REGIONAL COMMITTEE 13
Provisional Agenda item
Fifty-ninth Session
Dhaka, Bangladesh 22-25 August 2006
SEA/RC59/12 (Rev.1) 20 July 2006
STRENGTHENING PUBLIC HEALTH WORKFORCE IN SEAR COUNTRIES
Contents Introduction.................................................................................................... 1 Scope of the problem....................................................................................... 2 WHO response ................................................................................................ 3 Strategic directions.......................................................................................... 4 The way forward.............................................................................................. 6 For Member States...................................................................................................................6 For WHO..................................................................................................................................7
Introduction 1. to its effective operation as highlighted in The World Health Report 2006. There is a close correlation between qualified health workers and key health outcomes. Typically, human resources constitute two thirds or more of recurrent national health expenditures. 2. Donor funding has contributed to the ‘verticalization’ of the health workforce The health workforce is the backbone of the public health system and central
resulting in priority health programmes competing for the same health workers.
There is a tension between vertical disease control programmes and horizontal infrastructure development. In recent years, however, there is a growing recognition that functioning health systems with adequate human resources are essential to meet the Millennium Development Goals (MDGs). 3. decades: • The health workforce in the South-East Asia Region has had to address a growing burden of chronic diseases including HIV/AIDS which requires a continuum of care, in particular community-based care • Disease outbreaks such as SARS and avian influenza, and natural disasters the preparedness of the health workforce in the Region • • The health workforce has been damaged in conflict and post-conflict areas in the Region Finally, technological advances and growing consumer expectations are also making new demands on the health workforce. 4. such as earthquakes, the tsunami and severe floods have put to the test New pressures on the health workforce have emerged during the last two
This paper describes the extent and nature of the health workforce crisis in
South-East Asia and provides short and long -term strategic directions for roles and responsibilities for Member States and WHO to move the initiative
strengthening the health workforce in the Region. Finally, it proposes possible forward. For the purpose of this paper, the health workforce will include all people, in the public as well as the for-profit and not-for-profit private sectors, whose primary job is to protect and improve the health of their communities
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Scope of the problem 5. workforce situation is patchy and there is a lack of uniformity in the classification system. Data are generally more complete for health service providers than for health management and support workers. Data are often limited to public sector health workers and within this group, to doctors and nurses rather than the entire range of health workers. Community health workers are often excluded from the head count. Notwithstanding differences between them, countries in South-East Asia share common problems: • Shortages: WHO estimates that South-East Asia is experiencing a shortage of between 6 50 000 and 1 500 000 doctors, nurses and midwives. The most affected countries are Bangladesh, Nepal, Bhutan, and Indonesia who have less than one doctor, nurse and midwife each per 1,000 population. • Maldistribution: While Europe and North America together have only 21% of In most countries, information on the extent and nature of the national health
the world population, they command 45% of the doctors in the world and 61% of its nurses. In contrast, South-East Asia, with 26% of the world population has only 20.2% of its allopathic doctors and 7.9% of its nurses. These geographic imbalances are aggravated by imbalances within countries with a shortage of staff in rural areas compared to cities. • Migration of skilled health professionals: The pull of higher salaries in industrialized countries and the push of poor working conditions at home drive thousands of health professionals, particularly doctors, to jobs abroad each year. • Skill mix imbalances: Training in the Region is heavily tipped towards the production of physicians and nurses at the expense of public health and management cadres. Community health workers comprise a ‘third workforce’ that is largely untapped. Unfortunately, ministries of health usually have limited influence on the number and types of health workers to be trained. • Inadequate production capacity: Unlike other inputs, it takes decades to build up a qualified health workforce. Many countries in the Region lack the means to train an adequate health workforce. Furthermore, teaching
methods and materials tend to be outdated and irrelevant. Private schools have emerged as a growth industry, largely outside the national regulatory framework.
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•
Lack of appropriate knowledge and skills: Lack of standardization in training quality and nonavailability of adequate facilities for continuing education have deprived many health care workers from acquiring appropriate level of knowledge, skills and positive attitudes to respond to the growing consumer expectations.
• •
Lack of public health orientation: South-East Asia has only five percent of public health schools in the world. Weak incentive and management policies and practices: Insufficient incentive systems and effective management policies and practices lead to attrition and low productivity of the health workforce.
•
Dual employment : To compensate for unrealistically low salaries, health workers in many countries in the Region usually combine salaried public sector jobs with fee-for-service private practice at the detriment of the public health sector.
•
Ineffective regulatory oversight of the private sector: While no single regulatory approach to the private sector is appropriate for all countries in the Region, countries often lack the capacity, skills and resources, to develop and enforce regulatory strategies that protect the public from market abuses and contribute to the efficiency, quality and equity goals of the health system.
WHO response 6. health workforce at the centre of health-related goals. In 2002, the Fifty-fifth World Health Assembly (WHA) asked the Secretariat “to accelerate development of an action plan to address the ethical recruitment and distribution of skilled health The UN MDGs have helped to place health at the heart of development and the
care personnel, and the need for sound national policies and strategies for training and management of human resources for health”. In recent years, the World Health Assembly has endorsed a series of resolutions addressing different aspects of the health workforce crisis. These include: resolution WHA57.19 on the challenge posed by the international migration of health personnel in 2004; resolution resolution WHA59.27 on strengthening nursing and midwifery, also in 2006. 7. together and mobilize key stakeholders engaged in global health to help countries WHO launched the Global Health Workforce Alliance in May 2006 to draw WHA59.23 on rapid scaling up of health workforce production in 2006; and,
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improve the way they plan for, educate and employ health workers. The new global partnership aims to achieve a rapid increase in the number of qualified health workers in countries experiencing shortages. It will work through five strategies: • • • • Mobilizing direct financial support for health training institutions Training partnerships between schools in industrialized and developing countries Nurturing a new generation of academic leaders in developing countries in clinical, public health and managerial sciences Developing innovative approaches to teaching with state-of-the art teaching materials and continuing education through information and communications technology • 8. Assistance with the creation of planning teams for the development of comprehensive national health workforce strategies WHO is working closely with Member States in the Region to build a regional health workforce that is prepared to face an ever-changing global scenario. The following offers an overview of recent regional efforts: • • Taking stock of the health workforce : WHO has collected preliminary data on the number and types of healthcare providers in the Region. Strengthening nursing and midwifery: Since nurses and midwives comprise the greater part of the health workforce in the Region, WHO has
undertaken activities that focus on management of the nursing and midwifery workforce, training skilled birth attendants and community health nurses, and improving the quality of nursing education and services. • Strengthening public health education: Finally, within the framework of the “South-East strengthening public health education programmes in the Region and (SEAPHEIN) in 2004 to facilitate exchange of knowledge and resources within the Region. Asia Public Health Initiative (2004-2008)”, WHO is
created the South-East Asia Public Health Educational Institutes Network
Strategic directions 9. is an urgent need to develop national plans that can deliver: Both short-term and long-term strategies are needed. In the short term, there
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• • • •
An increase in the number of health workers in countries where there are shortages More direct investment in the training and support of health workers More efficient use of the existing health workforce Delegation of some simple health care tasks, now assigned to highly skilled personnel, to less skilled workers provided sufficient supervision and support can be ensured
• • • • • • • •
Protection and fairer treatment of health workers Access to effective HIV prevention and treatment for all health workers Encouragement of women to enter health professions Decreased incentives for early retirement Comprehensive preparedness plans in every country for a workforce response to outbreaks and emergencies areas Orientation of health worker training and development of career incentives to encourage service in rural and disadvantaged areas own health care. Better strategies to more actively engage communities and patients in their Reassignment of health workers to areas in need in conflict or post-conflict
10. In the longer-term, strategies are needed to improve all aspects of human resource development including recruitment, retention and distribution of health workers: • • • •
Scaling up production and deployment of human resources for health, particularly community-based health workers, to reach the un-reached health education and training institutions Strengthening management of human resources, particularly through a performance-based reward system Strengthening knowledge generation and management. Improving quality of health professionals’ education, particularly public
11. While every country must ultimately develop its own health workforce strategies according to its unique situation and needs, countries in the Region will
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need to embrace a broader concept of health. This more comprehensive concept of health calls for an approach that is: • • • • Intersectoral – involving sectors and industries other than health such as education, labour, agriculture, mining and manufacturing handle their own health problems Participatory – empowering communities and individuals to effectively Equitable – taking into account the needs of the most vulnerable focused on health promotion and disease prevention – thus reducing the need for curative services. workforce will ideally be: • • • • population-based – including community health workers who are able to reach out to all corners of the community, both rural and urban multi-disciplinary – including clinicians, public health workers flexible – able to respond to crises and rapidly changing health needs mobile – able to reach the ‘unreached’ and contribute to equity in health.
12. In order to meet the ever-changing needs of the population, the future health
The way forward For Member States • • Create multi-stakeholder planning teams to develop a multisectoral health workforce plan, Develop and implement both short- and long -term national strategies and plans for the health workforce that take into account the full spectrum of health workers in both the public and private sectors, the largely untapped resource of community health workers, and the flows of migrant health workers, • • • Invest in the development of human resources for health in order to meet the projected requirements, Strengthen the quality and capacity of training institutions with a particular emphasis on public health education, nursing and midwifery, Revitalize the role of community health workers ensuring strong supervisory and support systems,
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•
Strengthen national knowledge generation and management.
For WHO • Coordinate, through an inclusive consultative process, the development of a strategic framework and package of interventions and tools for strengthening the health workforce in the Region, • • Provide technical support to Member States, as needed, in their efforts to revitalize and build their health workforce, Strengthen regional and national training capacity through the introduction of innovative approaches to teaching with state of-the-art teaching materials and continuing education through the use of the latest information and communication technology, • Facilitate the establishment of training partnerships between schools in industrialized and developing countries, regional networks such as SEAPHEIN, as well as other networks that promote the exchange of information and best practices on human resources for health.
REGIONAL COMMITTEE Fifty-ninth Session Dhaka, Bangladesh 22-25 August 2006
Provisional Agenda item 13 SEA/RC59/Inf.7 1 August 2006
STRENGTHENING PUBLIC HEALTH WORKFORCE IN SEAR COUNTRIES
Contents Introduction ........................................................................................................................... 3 Scope of the problem ............................................................................................................. 4 Shortages .................................................................................................................................................... 5 Maldistribution............................................................................................................................................ 5 ‘Brain drain’ (Migration of skilled health professionals).................................................................................. 5 Skill-mix imbalances.................................................................................................................................... 6 Inadequate production capacity .................................................................................................................. 6 Lack of public health orientation.................................................................................................................. 7 Widespread ‘demotivation’ (or weak incentive and management policies and practices) .............................. 7 Problem of dual employment ...................................................................................................................... 7 Poor capacity to regulate professional practice ............................................................................................. 7
WHO’s response .................................................................................................................... 7 WHO South-East Asia Region’s response...................................................................................................... 9
Strategic directions................................................................................................................ 11 Scaling up production and deployment of human resources for health, particularly community-based health workers, to reach the unreached ......................................................................... 13 Improving the quality of education of health professionals, particularly public health education, and of training institutions ......................................................................................................................... 13 Strengthening the management of human resources, particularly through establishing performance-based reward system............................................................................................................. 13 Strengthening knowledge generation and management .............................................................................. 14
The way forward .................................................................................................................. 14 Recommendations .................................................................................................................................... 14
References ........................................................................................................................... 15
Introduction 1. The health workforce is the backbone of the public health system and central to its effective operation as highlighted in The World Health Report 2006. It is health workers, clinical and non-clinical, who determine the use of all the other inputs into the health care system. The performance of health care systems ultimately depends on the knowledge, skills and motivation of the health workforce. 2. There is empirical evidence of a close correlation between the presence of qualified health workers and key health outcomes. For instance, there is a direct relationship between the density of health workers and survival of women during childbirth and of children in early infancy1. As the number of skilled health workers declines, survival rates decline proportionately. 3. The human resources bill is usually the biggest single item in recurrent budget. A typical country devotes just over 42% of total general government health expenditure to paying its workforce, though there are regional and country variations around this average2. It is therefore paramount to manage this investment carefully in order to optimize the performance of the health system and achieve the greatest health outputs. 4. Donor funding has contributed to the ‘verticalization’ of the health workforce. Priority health programmes compete for the same health workers. This has created a tension between vertical disease control programmes and horizontal infrastructure development. In recent years, however, countries and global development partners have come to recognize that functioning health systems with adequately trained and deployed human resources are essential to meet the overarching Millennium Development Goals (MDGs). As a result, there is now a move towards a more integrated approach. Today, the largest global health partnerships, such as Global Alliance for Vaccines and Immunization (GAVI) and Global Fund to fight AIDS, TB and Malaria (GFATM), emphasize health systems and human resource development in their funding policies. 5. New pressures on the health workforce have emerged during the last two decades. New and growing health needs, coupled with mounting health worker shortages and imbalances, have created a workforce crisis. The key dimensions of this crisis are described below: • Health-worker shortages are interfering with efforts to achieve the internationally agreed health-related development goals, including those contained in the MDGs. Health interventions cannot be scaled up without an adequate health workforce1. The impressive mobilization of donor funds to achieve the health-related MDGs – reducing child mortality, reducing maternal mortality, and combating HIV/AIDS and other diseases such as malaria and tuberculosis – has created a new environment in which the shortage of human resources has replaced financial constraints as the most serious obstacle to achieving goals. Only when high-level initiatives, financial resources and technologies are matched by an investment in people will the formula for better health for all be complete. The health workforce has had to address a growing burden of chronic diseases, the majority of which are not addressed in the MDGs. These diseases, including AIDS,
•
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require a full continuum of care-from specialist care to self care – with an emphasis on community-based care and a renewed impetus on community health workers-both paid and volunteer. • The preparedness of the health workforce has been tested in a more dramatic way with disease outbreaks such as SARS and avian influenza, and natural disasters such as the earthquake and tsunamis that hit South-East Asia in December 2004, severe floods in Bangladesh and India in 2004 and 2005 respectively, and the earthquake that struck Yogyakarta, Indonesia in June 2006. There has been severe and long-lasting damage to the health workforce in conflict and post-conflict areas such as in Sri Lanka, Nepal, Thailand-Myanmar border, and TimorLeste. Finally, technological advances and growing consumer expectations are also making new demands on the health workforce.
•
•
6. For the purpose of this paper, the health workforce will include all people, in the public sector as well as the for-profit and not-for-profit private sectors, whose primary job is to protect and improve the health of their communities. It will include: • • • Health service providers such as doctors, nurses, midwives, pharmacists, laboratory technicians, and traditional practitioners; Health management and support workers such as planning, administrative, managerial, logistics, maintenance, and clerical staff, and Community health workers who link health systems to the communities they serve.
7. The health workforce includes people working in the different domains of the public health system such as personnel in the curative and preventive sectors, community-based public health interventions, health promotion and disease prevention activities. It also includes the informal health care sector, including traditional healers and community health workers. 8. This paper describes the extent and nature of the health workforce crisis in the South-East Asia (SEA) Region. It goes on to describe how WHO has responded to the crisis. It provides strategic directions/guiding principles for the development of a regional strategy for strengthening the health workforce in the Region. Finally, it suggests possible roles and responsibilities for Member States and WHO to move the initiative forward.
Scope of the problem 9. In most countries, information on the extent and nature of the national health workforce problem is patchy at best. An accurate count of all health workers is difficult partly because there is a lack of uniformity in the classification system. Data are often limited to public sector health workers and within this group, to doctors and nurses rather than the entire range of health workers. Data are generally more complete for health service providers than for health management and support workers. And although they contribute substantially to the health workforce in the SEA Region, community health workers are included in the official count in some
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countries such as Bangladesh, Bhutan, Maldives and are excluded in others. Notwithstanding differences between them, countries in SEA Region share common problems. These are described in the paragraphs that follow.
Shortages 10. While there are no absolute norms regarding the right ratio of health workers to population, rules of thumb can be useful. WHO has identified 2.28 per 1000 population as the ‘threshold’ density of doctors, nurses and midwives below which the coverage of essential interventions, including those necessary to meet the health-related MDGs, is very unlikely1. Based on the human resource information received directly from Member countries of the Region, the average density of doctors, nurses and midwives is estimated to be 2.12 per 1000 population, ranging from 0.56 per 1000 population in Bangladesh to 7.43 in DPR Korea (see Figure 1 on page 9). Based on a “threshold” density ranging from 2.02 to 2.54 per 1000 population, the SEA Region is experiencing a shortage of between 650 000 and 1 500 000 doctors, nurses and midwives. The most affected countries are Bangladesh, Bhutan, Indonesia and Nepal which have less than one doctor, nurse and midwife per 1000 population.
Maldistribution 11. Health workers are inequitably distributed throughout the world, with severe imbalances between developed and developing countries. While Europe and North America together have only 21% of the world population, they command 45% of the world’s doctors and 61% of its nurses. In contrast, the SEA Region which has 26% of the world population, commands only 20.2% and 7.9% of doctors and nurses respectively. 12. These geographic imbalances in the distribution of the health workforce are made even worse by imbalances within countries. In most countries in the Region, there is shortage of staff in rural areas compared to cities where urban hospitals attract an over-concentration of physicians and other highly qualified personnel. The geographical distribution of physicians is a particular concern in countries such as Bhutan, Indonesia and Nepal where the population is dispersed in remote islands, valleys or forest locations that have few amenities, no opportunity for private practice, and poor communications with the rest of the country.
‘Brain drain’ (Migration of skilled health professionals) 13. An ever-growing demand for health workers to care for an ageing population in developed countries is compounding the imbalances. The pull of higher salaries in industrialized countries and the push of poor working conditions at home drive thousands of health workers to look for jobs abroad each year. The migration of health professionals, particularly doctors, from the SEA region began in 1950s, 1960s, and 1970s as a post-colonial phenomenon common to India, Sri Lanka and Pakistan, and later extended to Bangladesh and Nepal3. Nursing professionals began their journey mostly to the Middle-East, but have currently shifted attention to the United Kindgon of Great Britain, the United States of America and Australia. The effects of migration of
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physicians are difficult to assess in view of several factors operating for and against this phenomenon. Whereas ministries of health are concerned with the loss of health personnel, ministries of finance are interested in remittances.
Skill-mix imbalances 14. In many countries of the Region, the skill-mix of the health workforce is mismatched to the needs of the population and the health care system. In Bangladesh and Myanmar, for instance, where physicians outnumber nurses and midwives, physicians often perform tasks that could be conducted by less-trained providers. Training of health care workers in the Region is heavily tipped towards the production of physicians and nurses. As a result, there are widespread shortages of public health and management cadres. 15. Community Health Workers (CHWs), both paid and volunteer, comprise the ‘third workforce’ in the Region and provide a valuable, largely untapped interface with communities4. However, they also require training and supportive supervision commensurate to the tasks they are delegated, if they are to be effective members of the workforce. 16. Unfortunately, ministries of health usually have limited influence and capacity to determine the number and types of health workers to be trained to meet future health needs. Workforce planning is generally under the control of civil service commissions or ministries of finance, while education and training fall under ministries of education.
Inadequate production capacity 17. Unlike other inputs, a health workforce is an investment. It cannot simply be bought on demand. It takes decades to build up a dedicated, professional and effective health workforce. This makes ‘poaching’ of health workers from resource-poor countries an even more serious matter. 18. Many countries in the Region lack the financial means, facilities and sufficient trainers to train an adequate health workforce. Bhutan, for instance, must send doctors, specialists, and nurses (beyond the most basic training) overseas for training. In some other countries, educational methods and content have become irrelevant and outdated. 19. In contrast, private medical and other health professional schools have emerged as a growth industry in several countries in the Region, largely outside of the national regulatory framework. This growth is spurred by a high demand and competition for a limited number of seats available in public universities and colleges. While this trend has the potential to improve the capacity of the Region to produce much-needed health workers, it also carries some potential risks such as escalating the cost of health care worker training, poaching scarce faculty from public sector institutions, lack of accreditation procedures to ensure quality and mismatch between the mix and skills of health workers produced and the health needs and priorities.
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Lack of public health orientation 20. In contrast to nursing and medical schools, and with rare exceptions, the Region has remarkably few schools of public health (not counting departments within other schools) compared to other regions. It has only 5% of public health schools in the world1.
Widespread ‘demotivation’ (or weak incentive and management policies and practices) 21. Insufficiently attractive incentive systems and ineffective management policies and practices lead to attrition and low productivity of the health workforce. In some countries, the salaries are low and the salary increases are generally based on years of service and are not linked to performance. Supportive supervision is often lacking. The working environments are poor. Opportunities for career advancement and personal development are inadequate. All these lead to demotivation of health care workers.
Problem of dual employment 22. The notion of full-time civil servant exclusively dedicated to his/her public sector job is disappearing. To compensate for unrealistically low salaries, health workers in most countries in the Region combine salaried public sector jobs with fee-for-service private practice. Were this without consequences for the performance of the public health sector, it would not have been a problem. In fact, dual employment creates a conflict of interest for the provider who must compete with himself for patients. It generally lowers the quality of care provided in the public sector, de-legitimizes public sector health services, often results in the misuse of public sector facilities and supplies, and contributes to public-to-private brain drain5.
Poor capacity to regulate professional practice 23. Regulations of professional bodies can promote or restrict the supply and performance of the health workforce. The types of regulations associated with a profession plays an important role regarding the supply of members of the profession while maintaining high professional standards. A regulation has the power to establish both entry requirements and rules regarding professional and ethical conduct. While these barriers are a means to ensure quality of care and to protect patients from incompetent providers, sometimes they can backfire and create barriers to recruitment of professionals in adequate numbers to expand the health services coverage, particularly among the poor and those living in rural and remote areas.
WHO’s response 24. Since its inception, WHO has been a key player in facilitating the development of the health workforce. In earlier years, the emphasis was on increasing the numbers of health workers. In the 1970s, the emphasis shifted to qualitative aspects. Since 1980s, strategies have aimed to link human resources development to health systems. 25. The UN Millennium Development Goals (MDGs) have helped to place health at the heart of development and the health workforce at the centre of health-related goals. In 2002, the
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Fifty-fifth World Health Assembly requested the Secretariat “to accelerate development of an action plan to address the ethical recruitment and distribution of skilled health care personnel, and the need for sound national policies and strategies for training and management of human resources for health”. 26. In recent years, the World Health Assembly has endorsed a series of resolutions addressing different aspects of the health workforce crisis. Theses include: • Resolution WHA57.19 (2004): International migration of health personnel: a challenge for health systems in developing countries which urged Member countries and requested WHO to develop strategies to mitigate the adverse effects of migration of health personnel in order to minimize its negative impacts on health systems.6 Resolution WHA59.23 (2006): Rapid scaling up of health workforce production which urged Member countries and requested WHO to facilitate the scaling up of activities to increase the production of competent health workforce in countries.7 Resolution WHA59.27 (2006): Strengthening nursing and midwifery which urged and requested Member countries and WHO to establish comprehensive programmes for the development of highly skilled and motivated nursing and midwifery workforce.8
•
•
27. A new global partnership, the Global Health Workforce Alliance, was launched in May 2006 to draw together and mobilize key stakeholders engaged in global health to help countries improve the way they plan for, educate and employ health workers. The Secretariat of the Global Health Workforce Alliance is hosted by WHO in Geneva. The new partnership will start an ambitious programme – the Fast Track Training Initiative – aimed at achieving a rapid increase in the number of qualified health workers in countries experiencing shortages. The Initiative will work towards that goal through five strategies: • Mobilizing direct financial support for health training institutions, through a model similar to that of the Education for All Fast Track Initiative – a global partnership between donor and developing countries to ensure accelerated progress towards the MDG of universal primary education. Strengthening training partnerships between schools in industrialized and developing countries involving exchanges of faculty and students, with the aim of improving the education of doctors, nurses, midwives and paraprofessional health workers, and training them in greater numbers. Nurturing a new generation of academic leaders in developing countries with the support of experts in the clinical, public health and managerial sciences from around the world. Developing innovative approaches to teaching in developing countries with state-of-the art teaching materials and continuing education through information and communications technology. Providing assistance through with the creation of planning teams in each country facing health worker shortages, and drawing on the top leadership of major schools, whose task will be to develop a comprehensive national health workforce strategy.
•
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•
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WHO South-East Asia Region’s response 28. WHO’s South-East Asia (SEA) Region continues to work closely with Member States to build a regional health workforce that is better aligned with priority health programmes and better prepared to face an ever-changing global scenario. The following offers an overview of recent efforts made at the Regional level:
Taking stock of the health workforce 29. WHO has collected preliminary data from Member countries on the number and types of health care providers. There is a health workforce of approximately seven million in countries of the Region, of which nearly five million are health service providers. Figure 1 shows latest available data on the number of health service providers (per 10 000 population) in countries of the Region. There is a great variation in countries of the Region as far as the total number of health service providers is concerned. It ranges from 15 to 110 per 10 000 population. On an average, there are 29 health service providers per 10 000 population available in the South-East Asia Region, which is well below the global average of 62. Figure 1: Number of health service providers (per 10 000 population) in countries of the SEA Region, 2005 Number per 10,000 population 120 110 100 90 80 70 60 50 40 30 20 10 0 15 22 25 28 29 32 33 33 34 47 93 110
SEA Nepal Indonesia Sri Lanka Thailand Bangladesh India Region Note: 1. Data as reported by countries 2. Reference year of data for some countries may differ from the reported year 2005
Bhutan
Myanmar Timor-Leste
Maldives
DPR Korea
30. Countries in the Region have developed their own classification systems for health workers. The wide variation in the numbers and categories* of health workers reported by countries in the Region highlights the need for a standard classification system which WHO is developing in collaboration with Member States.
Physicians; Nurses; Midwives; Dentists; Pharmacists; Physiotherapists; Laboratory workers; Radiographers; Environmental and Public Health Officers; Community Health Workers, and Others
*
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Strengthening nursing and midwifery 31. Since nurses and midwives comprise the greater part of the health workforce in the Region, WHO has undertaken activities that focus on management of the nursing and midwifery workforce, training skilled birth attendants and community health nurses, and improving the quality of nursing education and services. 32. Skilled birth attendance was the topic for the Technical Discussions held during the 42nd meeting of the Consultative Committee on Programme Development and Management (CCPDM) in July 2005. Resolution SEA/RC58/R2 on skilled care at every birth was adopted by the Regional Committee for South-East Asia at its 58th session. Among other recommendations, the resolution called upon Member States to address gaps in human resource policies for skilled care at birth. Through the country offices, the Regional Office is supporting Member countries to strengthen health systems, which will eventually ensure skilled care at every childbirth.
Strengthening public health education 33. Finally, within the framework of the “South-East Asia Public Health Initiative (2004-2008)”, WHO is strengthening public health education programmes in the Region and created the South-East Asia Public Health Educational Institute Network (SEAPHEIN) in 2004 to facilitate exchange of knowledge and resources within the Region. One of the key strategies of SEAPHEIN is the development of core competencies in public health. Some activities in this area include: • • • Development of accreditation guidelines for Public Health Institutions, January 2002. International Executive Programme in Public Health in collaboration with the University of Padjadjaran at Bandung, Indonesia, September 2002. Informal consultation on “Future Direction in Public Health: Calcutta and beyond”, December 2003.
34. Regarding medical training, WHO is actively promoting curriculum reform in medical schools in the Region to strengthen the psycho-social and ethics components of medical education. 35. The South-East Asia Public Health Initiative 2004-2008 was launched in November 2001. Its main goals are to: • • • • Position public health high on the regional and national agendas, and make it a priority issue to generate strong commitment through national policy; Facilitate the strengthening of public health education in countries of the SEA Region; Enhance technical cooperation on the development of national public health training institution(s) in selected countries; Facilitate the establishment of a public health education institutions’ network and foster regular interaction among members of the network, and
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•
Facilitate countries to define an appropriate package of essential public health functions tailored to each country’s situation and needs and support them to implement these functions.
36. At this stage, the focus is on strengthening public health education, supporting the meetings of public health education institution network, and advocating public health discipline to governments and the public.
Strategic directions 37. The ultimate aim of strengthening public health workforce in the SEA Region is to ensure that all countries in the Region have in place well-trained public health professionals who can provide the necessary leadership in health systems. While every country must ultimately develop its own health workforce strategies and plans according to its unique situation and needs, the following set of concepts and strategies are proposed to guide WHO and Member States in their approach to the health workforce crisis. (a) A broader concept of health with an approach which is: • Intersectoral – health depends as much on strengthening of other sectors such as education and socioeconomic development, as on strengthening of the health care system; Participatory – empowering communities and individuals to effectively handle their own health problems; Equitable – in that it takes into account the needs of the most vulnerable, and Focused – on health promotion and disease prevention, thereby reducing the need for curative and rehabilitative services. Population based − reaching out to all corners of the community, both rural and urban; Multi-disciplinary − which can work across sectors and carry out public health programmes including clean water and sanitation, disease prevention and control, nutrition, maternal and child health; Flexible − able to respond to the changing health needs and to crises, and Mobile − able to reach the unreached and thereby contribute to equity in health.
• • •
(b) This broader perspective on health favours a workforce that is: • •
• •
38. Based on the commonalities of problems and the socio-cultural contexts prevailing in the Region, the following short- and long-term strategies should be considered on priority by Member States: 39. In the short term, there is an urgent need for: • A national plan for health workforce and an increase in the number of health workers in all countries with serious shortages. This will require political leadership, a
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comprehensive plan for an effective health workforce, and a commitment for necessary funds. Funding must not only cover health service providers, but also the management and support workers who provide crucial services to the health system. Governments also need to invest in training existing health workers, in order to keep them up to date with changing priorities. • More efficient use of the existing health workforce. Simple, inexpensive measures like improving management and supervision and writing clear job descriptions would help. Another helpful strategy is "piggy-backed" services − meaning that workers delivering one specific service, such as a vaccine during an immunization campaign, can simultaneously deliver other services, such as a needed dose of vitamins. Reviewing of job descriptions will enable simple health care tasks now assigned to highly skilled personnel to be delegated to less skilled workers who will be able to carry them out competently. With sufficient supervision and support, volunteers, community health workers and workers, with limited training can improve the efficiency of health services. Protection and fairer treatment of health workers. They face difficult and often dangerous working conditions and low salaries in many developing countries. Access to effective HIV prevention and treatment for all health workers. HIV has affected health workers disproportionately in many countries. It is vital that they receive these services under the condition of confidentiality. Encourage women to enter health professions. Their needs should be accommodated through flexible work arrangements and leadership career tracks adapted to family life. Decreased incentives for early retirement. Countries with serious shortages also should also provide opportunities for retirees to go back to work. Comprehensive preparedness plans in every country for a workforce response to outbreaks and emergencies. They should include plans for how health workers will collaborate with staff in the military, transport and education sectors to maximize the efficiency of scarce human resources. In conflicts, reassignment of health workers to areas in need. Workers given such assignments need protection and support; and international donors and other major actors need to take measures to protect existing health worker networks. Orientation of health worker training and development of career incentives to encourage service in rural and disadvantaged areas. These actions would help counteract the tendency of health workers to cluster around cities. Better strategies to more actively engage communities and patients in their own health care. Partnerships between patients and health workers can improve the quality of care, as well as health outcomes. More direct investment in the training and support of health workers.
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40. The long-term needs in the development of a health workforce require strategies and approaches to improve all aspects of human resource development including recruitment, retention and distribution of health workers.
Scaling up production and deployment of human resources for health, particularly community-based health workers, to reach the unreached 41. A large population of most countries in the Region who live in rural remote areas and urban low-income communities have only limited access to quality health services. The first priority for countries with limited health service coverage is to produce sufficient number of skilled health workers with technical competencies whose background, language and social attributes make them accessible and who are able to reach the unreached. Evidences from both developed and developing countries show that appropriate recruitment policies, simplification of tasks, and training and supervision can lead to the production of efficient and effective community-based workers. 42. Stringent selection criteria should be used to ensure that such workers come from communities they will serve, are at least 18 years old, have successfully completed middleschool education, and are recommended by residents of their community as good candidates. 43. The training programme should be aligned to practice and should be long enough to enable the workers to acquire competencies to perform assigned tasks, such as treating minor ailments and making referrals for more serious conditions, recording the vital community statistics, conducting basic health education, providing contraception to couples, and liaisoning between their communities and the formal health system, thereby helping to coordinate various functions, such as immunization and anaemia control, and collecting sputum from chronic cough patients, etc. Community-based workers should be paid according to the prevailing rules and regulations adjusted to labour market prices. The production of doctors, dentists and other highly qualified health professionals should be scaled up as much as possible.
Improving the quality of education of health professionals, particularly public health education, and of training institutions 44. The demand for clinical services and health professionals in health care service delivery institutions, particularly on the part of among the well-off, is very much higher than the demand for public health services and public health officers. Accordingly, Member States should allocate enough resources to strengthen public health institutions.
Strengthening the management of human resources, particularly through establishing performance-based reward system 45. The performance of human resources for health in the Region should be improved significantly because it has an immediate impact on health service delivery and ultimately on the health of populations. An integrated package of interventions needs to be implemented, instead of piecemeal interventions, in order to have a well-performing workforce. A case study from
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Shandong, China shows that bonus system contributes significantly to an increase in hospital revenue and hospital cost recovery. However, it can also lead to an increase in unnecessary care. The scope of health workers’ performance includes: availability; competence; responsiveness, and productivity. Several sets of activities lever the performance of human resources, such as: developing clear job descriptions; supporting norms and codes of conduct; matching skills to tasks; exercising supportive supervision; ensuring appropriate remuneration; ensuring adequate information and communication; improving infrastructure and supplies; promoting lifelong learning; establishing effective team management, and combining responsibility with accountability. In solving the problem of nonavailability of doctors in rural areas, Thailand has implemented integrated strategies including development of rural infrastructure, reforming medical education, and providing social and financial support.
Strengthening knowledge generation and management 46. The Region lacks the basic information on human resources for health. Therefore, steps should be taken to strengthen knowledge generation and management significantly, both at regional and country levels. Regional cooperation should be strengthened to improve the access to quality tools and expertise.
The way forward 47. While several countries, with WHO support, have already implemented plans to address the main elements of public health workforce problems, particularly through strengthening education and training institutions, it still remains a challenge to address the overall public health problems in a systemic manner. To overcome this challenge, much work needs to be done in areas of advocacy; human resources policy and planning; implementation of best practices in deployment and performance management, and education and research. The Regional Office is in the process of facilitating the development of a Regional Stratgic Plan for Human Resource Development with the active participation of all Member countries. It is expected that once it is finalized through a participatory approach, the strategic plan will provide the road map for countries to follow in developing competent and highly motivated health care workers in adequate numbers.
Recommendations For Member countries 48. It is recommended that Member countries should: • • Show strong commitment for greater investment in public health workforce; Develop and implement the long- and medium-term national public health workforce plans as integral parts of the Human Resources for Health Plan and National Health Systems Plan; Strengthen public health education and public health training institutions;
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Encourage research and enhancement in quality productivity, and equitable of distribution of public health workforce; Involve and facilitate professional organizations and public health education institutions; Advocate and/or legislate for public health professional as a recognized profession in the society, and Develop a public health workforce based on the human resources required to implement essential public health functions.
For WHO 49. It is recommended that WHO should: • Show technical leadership in developing and implementing long- and medium-term strategic and system-wide public health workforce plans as integral parts of the Human Resources for Health Plan and National Health Systems Plan; Establish evidence-based norms and standards on which to base key decisions on issues related to public health workforce, numerical and skill-mix requirements, including issues of quality, equity and productivity; Facilitate education and training for building capacity of public health workforce in all categories; Advocate for mobilizing global resources through existing networks and partnerships, as well as for their expansion, and Monitor and report on the progress made with regard to the public health workforce initiatives in the Region.
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References 1. 2. WHO: The world health report 2006: Working together for health, Geneva, WHO, 2006. Hernandez P, Drager S, Evans DB, Tan-Torres T, Dal Pos MR. Measuring expenditure for the health workforce: challenges and evidence. Geneva, World Health Organization 2006 (background paper for The world health report 2006; available at :http://www.who.int/hrh/documetns/en/). Adkoli BV: Migration of Health Workers: Perspective from Bangladesh, India, Nepal, Pakistan and Sri Lanka. Regional Health Forum, Volume 10, number1, 2006. Than Sein U: Health Volunteers: Third Workforce for Health For Al Movement, Regional Health Forum, New Delhi, WHO SEARO: Vol 10, No. 1, 2006. Ferrinho P, et al: Dual practice in the health sector: review of the evidence, Human Resources for Health 2004, 2:14 available from http://www.human-resources-health.com/content/2/1/14 accessed 15 June 2006.
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World Health Organization. Challenge posed by the international migration of health personnel. WHO Resolution WHA57.19 (2004) Geneva http://www.who.int/gb/ebwha/pdf_files/WHA57/A57_R19-en.pdf accessed 9 July 2006 World Health Organization. Rapid scaling up of health workforce production. WHO Resolution WHA59.23 (2006) Geneva http://www.who.int/gb/ebwha/pdf_files/WHA59/A59_R23-en.pdf accessed 9 July 2006. World Health Organization. Strengthening nursing and midwifery. WHO Resolution WHA59.27 (2006) Geneva http://www.who.int/gb/ebwha/pdf_files/WHA59/A59_R27-en.pdf. accessed 9 July 2006
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