Approaches to tackle Health Workforce Shortage in Low and Middle Income Countries
How Swiss Contributions to overcome Human Resources for Health Shortages may look like?
Von Kaspar Wyss / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
Over the last decade, funding for health in low- and middle-income countries has substantially increased principally through a number of new initiatives and instruments. There are a number of consequences including that Human Resources for Health (HRH) related problems have become more apparent and moved into the spotlight of interest, both in countries of low- and high-income. There are various options what Switzerland may do to address these problems.
Blood samples are taken by horse from Semenanyane clinic in mountainous eastern Lesotho to an urban centre for testing (© Eva-Lotta Jansson/IRIN)
Well trained and motivated health workers are the single most important input to health service provision and improved health. Without them, advances in health care cannot reach those most in need. Despite this, health systems in high- middle and low-income countries are finding it increasingly difficult to train, support and retain their health workforce. Likewise, Switzerland is not in a position to train enough health staff, especially doctors, but overcomes the shortage through massive recruitments in neighbouring countries: the most recent figures indicated that at least 25% of the Swiss health workforce has been trained abroad.
An inventory conducted in 2010* of Swiss cooperation practices shows that Switzerland supports through its development assistance a substantial number of initiatives and projects. Swiss investments in human resource development in low- and middle-income countries are channelled through different mechanisms (Swiss Agency for Development and Cooperation (SDC), Swiss National Science Foundation (SNSF), Swiss Cohesion Funds, State Secretariat for Economic Affairs (SECO), NGOs, etc.).
Broader health systems strengthening efforts
The developmental approach concerning HRH development chosen by the different actors of the Swiss Development Cooperation including governmental key actors such as the SDC, SECO, Federal Office of Migration, SNSF and non-governmental organisations (e.g. SolidarMed, Swiss Red Cross) rather focuses on individual priorities and projects. Indeed most projects with a human resource for health component focus on changing the conditions for health care workers in source countries, including increasing wages and opportunities for training and improving working conditions. It is being observed that Swiss investments in human resource for health development are substantial but typically do not relate to stand alone investments in HRH development or the prevention of migration and are in most instances an integral element of broader health systems strengthening efforts. Notable exceptions are the “Strengthening Nursing in Bosnia and Herzegovina” initiative which aims to foster the quality and efficiency of nursing services, with a focus on the primary healthcare level as well as “Medical education reform project in Tajikistan” which aims among else to improve the curricula and training of doctors and nurses.
At strategic level, Switzerland has greatly supported the adaptation of the Code of Practice on international recruitment of health personnel by the World Health Assembly 2010. Further, the Swiss foreign policy relating to health matters endorsed in 2012 by the Swiss Federal council provides steering and emphasises that attention should be given to problems relating to international migration of health workers, the respect of the international code of conduct for the ethical recruitment of health workers and emphasis the need to address human resource problems both in Switzerland and abroad. The implementation of HRH strengthening measures, suggestions, decisions and activities realised by multilateral organisations or foreign countries should be closely observed and translated into action, where applicable, by relevant Swiss ac-tors.
At the same time, Switzerland does not pursue a specific policy to minimize the reliance on foreign health professionals nor regulates the recruitment of health workers from European Union countries facing a shortage of health care workers. Albeit some universities have recently increased the intake medical students, there would be a need that Switzerland disposes of comprehensive and jointly agreed on human resource policy (embedded in a strategic vision on the Swiss health system development) to address among else the current and future workforce planning.
Beyond a better adequacy between the need/demand for health workers in Switzerland and outputs of Swiss training institutions, there are a number of options how Switzerland may address human resource shortages in low-and middle-income countries. They include:
- strong commitment to invest in human resource for health development,
- harmonisation of activities and projects across the Swiss governmental and non-governmental actors,
- bi-lateral treaties with low- and middle-income countries, and
- explore the potential of circulatory migration.
These options are obviously not mutually exclusive and are briefly outlined below.
Commitment to invest in human resource for health development
First and foremost governments and donors who aspire to achieve the ambitious United Nations Millennium Development Goals, such as reversing the child and maternal mortality rates or the spread of priority diseases (HIV/AIDS, malaria, tuberculosis), must commit themselves for mid and long-term investments in health systems and health systems strengthening, thereby acknowledging that human resources for health are the essential input to health systems. When comparing the activities across the different actors, a common picture emerges: HRH development is not specifically targeted as a project goal (see exceptions mentioned above) but is rather seen as a tool which constitutes an integral part of most projects and programmes. The dynamic nature of health systems is reflected very clearly through the “human resources crisis” which whom both Switzerland and low- and middle-income countries are confronted with. As national capacity has developed in low- and middle-income countries over the years, less external assistance has been focused on, for example, pre-service training. Now, the internal and external brain drain health teaching institutions have been substantially weakened. This shows the need for a long term and continually evolving and flexible approach when it comes to human resource development. Typically, this is not an area where there are any short term solutions and the questions raised continue to be demanding and difficult. The recognition of this should translate either into comprehensive health systems strengthening initiatives which emphasis adequately HRH problems for example through specific components and/or specific human resource projects putting HRH in the centre of activities.
Harmonisation of activities and projects across the Swiss governmental and non-governmental actors
Second and in relation to an improved Swiss health policy for cooperating with low- and middle income countries to combat health worker migration a better understanding of the concept of policy coherence for development is of importance. Concurrently, source and destination countries of health workers must adopt migration regimes that seek to secure within source countries an adequate number of health workers who are further adequately trained and are well performing. Albeit there is general agreement on the end goals, approaches that different actors and countries may support are contested. At present a strong will to consolidate the work in the area of HRH development exists in practice and in the field. However, there is room for improvement for programme harmonisation. Albeit the Swiss foreign policy relating to health matters has been approved in 2012, there is a need that this translates into a vision and practices of policy coherence for development common to all federal offices and if possible also of non-governmental actors. In parallel, there should be efforts to better measure, monitor, and report on the impacts of its domestic and foreign policies on its development efforts and results.
Bi-lateral treaties with low- and middle-income countries
Thirdly, Switzerland may promote bilateral treaties so to steer health worker flows that are more beneficial to source countries. Such treaties may as in the case of Norway limit recruitments by the public sector from most low-income countries. As Switzerland is however recruiting its health staff principally from EU countries the impact of such measures are likely to be limited. Alternatively, Switzerland may establish and engage in agreements with middle and low income countries such as under the discussion with the Philippines which provide the frame for sending medical professionals to Switzerland in some instances under the pretext of training, internship and residency purposes. In other words, the implementation of vocational training opportunities in receiving countries regulated by agreements which specify recruitment contingents for both, source and receiving countries, with the aim to achieve a win-win situation, represents one possible measure as an element of bilateral treaties.
The Swiss development cooperation may also engage in facilitating the Migration of Health Care Professionals to Countries with Health Worker Shortages: A large number of health professionals are living outside of their country of origin. Many of them are willing to contribute their skills to their home countries and may be interested in initiating and sustaining initiatives for HRH development. There are a range of tools available to countries to promote such transfers, including allowing dual citizenship to foster more circular migration. Countries such as Switzerland may more systematically allow health staff to return to their country of origin under special arrangements that will not penalize them upon their return to Switzerland. Many health professionals abroad are unaware of opportunities at home, a weakness that organizations such as the International Organization of Migration are working on to strengthen.
Potential of circulatory migration
Forth, the Swiss development cooperation may promote Circulatory Migration. In-line with the concept of circulatory migration it might be considered to change the visa policies of Switzer-land to promote skills development through short-term visas. The hope is that such training could improve health care treatment and retention in the health care profession within source countries. We talk of circulatory migration when staff remain based in their home country and work in the system for the majority of the year - with all the benefits this holds for their colleagues and students gaining from their expertise and supervision. For the remaining, shorter part of the year they are based in another country, at a partner institution, where they provide input through teaching, supervising student, taking part in joint research projects, or spend part of the time accessing continuous training. They then start to move their way around the circle again. There is no notion of permanency attached to the migration and no intention to settle – neither from the perspective of the individual nor the receiving country. Clearly, the costs of running such schemes are high in terms of economic expenditure. Circulatory migration is also likely to be an approach to target specific categories of health professionals; typically the well educated who can easily adapt to training and research settings in Switzerland. Albeit Germany is using circulatory migration as an element in its strategy for HRH development, to date there is little hard evidence as to whether participation in such schemes really facilitates that highly qualified health professionals decide not to emigrate. Research into the benefits for receiving countries is also limited. The little data that is available indicates a “win-win” situation. In particular, universities in Germany engaged in such partnerships report a high level of cultural interaction, the generation of new ideas, and a rich exchange in both the subject matter and working approach.
Switzerland as well as many middle- and low-income countries are heavily exposed to HRH problems which potentially or effectively undermine health system performance. There is plethora of noteworthy “Swiss” examples in human resource development through capacity building and technical assistance being provided, for example, to regional health management teams to equip them with management, supervisory and technical skills to backstop district health teams or in the area of quality improvement and staff motivation. However, as plans in many low- and middle-income countries meanwhile underline the importance of human resource development, the performance monitoring and re-view becomes increasingly important thereby giving specific attention to investments in human resource development within broader health system development approaches.
*Kaspar Wyss is a Public Health Specialist and Deputy Head of Department at the Swiss Centre for International Health, Swiss Tropical and Public Health Institute. Kaspar Wyss has strong management and leadership experience and is in charge of a team of 15 staff focusing on health systems development primarily in low- and middle income countries. Activities relate to both research and health system monitoring and performance assessment, with a specific interest in the role and importance of human resources for health.
This text is partially extracted from the review “Swiss Contributions to Human Resources for Health Development in Low- and Middle-Income Countries” commissioned by the Swiss Federal Office of Public Health (FOPH) and the Swiss Agency for Development and Cooperation (SDC) .The full report can be downloaded from http://www.deza.admin.ch/de/Home/Themen/Gesundheit/Gesundheitssysteme_und_dienstleistungen