Toolkit for country health workforce strengthening

1 Toolkit for Country Health Workforce Strengthening © World Health Organization 2012 All rights reserved. This information material is intended for a limited audience only. It may not be reviewed, abstracted, quoted, reproduced, transmitted, distributed, translated or adapted, in part or in whole, in any form or by any means Document number: WHO/EURO:2012-2221-41976-57690 1. Background The health workforce plays a central and critical role in improving access to quality health care for the population. Mechanisms for optimizing the skills and skill-mix of health professionals will be essential to strengthening health systems and achieving better health outcomes. It is critically important that Member States develop policies that will ensure availability of enough health workers with the relevant skill-mix, competences and motivation to provide health services to their populations. Recent global and regional efforts have reiterated the urgency of addressing the increasing challenges for health workforces; these include shortages, imbalances, educational quality and productivity concerns. Strategies for human resources planning should adopt a comprehensive perspective b y addressing d em a n d , supply and mobility. Approaches that focus on the training of individuals without taking into account the work environment and mobility, will have limited success. Scaling up education in an isolated way will not compensate for weak motivation, high attrition, and increasing mobility. Building on the momentum created by various initiatives, the World Health Organization is undertaking actions which aim to enable countries to move forward with developing concrete national health workforce policies and strategies. WHO Regional Office for Europe supports i ts Member States in responding to the challenges by focusing on the following three vital areas, according to which the tools in this toolkit have been organized: 1. health workforce education and training 2. migration and retention 3. performance and management In recent years, the WHO Regional C om m i t t e e for Europe has endorsed t w o r e s o l u t i o n s addressing h e a l t h workforce policies in the Region. The Regional Committee highlighted both the consensus that exists on the responsibilities of Member States for the development of their national health workforce policies and plans in the light of the prevailing global crisis in human resources for health, and the need for collective efforts to tackle international migration. • Resolution EUR/RC57/R1 (2007) on health workforce policies urged Member States to improve information and knowledge base on their health workforce as well as to develop national health workforce policies, plans and strategies. It requested the Regional Director to facilitate the development and contribution to a global code of practice for the international recruitment of health personnel. • Resolution EUR/RC59/R4 (2009) urged Member States to enforce their efforts to develop and implement sustainable health workforce policies, strategies and plans as a critical component of health systems strengthening, particularly in view of the changing demographics and health care needs in the Region. The resolution calls to advocate the adoption of a global code of practice on the international recruitment of health personnel in line with the European values of solidarity, equity and participation, both within the WHO European Region and globally. The Tallinn Charter calls for investment in the health workforce, as it has implications not only for the investing country but for others due to the mobility of health professionals. The international recruitment of health workers should be guided by ethical considerations and cross-country solidarity. Building on such important commitments, new strategies are needed to enhance the effectiveness of health workers, and Member Sta tes should provide leadership in planning, formulating and implementing the required policies. 2. Program strategy Human resources form the largest single cost element in any health system constituting as much as 60 to 80% of the total recurrent expenditures. Overall, there is a chronic shortage of health workers – WHO estimates some 2.3 million health professionals globally. The human resources for health (HRH) programme supports Member States in addressing workforce challenges in several key areas, such as: health workforce governance and planning; health workforce migration and retention; 1 health workforce education and training; and nursing and midwifery. WHO Regional Office for Europe has reinforced its commitment to nursing and midwifery in the Region, revitalizing links with the Government Chief Nursing O f f i c e r s . Joint work between the Regional Office and this important group will facilitate the implementation of national policies relating to nursing and midwifery, and it will optimize the contributions of nursing and midwifery to achieving health-related development goals. Additionally, strong cooperation with the European Forum of National Nurs ing and Midwifery Association serves as a link between international and national policy-makers and the six million nurses and midwives in the Region. Action is needed to ensure that the Member S t a t e s of the European Region each have a dynamic and skilled health workforce that can adapt to the changing environment and respond to the new expectations of society. WHO Regional Office for Europe works at both regional and country levels to assist Member States in addressing health workforce challenges by: • improving the quality of data for HRH profiling and analysis through harmonizing standards, definitions and indicators; • monitoring health workforce dynamics, trends and progress on addressing the HRH challenges and to support informed decision-making; • facilitating multi-stakeholder dialogues on HRH at national and regional level; • developing country profiles on HRH in all Member States; • organizing capacity-building workshops and training courses on how to use WHO tools and other guidelines for HRH policy analysis, planning and management; • contributing to the scientific evidence base for policy-making through research activities and symposiums; • building and maintaining technical cooperation, networks and partnerships in HRH thematic areas with all relevant agencies and organizations. 2.1. Education and training Efforts to scale up health professional education must address not only the quantity, but also the quality and relevance of health professionals in order to meet population health needs. Quality assurance is a collective responsibility of the academic community, health systems, regulatory authorities and governments.This involves a broad scope of activities, including accreditation of educational institutions and programmes, as well as professional regulation (registration, certification, licensing). At the request of its member states and partners, WHO is developing policy guidelines to assist countries, development partners and other stakeholders in efforts to expand the health workforce and to improve alignment between the education of health professionals and population health needs. WHO Regional Office for Europe supports Member States by: • providing technical consultancy and support to countries in their efforts to improve the quality of education and training of health professionals; • building national and institutional capacity to introduce evidence-based approaches in education and practice; • advising on the Bologna Process in health professionals’ education. Selected Tools Accreditation: • WFME Global Standards for Quality Improvement in Medical Education: European Specifications (English, Russian and Turkish) http://www.wfme.org/standards/european-specifications With these specifications, MEDINE intends to provide a tool for reform processes, and criteria for the recognition and accreditation of medical education institutions and programmes, for the benefit of the constituency of medical education, health services and health systems throughout the region. • WHO/WFME Guidelines for Accreditation of Basic Medical Education (English, Russian and Spanish) http://www.wfme.org/accreditation/whowfme-policy These guidelines have been developed as a tool to assist national authorities and agencies responsible for the quality of medical education to either ensure adequate activity and transparency of existing accreditation 2 systems, or to assist in the establishment of new systems in countries and regions which so far have not used accreditation. • Standards for PhD Education in Biomedicine and Health Sciences in Europe http://www.wfme.org/standards/phd The aim has been to bring together, in a common format, the ORPHEUS position on standards for the PhD degree in biomedicine and the WFME standards for medical education. • Global standards for the initial education of professional nurses and midwives (English and Russian) http://www.who.int/hrh/resources/standards/en/index.html The need for global standards has arisen for several reasons – the increasing complexities in health- care provision, the increasing number of health professionals at different levels, and the need to assure more equitable access to health care. This document describes the context and process followed in developing the global standards, and presents the standards with their respective goals. • World Directory of Medical Schools – AVICENNA Directories http://avicenna.ku.dk/database/medicine/ The Avicenna Directory for medicine includes the latest information from the new survey in progress of all the world’s medical schools, as well as information from the 7th edition (2000) of the WHO World Directory of Medical Schools, with updates submitted to the WHO Directory between 2000 and 2007. Each entry is marked to show if the information is new, or is from before 2007. Education/Workforce planning and collaboration: • Transformative scale up of health professional education http://www.who.int/hrh/resources/transformative_education/en/index.html The guidelines in this process recommend the transformative scale up of health professional education and aim to increase the quantity, quality and relevance of health professionals to strengthen their impact on population health. This information brochure provides a background and overview of WHO’s effort to provide guidance on the transformative scale up of health professional education. • Framework for Action on Inter-professional Education and Collaborative Practice http://www.who.int/hrh/resources/framework_action/en/index.html The Framework for Action on Interprofessional Education and Collaborative Practice highlights the current status of interprofessional collaboration around the world, identifies the mechanisms that shape successful collaborative teamwork and outlines a series of action items that policy-makers can apply within their local health system. The goal of the Framework is to provide strategies and ideas that will help health policy-makers implement the elements of interprofessional education and collaborative practice that will be most beneficial in their own jurisdiction. 2.2. Migration and retention The globalization of the labour market has major implications for health professionals, health systems and government. Some of these implications are positive, including a solution to current shortages in some countries. Globalization also provides opportunities for health professionals to improve their skills, career opportunities and standards of living. However, there are also significant negative consequences, primarily the (“brain”) drain this represents impacting the ability of less affluent countries to provide adequate healthcare for their citizens. The magnitude of health workforce migration and the unregulated practices of recruitment agencies highlight the relevance of strategies and policies for managing health workers. However, because statistics on flows of health workforce remain very limited, informed policy-making in this area presents a challenge. To address this challenge, the WHO Global Code of Practice on the International Recruitment of Health Personnel establishes voluntary principles and practices for the ethical international recruitment of health personnel and the strengthening of health systems. WHO Regional Office for Europe has been key in the development of the global code of practice for the international recruitment of health personnel. 3 Selected Tools WHO Global Code: • WHO Global Code of Practice on the International Recruitment of Health Personnel (English, French, Spanish, Russian, Turkish) http://www.who.int/hrh/migration/code/practice/en/index.html The Code aims to establish and promote voluntary principles and practices for the ethical international recruitment of health personnel and to facilitate the strengthening of health systems. Member States should discourage active recruitment of health personnel from developing countries facing critical shortages of health workers. The Code was designed by Member States to serve as a continuous and dynamic framework for global dialogue and cooperation. • User’s Guide to the WHO Global Code of Practice on the International Recruitment of Health Personnel (English) http://www.who.int/hrh/resources/guide/en/index.html This User’s Guide aims to provide a concise overview of the Code and to help readers understand its content. It explains the context in which it has been developed and teases out its main messages. It targets all stakeholders concerned with or interested in the international recruitment of health personnel. The Guide provides a simple and user-friendly introduction; readers are encouraged to refer to the Code itself for a fuller understanding of its recommendations. • National Reporting Instrument (English, French, Spanish, Russian) http://www.who.int/hrh/migration/code/code_nri/en/index.html To monitor the progress made in implementing the Code, and in accordance with the request of the World Health Assembly (Resolution WHA63.16), a national self-assessment tool has been created for Member States. These assessments will enable WHO to examine the global status of health personnel recruitment and, where possible, explore time trends. Geographic maldistribution: • Increasing access to health workers in remote and rural areas through improved retention: Global policy recommendations (English, French, Spanish, Russian) http://www.who.int/hrh/retention/guidelines/en/index.html This document proposes sixteen evidence-based recommendations on how to improve the recruitment and retention of health workers in underserved areas. It also offers a guide for policy-makers to choose the most appropriate interventions and to implement, monitor and evaluate their impact over time. Bilateral agreements: • Innovations in Cooperation: A Guidebook on Bilateral Agreements to Address Health Worker Migration (English and Russian) http://www.aspeninstitute.org/publications/innovations-cooperation-guidebook- bilateral-agreements-address-health-worker-migration The Health Worker Migration Initiative, a program of Realizing Rights/Global Health & Development at The Aspen Institute, provides concrete guidance on using bilateral agreements to better manage health worker migration. 2.3. Performance and management Globalization presents health workforce planners with a number of distinct challenges.The dynamics of globalized health labour markets are marked by an increasingly complex public/private mix, direct foreign investment, medical tourism and mobility of patients, which calls for new approaches to health workforce planning and management. Effective policy-making in response to these challenges requires three things. First, a well-functioning governance infrastructure devoted to evidence-based policies with valid supporting data. Second, the formulation of national policies and plans in pursuit of human resources for health development objectives requires sound information and evidence. Third, health workforce assessment, policy development and planning require dialogue between stakeholders from government and non-government partners who contribute to creating a sustainable and responsive workforce. Policy dialogues on health workforce and capacity planning have been effective tools towards better governance. 4 Selected Tools Monitoring and data collection: • Handbook on monitoring and evaluation of human resources for health (English, French, Spanish, Portuguese, and Russian) http://www.who.int/hrh/resources/handbook/en/index.html This tool aims to strengthen the technical capacity of countries to accurately monitor their own health workforce. It offers health managers, researchers and policy-makers a comprehensive and standard reference for monitoring and evaluating human resources for health. It brings together an analytical framework with strategy options for improving the health workforce information and evidence base, as well as country experiences to highlight approaches that have succeeded. • Data mapping template on human resources for health http://www.who.int/hrh/tools/situation_analysis/en/index.html This tool is to be used as a starting point for the collation, analysis and synthesis of data and evidence on HRH, as well as for monitoring the strengths and limitations of the underlying information systems. It has been developed as part of a series of efforts to enhance country capacities to generate, analyse and use data to assess health workforce performance and track progress towards their HRH-related goals. The spreadsheet may be used alone, or in conjunction with the Handbook on monitoring and evaluation of human resources for health and/or the Toolkit for monitoring health systems strengthening. • Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies (English) http://www.who.int/healthinfo/systems/monitoring/en/index.html This handbook describes a set of indicators and related measurement strategies, structured around the WHO framework that describes health systems in terms of six “building blocks”: service delivery, health workforce, information, medicines, financing and governance. Health workforce planning and projections: • Assessing financing, education, management and policy context for strategic planning of human resources for health (English, Russian, French) http://www.who.int/hrh/tools/situation_analysis/en/index.html This tool is designed as an initial diagnostic instrument to be used in the process of developing a national strategic plan on HRH. It helps to provide a rapid initial assessment and a preliminary strategic plan as part of a longer-term and sustained process of human resources planning. • Human Resources for Health Action Framework http://www.capacityproject.org/framework/ The framework is designed to assist governments and health managers to develop and implement strategies to achieve an effective and sustainable health workforce. By using a comprehensive approach, the Framework will help you address staff shortages, uneven distribution of staff, gaps in skills and competencies, low retention and poor motivation, among other challenges. The website provides an interactive overview of the framework with supporting tools, guidelines and resources, as well as country examples and critical success factors. • Models and tools for health workforce planning and projections. Human Resources for Health Observer - Issue No. 3 (English, Russian) http://www.who.int/hrh/resources/observer3/en/index.html This tool aims to take stock of the available methods and tools for health workforce planning and projections, and to describe the processes and resources needed to undertake such an exercise. This review is not meant to be exhaustive, but illustrative of the tools and resources available and commonly used in countries. • Workload Indicators of Staffing Needs/WISN (English, Spanish, Russian) http://www.who.int/hrh/resources/wisn_software_manual/en/index.html The Workload Indicators of Staffing Need (WISN) software application is a tool for using a computer to record, analyse, and report data related to staffing status and requirements at health facilities. The software complements the revised Workload Indicators of Staffing Need (WISN): User’s Manual. It assumes the 5 software user is familiar with the terms, concepts, and methodologies presented in it. • Tools for planning and developing human resources for HIV/AIDS and other health services (English) http://www.who.int/hrh/tools/planning/en/index.html Forecasting human resources needs to adequately train and supply a sufficiently large workforce is a challenging task. This manual presents, among others: an analytical framework and a way to update health workforce policy, rapid assessment of HR management needs, the impact of HIV/AIDS on human resources, a model for estimating workforce needs for antiretroviral therapy and other priority health services. A spreadsheet application helps to estimate the necessary health workforce. • Task shifting to tackle health workforce shortages: Global recommendations and guidelines http://www.who.int/healthsystems/task_shifting/en/index.html Task shifting is the name now given to a process of delegation whereby tasks are moved, where appropriate, to less specialized health workers. By reorganizing the workforce in this way, task shifting can make more efficient use of the human resources currently available. Nursing and midwifery: • Strategic Directions for Strengthening Nursing and Midwifery Services (SDNM) – 2011-2015 http://www.who.int/hrh/resources/nmsd/en/index.html Building on the 2002–2008 SDNM, the document seeks to provide policy-makers, practitioners and other stakeholders at every level with a flexible framework for broad-based, collaborative action to enhance the capacity of nurses and midwives to contribute to universal coverage, people-centred health care, policies affecting their practice and working conditions, and the scaling up of national health systems to meet global goals and targets. • European Strategic Directions for Nursing and Midwifery (European SDNM) The European SDNM provides stakeholders with an overarching framework for collaborative action to achieve the common goal of improving health outcomes for individuals, families and communities through the provision of relevant, competent and evidence-based nursing and midwifery services. 3. Strategic support to country health workforce strengthening The WHO Regional Office provides strategic and technical support to Member States in strengthening their capacity to plan, educate and manage their health workforces in order to ensure that health systems meet health needs. Guidance documents and policy briefs There are a number of main guidance documents at regional and global levels as well as key guidance documents on HRH for the EU countries. WHO Regional Office for Europe has also developed a number of policy briefs on HRH: (I) “How can the migration of health service professionals be managed so as to reduce any negative effects on supply”; (II) “How can optimal skill mix be effectively implemented and why?”; (III) “Do lifelong learning and revalidation ensure that physicians are fit to practice?”; (IV) “How to create conditions for adapting physicians’ skills to new needs and lifelong learning”; (V) “How to create an attractive and supportive working environment for health professionals”; (VI) “Assessing future health workforce needs”; and (VII) “Using audit and feedback for health professionals to improve the quality and safety of health care”. Capacity strengthening opportunities The WHO European Region is helping Member States to develop national HRH strategies, providing technical tools and guidelines, building capacities and facilitating processes aimed at developing health systems with universal coverage and effective public health interventions. 6 Box 1: Moldova project on migration of health workforce WHO Regional Office for Europe’s Human Resources for Health programme is developing the three-year project ”Better managing the mobility of health professionals in the Republic of Moldova” funded by the European Union. The aims of the project are to: • generate information and evidence on the status of the health workforce and its mobility inside the country and abroad; • support the efforts of the Ministry of Health to better manage the mobility of health professionals by fostering circular migration; • help mitigate the negative effects of brain drain and brain waste of health professionals in the Republic of Moldova. The project is being implemented by a WHO team in the Republic of Moldova in strategic partnership with 11 countries and institutions both in the Republic of Moldova and in the European Union, with support and coordination from the WHO Regional Office for Europe. Courses and workshops WHO Regional Office for Europe will continue to develop courses to familiarize participants with approaches to developing strategies and plans for human resources for health. For example, an international course on strategic planning in HRH was held in Kiev 24-28 May 2010; subsequent courses were held on evidence-based practice for Kyrgyzstan, the Ukraine and Belarus; and another for assessors for accreditation in medical education for Kazakhstan. Starting from October 2011, the WHO meetings of the Government Chief Nursing Officers were re-convened, which resulted in capacity-building workshops like those held with successful results previously. Box 2: Chief nursing officers renew collaboration with the Regional Office at European meeting A meeting of the Chief Nursing Officers (CNOs) of all Member States of the WHO European Region was held in Warsaw, Poland, immediately following the European Chief Medical Officers’ Meeting, on 7-8 October 2011. The meeting was attended by 40 participants representing their countries and profession from the Region. The meeting, the first of this group of CNOs since 2005, offered a unique opportunity to renew their collaboration with the Regional Office. The meeting aimed at revitalizing the network and encourage the full engagement of the participants in decision-making processes at regional level. This meeting also provided a forum for knowledge exchange on strategic directions for nursing and midwifery in the European Region. In recognition of the invaluable contribution that nurses and midwives make to promoting health and health care in Europe, participants were invited to discuss the new European Health Policy, Health 2020, and implementation of the Tallinn Charter. A capacity-building workshop was offered by Ms Jane Salvage on entrepreneurism in policy-making. Working with peer learning networks concerned with human resources for health These include the Network of national HRH focal points; the Network of HRH Experts; the Network of WHO Collaborating Centres; the European Forum of Medical Associations; the European Forum of National Nursing and Midwifery Association with WHO Europe; and the World Federation for Medical Education. Box 3: WHO collaborating centres on nursing and midwifery met in Copenhagen In February 2012, the WHO Regional Office for Europe met with the network of WHO collaborating centres on nursing and midwifery. The parties agreed to further strengthen their collaboration. WHO acknowledged the important contributions made by the WHO collaborating centres in supporting the Member States in line with the Munich Declaration “Nurses and Midwives: a force for health”. The reinforced commitment by the nursing and midwifery collaborating centres will support the preparation of the essential components for the new European Health Policy, Health 2020, and the European Action Plan on Public Health. The Regional Office for Europe would like to recognize the importance of the contributions made by the nursing and midwifery collaborating centres for the implementation and achievement of the Organization’s planned strategic objectives, enhancing the scientific validity of its health work, as well as strengthening institutional capacity in countries on nursing and midwifery. 7 Support to sub-regional networks This support has been provided, for example, to the Executive Committee of the South-eastern Europe Health Network. Policy dialogues HRH assessment, policy deve lopm ent , planning and monitoring require d ia logue between stakeholders from government and non-government partners who contribute to creating a sustainable and responsive workforce. The policy dialogue model is particularly useful when policy-makers explore strategic options for further health system reform. Policy dialogues aim to offer policy-makers in a country or a group of countries a neutral platform to discuss a particular key policy issue on the basis of comparative evidence and sharing experience. Policy dialogues on HRH and capacity planning have been effective tools towards developing integrated strategies. Box 4: Technical Meeting on Health Workforce Retention Policies Bucharest, Romania, 28-29 March 2011 In collaboration with the Executive Committee of the South-eastern Europe Health Network, WHO Regional Office for Europe organized a Technical Meeting on Health Workforce Retention Policies. The aim of the meeting was to develop evidence on retention practices, to exchange experiences gained in countries of the South-eastern Europe Health Network, and to develop and agree upon a linking and learning path for retention policies and strategies in the region. The output from the meeting comprised a collection of examples of emerging retention practices in countries of the SEE health network which served as the foundation of a policy brief. The policy brief further supported embedding retention in current initiatives in the SEE Region and establishing a Regional Health Development Centre on HRH. This meeting was sponsored by the joint partnership programme between the Netherlands Ministry for Development Cooperation, the Netherlands Ministry of Health, Welfare and Sport and WHO Regional Office for Europe. The Dutch technical partner institution of WHO is the Royal Tropical Institute (KIT), a WHO Collaborating Centre for Research, Training and Development of Human Resources for Health. Box 5: Subregional Policy Dialogue on Health Professional Mobility in Central and Eastern Europe, 5 April 2011, Budapest, Hungary The international recruitment and migration of physicians, nurses and other health workers has been a growing feature of the global health environment in recent years. A research project funded by the European Commission on health professional mobility in the EU (PROMeTHEUS), begun in 2009, is striving to improve information on this issue. The initial results of the project were presented by the European Observatory on Health Systems and Policies and discussed during the policy dialogue. The initial findings show that, although workforce flows overall have increased only moderately so far in the 17 EU countries studied, some countries have experienced greater changes. 4. WHO Regional Office for Europe contacts Dr Galina Perfilieva, Programme Manager | Tel.: +45 39 17 15 44 | E-mail: gpe@euro.who.int Dr Altin Malaj, Project Coordinator | Tel.: +45 39 17 14 27 | E-mail: aml@euro.who.int Mr Casimiro Dias, Technical Officer | Tel.: +45 39 17 14 59 | E-mail: cad@euro.who.int Mrs Sharon Miller | Tel.: +45 39 17 15 39 | E-mail: smi@euro.who.int Mrs Elena Galmond | Tel.: +45 39 17 12 32 | E-mail: egm@euro.who.int WHO Regional Office for Europe Scherfigsvej 8 2100 Copenhagen Ø Denmark http://www.euro.who.int/en/what-we-do/health-topics/Health-systems/health-workforce 8 12 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan World Health Organization Regional Office for Europe Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark Tel.: +45 39 17 17 17. Fax: +45 39 17 18 18. WHO/EURO:2012-2221-41976-57690