Human Resources - the Heart of every Health System
Von Karin Martin, Kaspar Wyss, Svenja Weiss & Nicolaus Lorenz / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
Strong and well-functioning health systems are a prerequisite for efforts to reach the Millennium Development Goals. Human Resources for Health play a central role – right at the heart of every health system! While strong national leadership and stewardship are of utmost importance to initiate the structural changes needed to overcome the human resource crisis, global alliances are also much needed to provide capacity building, scientific knowledge transfer and funding support.
More than half way towards the Millennium Development Goals (MDGs), there is an urgent need to respond to the global human resource crisis in health. Despite a fast moving 21st century which has brought about a wide range of technological and medical advances and tremendous efforts to create global alliances for international health, the health needs of many populations remain far from being met. The gap between rich and poor countries is widening. Many health systems remain inadequate and at the brink of failing, life expectancies in some of the poorer countries are decreasing, preventable diseases such as Malaria, TB and HIV/AIDS are causing a heavy death toll and even the most basic health services are not being provided. The precarious health resources situation further adds to this crisis situation and is the result of numerous factors: sheer shortage of staff, low salary levels, low motivation and productivity, lacking incentives, geographic imbalances, a lack of suitable education, pre-service and continuous training opportunities, the impact of HIV/AIDS and a one-way South-North migration of health personnel. The full implications of these facts and figures are complex, but at the bottom line there is a global shortage of more than 4 million doctors, nurses, midwives and other cadres of health staff with 57 countries suffering from a critical health personnel shortage (WHO 2006).
A Symposium “Human Resources for Health – Beyond the Declarations” was hosted by the Swiss Tropical Institute (STI) in Basel on 21st March 2007 to take up the current debate and to point out potential ways forward. Several speakers from the World Health Organisation (WHO), Swiss Agency for Development and Cooperation (SDC), Council on Health Research for Development (COHRED), Special Program for Research and Training in Tropical Diseases (TDR), Community Health Department of the University Hospital Geneva (HUG) as well as international guests from Zambia and the Ivory Coast contributed to the discussion. As the presentations showed, the key issues coincide with those raised in the ongoing human resource discussions at the global level. There is a need for action!
The raw material for health systems
A strong and well-functioning health system is a prerequisite to reach the MDGs goals and health system strengthening should therefore be seen as an integral part of national health policies. Only efficient and equitable health systems are able to successfully deliver treatment for those infected with HIV, to meet reproductive health needs, implement immunisation programmes and to channel aid investments in a sound manner. But the raw material for health systems is made up of those people who make it work on a daily basis - those who treat and care for patients and those who work at the managerial and support level. It is therefore not surprising that the distribution and density of skilled health staff coincide with a country’s health outcome. Specific examples were highlighted during the Symposium discussion; high density of health staff strongly correlated with a low child mortality in countries like Norway or the UK, whereas the opposite trend is observed in many African countries such as Sierra Leone, Ethiopia and Uganda. Efforts to maximise the best mix of skills that can be achieved from the limited numbers of the various health cadres available need considerable back up and support from decision-makers and planners as well as from those providing the funding. Unfortunately there is no standardised approach to solving the human resources problematic. Each country has to define its own strategies.
So why do so many countries, especially in the African region, experience chronic shortages of health staff? The reasons are manifold and can best be highlighted through the country-level examples presented at the Symposium. While a decade ago, migration of health staff in Zambia was insignificant it has nowadays reached extremely high levels. Today, 5% of the total Zambian nurse workforce is practicing in European countries. Many more decide to migrate to the neighbouring countries South Africa and Botswana or continue their profession in the private sector or in other organisations. Further figures that give rise to concern were presented for Ghana and Zimbabwe where 13% and 34% of nurses respectively are already working in foreign countries. The main forces serving to drive health staff from Zambia in search of a brighter future abroad include higher salary levels (especially for nurses), better working conditions, enhanced educational possibilities and a future oriented career development. A regional maldistribution of skilled professionals adds to this crisis leading to a disproportionably high number of health personnel being found in the urban environment whereas rural areas experience immense deficits.
Besides migration, the largest cause of attrition of health service staff is death due to HIV/AIDS. In Zambia, 2 nurses out of 1000 died of AIDS in the 1980s while figures climbed to 27 deaths out of 1000 in 2001. Such a development is alarming as it not only implies that health workforce numbers are declining in overall terms but also that the very staff who are needed to deliver antiretroviral treatment are themselves succumbing to the disease. Only functioning health systems which have sufficient staff are able to provide the health services - including antiretroviral treatment - that save lives! This needs to be kept in mind when considering the strong interrelationship between the number of service providers and plans to achieve Universal Access to antiretroviral treatment by 2010.
WHO has recently set up a new programme which follows a triple strategy to strengthen HRH for different disease programmes, especially HIV/AIDS. The initiative is known as Treat, Train, Retain (TTR). ‘Treat’ stands for a package of HIV treatment, prevention, care and support services for health workers, who may be infected or affected by HIV or AIDS. WHO will hereby collaborate with the International Labour Organisation (ILO) to support the roll-out of the workplace programmes. For ‘Train’ WHO will support standardised training and certifying of all cadres to deliver HIV services. ‘Retain’ covers financial and other incentives and occupational health and safety. Migration issues will be taken up together with the International Organisation for Migration (IOM). The efforts are promising and mark an important way forward.
In many countries, investments in health staff pre-service training and continuous education have so far been limited, thus constricting the supply of young professionals. A global snapshot of the availability of medical education facilities draws a bleak picture. Great disparities exist concerning the distribution and number of medical educational facilities. Whereas the USA has more than 500 medical schools with a yearly graduate output of 68,500, Africa lags far behind with less than 100 medical schools and an average of 5,100 graduates per year only. A major step forward would thus be to invest in the establishment of high quality training institutions which assure the coverage of the health needs of the population and satisfy the labour market in countries suffering from serve health shortages. As was commented at the Symposium, “if millions are invested in individual diseases, the responsibility also exists to invest in HR development”. The results of such investments are most likely not as measurable, rewarding and presentable in the short term but would significantly contribute to long-term health system strengthening. The aim should be to achieve the right mix of health worker numbers, professional skills and competencies through qualitative and accredited curricula which target practice based teaching, problem based learning and patient focused services. Supported through a higher level of financing, political commitment, development partner support and combined efforts of decision making bodies, changes towards better coverage of essential interventions can be achieved.
At the symposium a successful example for capacity building was presented for a project led by a consortium of “Partnerships in Health” and the University hospital of Geneva (HUG) in the former Yugoslavia. During the war between 1992/1995, major parts of the health infrastructure of Bosnia Herzegovina were destroyed and many health workers migrated abroad. Years of isolation and a lack of training of health care personnel lead to the break-down of prevention programmes and a general deterioration of health conditions and outcomes. The project of the HUG, aimed at training and retraining primary care doctors and nurses and offering capacity building for the health tutors themselves in curriculum development and family medicine. Starting in 1998, the FaMi project has seen ever increasing interest amongst health staff to take part in the trainings being offered. In 1988 there were just 38 participants. Last year the number had risen to 220. Specific project outcomes include the training of 810 doctors and nurses, 120 “Training of Trainer” courses (TOT), creation of 4 family medicine training centres and 70 medical practices rebuilt and newly equipped. The family medicine training programme placed great emphasis on sustainability through joint training of doctors and nurses, empowerment of nurses, interactive training methods, gradual replacement of the Swiss trainers by their Bosnian counterparts, development of local responsibility and ownership, progress monitoring, supervision and coaching on the job and systematic involvement of local institutions. In addition, organizational changes were implemented for patient registration, appointment systems, patient files, task division, team meetings, telephone advices, health promotion activities, continuity of care and home and palliative care.
New efforts for capacity building are, however, not enough! Access to quality teaching materials and technologies (computerised systems including e-learning possibilities etc.) as well as access to research programmes and data in general represent additional challenges. Despite the widespread acknowledgement that research and development is key to health, equity and economic development, there is no clear approach as to who, where and how research for health should be addressed. As a result, almost all new research efforts for the South are still concentrated in the North. If this development is not explicitly targeted, developing countries will remain spectators while the North continues to act on their behalf by identifying the country problems, deciding on the amount and type of funding and conducting the research. It must be clearly stated here that the South needs to become actively involved in research for health in order to drive development forward. From a national perspective, development is a key outcome which requires research capacity strengthening at national level to become better understood, studied and addressed. Human resources for health research (HR-HR) remains an area that lacks clear strategies and monitoring. As a consequence HR-HR is not living up to its expectation and there is no common scaling-up. In order to change the invisible and implicit character of HR-HR, a multilevel approach needs to be initiated, involving the individual, institutional, system, economic and political level. A strong political leadership combined with the establishment of research alliances alongside health research priorities, the creation of institutions and a targeted investment in science technology and innovation is called for. Country empowerment involving local institutions and addressing local health priorities is a further must!
Well-targeted HR-HR would generate the long-strived for data on human resources in health. Efforts to strengthen the use of basic modern communication technology such as telephones, computers and access to internet could also be made to improve the efficiency of data management. Vital basic information on the number and distribution of important diseases, child mortality and vaccination programmes could be used more effectively as the basis of planning. No matter how well-trained and motivated health staff are, inadequate health infrastructure and health information management systems will hamper their performance.
There is no single, blueprint approach
A common conclusion of the Symposium showed, that Global health initiatives have taken off, but a blueprint approach will never be achieved. On the contrary, effective workforce strategies have to be adapted to each and every individual country context as workforce dynamics are deeply embedded in the history and the present political situation of a country. Until recently, development partners and health planners concentrated more on their own disease priority assuming that such interventions would also benefit the health systems. GHIs are only recognising now, that well functioning health systems are fundamental for effective aid interventions and successful disease programme implementation. Thus, awareness about the global human resource crisis is increasing among major institutions and international organisations and they are starting to address the problem.
One example presented at the STI Symposium refers to combined efforts of the German development cooperation, mainly consisting of the German Technical Cooperation(GTZ), German Development Bank (KfW), Centre for International Migration and Development (CIM), German Development Service (DED), German Academic Exchange Service (DAAD), Capacity Building International (InWEnt) and the Centre for International Migration and Development (CIM). The German Development Cooperation has long-term experience in providing health system support, at national, regional and district level. Concrete strategies need to be adapted to the context in question and require involvement at macro level with a strong linkage to the national decision making bodies - including the ministries of finance and other social sectors. The German Development Cooperation acts increasingly through a programme approach that draws on the individual competencies and strengths of each organisation. The GTZ, has a strong focus on strategic human resources planning, capacity building and supporting closer collaboration between public and private health providers. Budget support and infrastructural improvements form the – often indirect - contribution of KfW, whereas the DED ensures that the linkage to the district level is maintained. Capacity building and continuous personnel development such as through e-learning courses and provision of health learning materials has long been a priority area of InWEnt and will be further continued. Complementary to this, the DAAD facilitates academic and research possibilities in Germany for scholars from around the world while encouraging them to return and practice in their home countries upon qualifying. In line with this approach, CIM takes on a twofold strategy by actively organising the return of health professionals to their country of origin and enabling senior and well-qualified professionals from Europe to work in resource poor settings with the aim to transfer skills and know-how.
International support needs to go hand in hand with national leadership and priority-setting and be underpinned by well formulated national HRH policies. Social Sector Ministries have to take up the issue as part of their national leadership. In other words, it is their duty to act as stewards of the health or education system and lobby for health system and HR strengthening.
The way forward?
We observe that there are many initiatives already underway, but no quick fit solution for all. Initiatives do already exist as the German and the Bosnia Herzegovina examples have shown, but their full potential can only be reached when structural changes are made and these can only be instigated at the highest political level. It is widely acknowledged that the health workforce is at the heart of each and every health systems and central for improving health. In order to tackle the human resource challenge, the supply of health workers needs to be increased, and those in place need to be offered appropriate payment levels comprising monetary and non-monetary incentives, access to well equipped and functioning health infrastructures, acceptable working conditions and high quality training opportunities to strengthen their professional skills. As long as not even the basic health infrastructure exists and the rights of the individual health worker are not respected, the exodus of health professionals can only be expected to continue.
A strong national leadership and stewardship is of utmost important. A stable political, regulatory and strategic framework needs to be put in place by national authorities in order to lay the groundwork for ways out of the HR crisis. The involvement of multiple national actors including ministries of health, labour, trade and immigration is needed together with support from health professionals and health training and regulatory institutions. An interlinkage to the policy level and to other reform processes is a prerequisite.
For this most crucial of issues national leadership needs the exceptional support of global solidarity – be this in regard to health system strengthening, capacity building, scientific knowledge support and well-targeted funding. The Bosnia Herzegovina example has shown a successful approach for capacity building where various medical professionals were brought together, local involvement was emphasised and a reward based system under supportive supervision was introduced. There is a need to train beyond academic capacity and enhance the skills of leadership, planning and management. The catalysation of knowledge e.g. through research collaboration according to a research agenda set by the South, based in the South and with the South requesting technical support from the North where it sees a need, rather than the other way around would be another step forward.
Operations research that looks for simple solutions to locally identified problems would pave the way for data generation for decision making and strategies that work. A coordinated and harmonised response from the donor side is also vital for setting up immediate and sustainable financing mechanisms for human resource development. A considerable part of the investments need ultimately to be directed towards structural change and to bear in mind that human resources lie at the heart of every health system.
*This article is based on the presentations and discussions made at the Spring Symposium “Human Resources for Health – Beyond the Declarations” on 21 March, 2007. It can be described as symposium review embedded in the current HR context with a focus on HR and Global Health Initiatives, health system and HR strengthening and capacity building. The views and ideas expressed herein are those of the authors and do not necessarily imply or reflect the opinion of the individual presenters.
Svenja Weiss is a public health specialist with focus on health systems and human resources. She is involved in various consultancy and evaluation services and studies in the field of public health at the STI. All authors work at the Swiss Centre for International Health, a department of the Swiss Tropical Institute, “Improving Health Systems Worldwide”. Contact: www.sti.ch, Kaspar.Wyss@unibas.ch
Working together for Health - The World Health Report 2006. The World Health Organisation, Geneva, Switzerland, www.who.int/whr/2006