::

Preparing the Workforce

Planning Education

Recruitment _{Enhancing worker} Workforce:

performance Supervision Compensation Systems support Lifelong learning Exit: Managing attrition Migration Career choice Health and safety

Retirement

Availability Competence Responsiveness

Projecting the supply of health personnel

– Base year active* health worker supply, plus…

– Annual new graduates, plus…

– Annual flow of health workers into country, minus…

– Annual flow of health workers out of country,

minus…

– Losses to base year active health worker supply and to new graduates, equals…

• Target year active supply

Supply projection problems

• However, calculating the projected supply can be complicated

– Determining data inputs (numbers, ages, work locations, etc.) are relatively easy to obtain and accurate (at least in industrialized countries). – Determining data outputs (ie, projections),

however, even using the same base year, input data and target year, can result in wide variations in projections of the effective workforce

Supply projection problems

• Supply projections are subject to important uncertainties.

• Projected work hours or FTEs (full-time equivalents) vary due to….

– Age at retirement

– Rates of in- and out-migration of personnel – Gender ratios: Women work less…

• Weeks/year, hours/day, years/career

– Hours worked, by age (as age increases hours worked per year decrease)

– Hours worked by specialty – Patients seen per hour

World supply of health workers varies widely

– Different training intakes

• Wide variation in school numbers and capacities – Different graduation rates

• Up to 50% attrition of students during course of studies – Different retention rates in service due to:

• Early retirement (before reaching pensionable age) • Change of occupations (outside of health sector)

• Early pensionable age of retirement (55-67 years, with average of 58 in Africa and 55 in SE Asia)

World supply of health workers varies widely

• In most countries there is a gross under-production of health workers

– Too much emphasis placed on training high status, high income occupations, leading to shortages of technical and support staff

– Severe faculty shortages limits training opportunities – Much training is didactic, rote learning with limited

hands-on clinical and field experience, leading to a poorly qualified health workers

Projected declining supply of health

workers in Africa based on current trends

50,000 100,000 150,000 200,000 250,000 300,000 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4 201 5 Number s Years

Physicians Nurses/Midw Prof

Projected declining supply of health workers in Africa based on current trends

Regional disparities in the numbers of medical schools and of their graduates

Global Health workforce, by density

Case study

A Latin American country in the mid-1960s had 5000 practicing physicians, many under-employed despite very inadequate health

services for most of the population. At the five medical schools, 20% of recent graduates found no employment. The rate of doctor emigration was high due to the over-supply of doctors relative to the country’s

economic capacity to support them. In addition, 5000 students from this country were studying medicine abroad and likely to return on

graduation. Despite an evident doctor surplus three new medical schools were opened, in part to give faculty jobs to under-employed doctors.

*T.L. Hall, personal observation

A doctor ‘surplus’ in the face of severe national

‘need’ for health care*

Requirements: The basics

• Supply and requirements are two sides of the same coin; one without the other is of little use for planning

• Central problem – to convert the projected population to the required (and affordable) personnel

• Four ‘conversion’ methods

– Ratio method: directly converts population into personnel – Other methods converts population into services, and then

services into personnel using FTE (full-time equivalent) productivity norms

• Eg, if 20 million doctor visits are ‘required’, and if the average FTE doctor produces 6000 visits/year, then 3333 FTE doctors are ‘required’ for that component of service requirement (20M ÷ 6000 = 3333)

Projecting requirements: Four methods

• Ratio method (population-to-personnel, eg, 1 doctor per 1000 population, 1 nurse per 500 population)

• Needs method (for health services based on professional judgments, eg, GMENAC* study in US in late 1970s for >30 occupations; an elegant but costly and complex) study that had little effect on policy

• Demands method (for health services based on self-perceived needs, access to services & ability to pay)

• Targets method (for production of services to meet specified targets based on both ‘needs’ and ‘demands’)

*Graduate Medical Education National Advisory Council

The next 3 slides provide brief descriptions of each method and comments on their merits and limitations

The central task is to convert population into health personnel. There are two major routes, (1) directly from population into personnel, and (2) via an intermediate step of services required or to be delivered. The sections presented below show the paths followed in four generic methods, here termed: Personnel-to-Population Ratios, Health Needs, Service Demands, and Service Targets.

PERSONNEL-TO-POPULATION RATIOS METHOD

Population to be served, occasionally disaggregated according to selected geographic or other major variables

Population is converted into personnel requirements using desired, normative, or empirically

determined personnel-to-population ratios, e.g., one doctor per 4000 population, one nurse per 1500 population, one anesthetic nurse per surgeon.

HEALTH NEEDS METHOD

Population to be served, disaggregated according to age, location, and perhaps other characteristics Estimate incidence and prevalence of illnesses and injuries for each population segment (children, pregnant women, youth, working population, elderly, etc.)

Estimate services according to provider, type of service, and time required to meet the professionally-determined needs for each type of illness or injury

Convert required services into health personnel requirements by use of normative staffing and productivity standards, e.g., one full-time equivalent doctor can produce 6000 general ambulatory visits per year.

SERVICE DEMANDS METHOD

Population to be served, disaggregated according to age, location, and perhaps other characteristics Estimate population-specific utilization rates for the diverse types of services (e.g., doctor visits,

dentist visits, hospitalizations) produced by the sector multiplied by the numbers of persons in each population segment

Convert services into health personnel requirements by use of normative staffing and productivity standards

SERVICE TARGETS METHOD

Population to be served, perhaps disaggregated according to selected major variables

Health service targets are specified by experts taking into account priorities, health wants and needs, and technical, administrative, and financial feasibility of providing health services. For example,

service targets might be set for pregnant women, infants, young children, and for services to the general population. These targets would be averages, taking into account many variables and recognizing that some persons in each target group would get more services than the target and others less or none.

Convert services into health personnel requirements by use of normative staffing and productivity standards.

SUMMARY OBSERVATIONS

The ratio method is easy, has been widely used in the past, but has many serious deficiencies. It is like a black box; ratios go in, workforce numbers come out, but it has no explanatory value, no intermediate assumptions, and does not lend itself to exploring the effects of one or another variable. The ‘needs’ and ‘demand’ methods require very large amounts of data and are not realistically feasible in low income

countries though they have been used in a few circumstances. The target method is considerably easier but still requires substantial data and many assumptions. All of the methods have been used in a wide range of countries, the needs and demands methods primarily in more developed countries. Major problems

encountered in projecting requirements include:

• The difficulty governments have developing, and sustaining, policies beyond 3-5 years. Most projections are for short periods even though significant changes in the size and composition of the trained health workforce take at least 10 years and more realistically, 15-30 years to accomplish.

• Use of an inappropriate projection method for the country’s health care system, its ability to implement policy, its ability to do sophisticated planning, and/or the availability and quality of baseline data.

• The lack of coordination and at times, cooperation, between the public and private sectors. This is especially true in the case of public and private training institutions such that training school capacity is either well below or above the country’s capacity to absorb the graduates.

• The reality of highly uncertain occupation-specific loss rates that result from early retirement, job changes, and emigration to other countries. If a country can’t anticipate losses it makes projection of requirements even more difficult.​

PROJECTION OUTPUTS - demographic estimates - economic estimates

- required health workers by type & specialty

- economic feasibility - proportion spent on HRH - hospital utilization rates - ambulatory utilization rates - base-target year analyses - projection comparisons - projection aggregations BASELINE DATA - population size - GDP - expenditure data - workforce supply - work settings - services produced - workforce incomes PLANNING ASSUMPTIONS:

- # work settings by type - average staff norms - average productivity

GROWTH RATE ASSUMPTIONS

- population growth - gross domestic product

- public & health sector expenditures - workforce incomes

World requirements for health workers

• Little information is available about the ‘need’ for health workers • WHO has identified a ‘threshold’ health worker density below which

essential interventions, including those necessary to reach the Millennium Development Goals (MDGs), cannot be delivered.

– 57 countries fall below this density

– There is an estimated shortage of 2.4 million doctors, nurses and midwives

• Lack of planning for the public and private sectors has led to a failure to account for the competition over personnel between these sectors.

The United Nations Millennium Development Goals include the following: 1. Eradicate extreme poverty and hunger.

2. Achieve universal primary education.

3. Promote gender equality and empower women. 4. Reduce child mortality.

5. Improve maternal health.

6. Combat HIV/AIDS, malaria and other diseases. 7. Ensure environmental sustainability.

8. Develop a global partnership for development.

Health workforce shortages, inappropriate geographic distribution, and training deficiencies are all major contributors to the difficulties faced by countries as they seek to meet health-related Millennium Development Goals.

Population density of health care

professionals

Conclusion: To attain 80% coverage of skilled birth attendance requires 2.3 key health workers per 1000 population. The majority of countries fall below this requirement.

Distribution of health workers by level

of Health expenditure

Conclusion: Areas with increased disease burden, and therefore increased demand for health workers, have a smaller percentage of the global health workforce, demonstrating mismatched supply and demand.

Case study

• Malawi* has a very low health staffing density, even for Africa. Of 27 districts, 15 districts have less than 1.5 nurses per facility, and 5

districts don’t even have one nurse. Four districts have no doctors.

Despite this, there are 800 qualified nurses in Malawi who don’t work in health.

• A six-year Emergency Human Resource Development Programme was established to resolve these health workforce staffing problems. $278 million was provided by the Global Fund to Fight AIDS,

Tuberculosis and Malaria and other donors. Policy changes included improved incentives for recruitment and retention, increasing domestic training capacity, and interim reliance on expatriate staff. The early results of this initiative are encouraging.

Health worker distribution is very uneven

• By geographic location (urban / rural) • By sector (public / private)

• By clinical specialty

• By level (within the health hierarchy)

• By ‘mix’ (type of health worker, eg, doctor, nurse, technician, auxiliary)

Geographic distribution

• There are huge rural / urban disparities in most countries • Cities are considered more desirable, especially for

professionals who:

– Generally come from and are trained in cities and towns – Have less support of all kinds in rural areas, and hence

are less able to feel professionally fulfilled – Find rural living conditions more difficult

– Fear that being “out of sight” will leave them “out of mind’ for further training and advancement

Rural-urban distribution of health

service providers

Conclusion: While only 54% of the world’s population lives in urban localities, greater than 75% of doctors and 60% of nurses live in urban areas.

Strategies for improving distribution

• Mandatory rural internship as a prerequisite to full licensure • Improved incentives for rural service practitioners

• Use of paramedicals

– Medical assistants, nurse practitioners, midwives, dental nurses, community health workers, etc.

• Implement cost-of-education payback policies • Encourage part-time private practice after hours • Improve employment conditions

• Require prior community service as prerequisite for public sector employment

• Preferentially recruit applicants with rural backgrounds

See the next 3 slides for additional comments about the options for reducing geographic maldistribution

Options for Correcting Geographic Maldistribution (1)

Below are expanded descriptions of the modalities and potential concerns of the options for correcting uneven geographic distribution presented in the slides.

1. Mandatory rural internship as prerequisite to full licensure. This may be inadequate for providing quality care in rural areas as interns often have little or no explicit preparation for rural service and are the least qualified to serve in difficult, isolated positions where they have little or no supervision and support. Interns may also return to urban areas on

completion of their required service with a firm commitment never to return to rural areas. Furthermore, they may use their connections to avoid rural service and thus introduce inequities into the system. This policy can also give the government the illusion that if a doctor or nurse is posted to a rural area, health needs are thereby met, despite the limitations of these posted interns.

2. Improved incentives for rural service practitioners. These incentives can include higher pay or more rapid salary advancement for those in rural service, as well as preferential selection of rural residents for training (a policy which has shown some positive effects in the USA). Promoting research into the obstacles of rural service could be beneficial, as well as promotion “regionalization” of services, whereby strong referral, training and supervisory linkages are made between different levels of facilities in the region.

Options for Correcting Geographic Maldistribution (2)

3. Use paramedical, (e.g., medical assistants, nurse practitioners, dental nurses,

community health workers). These personnel are less likely to seek metropolitan locations and are often “closer” in language and customs to the people they serve. Higher level

paramedical, e.g., physician assistants, nurse clinicians, extended duty dental personnel, can meet up to 70% of patient needs as well as generalist doctors and dentists can.

However, it is important to ensure that there is professional backup and team training so that each level knows what to expect from other levels in the team, and opportunities for career progression in the rural setting.

4. Implement cost-of-education payback policies. If student loans were provided, loan balances can be reduced by x% for each year of rural service. Alternatively, if

professional education was provided at a low, subsidized cost, a professional with no or limited community service could be charged for the full cost of education.

5. Encourage part-time private practice after hours. This practice could occur in either a private office or facility, or a public facility (= “geographic full-time”). Offering use of public facilities is especially valuable for specialties requiring much equipment (e.g., radiology, dentistry, surgery). If this approach is taken, it is Important to monitor the practice carefully in order to minimize abuse.

Options for Correcting Geographic Maldistribution (3)

6. Improve employment conditions. Provide housing, a vehicle, continuing education, regular supervision and communications with higher level facilities, better staff support and equipment, an education allowance for children, increased vacation leave.

7. Require prior community service as a prerequisite for public sector employment. Many health workers will want eventual part-time government employment which offers a more stable income, sick and vacation leave and perhaps a pension. It would also be useful to include this prerequisite for academic employment.

8. Preferentially recruit applicants with rural backgrounds. This could be done through community nomination and/or selection. Providing academic and mentoring support to these nominees will ensure completion of training. Alternatively, shifting more

postgraduate training to provincial and district hospitals will encourage rural “location decisions.”​

Case Study

Multiple strategy “packages” are more effective than relying solely on compulsion. Chile applied these policies in the 1960s. Faster salary advancement was provided for those in rural service, with a 20%

increase after 3 years in rural service, as opposed to 5 years in an urban area. Rural service became a requirement for government jobs.

Rewards for rural service included support for advanced specialty training and annual awards and publicity to superior doctors.

Improving distribution in Chile*

This policy was in use during the 1960s and was observed by the author. Though to my knowledge the effects of this multi-dimension policy have not been documented, it appeared to be very effective. Without being compulsory it presented powerful incentives, especially the assurance of post-graduate specialty training, faster advancement, and access to government positions in the future. Relatively few doctors, especially recent graduates, can make a living entirely in the private sector. The three-year assignment also was much more effective than the more typical one or two-year rural internship. A nice touch, though not a major factor, was the annual invitation to last year rural doctors to submit essays on their experiences and observations over the course of their rural assignment. A panel of the Colegio Médico of Chile

Case Study

• A policy of posting two recent graduate doctors to each health center instead of one has these results….

– Half as many health centers have doctors

– Less centers are compensated by more health posts – Two center doctors can alternate visiting health posts – Two center doctors can alternate “on call” time

– Two center doctors provide each other support

• Regional hospitals provided additional support to the health centers.

Distribution by ‘sector’

• Private sector tends to have more desirable work conditions than the public sector:

– Greater urban emphasis

– Higher unit costs for services – Higher staff incomes

– Better facilities and equipment

• Sectoral imbalance in working conditions can lead to attrition from public to private service

• Furthermore, private sector gives more emphasis to

Distribution by specialty

• All health systems need specialists, but…..

– Methods for determining specialist requirements are relatively crude and seldom used

– Procedures for allocating specialty training positions according to need are often weak or non-existent

– Postgraduate training may overemphasize specialization • Specialists require more costly specialty equipment and

services than generalists

• More specialists, if in surplus, can result in specialists providing generalist services, at additional costs

Distribution by health worker level

• The health workforce should be shaped like a pyramid – Small numbers of high level, high cost professionals

• Doctors, dentists, pharmacists

– Larger numbers of mid-level personnel

• Nurses, midwives, technicians, therapists – Still larger numbers of support personnel

• Auxiliaries (nurse auxiliaries, cooks, drivers, orderlies, clerks, maintenance staff, community health workers)

Optimal mix of mental health services

Distribution by level of health worker

• Student and university pressures may result in too much emphasis on high level categories resulting in an

‘hourglass’ configuration rather than a pyramid

– Higher expenditures on professionals results in less funds for mid- and lower-level personnel

– Relative shortage of mid-level personnel reduces productivity of high-level personnel

– Doctor supply may exceed economic demand for medical services, leading to underemployment,

Case study

• An African country* in the 1990s had 16,000 nurse auxiliaries. The government decided to stop auxiliary training and replace auxiliaries with four-year university nurses earning twice as much.

– Projected short term effects showed little change since most auxiliaries would still be in the workforce.

– Projected long-term effects, after retirement of many auxiliaries and rapid population growth, showed a steep nurse-to-population ratio drop and a large cost increase. • The decision was reversed.

*T.L. Hall, personal observation

‘Brain drain’: International migration

• Brain drain is a major and growing problem. It is the emigration of trained personnel to other nations

• Causes are both obvious and complex

– ‘Pull’ factors that pull health workers away from home to another country

– ‘Push’ factors that push workers away from home to another country

The upward and outward migration of health

Doctors and nurses trained abroad

working in OECD countries

Conclusion: Foreign-trained doctors account for up to 34% of total and foreign-trained nurses for up to 21% of the total found in OECD countries.

Doctors trained in Sub-Saharan Africa

working in OECD countries

Brain Drain - Pull factors

• Pull factors that pull personnel to other countries: – Higher salaries, benefits and chances for

advancement

– Better living, educational and other opportunities – Family and friends already in destination country – Better equipment and support staff

– Greater personal safety – Recruiting bonus

Brain drain – Push factors

• Push factors that push workers away from home – Poor working conditions, lack of peer and staff

support, supplies, equipment

– Low salaries, benefits, small pensions – Limited opportunity for advancement – Physical insecurity

• Random and directed crime and violence • Kidnappings, terrorism, civil wars

• Risk of HIV, tuberculosis and other infections are reducing health worker life expectancies as well as the rest of the population

Health workers’ reasons to migrate in

four African countries

A higher income is not the only important factor in brain drain

Brain drain – Push Factors

• Remittances to families in the home country are a major consideration in some countries (eg, Philippines)

– Remittances can account for a significant % of national GDP and foreign exchange earnings • Some countries train “for export”

– Countries are proud of international acceptance of their graduates

– English-language training enhances employability, e.g., Anglophone African countries, Philippines

Reducing Brain-Drain pull factors

• Increase training capacity in recipient countries • Reduce or limit overseas recruitment, and ensure

ethical recruitment

• Set time limits on service; mandate return to home • More stringent licensure and certification policies

• Require recipient country payments to donor countries to pay for costs of training

Reducing Brain-Drain push factors

• Improve salaries & benefits, though this can introduce inequities in public sector salaries

• Improve health system infrastructure and management

• Improve and provide more appropriate pre-service, in-service and continuing education training

• Increase research and postgraduate training opportunities • Change school culture, emphasizing ‘service’

• Reduce risks of infection & other hazards

Productivity and management

• Administrative deficiencies greatly affect performance

– Deficient supply chains for drugs, equipment, supplies – Inadequate and poorly designed and maintained facilities – Poor or irregular transport and communications

– Inadequate or no staff supervision

– Lack of continuing education programs

– Lack of clear job definitions, with job overlaps and gaps – Weak or no accountability for performance

– Deficient salary & benefit plans and mechanisms – Inefficient deployment of personnel

Case study

In a Latin American 1000-bed teaching hospital, three medicine wards were under the supervision of one professor. Average patient length of stay was 22 days, 7 for diagnosis (x-rays, lab tests, specialist consultations), 10 for

treatment, and 5 for discharge (due to poor discharge planning and followup). One ward was closed and ward personnel were reassigned to clinics for better diagnostic and post-discharge services. Average patient stay decreased to 13 days, with 2 for diagnosis, 10 for treatment, and 1 for discharge. Besides

improving hospital capacity this resulted in less patient time away from family or work.

Of note, in the same hospital, a different professor running a similar three-ward section did not implement this obviously more effective system. An example of the difficulty often encountered in transferring improved methods and

procedures.

*T.L. Hall, personal observation

Why is the health workforce so challenging?

management, characterized by:

– Salary and benefits system complexities & controversies

– Union pressures, strikes, slowdowns

– Complaints by the public and periodic scandals – Misuse and abuse of resources

– Public-private sector tensions

– Diverse and often class-specific insurance schemes, e.g., salaried vs. blue collar employees

Why is the health workforce so challenging?

• Workforce policies are often controversial, and governments avoid making decisions in order to avoid conflicts with

professional associations, employees and training institutions

• Legislators and the general public tend to equate more doctors with better health, to the neglect of other inputs

• There may be weak coordination between public and private sector training institutions

Why is the health workforce so challenging?

• Personnel are the most costly component of the health

system, accounting for 50-80+% of the public sector health budget

– As percent spent on staff increases, less money is available for drugs, supplies, maintenance, etc.

– Managers can delay purchases of drugs, supplies and equipment but not salaries

Why is the health workforce so challenging?

• Workforce changes are slow and difficult

– Vested interests strive to preserve status quo

– A 10% change in medical student intake results in <3% supply change in the first decade (“pipeline problem”)

– Decades necessary to make major changes in workforce skills, attitudes and motivation

• In contrast, rapid changes can be made in the purchase of drugs, supplies and equipment

Why is the health workforce so challenging?

– Incomplete coverage, especially of private sector – Limited information on losses from schools, practice – Lack of reliable, consistent registration systems

• Requirements projection methods tend to be costly and/or used inappropriately

• Government planning tends to be short range, e.g., 3-5 years • Governments have difficulty maintaining policies over several

Why is the health workforce so challenging?

• Workforce planning is often crisis oriented leading to a short-term response for a long-term problem

• Decision-making is often fragmented and/or policy coordination is poor between the many stakeholders, including the Ministry of Health, Ministry of Education, individual universities and schools, and private sector institutions

WHO Ten-year plan 2006-2015*

• WHO has established a comprehensive action plan to address the health workforce for the next ten years, taking into account the short, medium, and long-term.

• Immediate, 2006 objectives

– Cut waste, improve incentives – Revitalize education strategies

– Develop common technical frameworks – Pool expertise on workforce matters

– Advocate ethical recruitment & migrant worker rights – Pursue fiscal space exceptionality

– Finance national plans for 25% of crisis countries

– Agree on best donor practices for human resources for health

WHO Ten-year plan 2006-2015

• 2010 mid-point objectives

– Use effective managerial practices – Strengthen accreditation and licensing – Overcome barriers to implementation

– Assess performance with comparable metrics – Fund priority research

– Adhere to responsible recruitment guidelines – Expand fiscal space for health

– Expand financing to half of crisis countries

WHO Ten-year plan 2006-2015

• 2015 decade objectives

– Sustain high performing workforce – Prepare workforce for the future

– Evaluate and redesign strategies, based on robust national capacity

– Share evidence-based good practices

– Manage migratory flows for equity and fairness – Support fiscal sustainability

Summary

• The workforce is the key and most costly and complex resource of the health sector

• Gross imbalances exist between the supply of and requirements for personnel in low income countries • Accomplishing major changes in workforce

numbers, distribution, qualifications, productivity, mix, etc., is difficult and slow

• The brain-drain of professional level personnel is a serious and growing problem

General References

​1. The health workforce literature is enormous and covers all phases of health workforce

development from planning to training and management. These publications will provide good overviews to the field and recommendations for action.

2. WHO. The world health report 2006 - working together for health. 2006, 209 pp.

Chapter 1: Health workers: a global profile; Chapter 2: Responding to urgent health needs; Chapter 3: Preparing the health workforce; Chapter 4: Making the most of existing health workers; Chapter 5: Managing exits from the workforce; Chapter 6: Formulating national health workforce strategies; Chapter 7: Working together, within and across countries; Index Available online at:

www.who.int/whr/2006/whr06_en.pdf​ ​

​3. Joint Learning Initiative. Human Resources for Health: Overcoming the Crisis. 2004, 217 pp. In this analysis of the global workforce, the Joint Learning Initiative (JLI) — a consortium of more than 100 health leaders — proposes that mobilisation and strengthening of human resources for health, neglected yet critical, is central to combating health crises in some of the world’s poorest countries and for building sustainable health systems in all countries. Nearly all countries are challenged by worker shortage, skill mix imbalance, maldistribution, negative work environment, and weak

knowledge base. Especially in the poorest countries, the workforce is under assault by HIV/AIDS, out-migration, and inadequate investment. Effective country strategies should be backed by international reinforcement. Ultimately, the crisis in human resources is a shared problem requiring shared

responsibility for cooperative action. Alliances for action are recommended to strengthen the performance of all existing actors while expanding space and energy for fresh actors. Available online at: www.globalhealthtrust.org/Report.html See also

General References

​

4. World Bank. World development report 1993 : investing in health. 1993, 344 pp. Though dated, this comprehensive overview to the opportunities, challenges and limitations of investing in health care provides a wealth of information relevant to the health workforce. Many of its findings are still valid. Available online at:

http://www-wds.worldbank.org/external/default/main?pagePK=64193027&piPK=64187937&theSitePK=523 679&menuPK=64187510&searchMenuPK=64187283&siteName=WDS&entityID=000009265_ 3970716142319

​5. Physicians for Human Rights. An Action Plan to Prevent Brain Drain: Building Equitable Health Systems in Africa. July 2004, 120 pp. Available online in pdf from:

http://physiciansforhumanrights.org/library/report-2004-july.html

6. Labonte, R., et al. The Brain Drain of Health Professionals from Sub-Saharan Africa to Canada. African Migration and Development Series No. 2, 2006. Southern African Migration Project, 92 pp. Available online at:

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Credits

Thomas L. Hall, MD, DrPH,

Dept. of Epidemiology and Biostatistics, Univ. of California at San Francisco, [email protected]

Nicole Bores,

University of California at San Francisco,

Sponsors

The Global Health Education Consortium gratefully acknowledges the support provided for developing these teaching modules from:

Margaret Kendrick Blodgett Foundation The Josiah Macy, Jr. Foundation

Arnold P. Gold Foundation

This work is licensed under a

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0