Responding to the health workforce crisis

The shortage of health workers with the right expertise and experience has reached crisis levels in many developing countries. The ability of health services to deliver care depends on the knowledge, skills and motivation of health workers. Without enough skilled staff in the right place at the right time health systems cannot function effectively and populations are left without the treatment and support they need.

Community health volunteers in Nepal test materials developed for the distance education Radio Health Programme.
© 2005 Buddhiman Shrestha/CCP, Courtesy of Photoshare

The human resources (HR) crisis is now firmly on the international policy agenda. The work of the Joint Learning Initiative and the High Level Forum on Health has described the magnitude of the HR challenge, identified the key contributory factors and defined some of the potential solutions. As Gilles Dussault highlights in this issue of id21 insights, without coordinated action to address the HR crisis, health systems will not deliver the care required to meet the Millennium Development Goals (MDGs). There is an urgency to expand and upgrade the health care workforce through a rapid increase in staff numbers, skill enhancement and improvements in productivity.

Challenges

The main challenges facing developing countries are familiar to any health sector manager or policymaker:

• The health sector workforce is large and diverse and comprises separate occupations often represented by powerful professional associations or trade unions who pursue their members’ interests.
• Health systems tend to be characterised by a broad range of active stakeholders, such as professional associations and different government departments, with a high level of direct and indirect governmental and regulatory intervention, and 'top-down' attempts at reform.
• Health is labour intensive. The proportion of the total expenditure spent on staff, at 60 to 80 percent, is much higher in health than in most manufacturing industries, and in many service industries.

Pressures on under-resourced health sector workforces are heightened by the impact of HIV/AIDS. Health workforces in parts of sub-Saharan Africa are hit by HIV related increases in workload, higher stress levels and increasing death and absenteeism rates.

Responses

The workforce is the most important but also the least predictable aspect of planning and managing health systems. HR permeates every aspect of health care delivery, but has often been overlooked in health policy making – in the past it has often been an afterthought. This has now changed. The big challenge is no longer to advocate and demonstrate that HR is important, it is to implement HR policies that deliver more effective care.

Not all HR policy solutions will work equally effectively. For example, decentralisation is not in itself the answer. It brings with it the increased need for better management, as noted by Tim Martineau. Some solutions are only relevant for specific occupations or professions, while others may work in one health organisation, system or culture, but be inappropriate or ineffective in another. Some will have unintended consequences, as highlighted by Ken Sagoe from Ghana Health Services, where an attempt to improve staff retention by providing a financial incentive reportedly angered and distanced nurses.

Recruitment and retention

Pay in some countries is insufficient to provide health workers with a living wage. Some workers have to resort to informal and unregulated work in public and private health sectors (dual practice), theft, or bribes from patients. Donor financial support, such as the UK Department for International Development funding to raise health workers’ pay in Malawi, is an example of more direct donor action of the type that Gilles Dussault describes.

Movement of health workers

Some health workers have sector-specific skills, but migrate from health sector employment in one country to a similar post in another country; while others move from the health sector to employment in other sectors. Health worker migration is a symptom of deeper issues linked to poor career opportunities where resources are limited, and inadequate planning and underinvestment in countries that are better resourced. James Johnson argues that developed countries need to become self sufficient in meeting their own health workforce requirements, but the biggest English speaking health care labour market – the USA – will have to be involved in any initiative if self-sufficiency is to work.

A more positive aspect of health worker migration, discussed by Eldred Parry, represents an opportunity for health workers from developed countries to make a contribution to developing countries. If well planned in cooperation with the destination country this can often provide additional specialised expertise and the individuals involved can experience personal and professional development.

Large scale 'volunteerism', however, with the temporary mobilisation of thousands of health workers from developed countries, is not necessarily the best use of resources, even in a crisis situation where immediate action is required. Resources may be better invested in training community health workers already in the country.

The right skills in the right place

The HR crisis requires a creative response that sets aside old constraints and regulations. As Dela Dovlo discusses, using substitute health workers (SHWs) to take on the priority roles of health professionals, may be a time and cost-effective option. The use of SHWs, as in Tanzania and Mozambique, is most effective when they are matched to the best mix of skills and staff to deliver care using available resources for a population.

However, the primary purpose of using SHWs must not be to create workers who cannot migrate because they have different or lower skills than required by international standards. The chances are some will migrate in any case: well qualified nurses from developing countries are working as unqualified care assistants in care homes in developed countries where their qualifications are not recognised. SHWs must be used where they make economic sense and have the right skills to make a quick and positive difference to health care delivery.

Even if they have the right skills, health workers are not always in the right place to make the most effective contribution. As noted by Kasper Wyss, the poor distribution of health workers aggravates the impact of staff shortages. This problem often reflects a situation where the best opportunity for a living wage is in urban areas and where any attempts at controlling staff location are compromised by poor management.

New approaches to motivating staff to move to or remain in rural areas can make a difference. To be successful however, any changes have to be linked to improved management practice, and the integration of paid employees who are either absent without leave or located elsewhere within the health system.

Moving forward

Health HR policy making must open its eyes to good practice in other sectors. There is strong evidence from research in some health systems, such as the USA, and other sectors such as manufacturing and finance, that coordinated human resource policy and practice can improve productivity and performance.

• There is a need to ensure that HR interventions fit the characteristics, context and priorities of the organisation in which they are to be applied.
• Coordinated interventions are more likely to achieve sustained improvements in HR practice than single or uncoordinated interventions. In the often politicised health sector this is an important message.
• A rapid and substantial injection of resources required to increase health workforces is critical to achieving the health MDGs. Yet it is not just about getting and keeping an adequate number of health workers to meet a target or comply with a plan: it is about supporting and motivating health workers to make the best use of their skills. The ultimate goal is not more health workers, it is better care.

James Buchan
Queen Margaret University College
Clerwood Terrace
Edinburgh EH12 8TS
UK
T + 44 (0) 131 317 3600
F +44 (0) 131 317 3605
jbuchan@qmuc.ac.uk

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