Workshop on Resource Management on Health Workforce, Shanghai, China, 21-25 June 1999 : report

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

REPORT WORKSHOP ON RESOURCE MANAGEMENT OF HEALTH WORKFORCE Shanghai, China 21-25 June 1999

Manila, Philippines October 1999

(WP)HRH/ICP/HRH/002 Report series number: RS/99/GE/16(CHN)

English only

REPORT

WORKSHOP ON RESOURCE MANAGEMENT OF HEALTH WORKFORCE

Convened by:

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC SHANGHAI, CHINA 21-25 JUNE 1999

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines October 1999

NOTE

The views expressed in this report are those of the participants in the meeting and do not necessarily ret1ect the policy of the World Health Organization.

This report has been prepared by the World Health Organization Regional Office in the Western Pacific for governments of Member States in the Region and for those who participated in the Workshop on Resource Management of Health Workforce, which was held in Shanghai, China, from 21 to 25 June 1999.

CONTENTS

SUMMARY

...................................................

1

1.

INTRODUCTION ..................................... · · · · · · · · · · 1.1 1. 2

Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Opening ceremony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 2

1. 3 2. 3.

Organization of the meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 2 3

PROCEEDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONCLUSIONS ...................................... · · · · · · · · · · ANNEXES : ANNEX 1 - LIST OF PARTICIPANTS, CONSULTANT,............... TEMPORARY ADVISER AND SECRETARIAT ANNEX 2 - PROGRAMME OF ACTIVITIES............. . • • • • • • • • • • ANNEX 3 - OPENING REMARKS BY DR SHIGERU OMI , . . • • • • . . . . • • • REGIONAL DIRECTOR FOR THE WESTERN PACIFIC ANNEX 4 - DISCUSSION PAPER ON RESOURCE MANAGEMENT • • • • • • OF HEALTH WORKFORCE ANNEX 5 - NEW ZEALAND HEALTH WORKFORCE DEVELOPMENT CASE STUDY ANNEX 6 - ACHIEVING BALANCE IN WORKFORCE PLANNING AND MANAGEMENT ANNEX 7 - THE CHANGING ROLES OF THE STATE, WHO • • • • . • • . . . AND THE WORLD BANK IN HEALTH WORKFORCE DEVELOPMENT ANNEX 8 - COUNTRY PAPERS • • • • • • • • • • • • • • • • • • • • • • • • • • . • • • • • • • ANNEX 9 - HUMAN RESOURCE DEVELOPMENT POLICY • • • • • . • • • • • FORMULATION: A FRAMEWORK FOR ANALYSIS

7

13 17

21

37

41

43

47 83

IKeywords:

Staff development I Human resources I Health personnel I China

SUMMARY

Human resource management is the process of getting the right numbers of the right kinds of health personnel, with the right skills and competencies, in the right place, at the right time _ The health workforce needs to be continually strengthened in order to deliver appropriate and safe health services and to make an optimal contribution to changes in health care delivery. There is a need for interaction between countries in the Region on experiences and constraints met in implementing national health workforce policies to identify common areas and plan fi.tture activities in accordance with the changing needs of the health care system management.

1. INTRODUCTION

Health systems around the world are in the process of transition and refonn. Most systems are moving away from central planning and relatively stable bureaucratic stmctures and towards l~ss stable and more fluid market arrangements. These changes present new challenges for those whose task it is to guide the plarming and management of human resources for health.

In support of countries, the workforce planning methods developed and used by WHO since the 1960s have tried to promote broadly-based, whole-system approaches. But due to infonnation, organizational and other limitations, the reality, as opposed to the theory, has often been top-down supply-dominated planning. Much of the plam1ing guidar1ce previously provided by WHO presupposes that central government will play the leading and controlling role in health workforce development. Further, it has been assumed that there will be a central planning unit to oversee and coordinate the information gathering, analysis, plmming and management functions. In fact very few countries, developed or under-developed, have been successfi.tl in creating a strong and credible central focus for health workforce development. Now, in times of political, social and economic instability when planning infrastmctures and commitment to the planning nmction are generally weak, it is necessary for both countries ar1d WHO to rethink ar1d revise their approaches to health workforce development. To this end, a start has already been made by WHO. In September/October 1998, WHO held an intercountry consultation on policy formulation process and implementation methods with a special focus on the development of human resources for health in Colombo, Sri Lanka. The report of this consultation provides a policy analysis framework and other usefi.tl guidance for human resource development in an ever changing health enviromnent. The report of the Sri Lanka consultation provided a useful starting point for the Shanghai workshop the purpose of which was to enable 13 participants from Cambodia, China, the Lao People's Democratic Republic, Mongolia m1d Viet Nan1 to share their experiences, to explore together changing ideas ar1d concepts in plarming and managing humar1 resources for health, and to fi.trther their health workforce plarming in one or two high priority areas. A list of participant is attached as Atmex 1 and the programme of activities as Atmex 2.

-2-

1.1

Objectives The objectives of the workshop were: ( 1) to review the principles of resource management of the health ·workforce;

(2) to exchange and review country experiences on resource management of the health workforce; (3) to define scope for appropriate teclmical cooperation among participating countries in such areas as standardized job description, accreditation protocols and regulations; and to develop a preliminary plan of action for the fonnulation of national health (4) workforce management. 1.2 Opening ceremonv

Dr R.W.K. Gee, WHO Representative in the People's Republic of China, opened the meeting on behalf of Dr Shigeru Omi, Regional Director of the Western Pacific. In his opening remarks (Aimex 3), Dr Gee observed that health services were in a state of transition, worldwide. This was requiring countries to consider fundamental changes in the management of their health resources to meet current and future health challenges. Despite widespread dissatisfaction with the old order there was very little clarity about what the new order should be. What seemed clear was that each country must find its own way, must identify its own vision for health and health services, and must seek to evolve ways and means of making that vision a reality. In speaking of the continuing role ofWHO, Dr Gee said that collaboration with countries and areas on aspects of health workforce development was, and would remain, a major part of WHO's work in the Western Pacific Region. He saw the Shanghai workshop on resource management of health workforce as a timely and important step forward in a comprehensive approach aimed at developing the best possible human resources to deliver efficient and safe health services in the Region. 1. 3 Organization of the meeting

Mr Li Feng from China was selected as Chairperson and Mrs Keat Phuong from Cambodia was Rapporteur for the workshop. In addition to the members of Secretariat from WHO, teclmical advice was provided by Dr George Salmond, Consultant, and Professor Ren Huimin, Temporary Adviser. The workshop worked both in plenary session and in small groups. Following the opening presentations and associated discussions, most of the workshop took place in country specific groups with frequent reporting back in plenary sessions.

2. PROCEEDINGS

Dr Salmond provided an overview by speaking on his discussion paper on resource management of health workforce (Aimex 4). To illustrate the underlying principles and concepts, and to introduce key issues for discussion by the workshop, he used a New Zealand case study to

-3-

demonstrate the linkages between societal change in tenns of social and economic development, changing political and administrative ideologies, health sector refonn, and health workforce development. Further details are provided in Aim ex 5. In light of the opening presentations and the associated discussions, the participants, working in country groups, sought to place their country in terms of social and economic development and to identify the associated phase of health ·workforce development. Also, for each country, participants identified up to three of what they perceived to be the most important health workforce development issues. In the plenary session, Dr Salmond went on to discuss the changing role of the state in health workforce development. Emphasis was placed on strong leadership by governments and their ministries of health and the need for well-balanced developmental plmming m1d mm1agement approaches. These concepts were illustrated using the balance principle ofying and yang. A working paper on achieving balance in workforce planning and management is provided in Annex 6. Speaking again of the discussion paper, Dr Salmond went on to expand on the changing role ofthe State, ofWHO, and of the World Bank in health and health workforce development. A working paper with further details is attached as Almex 7. In the light of these plenary presentations and the associated discussions with the participants, working in country groups and in report-back plenary sessions, prepared and refined one or two high priority proposals for workforce development in their countries. Each of the countries represented at the workshop has plans to better design and meet the workforce development needs of front-line health workers . For each country the approach is different. Cambodia has taken a strong line in refocusing training at the community level, medical practitioner to lead health development at the conununity level; the main focus in the Lao People' s Democratic Republic is on the training and deployment of nurse practitioners ; Mongolia is seeking to retrain medical practitioners for roles as fmnily doctors; and Viet Nan1 is revising the training curriculum for all health workers with a strong emphasis on community health development. Based on these unique and individual approaches, each country prepared and, in discussion, refined proposals to strengthen the front-line workforce. These plm1s are an important outcome of the workshop (Annex 8) . The participants found much in common in discussing future prospects for health, for health services, and for health workforce development in their countries . They were able to readily identify unifying principles, policies, processes m1d practices for the improved planning and management of human resources for health. The workshop findings/outcomes are presented below in the fonn of conclusions and guiding principles.

3. CONCLUSIONS

The outcome of the workshop is presented in two parts. Part 1 contains general conclusions about health workforce development in a changing environment. Part 2 contains more specific conclusions and guiding principles which bear on the plam1ing and management of human resources for health.

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3 .1

General conclusion on health workforce development .in a changin!"! environment

The workshop concluded that the management of human resources for health should be seen in the context of the social and economic changes taking place in countries. As a result of changing social and economic circumstances major changes are occurring in the financing, structuring and functioning of health services. This is happening in all countries and must be reflected in changes to the way in which the health workforce is plaJmed and managed. The new health sector enviromnent requires a much broader and dynaJnic approach to health workforce development than in the past. This applies both to countries aJ1d to WHO. Each of the countries at the workshop is currently engaged in significant health sector refom1. In general, change is away from central planning and stable bureaucratic structures and processes 3.11d towards less stable and more fluid market arrangements. To ensure that these chaJ1ges enhaJ1ce, and do not daJUage health and health services, the workshop concluded that govermnents 3.11d their ministries of health must play strong and leading roles in the regulation of health sector markets and in guiding health sector development. They must also play strong and leading roles in health workforce development. HumaJ1 resources are fundaJUentally important to the future of health services. This has not always been recognized, particularly by countries which have moved quickly to introduce more market arrangements. There is now growing evidence to suggest that without a well-trained, highly-motivated, well-distributed and well-managed workforce, which understands and supports the changes, health sector refonn is not likely to achieve its full potential. In light of this general concluding statement agreed by the workshop the following are the more specific conclusions and reconm1endations. 3 .2 Policy analvsis framework

The workshop considered and supports the Human Resource Development policy analysis framework developed aJld now being used by WHO (Almex 9). In using this fraJnework, the workshop concluded that the following factors must be taken into account and balanced to achieve success in human resource management: Policies and processes for human resource management must • • • • • • fit the political and economic context; adapt to the specific design of public aJld health sector refonn; have a high level of political and administrative support; identify and meet the legitimate needs of health workers, at all levels; use a good human resources for health process: data, monitoring, evaluation; be owned by the govenm1ent of each country and be specifically tailored to meet the national needs; have strong leadership, at all levels; be grounded in consultation, networking, partnerships and good management process; and have secure and sufficient financial support.

• •

•

-5-

The workshop concludes that all countries should use the HRD policy analysis framework developed and used by WHO . 3.3 Ownership and leadership

Each country, based on its history, its traditions, its culture and level of social and economic development, requires a unique and individually tailored approach to health planning and to health workforce development. To succeed, governments must take ownership and lead the way in seeking to better address the health and workforce development needs of the domiciled population. Only govenunents have the authority to bring together all of the various stakeholders who must be involved and conm1itted if workforce policies are to be agreed and plans implemented. Without regulation, health markets cannot achieve the level of cooperation required for integrated health workforce development. International organizations like WHO and the World Bank have important roles to play in technical and financial support. But governments should lead the way. They should take strong and leading roles in the planning and management of the health workforce. 3 .4 Focus on front-line workers

In 1994, WHO reviewed the achievement of its health for all primary health care approach. Despite many successes, major flaws were identified in the strategy. The most important of these was preoccupation on the part of governments and WHO with bureaucratic structures and processes rather than addressing directly the health needs of the people and their conununities . The review concluded that the front-line units in many countries are poorly organized, underresourced, over-bureacratised and badly managed. The workshop agrees with this conclusion. Further it believes that the highest priority for workforce development must be given to the frontline health workers. To this end, efforts must focus on: • • • • • basic training, continuing education and support; motivation and rewards; improved management; improved public health and clinical leadership; and teclmically and culturally appropriate, community-based training methods and models .

The highest priority for workforce development should be given to the training, deployment and support of front-line health workers in keeping with individual and specific country requirements. 3.5 Workforce planning methods

In the past, workforce planning has been based on methods and models the aim of which has been to develop , for defined occupational groups, practitioner to population planning ratios. Often these models have had to be based on unreliable political, administrative and economic assumptions and inadequate supply and demand data about the health workforce. Added to this such methods have been highly dependent upon state bureaucracies for information and plam1ing support. Historically, within countries, such plmming methods have had serious limitations. Cross-country comparisons are practically meaningless . There will always be a place for data gathering and modelling the health workforce. But the limitations of such planning must be recognized, particularly in the more market-based

-6-

enviromnent. Using broader, more pragmatic and developmental approaches each country should address its own workforce development needs, in its own context and in its own way. In this regard, international comparisons in terms of practitioners to population ratios have limited utility. There can be no standard ratios for general use. What is much more important is that each country defines its own workforce categories, its own job descriptions, its own personnel policies, its own basic and continuing education requirements and its own planning ratios, to meet its own defined requirements. Each country should develop its own planning methods and supporting arrangements to meet its own specific health workforce development requirements. To this end, WHO and other international agencies may be looked to for technical support. 3. 6 In pursuit of delav

From a workforce development perspective quality assurance has two distinct dimensions. The first relates to the competence of individual health workers as measured by relevant education, training, qualifications, occupational registration, work experience and the like. All ofthe countries represented at the workshop are working in various ways to improve the individual competence of workers, especially front-line workers. However, it is important not to overlook the collective dimension of quality which is more concemed with effective teamwork. Quality depends as much on good management and effective teamwork as it does on the individual competence of workers. In pursuit of quality it is therefore important that a balanced approach be taken to both the individual and collective dimensions of care. In pursuit of quality, a balance should be struck between measures aimed at improving the individual competence of health workers and efforts aimed at promoting team work and organizationalleaming. 3.7 Collaboration and cooperation

The workshop has shown that countries of a similar type and level of development have much to share and to leam from each other in the area of health workforce development. In the past such sharing, if it has occurred at all, has been opportunistic and episodic. Regular and better organized communication should be arranged by the countries themselves, with technical support from WHO as required. Similar countries should work together regularly to share and leam from their workforce development experience with technical support as required from WHO.

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ANNEX 1

WORLD

HEALTH

ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

WORKSHOP FOR RESOURCE MANAGEME NT OF HEALTH WORKFORC E

WPR/HRH/H RH(4)/99/IB/2 Rev. 20 June 1999 ENGLISH ONLY

Shanghai, China 21-25 June 1999 INFORMATI ON BULLETIN NO. 2

PROVISIONA L LIST OF PARTICIPAN TS, CONSULTAN T, TEMPORAR Y ADVISER, AND SECRETARI AT

1. PARTICIPAN TS

CAMBODIA

Mrs Keat Phuong Deputy Director Department of Human Resource Development Ministry of Health 151 Kampuchea Krom Street Phnom Penh Fax No. (855-23) 426211 Tel. No. (855 23) 880374 Dr Mao Tan Eang Deputy Director Planning and Health Information Department Ministry of Health 151 Kampuchea Krom Street Phnom Penh Fax No. (855-23) 426211 Tel. No. (855-23) 366337

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Annex 1

CIDNA, PEOPLE'S REPUBLIC OF

Mr Li Feng Director of Professional Department of Personnel Ministry of Health 44 Houhai, Beiyan Beijing 100725 Fax No . 6401 3372 Tel. No. 6407 0069

Mr Sun Lijun Deputy Director Foreign Affairs Division Shanghai Municipal Health Bureau No. 223 Hankou Road Shanghai 200002 Fax No. 0086 21 6329 1395 Tel. No . 0086 21 6321 8786 MsWang Chen Department of Personnel Ministry of Health 44 Houhai, Beiyan Beijing 100725 Fax No. 6401 3372 Tel. No. 6401 3372 Ms Xue Puying National Health Programme Coordinator Department of International Cooperation Ministry of Health 44 Houhai, Beiyan Beijing 100725 Fax No. 8610 6401 4332 Tel. No. 8610 6402 4266 LAO PEOPLE'S DEMOCRATIC REPUBLIC Mrs Staphone Insisiengmay Chief of Nursing Unit and Deputy Chief of Human Resources for Health Division Ministry of-Health Vientiane Fax No. 856 21 218488 Tel. No. 856 21 212221 Mr K.hamhoung Heangvongsy Director, Human Resources for Health Ministry of Health Vientiane Fax No. 856 21 218488 Tel. No. 856 21 212220

- 9 Annex 1

MONGOLIA

Dr Galsan Dashzeveg Consultant for Human Resource Development Project Ministry ofHealth and Social Welfare Olympic Street-2 Ulaanbaatar-48 Fax No. (00-976-1)-320916 Tel. No. (00-976-1)-327872 I 323990 Dr (Ms) Dashdorj Ulziibayar Chief, Postgraduate Training Centre Medical University of Mongolia Street Jamyan-Gun Ulaanbaatar-48 Tel. No. (00-976-1) 321194

VIETNAM, SOCIALIST REPUBLIC OF

Dr Nguyen Van Thai Health Expert Department of International Cooperation Ministry of Health 13 8A Giang Vo Street HaNoi Fax No. 84 4 8462195 Tel. No. 84 4 8464050 Mr Nguyen Trang Thuy Deputy Director Department of Organization and Manpower Ministry of Health 13 8A Giang Vo Street HaNoi Fax No. 84 4 8464051 Tel. No. 84 4 8462251 Associate Professor Nguyen Van Tuong Deputy Director Depart.nient of Science and Training Ministry of Health and Vice Rector, HaNoi Medical School 138A Giang Vo Street HaNoi Fax No. 84 48 525115 Tel. No . 84 48 464918

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Annex l

2. CONSULT ANT

Dr George Salmond Director Health Services Research Centre Victoria University P.O. Box 600 Wellington 5 New Zealand Fax No. 64-4-496 6568 Tel. No. 64-4-496 6565 E-mail: George.Salmond@vuw.ac.nz

3. TEMPORARY ADVISER

Professor Ren Huimin Professor and former President Xi'an Medical University Xi'an People's Republic of China Fax No. 86-29-536-7324 Tel. No. 86-29-526-7354 E-mail: ren@irix.xamu.edu.cn

5. OBSERVERS

SHANGHAI MUNICIPAL HEALTH BUREAU

Mr Jun Xiang Guang Policy Research and Development Division Shanghai Municipal Health Bureau No. 223 Harikou Road Shanghai2000 02 People's Republic of China Mr Xin Ya Dong Policy Research and Development Division Shanghai Municipal Health Bureau No. 223 Hankou Road Shanghai 200002 People's Republic of China

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Annex 1

OBSERVERS (Contd.)

Mr Zhao Dan Dan Policy Research and Development Division Shanghai Municipal Health Bureau No. 223 Hankou Road Shanghai 200002 People's Republic of China Ms Wang Jian Ping Division of Scientific Research Shanghai Municipal Health Bureau No. 223 Hankou Road Shanghai200002 People's Republic of China Dr Xue Di Division of Medical Education Shanghai Municipal Health Bureau No. 223 Hankou Road Shanghai 200002 People's Republic of China MrYe Ning Personnel Division Shanghai Municipal Health Bureau No. 223 Hankou Road Shanghai 200002 People's Republic of China Mr Chen Ming Sheng Director of Personnel Division Shanghai Municipal Health Bureau No. 223 Hankou Road Shanghai 200002 People's Republic of China Mr Li Lin Qang Personnel Division Shanghai Municipal Health Bureau No. 223 Hankou Road Shanghai 200002 People's Republic of China Mr Sun Xiao Ming Director of Policy Research and Development Division Shanghai Municipal Health Bureau No. 223 Hankou Road Shanghai 200002 People's Republic of China

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Annex

1

6. SECRETARIAT

Dr R.W.K. Gee WHO Representative in the People's Republic of China 9-2-151 Ta Yuan Diplomatic Compound I Xindonglu Dongzhimen wai 100600 Beijing China Fax No. (86-10) 6532-2359 Tel. No. (86-10) 6532-6491 E-mail: whochina@public3 .bta.net. en who. org. china Mrs L. Kerse Regional Adviser in Human Resources for Health World Health Organization Regional Office for the Western Pacific P.O. Box 2932 United Nations Avenue 1000 Manila Philippines Fax No . (632) 521 1036 Tel No. (632) 528 9957 E-mail: kersel@who.org.ph

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13 ANNEX 2

WORLD

HEALTH

ORGANISATION MONDIALE DE LA SANTE

ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

WORKSHOP FOR RESOURCE MANAGEMENT OF HEALTH WORKFORCE Shanghai, China 21-25 June 1999 PROGRAMME OF ACTIVITIES Monday, 21 June 1999 0815 0900 Registration Opening ceremony

WPR!HRH/HRH(4)/99.1(a) Rev. 1 21 June 1999 ENGLISH ONLY

Opening and keynote address by: Dr R.W .K. Gee, WHO Representative in the People's Republic of China on behalf of Dr Shigeru Omi, WHO Regional Director for the Western Pacific Welcome address by Professor Zhang Mindao, Deputy Director-General of Shanghai Municipal Health Bureau Election of Chairman and Rapporteur Self-introduction of participants Group photo session 1000 1030 Coffee break Adoption ofthe agenda Presentation of the discussion paper on resource management of health workforce 1200 13 30 Lunch break Group discussion on resource management of health workforce Field visit

1500

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Annex 2

Tuesday, 22 June 1999

0815 0900 1000 1100

Sununary of discussions on resource management of health workforce Presentation of country papers on resource management of health workforce Coffee break Continuation of presentation of country papers on management of health workforce Lunch break Continuation of presentation of country papers on management of health workforce Coffee break Group discussion

1200 1330

1500 1530-1630

Wednesday, 23 June 1999

0815 0900 1000 1030 1200 1330 1500 1530-1630

Evaluation of issues raised in group discussions Discussion on international support Coffee break Continuation of discussion on intemational support Lunch break Plmming and funding Coffee break Group discussion

Thursday, 24 June 1999

0800

Development of the plan of action for the formulation of national health workforce management Coffee break

1000

1030

Continuation of the development of the plan of action for the formulation of national health workforce management Lunch break

1200

- 15 Annex 2

1330

Continuation of the development of the plan of action on national health workforce management Coffee break Group discussion Review of the draft plans of action on national health workforce management

1500 1530-1630

_Friday, 25 June 1999

0800 1000 1100 1200

Evaluation and conclusion of the workshop Coffee break Closing ceremony Lunch break

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- 17 ANNEX 3

OPENING REMARKS OF DR SHIGERU OMI, REGIONAL DIRECTOR FOR THE WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC, AT THE OPENING CEREMONY OF THE WORKSHOP FOR RESOURCE MANAGEMENT OF HEALTH WORKFORCE SHANGHAI, CHINA, 21-25 JUNE 1999

DISTINGUISHED GUESTS, COLLEAGUES, PARTICIPANTS AND FRIENDS, LADIES AND GENTLEMEN, I am very pleased to welcome you to Shanghai on behalf of the WHO Regional Director for the Western Pacific, Dr Shigeru Omi. World-wide, health services are in a state of transition. There is increasing awareness that patterns of health issues are changing rapidly. This realization has led countries and areas to consider fundamental changes in the management of their human resources to meet current and future health challenges. To this end, many governments are focusing their efforts on organizational restructuring and managerial improvement. There are many areas of concern and these cannot be addressed by medical interventions alone. There is a need to strengthen human resources at the primary health care level as well as to strengthen referral centres. The health workforce of the next century will face issues associated with diminishing resources for education and training of a publicly funded workforce. They will also have to cope with the emergence of market forces which influence policy-makers in terms of numbers and categories of health professionals. The constraints and opportunities within the human resources

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Annex 3

context need to be recognized and systemically reviewed in the light of changing health needs. Pressures to change are forcing countries to rethink arrangements for financing, planning and delivering health services. This is occurring regardless of what the present arrangements happen to be. Despite widespread dissatisfaction with the old order there is very little agreement or clarity about what the new order should be. Change management under such circumstances is particularly challenging and complex. At this point, there are no given answers. Each country must find its own way, must identify its own vision for health and health services, and must seek to evolve ways of making that vision a reality. In WHO, we see health reform as a process of comprehensive health system development. The results will be continuing gains in health, reflected by gains in health status, and improved efficiency and effectiveness of health care services. This will lead to increased satisfaction for the population served and for the health care providers themselves. Development means change and adjustment. The plans and activities to bring about the changes should be based on knowledge regarding appropriate technologies in health care at individual and community level. A major part of WHO's collaboration with countries and areas in the Western Pacific Region involves working with governments to ensure that their health workforces are well managed. It is vital that this includes continuously improving and updating health personnel training to make it more relevant to the health requirements of the population. The increasing concentration of populations in urban centres will require new systems for the delivery of health services with direct links between tertiary centres and district facilities. This will require central staff

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Annex 3

to maintain a high level of understanding and appreciation of primary health care and at the same time, district staff will need to be adequately trained in the application of increasingly complex health technology. Thus, health systems of the future will provide communities and individuals with access to increasingly sophisticated means to address their health problems. However, the effectiveness and appropriate use of these means will continue to be critically dependent on a well-trained and adequately motivated health workforce. This Workshop for Resource Management of Health Workforce is a comprehensive approach to all aspects of development of health resources management in the Region. I know you are all committed to developing the best possible human resources to deliver efficient and safe health services. I also know that you are aware that all the technology in the world will not save lives if people are not trained to use it properly. I, therefore, call on you to contribute your expertise and experience in defining the scope for appropriate technical cooperation in the Region in such areas as developing and refining job description, accreditation protocols, regulations and other areas. Much hard work remains to be done. Let us join together as partners in meeting the health challenges of the twenty-first century.

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ANNEX 4

WORLD

HEALTH

ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

WORKSHOP FOR RESOURCE MANAGEMENT OF HEALTH WORKFORCE Shanghai, China 21-25 June 1999

WPR/HRH/HRH( 4)/99 .2 25 May 1999 ENGLISH ONLY

DISCUSSION PAPER ON RESOURCE MANAGEMENT OF THE HEALTH WORKFORCE

by

Dr George Salmond Director Health Services Research Centre Victoria University Wellington, New Zealand

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Annex 4

CONTENTS

1.

INTRODUCTION .. ...... ... ... .................. .. .. .. .. .. ............ .... ........ ......... ... .. .. .. . ~ .. .. ... ............. 1 1.1 1.2 1.3 1.4 15 Setting the scene .............................. ......... ... .... .. .. .. .. .. .. ... ........ ... ... .... .... .. ...... .. ... ......... 1 Reorganize or redesign ................... .. ........ .... ... .. ...... .. ... ....................... .. ....... .. .. ......... 2 Investing in health ........................... ..... ... ........ .... ..... .... .... .... .... .... .. ...... .. ... .. .............. 3 Networks, alliances and partnerships ...... .. ... ..... .... ................. .... .. .... ......... .... .... .. ...... 4 vVHO and the World Bank .............. ..... ... ......... .. .. ............... .... .. ... ... ..._ ..... ... ..... ......... 5

2.

WORKFORCE DEVELOPMENT IN A NEW ORDER ..... ... .... .... .... ... .... .... .... ........ .. ... -... 7 2.1 2.2 2.3 2.3 2.4 2.5 2.6 2. 7 2. 8 2.9 2.10 Key issues for a new workforce development order .. ....................................... ........... . 8 Health futures ........................................................ .................. ............ ......... ... .. ... ... . 9 The information and learning revolution .................. ...... .... ..... ... .... ........ .... .. ....... ..... .. . 9 Health determinants ................................................ ...... .... ........ ......... ... ........... ... ... .. 10 Health economics and financing of health services .. .............................. ... ....... .......... 10 History, culture, ethics and community development .. ........... .. .. .. ................. .. ..... ... .. 10 Governance and the management of change ............ ...... ..... ...................... .............. .. . II Role of central government ..................................... .. ............... ......... .. .. ..... ........ .... .. 12 Management of the health labour market.. ............... ...... .. ................................. ........ 12 Substitution ............................................................ .......... ...... ........... .... ........ .... .... .. 13 Research and development ................. .... ......... .. ................................ .... ...... .. .... ..... .. 13

3.

CONCLUSIONS ...................... .... .... ..................... ......... ................... .... ... ................ ... .... 13

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Annex 4

1. INTRODUCTI ON

Taking a-"whole system" and "health futures" perspective, this paper explores prospects for planning and managing human resources for health in a new order. Global pressures for change are forcing planners and managers to think beyond organizational restructuring to more fundamental redesign of health systems . Bureaucratical ly and professionally dominated structures and processes are giving way to more consumer-friendly and more open and flexible market arrangements . The paper explores the implications of these changes for health and health services in general, and for the health workforce in particular. It then deals briefly with some of the key issues which, in light of these changes, must be faced by those whose responsibility it is to chart and guide development of the health workforce.

1.1

Setting the scene

All around the world, governments are struggling to find appropriate ways to finance, organize and deliver health services. This is occurring at a time of massive and continuing global change. Globalization of knowledge, teclmologies and trade are forcing radical transformation of economic and social orders. In general the shift is towards private ownership of resources, competition and market forces and away from public ownership, central planning and public sector management. Many countries are in the midst of major programmes of health sector reform. In government and economic terms the declared aim of these reforms is to achieve equitable coverage of health services while providing health care more efficiently under tight budget control. To this end many governments have focused their efforts on organizational restructuring and managerial improvement. For many countries, one suspects, the prime aim has been to achieve public sector cost control. Some of those countries which moved quickly to reform their health systems in keeping with nanowly defined market and managerialist ideologies are now, in the light of experience, having to rethink their approaches . Improved efficiency in service delivery has been achieved in some areas. Greatest gains have come in relatively straightforward, high volume treatment areas, particularly where services are provided for relatively affluent and mainly urban populations . Generally disadvantaged by the changes have been population-bas ed public health services, people requiring complex or continuing care and poor people dependant upon publicly funded primary care services, particularly in rural areas . For much of the health workforce, especially those working in disadvantaged or socially and economically deprived areas, the changes have been demoralizing and disruptive. Not only has their share of the available resources been diminished but also the infrastructure support for services has been disorganized and sometimes demolished. Major human resource casualties have been centrally organized workforce planning, central support for basic and continuing education and training activities, and other provisions for career planning and development. In the past most of what passed for health sector planning and workforce development was initiated and driven by central government. This is reflected in much of the work that V!HO has done over many years in developing and refining models for workforce development. Based on often complex linear models, these planning processes are largely dependant upon central government for leadership, motivation, information and technical support, and for resources for implementation . Where they existed, such workforce development programmes were often early casualties of market-driven reforms. The theory has been that workforce planning, in the terms described, is ineffective, inefficient, often captured by vested occupational interests, and is better left to the market. There is now sufficient experience internationally to suggest that human resource development, across the full range of health sector activities, does require leadership, policy guidance, dedicated resources, and in significant measure, general facilitation by central government. Tlris does not mean a return to the centrally driven workforce planning methods of the past. However, it does mem1 that some

- 24 -

Annex 4 fundamental rethinking is needed about what the relative roles of markets and governments should be in health sector development generally, and in managing human resources for health in particular. Worldwide, health services are in a state of transition. Pressures to change are forcing countries to rethink arrangements for financing, planning and delivering health services. Tills is occurring regardless of what the present arrangements happen to be. Despite wide spread dissatisfaction with the old order, there is very little agreement or clarity about what the new order should be. Change management under such circumstances is particularly challenging, complex and d.iffi.cult. At this point there are no given answers . Each country must find its own way, must identify its ovm vision for health and health services, and must seek to evolve ways of making that vision a reality. 1.2 Reorganize or redesign

Health services are largely provided for and by people. Human resources are at the core of efforts aimed at health and health service improvement. Human resources account for 60-80% of health expenditure. It is therefore essential that those directly responsible for advising governments on human resource management for health be engaged directly in the larger task of reforming or redesigning health systems. To date, health sector reform in many countries has largely been the preserve of economic and management theorists. In the main, little regard has been given to assessing and meeting the needs and expectations of the consumers, the people. Nor have the ideas and perspectives of health workers, of all types and at all levels, been sought or taken seriously into account. The net result has been that efforts to reform health services have often been frustrated by the uncooperative and sometimes directly obstructive actions ofhealth workers. Nor have they been assisted by the lukewarm support, or at times organized opposition, by the public .

"Think globally and act locally" has long been a slogan used by WHO in support of its "health for all" primary health care strategy. At the core of the strategy is a whole-system approach to the protection and the promotion of health and to the financing, organization and delivery of health services. As described by WHO in 1978 in the Alma Ata Declaration:

"Primary Health Care is essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their foll participation and at a cost that the community and country can afford. It forms an integral part both of the country's health system, of which it is the nucleus, and of the overall social and economic development of the community". As well as being about physical, mental and social well-being, primary health care is about sustainable social and economic development. Those designing the approach recognized that one cannot predict the whole system by looking at its parts in isolation. What is needed is a well-articulated global vision for health and then to see what parts need to be brought together locally to realize that vision. Each country, indeed each community, in keeping with its local history, culture, values, ethics and resources must actively seek ways to protect and promote its own health and to address its own health service requirements. To achieve change in these terms will require more than organizational rearrangement. What is required is a much more fundamental redesign of the health system. Health sector organization is about coordination of the parts or elements of a complex human system, about putting it in working order. Health sector design, on the other hand, has as its concern the end view, the vision and the final purpose . Redesign of the health system:

- 25 -

•

Annex 4 begins with the vision, with articulation of the desired strategic direction and the setting of targets for health and social gain, and for efficient and equitable programme perfonnance; views needs (derived from medical and social epidemiological studies) and wants (consumer-based) for services in concert, and in resource allocation seeks to strike a balance between them; and develops programmes and mobilizes and manages human resources to achieve the specified outcomes .

•

•

A whole-system approach is one in which the vision is created first and then, in sequence, goals and targets are defined, outcomes determined, programmes specified and resources allocated. Only then do the issues of human resources and facilities come directly into focus. In the past, the disposition of facilities, the career and pecuniary aspirations of the workforce and bureaucratic considerations have tended to cloud the vision and prevented the whole system from achieving its full potential. At the highest level, those responsible for the management of human resources for health must recognize and address the need for a whole-system approach. In the past, workforce planners have tended to take a somewhat limited approach to their responsibilities and tasks . However, since the 1960s, health manpower planning practice in WH:O and elsewhere has progressively broadened in scope. Now, in the 1990s, human resource development has come to be defined as: • • • • • • the right number of people; in the right place; with the right skills; with the right attitudes and motivations; at the right cost; and doing the right work.

In the past, workforce planners have focused their attention on those parts of the system which look at organizing, modelling and managing human resources to achieve health and health service goals and targets . Often these goals and targets were loosely or otherwise ill-defined. In the days of relatively stable and centrally planned and managed health systems, where growth was generally linear and incremental, such approaches worked reasonably well. But, in what is now a less structured, more dynamic a.ild much more uncertain environment, more of a whole-system approach must be adopted. Much more attention must be given to trying to answer the question - are we doing the right work') l. 3 Investing in health

In middle and low income countries, the World Bank has come to play a leading role in health sector development. As stated the aim of the bank is to "reduce poverty and improve living standards by promoting sustainable growth and investing in people". With huge resources at its disposal the Bank, in its early years, developed a reputation for focusing too much on monetarist ideology and macroeconomic policies of structural adjustment. If these were right, and the necessary physical infrastructure put in place, the idea was that everything else would logically follow. However, in its most recently published health sector strategy (1997) the World Bank discusses at length the need for more careful approaches which balance its earlier enthusiasm for competition and raw market forces with the need for mutually supportive networks and partnerships, and government regulation. It suggests that, in poor countries where the private sector dominates health care provision, the role of the government should be to focus on preventive public health measures, provision of services for the poor, and tighter regulation of the private sector. However, in countries where the public sector dominates

-

26 -

Annex 4 governments should involve nongovernmental organizations (NGOs) more in the funding and provision of health services. In its early years the Bank tended to down play the health sector role of governments. More recently it sees governments as having a vital role to play in providing information, regulation, mandates and finance while at the same time fostering partnerships with external aid agencies, NGOs, organizations of health professionals, local cornrmmities and _private providers in service delivery. To this end, it concludes that countries must design and evolve, for themselves, new systems of governance, new ways of planning, organizing, resourcing and delivering health services . In the past, in keeping with its early image, the World Bank had a reputation for not working well with other organizations. This too has changed. In future the Bank has declared its wish to work more closely and cooperatively with its clients, other aid agencies and international organizations, including the World Health Organization. The World Bank perceives that it has two levels of collaboration with the WHO: biomedical and technical advice from WHO to improve projects at country level; and global collaboration to improve worldwide understanding of health issues. At both levels there is great scope for the Bank and WHO to work together with clients to guide and otherwise facilitate the planning and management of the human resources necessary to deliver the health programmes required by the new order. Unlike the Bank, WHO has a long experience in workforce pla.nrllng and human resource development. However, it is finding that this knowledge and skill cannot easily be applied in the new environment. Therefore, in the new found spirit of cooperation and partnership, there could be much to gain if the World Bank and WHO worked more closely together, with their clients, to jointly defme goals and design programmes to meet agreed objectives. 1.4 Networks. alliances and partnerships

Creation of sound infrastructure and the ability and capacity to build strategic alliances are likely prerequisites to improving health workforce development performance. In all countries this is likely to require improved networking, coordination and leadership at all levels and across the whole health sector. Improved networking, or working well together, may be the key to improved health sector performance. International research is beginning to show that high-performing industries are those which are able to attract and retain staff with the knowledge, skills and attitudes the industry requires, the energy to innovate and the capacity to handle constant change. Such industries create 'cluster musters' which are 'porous networks' of people who work creatively together in highly cooperative, interconnected and interdependent infrastructures. Such networks are highly flexible and made up of cooperative teams which are quick to use their rich array of connections to solve problems and to adapt quickly to constantly changing environments. The people working in these structures are highly valued and well rewarded by their organizations. The personal and professional development of such people is an important part of the organizational culture. Successful organizations are always on the look-out for talented and energetic people to add to their networks, new people to invest in. Such industries may operate in highly competitive environments but sensitive and creative workforce development policies are used to raise the capability of the workforce, increase job satisfaction and security, lower stress, enhance positive health, and improve organizational performance. Another reason for building networks and alliances is to attract interest and resources to activities which are beyond individual organizations or the health sector as a whole. For instance, broadly-based public health work requires workforce development initiatives which seek out and actively engage potential intersectoral partners, including education and community partners, and their resources, to achieve common public health goals. Success in the implementation of a networking strategy my well depend more on the process used to put the strategy together, and thus the eA.'i:ent to which it is owned by the stakeholders (health workers and the community) than it does on the ideology or scientific evidence upon which the strategy is based. Strategies and programmes often fail not because they are wrong or technically defective but rather

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Annex 4

because they are driven and applied top-down by policy-making elites and are not grounded in, and owned by, the health workforce and the community it serves. These ideas about importance of building networks and alliances have far reaching implications for human resource development for health. Workforce planning activities in the past have traditionally been centrally driven. The models used have tended to be supply-dominated, based largely on existing educational and occupational interests and expectations. In the future greater emphasis will have to be given to demand-dominated models which takes more account of the perceived needs, attributes and wishes of the population, locally agreed patterns of provision, and efficient and equitable use of all available resources. 'Supply-side' thinking tends to be driven by technical advances and the professional aspirations of the existing workforce. 'Demand-side' thinking on the other hand, addresses questions more from a 'whole system' and population health perspective. What is the burden of illness in the population? What interventions are possible? Which individuals or groups are missing out? How can existing resources be applied more efficiently and equitably? How can new resources be mobilized to better cope with demonstrated need? How can best use be made of the available human resources to meet such need? These are the sorts of questions which must be addressed. Traditionally most health workforce planning and development activities have centred around established educational and occupational interests, structures and processes. Professional issues have dominated workforce planning agendas. Consumer perspectives, economic considerations and related industrial issues have rarely been addressed as part of formal workforce planning. Here it is important to involve the public, not only as the object and funder of health and health service action, but also as key actors in the protection and the promotion of health and the provision of health care. Now, with moves towards increasing consumerism and achieving greater efficiency and equity in the use of health resources, these issues are rising up the agenda of researchers, managers, planners and politicians. A first step towards a new workforce development order is likely to be the establishment of an informed and ongoing dialogue between the key stakeholders. New workforce development processes will be needed which are information rich, timely, dynamic and flexible rather than ill-informed, rather rigid and mechanical, as they have often tended to be. New directions should be sensed and responded to quickly. Included in the networks and alliances should be policy-makers, funder/purchasers, providers educators and ilie relevant professional bodies. 1.5 WHO and the World Bank

WHO and the World Bank, between them, exercise considerable influence over health sector development, particularly in low- and middle-income countries. As already discussed, each has its own particular perspective on the need for health sector reform and the best way of making the required changes. Until now the two organizations have tended to act independently. Now there are signs that this might change and that in future they might work more constructively together. In the workforce development context it is helpful here to review and summarize the perspectives of the two organizations. WHO has more than 30 years experience in health workforce planning and development. The planning methods developed and used by WHO since the 1960s have tried to promote a broadly based, whole-system approach. But, what has often occurred is top-down, supply-dominated planning. Over the years, WHO has produced an impressive collection of books, manuals, technical reports and workforce planning models. It has also provided extensive guidance on personnel management and related matters. Much of the planning guidance and advice presupposes that central government will play an initiating and leacfu1g role in health workforce development and that there will be a central planning unit tasked with a series of workforce related planning and management functions. These include:

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28 -

Annex 4 • planning and programming; • • • • • information collection, coordination, analysis and dissemination; catalysis of the planning process; plan production; implementation, monitoring, quality control and evaluation; and research and development.

WHO has considerable knowledge, skill and practical experience in these planning functions. However, the reality is that workforce planning, in these terms, has rarely reached its theoretical potential, even in stable and highly controlled environments. In times of rapidly changing technology and political, social and economic instability, where planning infrastructures and commitment to the planning function has been generally weak, achievement has been limited. WHO's approach to health workforce development is not so much outmoded as inadequate in its application. The recommended whole-system approach has rarely been implemented as specified . Much of the knowledge, skills and methods publicized and promoted by WHO will be useful in a new workforce development order, but in many countries the infrastructure required for central planning is now disorganized or no longer exists . This does not mean that in future there will not be important roles for central government and for WHO in health workforce development. There will be roles but they will be different roles. Central government will be expected to facilitate and encourage rather than control planning and development of the health workforce. By regulation and other means, central government will be required to set up, prime and energize the networks and alliances necessary to plan and manage the health workforce . Rather than depend on central planning and resourcing, provider organizations will in future have to take a much more active interest in, and commit resources to workforce development. They will also need to take a more direct interest in changing health technologies and in changing community needs and demands for health services. Failure to do so, and to develop the programmes and services with the workforce capability to deliver high quality services at the required price, could lead to early exit from the market. So, in a new order, programme and service providers will have to accept much greater responsibility for workforce development. The task of WHO will be to guide and support such development. There is another aspect to WHO's involvement in workforce development In 1994, WHO reviewed the achievements of its primary health care strategy. Despite many successes, major flaws were identified in the strategy. Perhaps the most important of these has been preoccupation with ministries of health and other bureaucracies rather than with people and communities. The review concludes that front-line units in many countries remain poorly organized, under-resourced, over-bureaucratised and badly managed. At the community health worker level the review concludes that five issues demand urgent attention: • • • • • first-line workers are poorly trained; incentives to motivate and reward front-line workers are poor; management at the district and community level is inadequate; public health and clinical leadership is lacking; and education and training models and methods are often inadequate.

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Annex 4

In many countries, and not just poor countries, there is growing evidence to show that changing macroeconomic policies and structural adjustments are leading to a burgeoning of unregulated or poorly regulated private health markets with at the same time, under-resourcing and deterioration of publicly funded health infrastructures and services. The result is deterioration in not only services but also in the health status of poor populations .

This is totally at odds with what WHO set out to do with it's "health for all" primary health care approach. \Vhile it must be accepted that many of the factors which bear on this issue lie outside the health sector, they should be subject to health sector influence and advocacy. To address these concerns in working with countries WHO must try to remove bureaucratic obstructions and address more directly the problems involved in the provision of efficient and equitable primary health care in low- and middle-income countries . It should also draw to the attention of some high income countries the health and social consequences of widening income differentials and increasing relative poverty. Reducing poverty and its health consequences are aims declared and shared by WHO and the World Bank. Based on the evidence available one could suggest that what they have failed to accomplish working independently they could perhaps achieve working together. Much has already been said about the perspective and work of the World Bank. With huge resources at its disposal it has the potential to directly impact the health and well-being of large populations, particularly in low- and middle-income colmtries. Now that the Bank recognizes that investment in health will play a significant part in the achievement of its more ambitious economic objectives, the way is open at global and country level for the Bank and WHO to work more closely together. Already the Bank has embarked upon a series of major initiatives in countries in the area of health sector reform and sustainable financing. An 11-week, well resourced flagship course on this topic was used in 1998 to launch what is expected to be an ongoing programme in support ofhealth reforms in China. As currently specified, the course appears to focus narrowly on the economics and financing of health services. With WHO involvement perhaps this could be changed. As yet, the World Bank does not appear to have addressed directly, or in any significant way, issues of central concern for health workforce development. However, many of its projects and other activities have important implications for the health workforce. If this was recognized and the issues dealt with, in close association with WHO, more successful and sustainable outcomes might be achieved.

2. WORKFORCE DEVELOPME NT IN A NEW ORDER

The challenge at this time is to modify and develop new tools and processes which will better meet health workforce development needs in a new and evolving order. The task is made more difficult in situations where the command structures and processes of central government have been or are being dismantled, where the public sector infrastructure and services are being gradually eroded, where tl1e balance is moving strongly in favour of poorly or unregulated private provision, and where the social and economic consequences of structural adjustment are undermining the health and health services available to relatively poor people. In this evolving new order the focus of workforce development activities is shifting away from central government and towards those organizations and agencies charged with the task of providing efficient, competitively priced health care within tight budget constraints. To be successful in health care markets providers must compete on both quality and price if they are to win contracts to provide services. To be sustainable they must be efficient producers of high quality services. To do tlus they must have secure access to high quality human resources - to health workers who are well trained, well organized and well managed. A strong imperative therefore exists for health-service-provider organizations to invest in workforce planning and human resource development.

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Anne x 4

instances, In the past such provi der organizations have, .in many measure depended upon central us vario in development responsibilities serio usly. They have

not taken their work force

health profe ssion s to set and monitor educational government, education authorities, and the or~ed of healt h workers required to meet the changing stand ards and to produce and maintain the suppl y organizations have generally not invested in the needs and demands of the system. Also, provi der at This too has been left to others, if it has been done continuing education and upgradln,g of thejr staff. all. In the new order this will have to change. ven health care works best in relatively Howe ver, there a:re no simple answers. Market-dri ders competing for contracts to provide discrete affluent urban areas whete there are a munb er of provi lts are much less satisf actor y in situations of items of tightly specified care, in high volume. Resu provi ders willing and able to provide required mark et failur e where there are few and possi bly no ult to specify and cost, or wher e the required services, where services are complex, ill-defined, diffic popu lations in low- and middle-income countries. volumes are low. Typic ally this is so for large rural to the planning and development of h tliUan There is and can be no "one size fits all ' appro ach e regulated mark ets can be used to achieve resources for healt h. In those parts of the syste m wher to see service-'provider organizations playing efficient and equitable delivery of services we are likely To succeed and be susta inabl e .in a business sense much more active roles in workforce development. envisioned in the provision of strmg h!for ward they will have to do so. Sucl1 situations are most easily vely affluent urban popu lation s. Howe ver, as discrete services~ such as surgi cal services, for relati acting and healt h financing grow, it may become experience and capability in healt h economics, contr of services, to contr act for the provi sion of those possible to more precisely define and cost packages this way it may be possi ble to gain the benefits of services, and to monitor provi der performance. In r. us-ing mark et approaches more widely across the secto et-driven approaches will not be achieved This transition from centrally planned to more mark to push the pace of such reforrtls may be quickly. In fact, ill-informed and impa tient efforts ge the trans ition in its own way and at its own counterpro ductive. Eacl1 count ry should try to mana and the Worl d Bank are to facilitate but not pace. The role of international organizations like WHO drive this process. and to mana ge the health work force To redesign health systems along the lines suggested tak.ing which will take time. There are and can be consequences is an extra ordin ary and comp lex under required is a well-designed, whole-system, no instant structural or definitive answers. Wha t is sarily be slow but it must be well mana ged. evolu tiona ry approach. Such a process need not neces ces needed to foster relationships, raise levels of Care mllSt be taken to creat e the networks and allian social capit al in the system. To be succe ssful, in a cooperation and trust, and increase the human and stretc h far beyon d the tradit ional boun daries of public health sense, these networks and alliances must the health sector. n resou rce development is the creation of a The key to success in health sector redesign and huma mill about. There are and can be no definitive share d vision. With out this the system will simply in redesigcing the health sector a11d its answers to the big questions which must be addressed y well-informed, flexible ongo.ing, robus t and widel 'Norkforce . What we must seek to create are open, its review and it revis arly regul to and its workforce mandated processes whic h enable the healt h secto r changing environment. everan of nges challe the vision and evolve to meet 2.1 Kev issues for a new workforce development order

at any length with issues which could be It is not possible, ill the context of this paper , to deal . Some generalization is possi ble but many of critical to huma n resou rce mana geme nt in a new order of detail and level of relevance. The following the key issues will be highly country-specific in terms are offered as starting point s for discussion .

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2.2

Health futures

Annex 4

Those responsible for the redesign of health systems and their workforces should be fanlliiar with the thinking and what is being written about "health futures". As an area of study with its ovvn developing body of knowledge and research methods health futures is relatively new. In 1993, WHO published a useful global synthesis on health futures in support of its "health for all' strategy. For health workforce development people seeking an introduction to 'health futures' this publication is a good place to start. Futures-thinking methods are now being used in many countries to guide research investment in support of sector and nationwide economic and social development planning. In western countries the most highly developed and widely used strategy is called 'Foresight' . Those seriously interested in health sector redesign should be familiar with the basic workings of any Foresight-type futures project in their own countries. 2.3 The information and learning revolution

Within the last ten years or so there has been an information technology explosion, the full impact of which has yet to be felt in health systems around the world. Fifteen key trends have been identified which between them must influence the future shaping of health systems and their associated workforces. These are:

• •

the age of instant communications; a world without economic borders; a one-world economy; the new service society; from big to small - "small is beautiful"; a new age ofleisure; the changing shape of work; women in leadership; the decade of the brain; cultural nationalism; the growing underclass; the active ageing population;

• • ., • • • • •

•

•

• the new do-it-your-selfboom;

• cooperative enterprise; and • the triumph of the individual . It is not possible to even guess what the full impact of the information and learning revolution will be on health and health services. It suffices to say that this is an aspect of futures thinking that health workforce planners ignore at their peril.

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Annex 4 Health determinants 2.3 Any vision for health should start with careful study of the social and economic as well as the physical and biological determinants of health. [n relation to these determinants assessments must be made of what potential there is to intervene for health gain and at what cost. Too often in the past health workforce planning has been narrowly focused on the public health and treatment services which already exist. Taking a whole-system and health-futures approach, health workforce planners must take fully accotmt of the key health determinan ts in light of the cost and social acceptability of possible interventions. In its 1997 policy review, theW orld Bank identified the following as key health determinants globally: • • • • • income levels and poverty; education, especially of girls and women; adequate food, clean water, and sanitation; culture and behaviour; and health-related public policies and interventions .

All over the world complex synergies exist among income levels, education, public policy and health policies -including workforce development plans and policies. In the past, health workforce planners have given insufficient, often. only notional attention to health determinants and related workforce issues. In the future this wiU have to change. 2.4 Health economics and financing of health services

Much has already been said about the economic imperatives driving health sector reform and the role of the World Bank in championing health sector structural adjustment, particularly in low- and middle-income countries. In the last few months there has been much criticism of the Bank's narrowly economic approach to health sector reform. The Bank has responded positively by seeking to broaden its approach to take more account of the social, health and health service consequences of its lending policies and other projects. However, the facts remain, health economics and health financing are vitally important factors in a health systems design and workforce developme nt. Health workforce planners in the future must have They . services health of financing and economics the of sound grasp of the principles and practices must be as familiar with economic concepts of efficiency and equity, with the basics of health care and health insurance markets, with the role of government in financing health care, and with funding and contracting for health services, as they are with the basic health sciences. There is now a burgeoning literature on health economics but much of it is not easily accessible to non-economists. This too is changing. In June 1998, the World Bank placed on its website an online learning course specifically geared to the requirements of health professionals. This provides a selfguided distance-learning programme for policy-makers, managers and researchers wishing to learn more about the economic foundations ofhealth sector reform in developing countries . The web address is http://www. worldbank. org//health reform/ class/module l. 2.5 History. culture. ethics and communitv development

In each country there is a sense in which the health sector, like everything else, is an accident of history. This being so, any efforts to redesign the sector and its workforce must take due account of the history, culture and ethics which underpin the existing arrangements. Some countries have health systems which are firmly grounded in private provision and treatment services, others historically have

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Annex 4 favoured more public health approaches . The institutionalized structures and processes associated with these traditions are often deeply rooted and not easily changed. WHO, in review of its "health-for-all" strategy, and the World Bank in review of its more recent structural adjustment refonns, have independently concluded that much more attention must be given to the relief of poverty and improvement of front-line health care in poor communities. This comes as no surprise. WHO has been talking and writing about this for years. But, by its own assessment, WHO has achieved only limited success. Now, as a consequence of globalization and the infonnation and learning revolution, and with the combined help of WHO and the World Bank, greater gains may be possible. With better access to professional , technical and other resources it may be possible for poor communities to become more economically and socially self-sufficient and sustainable, with the associated health service .improvement and health gains. On the other hand, if this does not occur, if poor communities are not sufficiently encouraged and supported in this way, if the income and health gaps between rich and poor continue to increase, as is currently occurring in many countries, then the global prospects for health and health services will remain bleak. This constitutes an enormous challenge for health sector designers and those who plan and manage human resources for health. 2. 6 Governance and the management of change

Governance may be defined as the means by which individuals and communities, private and public, arrange their common affairs. It is the means by which conflicts and different objectives are reconciled and resolved. Governance includes official institutions that have been given power to arrange matters, if necessary using coercion as a final resort. It includes unofficial arrangements by means of which people and their institutions independently pursue their causes and organize cooperation between themselves . Governance is a more demanding success factor in peoples' lives and in the activities of all of the different kinds of communities they form . The more complex and confused the world grows, the more important governance oflife and its purposeful management of change becomes . We must all be able to live in the midst of change, learn new things, and build trust between people. Governance is a more demanding success factor in relation to the future of the health system than globalization and new technology because one cannot adapt to it in the same way as with globalization, nor can it be bought easily from others, as to some degree is the case with technology. Governance is a phenomena that includes many levels. At the highest level it means taking control of central development factors relevant to the survival of the whole planet -sustainable social and economic development. Within states, on the regional and local level, it leans heavily on its social background and is the result of collective will.

In the past health systems have depended heavily for governance and leadership on centrally driven, bureaucratic systems . Politicians, bureaucrats and health professionals, usually medical practitioners, have usually provided the central leadership in such systems. The national focus for health workforce development was usually within such bureaucracies. This was usually reflected in the way the planning was done. · In the new more open and more market-driven health systems this will have to change. The greatest challenge will be to evolve some acceptable form of governance or leadership for the health system which strikes a workable and acceptable balance between raw market forces and government regulation. Based on its history, culture, values, ethics and level of development each country and each health system will have to find this balance for itself Also, it is important to recognize that the balance point will not be stable. It will require periodic adjustment in the light of changing technologies and evolving social and economic growth and development. Up front, it is important to recognize governance as an issue. Once recognized it should be the subject of careful and continuing thought and debate. It is useful to share ideas about governance and

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Annex 4 e and govern them. But the principles and leadership and the principles which seem to underli organization must work at and ant signific governance is something that each country, each sector, each work out for itself. 2. 7 Role of central government

debate to redesign the The prime task of central government is to underpin, not control, the services are accessible, health that health system . It should provid e the oversight necess ary to ensure are not uncerta in or nities conunu and affordable and of a uniformly high quality, and that individuals worried about the level or quality of services. government will vary by In governance and oversight of health sector redesign the role of central ted as roles in which sugges are ng country and over time. As a starting point for discussion the followi central government should lead: • • • • • • gain; articulate national frameworks for the achievement of health and social monitor and regularly report on the health of the total population; mes and services; regulate provision to ensure affordable and uniformly high quality program benchmark - particularly on outputs and outcomes; coordinate R&D and disseminate the results; and lead, not follow, on - studies to map change in social and economic health determinants; - technology assessment; - cost effectiveness studies; and - innovation, substitution and new progra mme and service development; - health workforce innovation and development. 2.8 Management of the health labour market free market in which In general there are three ways to .organize a market. First, there is the cratic

. Second, there is a bureau workers compete freely to be chosen and paid by employers or clients there is a professional market market which is hierarchically organized and controlled. And third, the consumer is in control, in which is controlled by a dominant occupa tion- the doctors . In the first is vested in the domina nt the second the manager or executive is in charge and in the third control occupation(s).

have their own strengths Elements of all three market types exist in most health systems . Each s when succes sful market Open and weaknesses. These vary depending upon one's point of view. have little job ly general rs increase efficiency. However, they are not always successful. Worke but may be ment, employ y of security. Bureau cratic market s are often reliable and provide securit ional markets profess In es. resourc insensitive to changing client demands and inefficienr in their use of Such markets ion. regulat ional the choice of both the consumer and employer may be limited by profess es. resourc of may also be inefficient and not equitable in their of allocation and use the balance strongl y in Recent health sector reforms in most countries have sought to move . These moves have control favour of open markets -and away from bureau cratic and professional rce. Depending upon workfo the of created tensions across the sector and within and between elements or negative growth and how they are managed these can be positive influences for development

- 35 -

Annex 4 influences which disorganize, discourage and demoralize the workforce. Achieving the right balance and managing these tensions is one of the greatest challenges faced by workforce planners and managers. 2 .9 Substitution

Substitution can be defined as the continual regrouping of resources across and within care settings, to exploit the best and least costly solutions in the face of changing needs and demands . Substitution is fundamental to health sector redesign. It is not merely the replacement of secondary care by primary care as some suggest, but can occur within and between care sectors . As a concept it can help to redesign almost anything. Changes can involve the technolo gy, methods, actors, timing, location, even the reasons for care. Skilfully used b y health sector planners and managers, it has great potential for innovation and improved efficiency .in. the use of scarce human and other resources. 2 .10 Research and development In most countries the health workforc e is a neglected area for research. Tins is surprisin g given that the bulk of health expenditure goes on the workforce in one way or another. Deficien cies in basic health workforce data cause perennial. problems the world over acting as a constram t on policy development and action. \Vhat little research is done is rarely focused on answering importan t workforce development questions, is frequently methodologically or otherwise unsound, is poorly coordinated and often wasteful of resources .

In the past what little research has been done has usuaLly been remote from the workplace. It has largely been motivated and carried out by central government agencies, health professio nal orga1rizations or universities/research institutes. Rarely is research firmly grounded at the workface, owned by front-line health workers and their management, and carried out using an action research and development format. In any new order this should change. Research should be seen, not as a remote activity, but as a necessary part of front-line management. Health workers, aJ.ong with their managers should not only be involved but also feel that they have ownership and a stake in the research, its findings and outcomes . Basic workforce statistics are important. Data must be gathered conscientiously, analysed carefuUy and the results widely shared. Howeve r, on its ov,;n, this is not enough. Much greater effort and resources r;nust be vested in locally ccmtrolled action research and development projects aimed at exploring s:ubstitutionpossibiJities and other ways of making more efficient use ofhuman resources for health.

3. CONCL USIONS

Resource management of the health workforce must change to meet the requirements of an evolving new order in health and health services . Something of a renaissance is required. A new focus, a new format and new leaders must be found - persons who understa nd the new environm ent and have the knowledge, skills and energy required to shape the new order. The new networks and processes must be information-rich, timely, dynamic and flexible. New directions must be sensed and responded to quickly. Networks must include, and where possible commit, policy-makers, purchase rs, providers (employers and their workers), educators, professional bodies and other employee organizations, and representatives of the public as the funders and consumers of care.

- 36 -

Anne x 4 with professional issues : In the past, health workforce planning dealt almost exclusively . Consumer perspectives, econo.mic and professionally determined needs and demands for services were rarely addressed as part of workforce financing considerations and related industrial concerns sing consumerism and achieving greater development processes. r ·ow, with moves towards increa issues are rising up the workforce agendas of efficiency and equity in the use of health resources, these all interested stakeholders. for health must take more account of In future , those responsible for managing human resources ts of producing services. Planners and customer perspectives, quality issues and the cost and benefi and quality considerations. They must be managers must weigh - and may need to trade off- cost the division of labou r, job demarcation, prepared to raise and address important questions about professional and industrial issues. regulation, substitution:, relative remlmeration and other longer so. The trend is clearl gement for health in such an enviromnent industrial environment. Human resource planning and mana dynamic approaches than was the case even muSt be governed by more informed, more open and more a few years ago. orce enviro In the pas~ occupational hierarchies dominated the health workf used and more competitive er-foc custom more y towards a more open, nment. This is no

- 37 -

ANNEX5

NEW ZEALAND HEALTH WORKFORCE DEVELOPMENT CASE STUDY 1. Why is the health workforce important?

• •

people working with people 60-80% of health expenditure competence capacity cooperation culture community cost

• • • • • • 2.

Definition of human resource development Human resource development is: • • • • • • the right number of people at the right place with the right skills with the right attitudes and motivations at the right cost doing the right work

3.

Phases of health workforce development (the New Zealand experience) • • • • • • General disorder Environmental health Biomedical/hospital expansion Government leadership and regulation Minimal government and market forces Balance regulation and market forces

- 38 -

Ann ex 5

4.

(Pre 1900) Health and health services in New Zealand • • • • • • • tent, often ineffective local authorities public health administration largely non-exis poor environmental hygiene widespread infectious disease private arrangements for care ion traditional remedies/comfort and compass poorly trained and managed workforce low public health expenditure

(general disorder) ( 1900-1940 Health and health services in New Zealand • • • • • • • • • Department ofH ealt h established in 1901 strong central direction trained professional staf f public health legislation military style structure and operation water/food/waste/housing infectious disease control limited treatment services modest public e&rpenditure

(Environmental health) 6. (1940-1970) Health and health services in New Zealand • • • • • • • strong economic growth biomedical/therapeutic revolution rapid growth of hospitals health professionals (doctors) dominant poor information ming episodic planning, including workforce plru. agement inefficient orgru.lizational m1d resource man

-

39 -

Annex 5

• •

public health services in early decline rapidly rising hospital expenditure

(Biomedical/hospital expansion) 7. Health and health services in New Zealand (1970-1984) • • • • • • • • • economic stagnation doubts about medical effectiveness management and efficiency concerns medical dominance challenged computers/information systems more effective evidence-based planning systematic workforce planning improved sector management rising concern about health costs

(Government leadership and regulation) 8. Health and health services in New Zealand (1984-1995) • • • • • • • • • • radical structural readjustment with associated social and economic changes tight control of public finance dismantle public services sale of state assets abandoned central planning - including workforce planning policy/purchaser/provider separation contract culture declining performance of public health services fragmented and demoralized public sector workforce growing private sector

•

public health expenditure contained

(Minimal government and market forces)

- 40 -

Annex 5

9.

Health and health services in New Zealand (1995-present) • • • • • • • • • • economic stability with slow growth deteriorating health status increasing income differentials, rising poverty levels and y and value for money strong management focus on effectiveness, efficiency, qualit rising public concern about access, affordability and equity declining public confidence in public health services concern to balance marke t forces and regulation renewed interest in planning, including workforce planning controlled but rising health expenditure new emphasis on leadership and learning willingness to explore new forms of governance

(Balance regulation and marke t forces)

- 41 -

ANNEX 6

ACHIEVING BALANCE IN WORKFORCE PLANNING AND MANAGEMENT: YING AND YANG

PLANNING • • • • • • • • • • • • • • Vision I Resources Strategy I Operations Regulation I Market Tradition I Reform Evolution I Revolution Medical treatment I Protection and promotion of health Medical science I Community health development City I Rural and remote Evidence I Politics Cooperation I Competition Costs I Benefits Equity I Efficiency Plans I Action Rhetoric I Reality

PRACTICE- MANAGEMENT • • • • • • Central I Local control Guidance I Direction Tight I Loose Individual competence I Successful team Clinical I Managerial strength Basic I Continuing education

- 42 -

Annex 6 • • •

Responsibility I Authority Organizational expectations I Personal expectations Eff01i I Reward

• •

Direction "Carrot"

Appreciation "Stick"

- 43 -

ANNEX7

THE CHANGING ROLE OF THE STATE, WHO AND THE WORLD BANK IN HEALTH WORKFORCE DEVELOPMENT- A WORKING PAPER

l. 1.1

Rethinking the health and health workforce development role ofthe Sate Role in context • • Recognize that health is an integral part of social and economic development Recognize that the State must play a leading role in regulating for health and health services Accept ownership and provide leadership of a country's health system Create the enviromnent and frameworks needed to encourage key health sector interests to work together and with others outside of the sector Encourage and support health and health workforce plmming in the broader context of national, social and economic plmming Ensure that the required policies, finance and supporting services are available to meet declared govermnent objectives Value, encourage and reward the health workforce

• •

•

•

• 1.2

Role in policy • Develop macroeconomic social and financial policies which take health and health services into account Create policies to research and explore options for health futures, set strategic directions, establish priorities and operationalize plans Within the broader plmming framework develop policies and plans for hmnm1 resource planning and development Encourage wide policy development networks which include appropriate health sector interests Put in place mechanisms to mediate or decide issues where policy differences cmmot be resolved within networks or between interested parties

•

•

•

• 1.3

Role in support Information: • • open systems basic data systems

- 44 -

Annex 7 • • • • • • assessment tools management systems research and development monitoring, audit and evaluation technology assessment communication, conferences, workshops

Human resources: • • • • • encourage leadership and organizationalleaming strengthen networks and institutions technical support for research and planning occupational regulation disputes resolution

Financial resources: • • • • 2. 2.1 advocate nationally for resources for health open consultative systems for priority setting and resource allocation efficient financial management systems incentives, performance recognition and rewards

Rethinking WHO's human resource management approach Key elements in analysing and managing complexity Context: • • • political and socio-economic environment disease patterns stakeholder involvement

Policies: • • • • macroeconomic public sector reforms health sector policies HRH policies

- 45 -

Annex 7 Supporting system: • • • • 2.2 information human resources fmancial resources management resources

Factors for success in achieving a workable balance • • • • • • • • • Fit the political and economic context Adapt to the specific design of government and health system refom1 High-level political and administrative support Identify and meet the legitimate needs of health workers Use good HRH process: data, monitoring and evaluation Ownership issues Consultation and networking Strong HRH leadership Secure and sufficient financial resources

2.3

Refocus on the primary health care approach • • • • • • Focus on people, conununities and front-line workers Train and support front-line workers Motivate and reward front-line workers Improve the management of front-line resources at the district and cmmnunity levels Raise the levels of public health and clinical leadership Use technically and culturally appropriate, cormnw1ity based, training methods and models

3. 3.1

Rethinking the World Bank' s approach to health and health workforce development Objectives and key factors

The declared aim of the World Bank is to improve living standards by promoting sustainable growth and investing in people. To this end the Bank has identified the following key factors pertaining to health: • income levels and poverty;

- 46 -

Annex 7 • • • • 3.2 education, especially for girls and women; adequate food, clean water, and sanitation; culture and behaviour; and health-related public policies and interventions.

Recent criticisms ofthe World Bank • • • • • • Strong monetarist ideology Macro-economic focus Structural adjustment approach Narrow focus on health economics and health financing Arrogant and bullying approach Not cooperative with others

3. 3

A revised approach • • • • • Less emphasis on competition and raw market forces Greater emphasis on cooperation and on mutually supportive networks and partnerships Recognize a strong leading role for the State Regulation of health markets More emphasis on people in all aspects of health and health care including workforce development A more humane face to the Bank More active cooperation with others, including WHO

• • 3 .4

Cooperation with WHO Two levels identified: (1) (2) Biomedical and technical advice to improve World Bank projects Collaboration globally to improve world-wide understanding of health issues

- 47 -

ANNEX 8

WORLD

HEALTH

ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

WORKSHOP FOR RESOURCE MANAGEMENT OF HEALTH WORKFORCE Shanghai, China 21-25 June 1999

WPR/HRH/HRH( 4)/99 .3( a) 25 May 1999 ENGLISH ONLY

COUNTRY PAPER ON RESOURCE MANAGEMENT OF HEALTH WORKFORCE IN CAMBODIA

by

Mr Tek Leng Soeu Head, Bureau of Continuing Education Human Resource Depatiment Ministry of Health

Annex 8

- 48 -

' l ] ~ .,.: J

.

t~~ *****

J~)i

!~ ·~

-KINGDOM OF ·cAMBODIA NATION-RELIGION-KING

Ministry of Health

.

Roles and Responsibilities and

1999 Plan of Action for

Human Resources Department

Unofficial English Translation

- 49 -

Annex 8

Report of Outputs of a Workshop to Develop an Action Plan for the Human Resource Development Department

The HRD Department conducted a two-day Workshop from 14th- 15th January 1999, with all HRD staff participating. The objective of the Workshop was to review the role

··a-na·tu-rictions"·ot the· DepEirtme'r1t ana cit eacri-·sure-a:u ·within tile 'ber)aiiment, ·review ·r:n~o policies and to formulate an Action Plan for 1999. The Workshop was supported by WHO.

After two days of discussions, the outputs were as follows: • • • Developed role and functions of the HRD Department Developed role and functions of the three Bureau within the HRD Department Allocated functions to units or "work teams" within each of the Bureaus, and assigned responsibilities to staff within the Bureau • Identified strengths and weaknesses of the Department, and developed strategies to address weaknesses • • Finalized the draft of the HRD Action Plan for 1999 Developed monthly and quarterly plans of action for the Department and each Bureau • Decided on a mid-term evaluation Workshop for monitoring and evaluation of the activities

Detailed documents of the Workshop outputs are attached.

Seen and Approved ~., . Director of the Department

Phnom Penh, February 2nd, 1999

The Reporter,

/\

!1_/ - \)J»U'-t rJ Pharm. Tek Leng Soeu (

- so Annex 8

Role and Functions of the Human Resource Department 1. J;>~ann!ng

I Management Functions

HRD Policy formulation Strategic Planning for national human resource development Health Workforce Planning Establishment of categories, numbers, deployment Projection of future staff requirements Maintenance of current training statistics Projection oftraining inputs and outputs to meet requirements Projection of staffing and other training costs Contribute to management ofhealth workers (recruitment, deployment etc.) Manage Department for efficient operation, including tracking input I output 2. Training Functions

Training Policy formulation Training Master Plan (pre-service, continuing and post-graduate) Fellowships (based on requirements of Training Master Plan) Organise/supervise implementation of teacher training for: Pre-service teachers Post-graduate I Specialist teachers Continuing education teachers Monitor development of Curriculum and Training Materials Programming, commissioning, accreditation of: Pre-service courses Post graduate courses Continuing education MPA courses CPA courses

- 51 -

Annex 8

Coordination and supervision of training activities of: Faculty ofMedicine, Phannacy and Dentistry TSMC . . .. - -· - ... ' Regional Training Schools National Programs NGO training activities ~

Monitoring and evaluation of training courses: Pre-service courses Post graduate courses Continuing- education· MPA courses CPA courses 3. Quality Enhancement Functions Registration/licensing of health personnel (in public and private sector) Regulation of health workers (Cambodians and foreigners) in private sector, including setting of minimum standards of training required for practice, for all categories of health worker Regulation and accreditation oftraining courses Regulation and supervision of examinations Establish standards I criteria for issuing of certificates for completion of training courses Regulation and supervision of timely issuing of certificates for graduates

Maintenance and use of database of health worker training Monitor and evaluate the operation ofthe Human Resource Department

- 52 -

Annex 8

Role and Function of the Bureau of Continuing Education

... ·· - - ... Under the overall supervision of the Director of the Human Resource Department, the Bureau of Continuing Education is responsible for the planning, management and evaluation of all in-service and post-graduate education of health workers. ~

1. Planning Functions Contribute to relevant policy formulation

Health Workforce Planning with regard to in-service and post-graduate training Maintenance of current training statistics for in-service and post-graduate training Projection of in-service and post-graduate training inputs and outputs to meet requirements Projection of staffing and other in-service and post-graduate training costs Support training institutions in their planning activities, ensuring consistency-with HRD strategic and operational plans ' Training Functions Contribute to in-service and post-graduate training policy formulation

Contribute to Training Master Plan (re in-service and post-graduate training) Organise/supervise implementation of training for in-service and post-graduate teachers Monitor development of curriculum and training materials for in-service and postgraduate training Make recommendations reprogramming, commissioning and accreditation of inservice and post-graduate training courses Coordinate in-service and post-graduate training activities of: Faculty ofMedicine, Pharmacy and Dentistry TSMC Regional Training Schools National Programs NGOs Monitor and evaluate in-service and post-graduate training courses

- 53 -

3. Quality Enhancement Functions Contribute to regulation and accreditation of in-service and post-graduate training

Annex 8

Supervision and regulation of examinations for in-service and post-graduate training courses Regulation of issuing of certificates for successful completion of in-service and postgraduate training Contribute to regular updating of database of health worker training

- 54 -

Annex 8

Role and Functions of the Bureau of Basic Training Under the overall supervision of the Director qf the Human Res_o:urce Department, the Bureau o.fBasic T-raining is responsible for the planning, management and evaluation of all basic (pre-service) training ofhealth workers. 1. Planning Functions

Contribute to relevant policy formulation Health Workforce Planning with regard to pre-service training (National and Regional) Maintenance of current training statistics for pre-service training (National and Regional) Projection of pre-service training inputs and outputs to meet requirements (National and Regional) Projection of staffing and other pre-service training costs (National and Regional) Support pre-service training institutions in their planning activities, ensuring consistency with HRD strategic and operational plans 2: Training Functions Contribute to pre-service training policy formulation Contribute to Training Master Plan (re pre-service training) Organise/supervise implementation of teacher training for pre-service teachers Monitor development of curriculum and training materials for pre-service training Make recommendations re programming, commissioning and accreditation of preservice training courses Coordinate and supervise pre-service training activities of: Faculty of Medicine, Pharmacy and Dentistry TSMC Regional Training Schools Monitor and evaluate pre-service training courses 3. Quality Enhancement Functions Contribute to regulation and accreditation of pre-service training courses Supervision and regulation of examinations for pre-service training courses Regulation of issuing of certificates for successful completion of pre-service training Contribute to regular updating of database of health worker training

- 55 -

Annex 8

Role and Function of the Bureau of Registration and Certification Under the overall supervision ofthe Director of the Human Resource Department, the Bureau of Registration and Certification is responsible for the planning, implementation, management and evaluation of a system of registration I certification for health workers. 1. Planning Functions Contribute to the formulation of relevant policy, strategy and legislation for development of a system of registration of health workers in Cambodia

2. Database Functions Responsible for overall maintenance ofHRD database of health worker training Maintenance of current statistics for all categories of health workers Contribute to Health Workforce Planning activities

3. Registration Functions Develop Registration system through consultative process Implement system when developed(? incremental process) Maintain system when operational, including problem solving Monitor and evaluate Registration system

4. Evaluation and Certification Functions Contribute to regulation and accreditation of training courses Contribute to supervision and regulation of examinations for training courses Contribute to issuing of certificates for successful completion of training courses

.,.

Department of Human Resources Development .. Director: Vacant

Deputy Director: Ms Keat Phuong

Bureau of Pre-Service Education Head: Dr Phum Sam Song

Bureau of Registration and Certification Head: Dr Ung Thol

Bmieau of Continuing Education Head: Mr Tek Leng Soeu

'

I TSMC/ RTCs Phum Sam Song Leng Map Un Chenda Policy I Planning C11rriculum Dev. Recruitment )tudent I Graduate Statistic's Co-ordinaiion

T

I

. I

I

I Quality Enhancement Ly Seila Mony Duk Vannarith Neag Ren Co-ordination Monitor I Evaluate Training HWF Management

I In-service Tek Leng Soeu So Ka Touch Sokneag MPA I CPA Short Course Practical Training

I Post-graduate ~am Sina Nop Sotheany Ph eng V isoth

Faculty of Medicine Lor Sivin Ly Sam Bona Sok Thea Chhay Sok Heng Policy I Planning Curriculum Dev. Training Report Student I Graduate Statistics

Curriculum Development Chong Vandara Satharin Monysetha MPA !CPA /lt!onitor & evaluate other curriculum l11 0'

Fdlowships Specitllist Training in Cambodia

Evaluation & Certification Ung Tho! Tao Sok Mony

Registration Min Duong Chan Sok Nara Bo Sokkha Vat Yathy MaintainHW Register for Public & Private Sectors

Database Lim I-Iuy Tourn Samath Kim Savuth Oeung Sokny Maintain Database HWF Statistics Public & Private

San Loch Luon Mundo! Verify Certificates Equivalency Khmer Translation

Department of Human Resources Development

Director: Vacant

Deputy Director: Ms Keat Phuong

I Bureau of Pre-Service Education Head: Dr Phum Sam Song Vice Head: Dr Lor Sivin Staff: Dr Ly Seila Mony Dr Ly Sam Bona Dr Leng Map Mr Duk Vannarith Mrs Un Chenda Mrs Sole Thea Mrs Neang Ren Ms Chhay Sole I-Ieng

I Bureau of Registration and Certification Head: Dr Ung Thol Vice Head: Dr Y at Yathy Staff: Dr Tao Sole Mony Dr Min Duong Chan Dr San Loch MA SoleNara Ms Tourn Samath Mr Bo Sokha MA Kim Savuth Dr Luon Mundo!

Bureau of Continuing , Education Head: Mr Tek Leng Soeu Vice Head: Dr Chong Vandara* Staff: Dr Im Sothearum f>r Sam Sina pr Satharin Monysetha Dr So Ka Dr Touch Soleneng Ms Nop Sotheany !yfA Pheng Visoth Dr Lim I-Iuy Ln -...J

* on leave from the 1-IRD Department

Bureau of Registratio n and Certificatio n :

Head: Dr Ung Tho!

Vice Head: Dr Yat Yathy

I Evaluation & Certificatiot! Ung Thol Tao Sok Mony San Loch Luon Mundo!

I Registration Yat Yathy Min Duong Chan Sok Nara Bo Sokkha Maintain HW Register for Public & Private Sectors

Dat;lhasc Lim Htiy Tourn Sarhath ' Kim Savllth Oeung S~lcny

Ul

CXl

Verif.i' Certificates Equivalency Translation to Khmer

Maintain Ddtabase 11/VF Stntt\'tics Public & Private

Bureau of Pre-Service Training

Head: Dr Phum Sam Song

Vice Head: Dr Lor Sivin

I TSMC/ RTCs Phum Sam Song Leng Map Un Chenda

l Faculty of Medicine Lor Sivin Ly Sam Bona Sok Thea Chhay Sok Heng

Quaiity Enhancement Ly Seila ,Mony Duk Van:narith Neag Ren

Policy I Planning Curriculum Dev. Recruitment Student I Graduate Statistics Co-ordination

Policy I Planning Curriculum Dev. Training Report Student I Graduate Statistics

Co-ordination Monitor I Evaluate Trainmg HWF Mani;tgement

Bureau of Continu ing Educati on

Head: Mr Tek [.. eng Socu

Deputy Head: Chong Vandara* ;

In-service Tek Leng Soeu So Ka Touch Sokneag

Post-gra duate Sam Sina Nor Sotheany Pheng Visoth

Curricul um Developm ent Satharin ~onysetha Chong Vandara* 0\

0

MPAICPA Short Course Praclical Training

Fellowships Specialist Training in Cambodia

MPA/CPA Monitor ~ evaluate other curriculum

* on leave of absence from Mol-l

HRD ACTION PLAN 1999

Department of Human Resources Development Plan title 1: HRD database database of MoH employees for use Objective: To establish a functional and comprehensive in planning, managing, and training for HR within the MoH Activities Time :

Respo .Where :

Possible funding

01 Q2 03 04 Opt 1.1 To review the existing database form for data collection s 1.2 To develop database software at central & RTC level 1.3 To organize the two-day workshop at national level to discuss on the information needed for HRD m, 1.4 To have a visit in Nepal to look at the database syste its management, and its decentralization 1.5 To review the software in compare to Nepal's system 1.6 To send the form to provinces and collect data 1.7 To train computer skills to relevant staff 1.8To produce information for users

y y y

HRD HRD HRD

:HRD

GTZ WHO HSRG

~HRD !

HRD

, y HRD '

GTZ

y y

':

HRD PO

HRD /GTZ HRD/P ADB HSRG

y y

HRD/G .HRD HRD lrlRD

Plan title 2: Revie w HWF Plann ing the need of the MoH, Obje ctive : To review the plan in line with the current situation and including training plan and staff allocation !

Activ ities

Time

Resp o 'W here

Poss ible fundi ng.

01 02 Q3 04 perso n 2,1 Set up working group 2.2 Data analysis of the staff needed in each province 2.3 Training plan in line with the health coverage plan and the current situation in each province

y y y

;

WG WG

'

'MoH

WHO

MoH/Prov. ;

y

y

WG

HRD :

"' N

-

Plan title 3:Job description for PHD & 00 Office description for Objective: To develop job description for key staff at PHD & review job ;

o Office o·

. Activities Time Respo Where Possible funding HRD HSRIII/WHO :

01 02 03 04 person 3.1 Set up working group: representatives from HRD, Personnel, Planning&Health inf.,Preventive Med.Dept, some from PHDs & secretary 3.2 Develop PHD'JD for technical,admin.,finance,& drug bureaus 3.3 Review OD'JD for technical section&admin-finance section 3.4 Field visit to provinces and finalized the JD

y

WG

y

y y y I

'

Plan title 4: In-se rvice train ing staff skills in prov iding MPA & CPA Obje ctive : To stren gthe n in-se rvice train ing to impr ove '

Activ ities

Time

Resp o .;where

Poss ible fund ing

01 02 03 04 pers on 4.1 MPA module development ( 14 Modules remaining ) 4.2 MPA module 1 training (contracting out) 4.3 Maintenance CE system 4.4 CPA: Basic surgery curriculum 4.5 CPA: Basic surge ry training rvice y 4.6 Coordination with NIPH & others with regards to in-se training 4.7 Training of district health managers on management ding 4.8 Coordination with donnors & training institutions regar training abroad activities

y y :

PIU PIU

'HRD HRD HRD HRD I

MoH/ADB BSk MoH/ADB BSk MoH/ADB BSk MoH /WB? '

y y

y

y

y

HRD WB

Y.

y y

y y

HRD HRD

3 prov. MoH /WB? :, 4 prov. I

y

y

y

y

y

HRD

.3RTCs MoH/WB I ;

'

MSF/UNICEF

:

Plan title 5: Basic training Objective: To routinely coordinate with training institutions regarding basic trainif!g

Activities

Time

Respo Where

Possible funding Government Government Govern men { I

01 02 03 04 person 5.1 Coordination activities regarding curriculum development 5.2 Coordination activities regarding training policies 5.3 Coordination activities regarding training plans

i HRD HRD

HRD HRD HRD HRD HRD

I~RD I

5A Coordination activities regarding student intake process 5.5 Coordination activities regarding monitoring activities & training evaluation

I

.HRD

Government Government

,HRD ,, ., I

I

Plan title 6: HRD Policies and strateg ies and functio ns. Objecti ve: to develop policies and strateg ies to suppor t the HRD Opt in fulfilling its roles Possib le Respo Where Time Activitie s 01 02 03 04 Opt 6.1 to review & clarify role & responsibility of each bureau & each staff member (including a two-day retreat for HRD Opt) 6.2 to collaborate with the MOEY&S for future direction of the health training institutions 6.3 to review and modify the existing policies, strategies and criteria for selection of students ( national & international ) 6.4 to review the role & function of St Treng RTC to meet a specific needs of the Nord East Region 6;5 to develop policies that promote the role of the HRD Opt as the coordinating agency for all health worker trainings in Cambodia 6.6 to collaborate with the Personnel Opt regarding the deployment of staff in Cambodia 6. 7 to continue the development & implementation of a system of registration for health workers in Cambodia :

funding · WHO I

y

3 Bure HRD

y

y

Basic B HRD

y

y

y

HRD '

WHO

y

CB/BB

WHO

I y y HRD I I

WHO

! '

y

y

',

y

' I

'

Plan title 7: HRD Staff Development work Objective: to increase the capacity of HRD in areas important to their Activities Time Respo Where Possible funding

01 02 03 04 person 7.1 To provide in-service training to HRD staff in : office management, including filing English language ( spoken and writing ) computer skills- word processing for all staff, database for some staff, excell for a few staff 7.2 To provide post-g raduate training to select HRD staff, particularly in Health Personnel Education, also in law related to regulation for health workers

y

y y y

y

CEB CEB CEB CEB

HRD HRD HRD

GTZ ADB

y y y

y

HRD HRD r I

y

y

CEB

Au sAID/ SCF Aust

(

Plan title 8: Staff Retent ion ies :aim at retaini ng staff Object ive: to invest igate the causes of high staff turnov er, and develo p strateg Possib le Respo Where Time Activit ies 01 02 03 04 person 8.1 To a quantitative and qualitative analysis of staff motivation, attendance turnover 8.2 To develop strategies to overcome the most common causes of high staff turnover Plan title 9: Job Descri ption for HRD staff Object ive: to develo p job descri ption for all HFD staff positio ns Activit ies Time Respo Where Possib le fundin g 01 02 03 04 person 9.1 Set up working groupnwith representatives from each Bureau 9.2 Develop job description for each position within each Bureau ( related to role & function of HRD ) fundin g

y

MOH MOH j

WHO HRD

y

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y

y

All

MOH MOH L

Bureau[

y

y

All

Bureau

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Plan title 10: Financing Strategies for HRD Objective: to develop strategies for financing HRD overall, and for particular Activities Time activ~ties

Respo Where

Possible: funding

01 02 03 04 person 10.1 Set up working· groupnwith representatives from each Bureau 10.2 Develop strategies for financing the operation of the HRD- consider direct revenue raising and support of donors

y

y

All Bureau

MOH

y

y

y

HRD

MOH

Plan title 11: Mid year review of HRD activities Objective: to review outputs of the HRD for Q1 & Q2 1999, and make strategies to ~trengthen if needed · Activities Time Respo /where Possible funding MOH WHO .

01 02 03 04 person 11.1 Hold a 1-2 day workshop to review 1999 H RD activities plan

y

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- 70 Annex 8

WORLD

HEALT H

ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENT AL

WORKSH OP FOR RESOURC E MANAGEMENT OF HEALTH WORKFOR CE Shanghai, China 21-25 June 1999

WPR/HRH /HRH(4)/99 .3(b) 25 May 1999

ENGLISH ONLY

COUNTRY PAPER ON RESOURC E MA.l~AGEMENT OF HEALTH WORKFOR CE IN THE PEOPLE'S REPUBLIC OF CHINA

by

MrLi Feng Mr Sun Lijun Ms Wang Chen Mx Xue Puying

-

7l -

Annex 8

SUMMARY ON HEALTH MANPOW ER DEVELO PMENT IN CHINA

In recent years, how to make reasonable use oflimited health manpO\:ver and improve the efficacy of health manpovver has become a very important issue in both developed and developing countries . Taking the world as a whole, about 70% of the health budget is usedio pay the salaries . for the health workforce. China is no exception. TI1erefore, reasonabl e use of health manpower must play a big role in improving the social and economic efficiency . Meanwhile, health manpower has some characteristics such as much more specialized, less chances of being replaced, . longer training periods which make it more necessary to further study on future needs in health workforce development in order to keep the balance between suppliers and consumers of health care. Thanks to the efforts of the Chinese central govennnent and the teclmical assistance from WHO, great improvement has been achieved on the developme~1t of health workforce especially in the considerable increase of the qu antity of the > vorkforce. TI1e quantity ofhealth m<mpO\ver, which used i o be a major problem of Chinese health manpm:ver development, could meet the need of the whol e people .in the country except for some poverty areas . However, like many other developing cmmtries, China has encountere d the follovving problems: ( 1) it is noted tl1at there is a difference in the health manpower between the urban and mral areas and among different regions because of the unbalanced economic development; (2) health workforce training categories are out ofline \'vith the actual needs:

(3) the distribution of health workforces in various departments, institutions and in different specialties is not rational; (4) the technical eA.1Jertise ofhealth workforce cannot meet the demand, especially in the nua1 areas; and (5) the advanced health workforces in grassroots health institutions in mral areas are deficient. At present, the problems encountered in China are more severe than developing countries . The reason for this can be concluded as follows: first, China is a large developing country with one fifth of the world population. More than 80% of its population are fanners. Moreover, there are great differences between urban and mral areas and among different geological regions vvhich lead to a quite unbalanced economic development in China. Secondly, China· s economy is now under its transition procession from the planned economy to a market economy. Naturall:·, some areas with better environmental and social conditions have developed even faster than others. As a result, tlus has somehow aggravated the uneven situation of economic development. i\11d a lot of health workforce in rural areas flovv into big cities, especially the developing cities . On the contrary, in the mral grassroots health institutions, many advanced health workforces has abandoned their position to seek for better working condition vvluch makes the scarcity of healtl1 care service for some population even worse. In addition, the teclnucal title system is complicated in China. Doctor is such an et.1:ensively used word tl1at even the person without nom1al training can take professional medical practice in China.

- 72 -

Annex 8

All in all, the nmdamental problems on health manpower development in China we are now facing we are now facing are not rational distribution structure, low distribution efficacy and deficiency of workforce quality. At present, the government is paying much attention to address the questions . The key issues of health workforce development should turn to improving quality, changing structure and increasing efficacy. Just as indicated by WHO STC, Dr Hornby. that reasonable assembly of individuals and elevation of economic efficiency is an important landmark when the traditional health manpower development is tuming to a modem model. There are different microcosmic and macrocosmic research methods in the field of health manpower development worldwide. However, none of these can be absolutely· appropriated in China since China has a special social, economic and health system. Therefore, in order to create a more open, more customer-focused and more competitive industrial envirom11ent with Chinese characters, we must take more account of our own perspectives while we leam methodology and technology from other countries.

- 73 -

Annex 8

WORLD

HEALTH

ORGANISATION MONDIALE DE LA SANTE

ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

WORKSHOP FOR RESOURCE MANAGEMENT OF HEALTH WORKFORCE Shanghai, China 21-25 June 1999

WPRJHRH/HRH(4)/99.3(c) 25 May 1999 ENGLISH ONLY

OVERVIEW OF HEALTH WORKFORCE MANAGEMENT IN THE LAO PEOPLE'S DEMOCRATIC REPUBLIC

by

Mrs Staphone Insisiengmay Mr Khamhoung Heangvongsy Ministry of Health Lao People's Democratic Republic

-

74 -

Annex 8

OVERVIEW OF HEALTH WORKFORCE MANAGEMENT IN THE LAO PEOPLE'S DEMOCRATIC REPUBLIC

1. 1.1

National context General characteristics

The Lao People's Democratic Republic is a land locked country in Southeast Asia bordered by China to the North, Myamnar to the Northwest, Cambodia to the South, Vietnam to the Northeast and Thailand to the West. It is mountainous country and covers the area of about 236.8 square kilometers which is predominantly rural and the major subsistence economic activities are agricultural. The country consists of 18 provinces including Vientiane Municipality and Saysomboun Special Zone; 137 districts, 12,567 villages and about 748,529 households. The population of 4.6 million people (National Statistic Center, 1995) is characterized as a very young population with relatively large numbers of young people and females in the childbearing age cohort. Female consists of 50.6 %, 15 .1% children under five and 44 .I% are the children below 15 years old. The rural population present 82.9%. The ammal Gross Product (GDP) growth rate is 6.8% *NSC, 1996). Lao PDR has a per capita Gross National Product (GNP) ofUS$370 (NSC, 1997) and the health expenditure per capita was US$3. 7 (Ministry of Health, 1996). 1.2 Social aiJd cultural situation

Lao PDR is a culturally diverse country of over 30 etlmic groups, divided into three main groups. The Lowland Lao people usually are lowland rain fed paddy fam1ers, eat glutinous rice. This group accounts for 65% of the population, live on the plain along the Mekong river. The Upland Lao constitute 22% of the population, live on the mid-slopes, plant glutinous rice. Highland Lao people who in the past planted upland dry rice, com and opium on the highest slopes moved to lower elevation to open up paddy land cultivation, comprise about 13% of the total population. The govermnent has recently intensified the implementation of its intemal resettlement policy, promoting stabilized agricultural systems (paddy cultivation or rotating upland) and eliminating envirom11entally destructive forms of sudden agriculture. 1. 3 Education

The adult literacy rate is 64% of population aged 15 years old and above. The female have the chance to literate less than male 20%. The institutions and duration of compulsory education is 6 years. They are Pre-school/Kindergarten (l year) and Primary School (5 years). The rate of enrolment in compulsory education of population for boys 56.6% and 43.4% for girls .

-

75 -

Annex 8

2. 2.1

General health situation Overview

Health and sanitation of the people are important in the social-economic development of the State and Party. The party has regularly paid attention and guided the health sector. This gradually leads to the development of health sector along with other sectors. The IVth National Health conference has finished in 1998, its main purpose are: • • to evaluate the implementation of new economic mechanism in the health sector; to use its primary outcome to be a foundation in determining guideline for the development of strategic health planning by the year 2000 and long tenn plan by the year 2020 according to the six major health program as below: 1. 2,

Health prevention and promotion program Curative care and rehabilitation program Consumer protection and essential dmg supply program Development of human resources program Medical sciences research program Health administration and management program

3. 4. 5. 6. 2.2

Health situation

The health sector has an attempt on disease prevention and curative care for the Lao ethnic people. The annual growth rate ofthe population is 2.6% . The life expectancy is 51 years old, with 40 for man and 52 for woman. The birth rate is 40/1000. The fertility is high with the fertility rate of 6.211000. The mortality rate was 104 per 1000 live births, the under five years old mortality rate was 170 per 1000 live births and the maternal mortality rate was 656 per 100,000 live births. The five leading causes of death are: malaria, haemorrhagic fever, pneumonia, encephalitis and meningitis (Source: Cabinet of MOH, 1996). 3. 3. 1 Health care system Organization

The Ministry of Health (MOH) is primarily responsible for the provision of health care, i.e. promotive, preventive, curative and rehabilitative care. Within MOH, there are five departments: the Department of Hygiene and Prevention, the Department of Therapy, the Department of Human Resources for Health, the Department of Food and Dmg and the Cabinet ofthe Ministry. According to the MOH organizational new refonn there will be two more departments such as the Department of Inspection and the Department of Plmming and Budgeting. At the micro-level these include institutes, centers, schools and various hospitals. At the provincial level, the Provincial Health Service is responsible for public health in each province, together with its own assistant bodies such as the district health services, and health centers. In order to carry out its responsibilities, the Ministry of Health has formed relationships with the Ministry of Labor and Social Welfare, the Ministry of Education, the Ministry of Agriculture, the Ministry of Interior and with other Ministries.

- 76 -

Annex 8

3.2

Medical care facilities

At present, throughout the country, the health care service consists of 2 central hospitals (600 beds), 6 special care centers (268 beds), 19 provincial hospitals (1924 beds), 133 district hospitals (2455 beds), 567 health centers (1724 beds) and more than 200 private clinics (Sources : Cabinet MOH, 1996). The govenunent mainly supports health services and health workers . Meanwhile, private health service practices have rapidly expanded with many types. Private clinic after official hour and 24 hours clinic. There is also an intemal and foreign investment on this matter with modem and traditional medicine. 4. Health manpower

According to the development strategic planning by the year 2000 and long tem1 plan by 2020, one of the six major health program is the development of human resources. At present, there are 4 institutions called "Public Health School" to serve as Continuing Training Center for the health workforce, one is at centra1level and the three others are in the three provinces to serve as both the Continuing Training Center for the health persmmel and the Nursing School. The total number of the Nursing School in the whole country are 6 schools, one situated at central level called "College of Health Teclmology", a three-year program including Diploma Nursing Section, Hygiene Section, Laboratory Section, Phannacy Section and Physiotherapy Section. The 2 years program in nursing are established in 5 provinces. In long tenn plan, there will be established 6 schools of 2 years program in nursing at 6 provinces. The 3 year diploma nursing program will be phased out while establishing a 4 years program. In order to develop scientific academic to be more updated, more efficient and more effective, an endorsement of the Prime Minister of Lao PDR established the National University of Laos in 1995 by merging the existing higher educational institutions in order to rationalize higher education in Laos and make it more effective in the way of training human resources to support the country needs. The Faculty of Medical Sciences is one of those higher educational institutions which at first belonged to the Ministry of Health and is presently operated under the National University of Laos, Ministry of Education. The overseas for postgraduate are provided by extemal assistance. The training in the country and abroad is quite well-developed. Each year there are great number of short courses, training, workshops, seminars and study tours organized in order to develop the human resources for health workforce. The total number of health persmmel is 10,471 including some selected staff as follows: 1.32% postgraduate staff with specific expertise; 12.38 physicians, 15.79% medical assistants, 6.20% phannacists, 1.63% dentists, 0.98% physiotherapist, 0.65% orthopaedists, 3.52% laboratorist, laboratory assistants and other health care providers (Source: Department ofHRH, MOH, 1997). The distribution ofhealth staff is 18% placed at the central level, 32% at the provincial level, 47% at the district level and health center and 3% the continuing education rate. 5. Conclusion

The Ministry of Health has strived in a number of ways to achieve the WHO's goal "Health for all by the year 2000". One of the effort is to improve the quality of service provided to the people. Since two decades, from 1976 to 1994, the number of health manpower for high level education was increased from 90 to 1395, 371 to 2976 for middle level education and 4561 to 4973 for first-level education. However, the endeavour seems to be constrained by so many

- 77 Annex 8

factors. An important factor concerns with health manpower in regard to number and quality. The most challenging factors are the quality of health personnel affected by the growth development of socio-economic mechanism, the health system management and the lack of the utilization of health manpower in the grassroots level. Although the ratios show not much shortage of health personnel, it is necessary to strengthen the resources management of the health workforce standards such as to improve the curriculum, to define the job description, to exchange experiences on resource management of the health workforce from other countries.

- 78. -

Annex 8

WORLD

HEALTH

ORGANISATION MON DIALE DE LA SANTE

ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

WORKSHOP FOR RESOURCE MANAGEMENT OF HEALTH WORKFORCE Shanghai, China 21-25 June 1999

WPRJHRH/HRH( 4)/99 .3( d) 25 May 1999 ENGLISH ONLY

COUNTRY PAPER ON RESOURCE MANAGEMENT OF HEALTH WORKFORCE IN MONGOLIA

Dr Professor G. Dashzeveg Dr Associated Professor D. Ulziibayar

- 79 -

Annex 8

CURRENT ISSUES OF THE RESOURCE MANAGEMENT OF HEALTH WORKFORCE IN MONGOLIA

Before 1990 Mongolia inherited a health care system that was designed on the Soviet model of public ownership and based on centralized planning to ensure that coverage was adequate. The Mongolian Government's objective has been to provide universal access to health services and to maximize coverage. The Government gave priority to curative and hospital services and indicators and targets were selected accordingly. The success of the health system was measured by the number of doctors and hospital beds per population. Central pla1ming for the health workforce utilized manpower/population ratios. This resulted in the production of health personnel to fulfil set ratios. In the transitional period of 19901992 no planning was carried out and in 1993, the policy directive was issued to have the doctor/population ratio to 25 doctors per 10 000 population by the year 2000. Old health system in Mongolia required a greater number of doctors and health pers01mel because each specialist services in all hospitals, even in the remotest sum (subdistrict), the Ministry of Health appointed specialists in facilities. The country needs to develop human and institutional capability in policy analysis, plan fonnulation and implementation in order to effectively address new problems and new issues arising as a result of refonn and change. The Ministry of Health and Social Welfare has committed itselfto developing an appropriate human resource policy and workforce plan as a framework for consistent and realistic decision on staff requirements, training, deployment and budgeting. A draft for National Policy on Human Resource Development was prepared. Job descriptions, licensing and quality assurance mechanisms, as well as ethical codes for health workers are also being developed as a management tool for effective utilization of the health workforce. The Health Law of 1998 includes provisions relating to the licenser of health practitioners and the accreditation of health care organizations. MOHSW is currently plmming more detailed rules and regulations for licensing and registering health practitioners in Mongolia. A national expert team has been established in the Health Management, Information m1d Education Centre to assist this work and a National Licensing Board was established in 1999. World Health Orgm1ization has supported the development of quality assurm1ce process through the provision of fellowships and workshops . A serious weakness of the system arising from over specialization is a shortage of general practitioners able to provide quality PHC. In 1998 only 982 of more than 6000 physicians were general practitioners. The concept of a fmnily doctor appeared only in 1991 m1d the first modifications in the medical curriculum to support the fmnily doctors were introduced in 1993. With the support ofWHO, the Govenunent revised the undergraduate medical curriculum in 1992 and 1994 to incorporate PHC, preventive medicine m1d traditional medicine. Students in medicine trained in the Medical University in Ulaanbaatar become doctors after 5-6 years of education. Many doctors in Mongolia were trained in a specialty for only three to six months after basic training. This reduction in professional training has a significant adverse impact on service quality especially in rural areas. Feldshers, nurses and medical technicians are trained in the Dornogobi Medical College, the Darkhan Uul and Gobi-Altai Medical Schools and the Ulaanbaatar Nursing School. Feldshers were trained for four years to provide PHC in rural areas, while nurses follow the smne four-year curriculum. Midwifery is a specialization for both feldshers and nurses. h1 1994 the Government introduced voluntary health workers in rural areas .

--.80 -

Annex 8

Above facts show that the health sector in Mongolia was generously staffed. But the health sector workforce, especially doctors, is concentrated in urban areas. The imbalance between cities and rural areas is increasing, as compulsory Government assignments to rural posts no longer exist. Doctors have started moving to the cities where social and professional opportunities are more attractive. The physician distribution is highest in Ulaanbaatar and the other cities. For exan1ple, there were 51.6 doctors per I 0 000 people in Ulaanbaatar but only 16.2 per 10 000 in the provinces. Currently there is no systematic planning for health workforce at the national and provincial levels. The general aim is to decrease the number of doctors and to increase nurse/doctor ratio.

- 81 -

Annex 8

WORLD

HEALTH

ORGANISATION MONDIALE DE LA SANTE

ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

WORKSHOP FOR RESOURCE MANAGEMENT OF HEALTH WORKFORCE Shanghai, China 21-25 June 1999

WPRJHRH/HRH(4)/99.3(e) 25 May 1999 ENGLISH ONLY

COUNTRY PAPER ON RESOURCE MANAGEMENT OF HEALTH WORKFORCE IN VIETNAM

Professor Nguyen Van Tuong Dr Nguyen Van Thai and Mr Nguyen Trong Thuy

- 82 -

Annex 8

MAJOR POLICIES ON MANAGEMENT AND UTILIZATION OF HEALTH WORKFORCE IN VIETNAM

Viet Narn has formulated policies to mobilize human resources for the basic health network to improve the care quality at this level such that public salary for commune/village health workers, upgrade training of local staff for them to go back to serve their communities. Efforts were made to staff 40% of conumme health stations with physicians by the year 2000 for the service of community health. The VietNam health system consisted of 3 levels: • • • Central level Province level District level

District is the basic level which includes district health centres and cormnune health station . VietNam has developed a policy to diversify human resources for health care with the participation of private providers in a system managed mainly by the State. Until December 1998, there was an annual supplement of 2000 university graduates and 6000 middle level health staff. The ratio of physician per 1000 population is 0.44; the ratio of physician and assistant physician per 1000 population is 1.51. From now to the year 2000, Viet Narn is reorganizing the health training network in order to respond to the coming responsibilities . Challenges were to solve the balance between generalists and specialists, the deficit of undergraduate and middle level persmmel in phannacy. Retraining and continuous training should be conducted for community health staff in order to improve primary health care. Policies should be developed to attract health vvorkforce for their service at the basic health care level for better health care.

Human Resources Development Policy Formulation: A. Framework for Analysis

I • • • • •

CONTEXT

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POLICIES

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SUPPORT

OVERALLENV1RONNlliNT Political .Socioeconomic Demographic Epidemiologic New technologies GOVERNMENTPROGRAMNffi • Macroeconomic and financial policies • Changes in priorities: productive and social sectors INFORMATION Assessment tools Nat'l health mgt info system HRH database & payroll Perfonnance monitoring 00

MAJOR REFORMS • • • • Civil service Decentralization Privatization Institutional reorganization

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HEALTH POLICY • Health sector refonns + Changes in priorities and

HUMAN RESOURCES • National capacities, including Institutional strengthening • Technical assistance I

strategies

MAJOR PLAYERS • ·• • • • Government Givil society Prof. assoc. & trade unions Private sector Donors HRD POLICY & PLANNING • Content • Fonnulation process

FINANCIAL RESOURCES • Mechanisms for allocation • Mgt systems & payment • Incentives

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