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Human Resources for Health
A Worldwide Crisis
Thomas L. Hall, MD, DrPH
Nicole Bores Univ. of California at San Francisco
September 2007
Prepared as part of an education project of the
Global Health Education Consortium
and collaborating partners
Page 2
Learning objectives
1. Appreciate the importance of the health workforce
2. Understand factors affecting workforce supply and requirements, and basic methods for their estimation
3. Learn about the variables affecting workforce distribution and interventions to improve distribution
4. Appreciate management issues that contribute to the workforce crisis
5. Recognize difficulties in estimating supply, requirements, and in making workforce changes
6. Understand changing health workforce priorities, and the implications for the future
Page 3
Frequently used Terms
• Human Resources Development (HRD)
encompasses the planning, training and
management of the health workforce
• Human Resources for Health (HRH) replaces the
earlier term “Health Manpower”
Workforce categories are on the following slide
HRH Category Type of Health Workers Educational Preparation Skills and Tasks
Researchers, Teachers Faculty members, lecturers,
laboratoy researchers,
pharmaceutical developers
Post-basic university
(Masters, PhD)
Developing new knowledge, preparing health
professionlas and others for entry to the workforce,
working with policy makers to implement new
knowledge into policy and practice
Health Professionals Doctors, nurses, dentists,
pharmacists, psychologists,
physician's assistants
Tertiary (professional college,
university)
Diagnosis and treatment of illness, hospital and
community care, promotion of health, education
about health, dispensing and supervision of
medication, public health, monitoring and
improvemnet, maternal and child care, mental
health and emotional care and support
Vocational Workforce Nursing aids, dental aides,
theatre technicians, laboratory
technicians, medical
assistants
Secondary school, college Home based care, assisting health professionals,
education and support for individuals, families, and
communities, technical support
Traditional Healers Curanderas, Shamans Varied Healing, counseling, use of traditional and natural
medicines
Community Level
Workers
Village health workers,
Community health workers
On the job local training,
primary/secondary school
Home based care, managment of simple family
health problems, sanitation, environmental health,
health education and promotion, supervision of
daily medication routines
Informal Workers Volunteers, home caregivers
(family and non-family)
Non specific to caring role,
informal education and
support from health workers
Practical care for sick family or community
members, supervision of daily medication
routines,transporting inddividuals in clinics and
hospitals, emotional support, community health
promotion
Non-Health Workforce in
Health Sector
Drivers, accountants,
managers
Varied Many skills to support health workforce
Source: Human Resources for Health: Overcoming the Crisis. Joint Learning Initiative, 2004.
Workforce categories and their functions
Page 5
Why is the health workforce important?
• The workforce is the primary determinant of health
system effectiveness. There is….
– No substitute for trained personnel applying skills
appropriately, at the right time, in the right place, to
address priority national health needs
– Ample evidence of a positive association between
worker quality and numbers with immunization levels,
primary care outreach, and mother and child survival.
Page 6
Why is the health workforce important?
• Health workers are most costly component of health system
– Personnel are 50-80% of recurrent public health sector
budget
• As % spent on staff increases, less money is
available for drugs, equipment, supplies, etc.
• Managers can delay purchase of drugs, supplies and
equipment but can’t delay salaries
Page 7
Why is the health workforce important?
• In sum, the health workforce…..
– Spearheads and glues together the health system
– Drives health status changes essential for development
Page 8
Health workforce priorities since 1945*
• Worldwide priorities, as reflected by WHO
policies and programs and by efforts in
developing countries, have undergone major
changes over the decades, by turns putting
emphasis on different qualitative, quantitative
and distributional aspects of the health
workforce
*Adapted and updated from Roemer and Fulop, WHO, 1978
Page 9
Health workforce priorities since 1945
• Increase numbers (1940s – ’60s)
• Attain international quality standards (1950s – ’60s)
• Match or exceed HRH ratios of peer countries (1960s)
• Expand use of multi-purpose auxiliary personnel (1970s)
• Improve geographic coverage (1970s – ’80s)
• Increase training efficiency (1970s – ’80s)
• Strive for more rational HRH planning (1980s – 90s)
• Increase training relevance to national needs (1990s)
• Increase numbers (and relevance) (2000s…)
• Introduce policies to reduce brain drain (1990s-2000s)
Page 10
Components of an effective workforce
• An effective health workforce is characterized by having:
– the ‘right’ number of health workers
– in the ‘right’ mix of different worker categories
– with the ‘right’ training
– in the ‘right’ places
– at the ‘right’ time
– providing the ‘right’ and ‘effective’ services
– to the people who need them
– at an affordable cost
• Creating a workforce that meet these characteristics is extremely
difficult, as the rest of this module will show.
Page 11
Working lifespan approach to workforce dynamics
*Unless otherwise noted the tables and figures are from ”Working together for health:
The World Health Report 2006. WHO, 2006, 209 pp.
Entry:: Preparing the Workforce
Planning
Education
Recruitment Workforce:
Enhancing worker
performance
Supervision
Compensation
Systems support
Lifelong learning
Exit: Managing attrition
Migration
Career choice
Health and safety
Retirement
Availability
Competence
Responsiveness
Productivity
Page 12
Projecting the supply of health personnel
• For each occupational category, eg, doctors, nurses…
– Base year active* health worker supply, plus…
– Annual new graduates, plus…
– Annual flow of health workers into country, minus…
– Annual flow of health workers out of country, minus…
– Losses to base year active health worker supply and to new graduates, equals…
• Target year active supply
*”Active health worker supply” refers to those who are working in the workforce
Page 13
Supply projection problems
• However, calculating the projected supply can be
complicated
– Determining data inputs (numbers, ages, work
locations, etc.) are relatively easy to obtain and
accurate (at least in industrialized countries).
– Determining data outputs (ie, projections),
however, even using the same base year, input
data and target year, can result in wide variations
in projections of the effective workforce
Page 14
Supply projection problems
• Supply projections are subject to important uncertainties.
• Projected work hours or FTEs (full-time equivalents) vary due to….
– Age at retirement
– Rates of in- and out-migration of personnel
– Gender ratios: Women work less…
• Weeks/year, hours/day, years/career
– Hours worked, by age (as age increases hours worked per year decrease)
– Hours worked by specialty
– Patients seen per hour
– Hours worked by sector (public & private)
Page 15
World supply of health workers varies widely
• Wide regional variability in worker density due to:
– Different training intakes
• Wide variation in school numbers and capacities
– Different graduation rates
• Up to 50% attrition of students during course of studies
– Different retention rates in service due to:
• Early retirement (before reaching pensionable age)
• Change of occupations (outside of health sector)
• Early pensionable age of retirement (55-67 years, with average of 58 in Africa and 55 in SE Asia)
• Migration to other countries (“Brain Drain”)
Page 16
World supply of health workers varies widely
• In most countries there is a gross under-production of
health workers
– Too much emphasis placed on training high status,
high income occupations, leading to shortages of
technical and support staff
– Severe faculty shortages limits training opportunities
– Much training is didactic, rote learning with limited
hands-on clinical and field experience, leading to a
poorly qualified health workers
Page 17
Projected declining supply of health workers in Africa based on current trends
-
50,000
100,000
150,000
200,000
250,000
300,000
200
0
20
01
200
2
200
3
20
04
200
5
200
6
20
07
200
8
200
9
20
10
201
1
201
2
20
13
201
4
201
5
Nu
mb
ers
Years
Physicians Nurses/Midw Prof
Projected declining supply of health workers in Africa
based on current trends
Page 18
Regional disparities in the numbers of medical schools and of their graduates
Page 19
Global Health workforce, by density
Conclusion: There is a tenfold regional variation in health workers per 1000 population.
Page 20
Case study
A Latin American country in the mid-1960s had 5000 practicing
physicians, many under-employed despite very inadequate health
services for most of the population. At the five medical schools, 20% of
recent graduates found no employment. The rate of doctor emigration
was high due to the over-supply of doctors relative to the country’s
economic capacity to support them. In addition, 5000 students from this
country were studying medicine abroad and likely to return on
graduation. Despite an evident doctor surplus three new medical
schools were opened, in part to give faculty jobs to under-employed
doctors.
*T.L. Hall, personal observation
A doctor ‘surplus’ in the face of severe national
‘need’ for health care*
Page 21
Requirements: The basics
• Supply and requirements are two sides of the same coin; one
without the other is of little use for planning
• Central problem – to convert the projected population to the
required (and affordable) personnel
• Four ‘conversion’ methods
– Ratio method: directly converts population into personnel
– Other methods converts population into services, and then
services into personnel using FTE (full-time equivalent)
productivity norms
• Eg, if 20 million doctor visits are ‘required’, and if the average
FTE doctor produces 6000 visits/year, then 3333 FTE doctors
are ‘required’ for that component of service requirement (20M ÷
6000 = 3333)
Page 22
Projecting requirements: Four methods
• Ratio method (population-to-personnel, eg, 1 doctor per 1000
population, 1 nurse per 500 population)
• Needs method (for health services based on professional
judgments, eg, GMENAC* study in US in late 1970s for >30
occupations; an elegant but costly and complex) study that had
little effect on policy
• Demands method (for health services based on self-perceived
needs, access to services & ability to pay)
• Targets method (for production of services to meet specified
targets based on both ‘needs’ and ‘demands’)
*Graduate Medical Education National Advisory Council
The next 3 slides provide brief descriptions of each method and
comments on their merits and limitations
Page 23
The central task is to convert population into health personnel. There are two major routes, (1)
directly from population into personnel, and (2) via an intermediate step of services required or to be
delivered. The sections presented below show the paths followed in four generic methods, here
termed: Personnel-to-Population Ratios, Health Needs, Service Demands, and Service Targets.
PERSONNEL-TO-POPULATION RATIOS METHOD
Population to be served, occasionally disaggregated according to selected geographic or other
major variables
Population is converted into personnel requirements using desired, normative, or empirically
determined personnel-to-population ratios, e.g., one doctor per 4000 population, one nurse per 1500
population, one anesthetic nurse per surgeon.
HEALTH NEEDS METHOD
Population to be served, disaggregated according to age, location, and perhaps other characteristics
Estimate incidence and prevalence of illnesses and injuries for each population segment (children,
pregnant women, youth, working population, elderly, etc.)
Estimate services according to provider, type of service, and time required to meet the
professionally-determined needs for each type of illness or injury
Convert required services into health personnel requirements by use of normative staffing and
productivity standards, e.g., one full-time equivalent doctor can produce 6000 general ambulatory
visits per year.
Major Approaches to Estimating Requirements (1)
Page 24
SERVICE DEMANDS METHOD
Population to be served, disaggregated according to age, location, and perhaps other characteristics
Estimate population-specific utilization rates for the diverse types of services (e.g., doctor visits,
dentist visits, hospitalizations) produced by the sector multiplied by the numbers of persons in each
population segment
Convert services into health personnel requirements by use of normative staffing and productivity
standards
SERVICE TARGETS METHOD
Population to be served, perhaps disaggregated according to selected major variables
Health service targets are specified by experts taking into account priorities, health wants and needs,
and technical, administrative, and financial feasibility of providing health services. For example,
service targets might be set for pregnant women, infants, young children, and for services to the
general population. These targets would be averages, taking into account many variables and
recognizing that some persons in each target group would get more services than the target and
others less or none.
Convert services into health personnel requirements by use of normative staffing and productivity
standards.
Major Approaches to Estimating Requirements (2)
Page 25
SUMMARY OBSERVATIONS
The ratio method is easy, has been widely used in the past, but has many serious deficiencies. It is like a
black box; ratios go in, workforce numbers come out, but it has no explanatory value, no intermediate
assumptions, and does not lend itself to exploring the effects of one or another variable. The ‘needs’ and
‘demand’ methods require very large amounts of data and are not realistically feasible in low income
countries though they have been used in a few circumstances. The target method is considerably easier but
still requires substantial data and many assumptions. All of the methods have been used in a wide range of
countries, the needs and demands methods primarily in more developed countries. Major problems
encountered in projecting requirements include:
• The difficulty governments have developing, and sustaining, policies beyond 3-5 years. Most projections
are for short periods even though significant changes in the size and composition of the trained health
workforce take at least 10 years and more realistically, 15-30 years to accomplish.
• Use of an inappropriate projection method for the country’s health care system, its ability to implement
policy, its ability to do sophisticated planning, and/or the availability and quality of baseline data.
• The lack of coordination and at times, cooperation, between the public and private sectors. This is
especially true in the case of public and private training institutions such that training school capacity is
either well below or above the country’s capacity to absorb the graduates.
• The reality of highly uncertain occupation-specific loss rates that result from early retirement, job
changes, and emigration to other countries. If a country can’t anticipate losses it makes projection of
requirements even more difficult.
Major Approaches to Estimating Requirements (3)
Page 26
PROJECTION OUTPUTS
- demographic estimates
- economic estimates
- required health workers by
type & specialty
- economic feasibility
- proportion spent on HRH
- hospital utilization rates
- ambulatory utilization rates
- base-target year analyses
- projection comparisons
- projection aggregations
BASELINE DATA
- population size
- GDP
- expenditure data
- workforce supply
- work settings
- services produced
- workforce incomes
PLANNING ASSUMPTIONS:
- # work settings by type
- average staff norms
- average productivity
GROWTH RATE ASSUMPTIONS
- population growth
- gross domestic product
- public & health sector expenditures
- workforce incomes
A framework for projecting personnel requirements
Page 27
World requirements for health workers
• Little information is available about the ‘need’ for health workers
• WHO has identified a ‘threshold’ health worker density below which
essential interventions, including those necessary to reach the
Millennium Development Goals (MDGs), cannot be delivered.
– 57 countries fall below this density
– There is an estimated shortage of 2.4 million doctors, nurses and
midwives
• Lack of planning for the public and private sectors has led to a failure
to account for the competition over personnel between these sectors.
The United Nations Millennium Development Goals include the following: 1. Eradicate extreme poverty and hunger. 2. Achieve universal primary education. 3. Promote gender equality and empower women. 4. Reduce child mortality. 5. Improve maternal health. 6. Combat HIV/AIDS, malaria and other diseases. 7. Ensure environmental sustainability. 8. Develop a global partnership for development.
Health workforce shortages, inappropriate geographic distribution, and training deficiencies are all major contributors to the difficulties faced by countries as they seek to meet health-related Millennium Development Goals. Source: United Nations Millennium Development Goals, http://www.un.org/millenniumgoals
Page 28
Countries with a critical shortage of health service providers
Page 29
Population density of health care professionals
Conclusion: To attain 80% coverage of skilled birth attendance requires
2.3 key health workers per 1000 population. The majority of countries
fall below this requirement.
Page 30
Distribution of health workers by level of Health expenditure
Conclusion: Areas with increased disease burden, and therefore increased
demand for health workers, have a smaller percentage of the global health
workforce, demonstrating mismatched supply and demand.
Page 31
Case study
• Malawi* has a very low health staffing density, even for Africa. Of 27 districts, 15 districts have less than 1.5 nurses per facility, and 5 districts don’t even have one nurse. Four districts have no doctors. Despite this, there are 800 qualified nurses in Malawi who don’t work in health.
• A six-year Emergency Human Resource Development Programme was established to resolve these health workforce staffing problems. $278 million was provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria and other donors. Policy changes included improved incentives for recruitment and retention, increasing domestic training capacity, and interim reliance on expatriate staff. The early results of this initiative are encouraging.
*WHO. Working together for health: The World Health Report 2006. pp.144-146.
Matching supply & demand
Page 32
Health worker distribution is very uneven
• By geographic location (urban / rural)
• By sector (public / private)
• By clinical specialty
• By level (within the health hierarchy)
• By ‘mix’ (type of health worker, eg, doctor,
nurse, technician, auxiliary)
• “Brain drain” away from the home country
Page 33
Geographic distribution
• There are huge rural / urban disparities in most countries
• Cities are considered more desirable, especially for
professionals who:
– Generally come from and are trained in cities and towns
– Have less support of all kinds in rural areas, and hence
are less able to feel professionally fulfilled
– Find rural living conditions more difficult
– Fear that being “out of sight” will leave them “out of mind’
for further training and advancement
Page 34
Rural-urban distribution of health service providers
Conclusion: While only 54% of the world’s population lives in urban localities,
greater than 75% of doctors and 60% of nurses live in urban areas.
Page 35
Strategies for improving distribution
• Mandatory rural internship as a prerequisite to full licensure
• Improved incentives for rural service practitioners
• Use of paramedicals
– Medical assistants, nurse practitioners, midwives, dental nurses,
community health workers, etc.
• Implement cost-of-education payback policies
• Encourage part-time private practice after hours
• Improve employment conditions
• Require prior community service as prerequisite for public sector
employment
• Preferentially recruit applicants with rural backgrounds
See the next 3 slides for additional comments about the
options for reducing geographic maldistribution
Page 36
Options for Correcting Geographic Maldistribution (1)
Below are expanded descriptions of the modalities and potential concerns of the options
for correcting uneven geographic distribution presented in the slides.
1. Mandatory rural internship as prerequisite to full licensure. This may be inadequate for
providing quality care in rural areas as interns often have little or no explicit preparation for
rural service and are the least qualified to serve in difficult, isolated positions where they
have little or no supervision and support. Interns may also return to urban areas on
completion of their required service with a firm commitment never to return to rural areas.
Furthermore, they may use their connections to avoid rural service and thus introduce
inequities into the system. This policy can also give the government the illusion that if a
doctor or nurse is posted to a rural area, health needs are thereby met, despite the
limitations of these posted interns.
2. Improved incentives for rural service practitioners. These incentives can include higher
pay or more rapid salary advancement for those in rural service, as well as preferential
selection of rural residents for training (a policy which has shown some positive effects in
the USA). Promoting research into the obstacles of rural service could be beneficial, as
well as promotion “regionalization” of services, whereby strong referral, training and
supervisory linkages are made between different levels of facilities in the region.
Page 37
Options for Correcting Geographic Maldistribution (2)
3. Use paramedical, (e.g., medical assistants, nurse practitioners, dental nurses,
community health workers). These personnel are less likely to seek metropolitan locations
and are often “closer” in language and customs to the people they serve. Higher level
paramedical, e.g., physician assistants, nurse clinicians, extended duty dental personnel,
can meet up to 70% of patient needs as well as generalist doctors and dentists can.
However, it is important to ensure that there is professional backup and team training so
that each level knows what to expect from other levels in the team, and opportunities for
career progression in the rural setting.
4. Implement cost-of-education payback policies. If student loans were provided, loan
balances can be reduced by x% for each year of rural service. Alternatively, if
professional education was provided at a low, subsidized cost, a professional with no or
limited community service could be charged for the full cost of education.
5. Encourage part-time private practice after hours. This practice could occur in either a
private office or facility, or a public facility (= “geographic full-time”). Offering use of public
facilities is especially valuable for specialties requiring much equipment (e.g., radiology,
dentistry, surgery). If this approach is taken, it is Important to monitor the practice carefully
in order to minimize abuse.
Page 38
Options for Correcting Geographic Maldistribution (3)
6. Improve employment conditions. Provide housing, a vehicle, continuing education,
regular supervision and communications with higher level facilities, better staff support
and equipment, an education allowance for children, increased vacation leave.
7. Require prior community service as a prerequisite for public sector employment. Many
health workers will want eventual part-time government employment which offers a more
stable income, sick and vacation leave and perhaps a pension. It would also be useful to
include this prerequisite for academic employment.
8. Preferentially recruit applicants with rural backgrounds. This could be done through
community nomination and/or selection. Providing academic and mentoring support to
these nominees will ensure completion of training. Alternatively, shifting more
postgraduate training to provincial and district hospitals will encourage rural “location
decisions.”
Page 39
Case Study
Multiple strategy “packages” are more effective than relying solely on
compulsion. Chile applied these policies in the 1960s. Faster salary
advancement was provided for those in rural service, with a 20%
increase after 3 years in rural service, as opposed to 5 years in an urban
area. Rural service became a requirement for government jobs.
Rewards for rural service included support for advanced specialty
training and annual awards and publicity to superior doctors.
*T.L. Hall, personal observation
Improving distribution in Chile*
This policy was in use during the 1960s and was observed by the author. Though to my knowledge the
effects of this multi-dimension policy have not been documented, it appeared to be very effective. Without
being compulsory it presented powerful incentives, especially the assurance of post-graduate specialty
training, faster advancement, and access to government positions in the future. Relatively few doctors,
especially recent graduates, can make a living entirely in the private sector. The three-year assignment
also was much more effective than the more typical one or two-year rural internship. A nice touch, though
not a major factor, was the annual invitation to last year rural doctors to submit essays on their experiences
and observations over the course of their rural assignment. A panel of the Colegio Médico of Chile
reviewed the essays, picked the winners, and they were invited to fly to Santiago to present their findings.
Page 40
Case Study
• A policy of posting two recent graduate doctors to each
health center instead of one has these results….
– Half as many health centers have doctors
– Less centers are compensated by more health posts
– Two center doctors can alternate visiting health posts
– Two center doctors can alternate “on call” time
– Two center doctors provide each other support
• Regional hospitals provided additional support to the health
centers.
Improving distribution in Chile
Page 41
Distribution by ‘sector’
• Private sector tends to have more desirable work conditions
than the public sector:
– Greater urban emphasis
– Higher unit costs for services
– Higher staff incomes
– Better facilities and equipment
• Sectoral imbalance in working conditions can lead to attrition
from public to private service
• Furthermore, private sector gives more emphasis to
specialty services and less to prevention and public health.
Page 42
Distribution by specialty
• All health systems need specialists, but…..
– Methods for determining specialist requirements are
relatively crude and seldom used
– Procedures for allocating specialty training positions
according to need are often weak or non-existent
– Postgraduate training may overemphasize specialization
• Specialists require more costly specialty equipment and
services than generalists
• More specialists, if in surplus, can result in specialists
providing generalist services, at additional costs
Page 43
Distribution by health worker level
• The health workforce should be shaped like a pyramid
– Small numbers of high level, high cost professionals
• Doctors, dentists, pharmacists
– Larger numbers of mid-level personnel
• Nurses, midwives, technicians, therapists
– Still larger numbers of support personnel
• Auxiliaries (nurse auxiliaries, cooks, drivers,
orderlies, clerks, maintenance staff, community
health workers)
Page 44
Optimal mix of mental health services Just as a
‘personnel
pyramid’ is
important to
minimize high
cost personnel,
so too is a health
service pyramid’
that minimizes
high cost
in-patient
services
Page 45
Distribution by level of health worker
• Student and university pressures may result in too much
emphasis on high level categories resulting in an
‘hourglass’ configuration rather than a pyramid
– Higher expenditures on professionals results in less
funds for mid- and lower-level personnel
– Relative shortage of mid-level personnel reduces
productivity of high-level personnel
– Doctor supply may exceed economic demand for
medical services, leading to underemployment,
unnecessary services, emigration, or early retirement
Page 46
Case study
• An African country* in the 1990s had 16,000 nurse auxiliaries.
The government decided to stop auxiliary training and replace
auxiliaries with four-year university nurses earning twice as
much.
– Projected short term effects showed little change since most
auxiliaries would still be in the workforce.
– Projected long-term effects, after retirement of many
auxiliaries and rapid population growth, showed a steep
nurse-to-population ratio drop and a large cost increase.
• The decision was reversed.
*T.L. Hall, personal observation
The importance of auxiliary staff
Page 47
‘Brain drain’: International migration
• Brain drain is a major and growing problem. It is the
emigration of trained personnel to other nations
• Causes are both obvious and complex
– ‘Pull’ factors that pull health workers away from
home to another country
– ‘Push’ factors that push workers away from home to
another country
Page 48
The upward and outward migration of health personnel
Page 49
Doctors and nurses trained abroad working in OECD countries
Conclusion: Foreign-trained doctors account for up to 34% of total and foreign-
trained nurses for up to 21% of the total found in OECD countries.
Page 50
Doctors trained in Sub-Saharan Africa working in OECD countries
Conclusion: Almost one-fifth of SSA-trained doctors are working abroad
Page 51
Brain Drain - Pull factors
• Pull factors that pull personnel to other countries:
– Higher salaries, benefits and chances for
advancement
– Better living, educational and other opportunities
– Family and friends already in destination country
– Better equipment and support staff
– Greater personal safety
– Recruiting bonus
Page 52
Brain drain – Push factors
• Push factors that push workers away from home
– Poor working conditions, lack of peer and staff
support, supplies, equipment
– Low salaries, benefits, small pensions
– Limited opportunity for advancement
– Physical insecurity
• Random and directed crime and violence
• Kidnappings, terrorism, civil wars
• Risk of HIV, tuberculosis and other infections are
reducing health worker life expectancies as well as
the rest of the population
Page 53
Health workers’ reasons to migrate in four African countries
A higher income
is not the only
important factor
in brain drain
Page 54
Brain drain – Push Factors
• Remittances to families in the home country are a major
consideration in some countries (eg, Philippines)
– Remittances can account for a significant % of
national GDP and foreign exchange earnings
• Some countries train “for export”
– Countries are proud of international acceptance of
their graduates
– English-language training enhances employability,
e.g., Anglophone African countries, Philippines
Page 55
Reducing Brain-Drain pull factors
• Increase training capacity in recipient countries
• Reduce or limit overseas recruitment, and ensure
ethical recruitment
• Set time limits on service; mandate return to home
• More stringent licensure and certification policies
• Require recipient country payments to donor countries
to pay for costs of training
Page 56
Reducing Brain-Drain push factors
• Improve workforce planning and implementation
• Increase public sector health expenditures
• Improve salaries & benefits, though this can introduce inequities
in public sector salaries
• Improve health system infrastructure and management
• Improve and provide more appropriate pre-service, in-service
and continuing education training
• Increase research and postgraduate training opportunities
• Change school culture, emphasizing ‘service’
• Reduce risks of infection & other hazards
• Provide incentives to repatriate health workers
Page 57
Productivity and management
• Administrative deficiencies greatly affect performance
– Deficient supply chains for drugs, equipment, supplies
– Inadequate and poorly designed and maintained facilities
– Poor or irregular transport and communications
– Inadequate or no staff supervision
– Lack of continuing education programs
– Lack of clear job definitions, with job overlaps and gaps
– Weak or no accountability for performance
– Deficient salary & benefit plans and mechanisms
– Inefficient deployment of personnel
Page 58
Case study
In a Latin American 1000-bed teaching hospital, three medicine wards were
under the supervision of one professor. Average patient length of stay was 22
days, 7 for diagnosis (x-rays, lab tests, specialist consultations), 10 for
treatment, and 5 for discharge (due to poor discharge planning and followup).
One ward was closed and ward personnel were reassigned to clinics for better
diagnostic and post-discharge services. Average patient stay decreased to 13
days, with 2 for diagnosis, 10 for treatment, and 1 for discharge. Besides
improving hospital capacity this resulted in less patient time away from family or
work.
Of note, in the same hospital, a different professor running a similar three-ward
section did not implement this obviously more effective system. An example of
the difficulty often encountered in transferring improved methods and
procedures.
*T.L. Hall, personal observation
Improved deployment of hospital staff*
Page 59
Why is the health workforce so challenging?
• HRH is the most complex component of healthcare
management, characterized by:
– Salary and benefits system complexities &
controversies
– Union pressures, strikes, slowdowns
– Complaints by the public and periodic scandals
– Misuse and abuse of resources
– Public-private sector tensions
– Diverse and often class-specific insurance schemes,
e.g., salaried vs. blue collar employees
– Significant geographical distribution issues
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Why is the health workforce so challenging?
• Workforce policies are often controversial, and governments
avoid making decisions in order to avoid conflicts with
professional associations, employees and training
institutions
• Legislators and the general public tend to equate more
doctors with better health, to the neglect of other inputs
• There may be weak coordination between public and private
sector training institutions
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Why is the health workforce so challenging?
• Personnel are the most costly component of the health
system, accounting for 50-80+% of the public sector health
budget
– As percent spent on staff increases, less money is
available for drugs, supplies, maintenance, etc.
– Managers can delay purchases of drugs, supplies and
equipment but not salaries
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Why is the health workforce so challenging?
• Workforce changes are slow and difficult
– Vested interests strive to preserve status quo
– A 10% change in medical student intake results in <3%
supply change in the first decade (“pipeline problem”)
– Decades necessary to make major changes in workforce
skills, attitudes and motivation
• In contrast, rapid changes can be made in the purchase of
drugs, supplies and equipment
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Why is the health workforce so challenging?
• Workforce database is often very deficient
– Incomplete coverage, especially of private sector
– Limited information on losses from schools, practice
– Lack of reliable, consistent registration systems
• Requirements projection methods tend to be costly and/or used
inappropriately
• Government planning tends to be short range, e.g., 3-5 years
• Governments have difficulty maintaining policies over several
decades as may be necessary for high level personnel
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Why is the health workforce so challenging?
• Workforce planning is often crisis oriented leading to a
short-term response for a long-term problem
• Decision-making is often fragmented and/or policy
coordination is poor between the many stakeholders,
including the Ministry of Health, Ministry of Education,
individual universities and schools, and private sector
institutions
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WHO Ten-year plan 2006-2015*
• WHO has established a comprehensive action plan to address the health workforce for the next ten years, taking into account the short, medium, and long-term.
• Immediate, 2006 objectives
– Cut waste, improve incentives
– Revitalize education strategies
– Develop common technical frameworks
– Pool expertise on workforce matters
– Advocate ethical recruitment & migrant worker rights
– Pursue fiscal space exceptionality
– Finance national plans for 25% of crisis countries
– Agree on best donor practices for human resources for health
*”Working together for health: The World Health Report 2006. WHO, 2006.
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WHO Ten-year plan 2006-2015
• 2010 mid-point objectives
– Use effective managerial practices
– Strengthen accreditation and licensing
– Overcome barriers to implementation
– Assess performance with comparable metrics
– Fund priority research
– Adhere to responsible recruitment guidelines
– Expand fiscal space for health
– Expand financing to half of crisis countries
– Adopt 50:50 investment guideline for priority programmes
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WHO Ten-year plan 2006-2015
• 2015 decade objectives
– Sustain high performing workforce
– Prepare workforce for the future
– Evaluate and redesign strategies, based on robust national capacity
– Share evidence-based good practices
– Manage migratory flows for equity and fairness
– Support fiscal sustainability
– Sustain planning funds for countries in crisis
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Summary
• The workforce is the key and most costly and
complex resource of the health sector
• Gross imbalances exist between the supply of and
requirements for personnel in low income countries
• Accomplishing major changes in workforce
numbers, distribution, qualifications, productivity,
mix, etc., is difficult and slow
• The brain-drain of professional level personnel is a
serious and growing problem
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General References
1. The health workforce literature is enormous and covers all phases of health workforce
development from planning to training and management. These publications will provide good
overviews to the field and recommendations for action.
2. WHO. The world health report 2006 - working together for health. 2006, 209 pp.
Chapter 1: Health workers: a global profile; Chapter 2: Responding to urgent health needs; Chapter
3: Preparing the health workforce; Chapter 4: Making the most of existing health workers; Chapter 5:
Managing exits from the workforce; Chapter 6: Formulating national health workforce strategies;
Chapter 7: Working together, within and across countries; Index Available online at:
www.who.int/whr/2006/whr06_en.pdf
3. Joint Learning Initiative. Human Resources for Health: Overcoming the Crisis. 2004, 217 pp. In
this analysis of the global workforce, the Joint Learning Initiative (JLI) — a consortium of more than
100 health leaders — proposes that mobilisation and strengthening of human resources for health,
neglected yet critical, is central to combating health crises in some of the world’s poorest countries
and for building sustainable health systems in all countries. Nearly all countries are challenged by
worker shortage, skill mix imbalance, maldistribution, negative work environment, and weak
knowledge base. Especially in the poorest countries, the workforce is under assault by HIV/AIDS, out-
migration, and inadequate investment. Effective country strategies should be backed by international
reinforcement. Ultimately, the crisis in human resources is a shared problem requiring shared
responsibility for cooperative action. Alliances for action are recommended to strengthen the
performance of all existing actors while expanding space and energy for fresh actors. Available
online at: www.globalhealthtrust.org/Report.html See also
www.globalhealthtrust.org/Publication.htm for other publications.
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General References
4. World Bank. World development report 1993 : investing in health. 1993, 344 pp. Though
dated, this comprehensive overview to the opportunities, challenges and limitations of investing
in health care provides a wealth of information relevant to the health workforce. Many of its
findings are still valid. Available online at:
http://www-
wds.worldbank.org/external/default/main?pagePK=64193027&piPK=64187937&theSitePK=523
679&menuPK=64187510&searchMenuPK=64187283&siteName=WDS&entityID=000009265_
3970716142319
5. Physicians for Human Rights. An Action Plan to Prevent Brain Drain: Building Equitable
Health Systems in Africa. July 2004, 120 pp. Available online in pdf from:
http://physiciansforhumanrights.org/library/report-2004-july.html
6. Labonte, R., et al. The Brain Drain of Health Professionals from Sub-Saharan Africa to
Canada. African Migration and Development Series No. 2, 2006. Southern African Migration
Project, 92 pp. Available online at:
www.queensu.ca/samp/sampresources/samppublications/mad/MAD_2.pdf
Website: http://www.queensu.ca/samp/sampresources/samppublications/
7. Black, R., et al. Migration and Development in Africa: An Overview. African Migration and
Development Series No. 1, 2006, 169 pp. Available online at:
www.queensu.ca/samp/sampresources/samppublications/mad/MAD_1.pdf
Page 71
Credits
Thomas L. Hall, MD, DrPH, Dept. of Epidemiology and Biostatistics, Univ. of California at
San Francisco, [email protected]
Nicole Bores,
University of California at San Francisco, [email protected]
Sponsors The Global Health Education Consortium gratefully acknowledges the
support provided for developing these teaching modules from:
Margaret Kendrick Blodgett Foundation
The Josiah Macy, Jr. Foundation
Arnold P. Gold Foundation
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0
United States License.
