A crucial element for achieving international development targets
Human Resources for Health (HRH)
Von Daniel Mäusezahl & Kaspar Wyss / Direktion für Entwicklung und Zusammenarbeit DEZA / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
International plans put Human Resources for Health development at the forefront
At the United Nations Millennium Summit in September 2000, world leaders of both low- and high-income countries committed themselves to combating poverty, hunger, disease, lack of basic education, environmental degradation and discrimination against women. Subsequently eight Millennium Development Goals (see www.un.org/millenniumgoals) were formulated, among them four related to the health of the poor. To achieve these targets it is necessary to ”eradicate extreme poverty and hunger, reduce child mortality, improve maternal health, combat HIV/AIDS, malaria and other diseases”.
For most priority diseases and major contributors to the global burden of disease, effective interventions do exist. In many countries only a minority of the population can benefit from these interventions and usually poor groups are those with the most limited access to the services. It has been estimated that each year between $35 and $63 billion of additional funding will be necessary to significantly improve coverage of priority interventions to address the health needs of the population, especially of poor groups.
A number of challenges have to be overcome in order for the additional resources to be invested effectively and efficiently. Thus, the next paragraphs will review challenges related to human resources. Initiatives such as the Millennium Development Goals, debt relief ear-marked to the health and education sector, the Global Fund or the Global Alliance for Vaccines and Immunization GAVI are not only based on the scaling-up of health related interventions but require human resources to implement them. HRH will also heavily influence absorptive capacities of supplementary resources to health systems in low- and middle income countries. Thus, for any large scale effort to rapidly increase coverage of the population, HRH will be a key to success.
Constraints to the development of Human Resources for Health
The rapid extension and building up of the HRH workforce necessary to achieve international development targets undergo a number of constraints. The most important challenges for a typical low-income country in sub-Saharan Africa are likely to include the following factors:
addressing the proportional representation of staff with a distinct social and ethnic background in the workforce;
tackling geographical imbalances in the distribution of health sector work-force;
extending qualitative and quantitative capacities of medical training institutions;
conceiving and implementing national HRH policies;
carrying forward good governance and a well conceived and balanced overall policy framework.
The size and extent of these constraints varies across different low- and middle income countries, but they will largely determine the pace of any effort to increase health service coverage of the population.
Representation of minority groups in the workforce
The Millennium Development Goals call for priority to be given to the poor. Often these groups are under- or not at all represented in the health sector workforce and are not sufficiently included in establishing priority needs in terms of health and social services. For example, it has been reported that a major reason for extremely low access to health services and coverage of nomadic communities in Niger consists in linguistic and cultural differences to the health personnel. Similar problems are described for minority groups such as the Roma in Eastern Europe or migrant labour. Thus, it will be necessary to employ personnel with a specific social, ethnic and cultural background for an effective and efficient delivery of priority interventions to the poorest and most disadvantaged.
The size and composition of the workforce will determine if priority interventions can be delivered effectively and efficiently. Countries such as the United Kingdom, Ghana, Mauritania or Zimbabwe report deficiencies of personal with specific skills (e.g. the UK reports huge shortages in nurses). Scaling-up of interventions will require staffing of health services with appropriate skill mixes. Regions with high HIV/AIDS prevalence are likely to rely on other skill mix patterns than regions where acute respiratory infections in children or malaria are predominant. Thus, it will not be enough to develop and implement staffing norms across a country, but to allow for variation based on cultural contexts and current and future epidemiological patterns of priority diseases.
More generally, organisational and management issues at the health sector level influence performance and productivity. Setting correct incentives in the health sector will be of crucial importance for having the right skill mix at the right place and for addressing geographical imbalances in the distribution of HRH and for establishing appropriate staffing patterns. For example, career plans, salary levels, recruitment, appointment and retention procedures will strongly affect where health workers practise and whether they stay in the health sector.
Salary level is strongly linked with motivation and retention. In many countries salaries of the governmental health sector workforce are low, in both absolute and relative terms. In Tajikistan, for example, the monthly pay of family physicians corresponds to around US$ 10, while for covering basic needs at least a tenfold amount is necessary. Parallel activities, such as working during the morning shift for a public provider and in the afternoon for a private one is a common strategy to complement low salary levels. In order to retain health staff at the work place and in the health sector, it will be necessary to consider salary increases. As in many countries HRH absorb already an important part of sectoral budgets (often around 80%), a significant increase in the pay of health sector workers may reveal difficult in terms of preferences and choices to be given to salary expenditures and in terms of the economic and political feasibility.
However, the experience of countries which have used monetary incentives for addressing motivation and imbalances in the geographical distribution of health workers indicates that non-monetary incentives are as important. In Thailand, the results of an increase in remuneration and the improvement of living conditions offered to those who work in rural areas could not reverse geographical imbalances. Other factors such as proximity to the family, continuous education, opportunities for research and teaching also influence an individual’s decision where to work.
In many countries, the scaling-up of priority interventions will require new personnel to be trained, especially general practitioners and nurses. Or, to work as a public health doctor is seen by a lot of physicians as less attractive than to practice as specialist.
Scaling-up of priority interventions is likely to require significant investments into training capacities. Given the lead-time required to produce new health workers, such investments must occur in the early phases of scaling up. With regard to initial training, appropriately trained staff will require significant changes in medical and nursing curriculum, pedagogical methods, and in admission criteria. The focus of medical training will need to shift from hospital to primary care assignments. Further, administration and management skills and/or the training of district managers will require attention. More generally, training approaches will need to tie into national health policies and priorities and respond to required HRH skill patterns.
Good governance and overall policy framework
The scaling-up of priority interventions is intimately linked to ongoing reforms in the health sector. Decentralisation, the promotion of private practice, new financing and payment schemes, hospital and/or pharmaceutical reforms are currently promoted in many countries as a means to improve performance and outcomes of national health care systems. The development of HRH will need to tie in to these reforms. Thus, coherent and well-formulated national HRH policies and strategies are required for giving direction on HRH development and on how HRH relate to health sector reform issues (e.g. decentralisation, public-private mix), the scaling-up of priority interventions, poverty reduction strategies, and training approaches.
In many countries the development of coherent HRH planning approaches is of low priority and respective planning departments are badly equipped, both, technically and personnel-wise. Recently it was pointed out that even countries such as Australia, France, Germany, Sweden and the United Kingdom have a partial approach to planning of the health sector workforce and that the relationships between different categories of health professions is ignored. More specifically, nurse workforce requirements for addressing disease patterns of the population are neglected.
The socio-political and economic situation of a country will largely determine human resource constraints for achieving the Millennium Development Goals. Many factors will influence in an important way whether and where health professionals will practice: e.g. political stability, priority accorded to social sectors, the overall policy framework, governance, and accountability.
Emigration of medical professional illustrates this. Recruitment policies, immigration laws and regulations in better off countries induce whether there is a demand for health professionals in high-income countries. Opposite, living conditions in a low-income country will determine whether health staff is encouraged to leave the country. With various high-income countries such as the USA, UK, France having a high demand for health professionals trained outside their country, there is a growing concern that they absorb large numbers of health staff from low- and middle-income countries. For example, it is reported that the US is short of several hundred thousand nurses and that the high demand for medically trained staff is not likely to be reversed in the coming years. In contrary, for Africa it is estimated that around 23 000 qualified academic professionals emigrate annually or for Ghana it is estimated that over 50% of doctors having graduated are living and practising outside the country.
Unless there is no possibility to address at the same time pull factors of migration in high income countries and push factors in low-income countries, investments in medical and nursing training are likely to be in vain. Thus it will crucial to elaborate and implement well balanced and solidly elaborated national retention strategies.
In summary, there are many mutually connected and interrelated challenges for typical low-income countries in sub-Saharan Africa or Central Asia for addressing HRH related issues in the context of scaling-up priority interventions towards the Millennium Development Goals. Essential elements of successful improvement of HRH problems consist in the elaboration and implementation of strategies that fit into health sector reforms and the political and macroeconomic context. Efforts to improve HRH should consider available human and financial resources, be in line with government administrative policies and should promote consultative policy-making processes and ownership at country level.
SDC support to the development of a HRH policy in Tajikistan:
The Swiss Agency for Development and Cooperation supported ”Tajik – Swiss Health Sector Reform and Family Medicine Support Project” (project Sino) focuses, among other elements, on institutional and human resource capacity building. In this context, the development and subsequent implementation of HRH related policies is seen as key for the country’s ability to retain and utilise existing staff and guarantee the stability required to achieve medium and long-term health sector reform objectives. More precisely, project Sino is assisting the Ministry of Health in elaborating a national policy for training in the area of family medicine.
A national expert group representing various Tajik key stakeholders (Ministry of Health and relevant training institutions) reviews past and current achievements and problems with regard to training of family doctors and nurses. Activities of the expert group are assisted by technical assistance provided by the Swiss Centre for International Health of the Swiss Tropical Institute which feeds into the policy elaboration process relevant international experiences. Results are actively shared with major partners of the Ministry of Health (World Bank, Asian Development Bank, WHO, etc.).
In a second step the expert group establishes a needs assessment for initial training and re-training of physicians and nurses for all parts in Tajikistan. The expert group also realistically estimates expected enrolment rates (current enrolment rates into the graduate program for family medicine are extremely low) and the specific curriculum changes required to modify the existing university program (e.g. team approach, interpersonal communication skills, management). Costs of these activities are estimated taking into current and potentially future national and external resources. The policy elaboration process is seen as a concerted action involving all relevant institutions and donors through the regular conduct of feed-back workshops.
*Kaspar Wyss (email@example.com) is public health specialist at the Swiss Centre for International Health of the Swiss Tropical Institute and coordinator of SDC mandate ”Tajik – Swiss Health Sector Reform and Family Medicine Project” (project Sino). Recently his interest has focused on human resource development in the context of the Millennium Development Goals. Daniel Mäusezahl (firstname.lastname@example.org) is epidemiologist and health advisor at the Social Development Division of SDC. This work has been done in the of a mandate by the SDC health desk. Further information on SDC activities in health can be found at www.sdc-health.ch.
SDC health projects in Tajikistan: www.sdc-health.ch/priority_countries/cis/tajikistan