Human resources for health

Text by Marjolein Dieleman
Development, Policy and Practice (DEV), Royal Tropical Institute

Over the past decade, the human resources situation in the health sectors in ‘developing’ and ‘transitional’ countries has reached a point of severe crisis and inability to provide basic health services. The WHO estimates that one million more healthcare workers are needed in low-income countries if they are to meet basic health goals. UNAIDS estimates that an additional 3070 medical doctors, 5700 nurses and almost 106.000 community health professionals needed every year in low-income countries over and above what is currently available in the health sector in order to deal with and scale up present level of care to the HIV/AIDS sufferers.

The Human Resources for Health (HRH) crisis in low and middle-income countries is currently receiving increased global attention, particularly the situation in Sub-Saharan Africa. At all levels, policy makers and planners are starting to realize that the achievement of the Millennium Development Goals is simply not possible if the HRH crisis is not more effectively addressed. HRH policies should accompany the increase in financing for healthcare through debt release, PRSP, fairer trade policies and specific programmes such as Global Alliance for Vaccines and Immunization and the Global Fund to fight AIDS, Tuberculosis and Malaria. As HRH are an essential part of health systems, HRH policies can not be successful without efforts to improve the overall functioning of the health system.

HRH policies and strategies need to address health worker “production” (training appropriate numbers and having an appropriate skills mix), retention, migration and performance. To effectively address the HRH crisis policy makers and planners need to analyse and share experiences and develop effective approaches to:

• Enhance health worker performance, especially in fragile states and rural remote and urban poor areas.

In general, analysis of HR plans and field experiences have demonstrated that HRH strategies are often not gender sensitive and that the impact of HIV/AIDS on health workers is not taken into consideration while both aspects are essential for retention and provision of quality care. The HRH crisis can only be solved if gender and social equity issues are consistently and comprehensively addressed in health systems development in general and in HRD policies and strategies in particular.
Moreover, in fragile states basic service delivery is either totally absent or organized without much participation of the government. Key institutions that were originally present have been partially or totally destroyed, while new organizations and networks are being formed, for which support is required.
In rural remote and urban poor areas, attraction and retention of staff and provision of quality of care is particularly difficult.
Due to the paucity of documented experiences and operational research, it is not clear what works (including experiences in public, private and private-not for-profit sector), what does not and why; and what such interventions cost. Policy makers and planners need this information to develop and implement effective strategies and to decide which experiences are sufficiently “positive’ for scaling up.

• Enhance good governance

Issues with respect to good governance in HRH are effective partnerships between health service deliverers, users associations, and (local) governments that have to oversee performance of health service delivery, provide funding and even staff. Attitude and performance of staff are important issues for patients, and there is thus a need to better include client perspectives on health worker performance in HRH policy. Strengthening accountability mechanisms at all levels is another key aspect (staff performance, financial management, decision making on duty station, grading etc.). This also means that health workers are entitled to know their rights and that their rights should be promoted and protected. In addition, a functioning M&E systems in combination with operational research on HRH, and capacity strengthening on interpreting these results for HRH also contributes to improved governance and for HRH agenda setting. Apart from “technical information” on HRH, political analysis is required to assess the feasibility of HRH plans and to build strategic alliances to move the HRH agenda forwards considering the conditions and stakeholder interests at country level. Moreover, in order to ensure the sustainability of HRH, HRH plans need to be an integral part of Health Sector Strategies and medium term budget planning. This entails developing and costing plans, but also obtaining commitment for resource allocation

• Manage internal and external migration

One of the factors contributing to the HRH crisis is exit of the health workforce from National health systems including emigration of skilled health professionals (medical brain drain). Research shows that international migration leads to internal migration: from rural to urban, public to private and from primary to specialist care. There is an urgent need of research on (i) labour market failure, including externalities and asymmetric information; (ii) role of remittances; (iii) global public goods; and (iv) political economy of migration and inequitable resource use as the consequences of emigration of health professionals. In order to get a holistic picture, there is also a need to include ‘unquantifiable variables’ by incorporating sociological and cultural theories of migration. This information will allow the formulation of international collective action to formulate new policies and institutions to manage migration including international financing of Global Public Goods for health and the role of recent GATS negotiations on further migration of health professionals.

• Obtain and retain appropriate competencies to implement tasks

Traditional training approaches have proven to be successful in short term improvements in knowledge and skills but appear less successful in sustaining improved performance on the job. Evidently there is a need to develop and document effective systems for continuous learning that better assure sustained performance for all groups involved in the health system: service providers, managers but also local government and civil society. • Integrate HRH plans for priority program in HRH plans for health systems

Priority health programs, such as TB control programs, HIV/AIDS programs and Sexual and Reproductive Health Programs have come to realize that they need to develop HRH plans in order to achieve their targets. There is an on-going debate to what extent these “vertical” HRH plans and activities disrupt or strengthen the HRH plans and activities in the health system. There is a need to develop and improve upon approaches to integrate HRH plans developed for priority programs with HRH plans developed for the overall health system