WORLD HEALTH ORGANIZATION EXECUTIVE BOARD 114th Session Provisional agenda item 4.4 EB114/17 29 April 2004
Human resources in health Report by the Secretariat BACKGROUND 1. Health workers – health professionals, informal carers, community health workers and managers, with their support staff – are at the heart of the health system of every country. There is a crucial relationship between the health workforce and the delivery of services. In many resource-poor countries where the health workforce is shrinking, the capacity to absorb other resources to increase health interventions and improve services may be compromised. The workforce, which accounts for at least 50% of a health system’s annual recurrent costs, needs effective planning and management. 2. This crisis in the health workforce comes at a time of unprecedented challenge in global health. Many countries face an urgent need to deliver more and better services to their poorest and sickest people, often the most difficult to reach. Health development is now outcome-based, and geared to achieving within the set time frame the Millennium Development Goals related to health. Although the challenges to developing the health workforce vary greatly between and within countries, the absolute shortage of health personnel, particularly in sub-Saharan Africa, is recognized as the principal constraint to achieving the Development Goals and other new health goals. The table shows by WHO region the numbers of physicians, nurses and midwives available for every 100 000 people, and highlights the plight of many countries in Africa, where shortages are so great that it is impossible to maintain even basic health service delivery. It also indicates the link between maternal mortality and numbers of skilled health workers. Research confirms the strong connection between the workforce and the health of populations. Few countries achieve 80% coverage of measles immunization without a minimum density of 1.5 workers per 1000 population. 3. Numbers however are not everything: although density of the workforce is important, some countries achieve better outcomes with similar low numbers of health workers. There is currently little understanding of why different numbers and mixes of professionals lead to different outcomes, but undoubtedly there is potential in some countries for improvements in workforce productivity. 4. Policy-makers and those developing health programmes increasingly recognize that insufficient capacity in the health workforce is a significant barrier to delivering crucial health interventions. In countries where there is a severe shortage of health workers, demands to deliver priority programmes alone will require the workforce to double or, in some cases, triple. As a result, some priority programmes are independently developing their own strategies for improving the capacity of the workforce. For countries implementing them this can become detrimental to a coordinated approach to workforce development, with fragmentation and duplication of effort, as every programme introduces new demands on the time of the same limited pool of health workers.
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SELECTED CATEGORIES OF HEALTH WORKERS PER 100 000 POPULATION BY REGIONa
Region
Physicians
Nurses
Midwives
Percentage of countries reaching 80% measles immunization (as of 2001b) 19 69 40 88 69 52
Maternal mortality ratio per 100 000 live births, 2000c Average 910 140 460 39 460 81 Range of uncertainty 390-1500 82-210 340-590 19-61 130-830 39-140
Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific a b
17 212 45 327 96 157
71 414 59 663 159 186
20 N/A 3 42 N/A 13
Source: http://www.who.int/hrh/documents/en/ (in construction). Source: http://www.who.int/vaccines/globalsummary/timeseries/tswucoveragemcv.htm. c Source: WHO, UNICEF and UNFPA. http://www.who.int/reproductive-health/publications/ maternal_mortality_2000/maternal_mortality_2000.pdf.
NATIONAL CAPACITY FOR ACTION 5. In some countries a deteriorating situation will become critical if immediate action is not taken, whereas other countries would benefit from medium- to long-term action to strengthen their health workforce. Everywhere there is a need to prevent further damage to workforce functioning by ensuring that all policy actions are assessed for their likely impact on human resources. Immediate action must be geared to, and not imperil, sustained development of the workforce. 6. National policy forums related to health frequently lack a health-workforce perspective. Fiscal sustainability may require a ceiling on health-sector expenditure, with no growth allowed in the wage bill. This means that increased recruitment and higher wages are impossible, and health systems are trapped in the cycle of increased demand to deliver priority health interventions with no possibility of workforce expansion. Specific analysis that focuses on the implications of macroeconomic measures on the workforce will assist governments to frame human-resources policies that strengthen the health system. Keys to successful framing and implementation of policy are an in-depth analysis of the workforce as a basis for action, inclusion of partners in policy-making processes, and vigilance in managing competing demands in order to minimize negative externalities. 7. Donors have been reluctant to contribute to payment of wages, preferring to finance technical support and training activities, chiefly on the grounds of sustainability. With the current demands on the workforce to address rapidly new health priorities, it would be timely to review donor policy on wages. Critical thinking is required about ways to support human resources in the context of new modalities to fund health systems. One possibility is that a proportion of all funding given to health programmes should go to workforce development, with no caveats about the way it is to be spent. 2
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8. The health labour market has a complex employer structure, with the public sector in competition with for-profit and not-for-profit enterprises, and with global multilateral organizations establishing operations in resource-poor countries, where they recruit local workers at higher-thanlocal wages under good working conditions. In some countries trained health workers leave the health sector for more profitable areas of work. The competing demands of this complex market need to be strategically managed, recognizing the special needs of the public sector; this aspect should be considered to be part of the government’s stewardship function in the provision of health care. 9. The movement of health workers is intensifying in response to changing global demands. Highly skilled workers are moving from poorer to richer countries, from rural to urban areas, and from public to private sectors. Continuing disparities in working and wage conditions between rich and poor countries afford “pulling” power to more developed countries. As demand for health workers grows in richer countries, it will lead to a need for more health workers in poorer countries. The flows of the health workforce require better monitoring in and between countries and regions. 10. The working environment strongly influences both motivation and performance. In addition to having equipment that functions properly, being able to work as a team with others, having adequate supervision and support from managers and colleagues, and benefiting from supportive leadership are all important in improving motivation. Leadership can act as a catalyst to encourage people to greater achievement, foster trust, enthusiasm and motivation in diverse situations and contribute substantially to improving productivity. Actions such as assessing need for improvements by asking health workers themselves, is likely to act as a motivator. Even in resource-poor settings, on-the-job coaching and mentoring of teams and supervisors can bring about improvement at low cost. 11. Conversely, violence in the workplace has been shown, not surprisingly, to be stressful and demotivating for staff. For many staff, especially women, violence can occur in clinics, on the journeys to and from home, and while visiting patients. A strong commitment to preventing violence is needed at all levels of the health system. 12. Both developed and developing countries are using or considering using “new” health workers, such as multiskilled “generic” care assistants, nurse practitioners, nurse anaesthetists and doctor’s assistants. Studies on the replacement of doctors by other health professionals reveal considerable scope for modifying the mix of skills, suggesting that between 25% and 75% of doctors’ tasks, most often those of generalists, could be carried out by other health professionals. To realize the potential gains, enabling legislation and strengthened supervision are needed. 13. Communities play a key role, now widely recognized, in health development and provision of health services. In many countries, trained community health workers have expanded access to basic health services of remote populations and other excluded groups, enhanced the community’s selfreliance in health, and provided a continuum of care between hospital, clinics and patients’ homes. But the experience of expanding community involvement in health care has had mixed success, and caution is needed in order to ensure an effective outcome. Nevertheless, there is growing evidence that community members can provide some treatment of more complex conditions, and efforts to strengthen community capacity in health development can start rapidly. 14. In the past 20 years significant efforts have been put into improving education for health professionals. New schools and educational programmes have been established, many in developing countries, to meet the needs for health workers. The establishment of private medical schools is a recent trend that changes the traditional public-based structure of education in the health professions. Initiatives have also been launched to increase the quality of education by introducing new technologies and educational innovations and broadening the scope of health interventions, including 3
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health promotion and prevention. Despite these positive changes, concerns remain about the quality and effectiveness of education in some places. In many countries, the quality of educators is less than desirable. They often lack continuing education and teaching materials. Better systems of accreditation are needed for all schools for the health professions in order to monitor their continuing suitability to fulfil their function. 15. In almost all countries the public-health workforce is not yet in a position to respond appropriately to existing challenges, let alone new ones. The outbreaks of SARS and avian influenza are the most recent examples of the critical need for a functioning public-health infrastructure, with appropriately educated public-health practitioners immediately available. With few exceptions, both the public-health workforce and its related infrastructure have been neglected. The core activities of public health practice include: monitoring the population health situation and the determinants of health; prevention and control of disease, injury and disability; health promotion; and protection of the environment. Few of these activities are carried out to a high standard even in wealthy countries, partly because public health training is not adequately integrated into basic curricula for health professionals. Thus they begin to practise without being able to perform basic public-health functions. Review of curricula could profitably include an imaginative look at how health professionals can become more responsive to population health needs.
REGIONAL COLLABORATION 16. Because of the complexity of health workforce issues, there are opportunities for collaborative action to address them at regional level. Increasingly countries are sharing experiences within regions, thereby acknowledging the need for integrated action to standardize education and manage migration flows, among other issues. One example is the Observatory of Human Resources in Health, a cooperative initiative among the countries of the Region of the Americas launched to generate, analyse and share information and knowledge necessary for incorporating human resources in health policy and framing better policies on human resources. 17. South-South mechanisms to support regional action and to share solutions could be given higher priority.
GLOBAL ACTION 18. Global action regarding the health workforce is gaining momentum. The Joint Learning Initiative, for example, has brought together more than 100 members in a global network to review evidence and issue a strategy report, with recommendations, later in 2004 on the future contribution of human resources for health, notably towards attaining the health-related Millennium Development Goals. Its work has highlighted the need to align macroeconomic policies with national needs in order to deploy the health workforce effectively. This requires a critical review of macroeconomic policy at national, regional and global levels. 19. The Global Alliance for Vaccines and Immunization, recognizing the importance of a sound human-resources infrastructure, has reviewed a human-resources plan for immunization and is designing strategies to reduce barriers. Trained personnel are recognized as essential to implement tuberculosis control programmes; investment in in-service training is acknowledged as vital, as are means to treat HIV-positive staff and prevent nosocomial transmission of HIV-associated tuberculosis. WHO has prepared a strategy and three-year programme of preparedness for, response to, mitigation
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of and rehabilitation after, emergencies which acknowledges the key role of human resources for health. A multistakeholder strategy for strengthening nursing and midwifery services identifies planning of human resources as a key area for intervention. 20. The High Level Forum on the Health Millennium Development Goals (Geneva, 8 January 2004) agreed to work with UNDP’s Southern Africa Capacity Initiative to consolidate countries’ experience in tackling human resources issues. Further, it was proposed that an action alliance should be formed to reinforce country work in development of human resources. Such an alliance would foster standardsetting, disseminate best practices, develop metrics and tools, and promote research to close knowledge gaps regarding human resources for health. The alliance would work closely with country stakeholders towards a practical and applied hands-on learning engagement in at least a dozen countries. Among other activities, WHO, in collaboration with the Joint Learning Initiative and other partners, will host a meeting to set an agenda for research on the health workforce in September 2004.
WHO’S ROLE 21. Across the Organization priority initiatives require people in the health workforce to deliver specific interventions. One example is the “3 by 5” initiative that calls for 100 000 health workers to be trained to deliver antiretroviral therapy; others are child survival programmes, and initiatives such as Stop TB, Making Pregnancy Safer and Roll Back Malaria, where health systems must have workers to deliver interventions. Reflecting the need for greater attention to be paid to health workforce issues, WHO is working at global and regional levels to implement action in five key areas: • developing coordinating mechanisms to foster cooperation at all levels in order to bring workforce issues to the continuing attention of policy-makers • compiling an inventory of policies and opportunities for managing the workforce more effectively, and consolidating and disseminating “best practices” in human resource planning and management, including the development and application of appropriate tools • identifying a research agenda with partners and ensuring that research is strengthened both in content and process • providing technical support upon request in order to strengthen capacity in all aspects of health workforce development • harmonizing initiatives to develop the health workforce so that they may be more easily implemented at national level, and that countries benefit from coordinated technical support.
ACTION BY THE EXECUTIVE BOARD 22. The Executive Board is invited to note the above report.
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