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Health workforce

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Health workers are all people engaged in actions whose primary intent is to protect and improve health. A country’s health workforce consists broadly of health service providers and health management and support workers. This includes:

  • private as well as public sector health workers
  • unpaid and paid workers
  • lay and professional cadres.

Overall, there is a strong positive correlation between health workforce density and service coverage and health outcomes.

Forces driving the workforce[1]

A “well-performing” health workforce is one that is available, competent, responsive and productive. To achieve this, actions are needed to manage dynamic labour markets that address entry into and exits from the health workforce, and improve the distribution and performance of existing health workers. These actions address the following:

  • How countries plan and, if needed, scale-up their workforce asking questions that include: What strategic information is required to monitor the availability, distribution and performance of health workers? What are the regulatory mechanisms needed to maintain quality of education/training and practice? In countries with critical shortages of health workers, how can they scale-up numbers and skills of health workers in ways that are relatively rapid and sustainable? Which stakeholders and sectors need to be engaged (e.g. training institutions, professional groups, civil service commissions, finance ministries)?
  • How countries design training programmes so that they facilitate integration across service delivery and disease control programmes.
  • How countries finance scaling-up of education programmes and of numbers of health workers in a realistic and sustainable manner and in different contexts.
  • How countries organize their health workers for effective service delivery, at different levels of the system (primary, secondary, tertiary), and monitor and improve their performance.
  • How countries retain an effective workforce, within dynamic local and international labour markets.

This section of the health system profile is structured as follows:

Contents

Analytical summary

Health workforce management systems are one of the weakest components of human resources for health development, as evidenced by:

  • ill-equipped health workforce departments in ministries of health
  • huge imbalances between rural and urban areas and in skill mix
  • lack of incentives
  • sometimes an adverse working environment.

These issues prevail all over Africa, exacerbated by low economic status throughout the continent. Human resource shortages are compounded by recent decreases in investment in health, freezes in recruitment of health workers, poor remuneration and incentives, and the migration of skilled staff. Effectively, the health workforce in Africa (see figure) is in crisis.

Physician-to-population ratio (per 10 000 population) in the WHO African Region, by country, 2000–2010

The WHO African Region requires approximately half a million more health workers than are currently available. It also requires a mix of workers of different categories, not exclusively doctors and nurses, if the right kinds of skills and competencies are to be available.

This requires revisiting the question of training. African training institutions are weak and numerically insufficient, and increasing funding shortages are aggravating this problem.

Evaluation of present training institutions is needed to assess how to move forward constructively:

  • increasing numbers of effective health workers
  • retaining them in service
  • allowing for flexibility in their approach to learning.

Innovative approaches to education and training, and retention must be identified. Otherwise, the shortfall in workforce numbers and lack of appropriate types of training creates a bottleneck in implementation of national health strategies.

To start countering these problems, there is a need for solid information, reliable research and a firm knowledge base. Similarly, it is essential to have the capacity to monitor and evaluate interventions to ascertain progress and identify problems.

Optimizing the use of the existing health workforce, mitigating the adverse effects of migration, and creating new categories of health worker are among the serious priorities and ways forward and the challenges to equitable and accessible health services delivery. The health ministries cannot meet these requirements alone, and strong engagement with other involved government departments and private partners is needed.

However, technical and financial partnerships focusing on planning for human resources for health are now being forged, and scaling-up initiatives is taking place, in the recognition that without further investment in this area, the Millennium Development Goals cannot be met.



Organization and management of human resources for health

Health workforce management is fundamental to effective health service delivery – a fact that requires greater recognition and action at national level. Many different sectors and institutions have a role to play in human resources for health (HRH) governance, including the Ministries of Health, Education, Finance, public sector commissions, and other branches of local and national government. Because health needs must be addressed cross-sectorally, the Ministry of Health should ensure that it has the necessary management capacity to maintain dialogue and coordinate action across sectors as appropriate.

Overview of the organization and management of human resources for health

Health workforce management systems are one of the weakest components of human resources for health development, as evidenced by:

  • ill-equipped health workforce departments in ministries of health
  • huge imbalances between rural and urban areas in skill mix
  • lack of incentives
  • a sometimes adverse working environment.

Optimizing use of the available health workforce and mitigating the adverse effects of migration are among the serious challenges to equitable and accessible health services delivery.

Improvement in human resources for health management is needed if the goals of enhanced leadership, motivation, deployment and productivity of health workers are to be met. The capabilities of managers and supervisors at different levels of the health system need strengthening through management training. However, training alone will not improve practice; standard operating procedures in work environments may need to be changed or modified so that the benefits of training can be made manifest.

A pilot process tested in Kenya to strengthen professional health workforce leadership and governance capacities shows promise. It trained participants from different sectors and institutions in a series of workshops held over the first 6 months of 2010. This approach will be extended to other countries.

Modes of remuneration

Stock and distribution of human resources for health

With less than 1% of the world’s financial resources available for health, Africa’s need for health workers is estimated at approximately 1 780 057 million, compared with its present number of 1 183 325. Countries with an existing human resource crisis need to train and deploy over 800 000 additional doctors, nurses and midwives to meet a minimum threshold of 2.28 health care professionals per 1000 population, representing a scaling-up requirement of 140%. It is now understood that an inadequate health care workforce represents a major bottleneck in implementing evidence-based interventions. It also calls into question Africa’s capacity to meet the health-related Millennium Development Goals.

Numbers and distribution of health workers

Physician to population ratio (top) and nurses and midwifery ratio (bottom)

Fig6section34regionaltable1.png
Nursing and midwifery personnel-to population ratio (per 10 000 population) in the WHO African Region,2000-2010

Education and training

No health system can afford the risk of giving health workers a poor education. Nor can a health system function properly if training is poorly matched to the health needs of the population. Yet education in many countries is slow to change, although people's health needs may be changing rapidly. There are three pressing reasons to pay closer attention to the training of health sector workers in Africa:

  • First, the world as a whole needs more health workers. The World health report 2006[2] has identified a global shortage of 4.3 million health workers. To prepare these workers, training institutions will need to expand their capacity.
  • Second, different categories of worker are often needed – not only more doctors and nurses but also more managers, public health professionals and community workers. Worldwide, the number of educational institutions is heavily tipped towards the production of doctors (over 1600 institutions) and nurses (about 6000 institutions), compared with public health specialists (about 375 schools). To produce a health workforce with a broader array of skills, the education system needs to broaden its present range.
  • Third, health sector needs are constantly changing. Disease risks evolve and treatment protocols are revised. Management structures are changed. Individuals, families and communities become increasingly knowledgeable about their own health and about the treatment they want. To ensure that health workers can respond appropriately to their changing environment, training institutions need to prepare graduates with the appropriate competencies and with the ability to be lifelong learners.

These three issues prevail all over Africa, which is additionally handicapped by low economic status. Human resource shortages are compounded by:

  • recent decreases in investment in health
  • freezes in recruitment of health workers
  • poor remuneration and incentives
  • the migration of skilled staff.

Poor infrastructure and scarce medical supplies, among other factors, restrict the productivity of existing health workers, so the true extent of Africa’s delivery gap may be larger than presently reported. Significant effort and investment will be needed to build the institutional capacity required, both for scaling-up and assuring the requisite quality of education and training in health sciences throughout the Region. This is a particular challenge as many African countries have weak training institutions, lacking even a sufficient supply of high-quality text books, educational materials and other essential training equipment.

Training courses

Technical cooperation is taking place among partners and stakeholders interested in scaling-up human resources for health. Training institutions and networks such as the African Health Leadership and Management Network, and the Epidemiology Training Institutions Network are involved.

A Master’s degree programme in human resources for health was established in Africa in 2009 as an alternative to overseas programmes in English-speaking and French-speaking countries and serving as part of the process for creating a critical mass of human resources for health professionals. Successful academic partnerships in scaling-up, with a particular focus on nursing and midwifery education, have been implemented in six countries (Ghana, Kenya, Liberia, Malawi, Sierra Leone and Zambia). A survey tool for collecting information on the outcomes of these initiatives has been jointly developed by WHO headquarters and the WHO Regional Office for Africa and will be used to track progress.

Pilot projects are being carried out in three countries (Congo, Guinea Bissau and Liberia) to expand the capacity of existing training infrastructure for health workers. The initiative plans to identify gaps and enable the development of business/investment plans that can be used to mobilize resources for scaling-up work.

Educational institutions by type of training programmes

The World health report 2006,[2] devoted to health workers, urged Member States to make the health workforce a priority over the next decade. But to know what kind of changes are most needed, African countries will have to assess the type and levels of training currently available to health care workers and compare it to present requirements. This will mean obtaining answers to essential questions, such as:

  • What preservice and in-service training institutions are available? In what areas do they provide training? How many students do they train annually? Where are they located? In what language do they provide training?
  • What are the current and likely future needs of the health sector and how will these affect the required skills and competences in the health workforce? Are new cadres needed, such as nurse practitioners, medical assistants or community workers?
  • Where are the gaps? To what extent can the country rely variously on domestic, regional or international schools? How much money needs to be spent, and how, to improve the training of the health workforce?

Strengthening training institutions is essential to building a long-term, sustainable supply of human resources for health. Contributions to human resources for health are being made through the President’s Emergency Plan for AIDS Relief. This anticipates that initial investments in expanding clinical capacity and in innovations that favour retention will be integrated into country planning in future years with the involvement of the ministries of health, education and labour. In addition to strengthening existing partnerships, the President’s Emergency Plan for AIDS Relief will also conduct countrywide assessments of nurse training capacity to inform capacity-building interventions.

Standards setting for professionals and educational institutions

Comprehensive evaluation of health sciences and medical training programmes continues. Guidelines have been developed and disseminated evaluating basic nursing and midwifery programmes and disseminated to countries.

Evaluation is an essential component of efforts to expand human resources for health training. Evaluation of training programmes is taking place in countries, including medical, nursing and midwifery programmes. Nursing and midwifery programmes were evaluated in eight countries during 2008–2009 and at least three countries assessed the capacity of their health sciences and medical training institutions. Assessment tools for health-training institutions have been produced and curriculum updating exercises undertaken. Accreditation guidelines have been provided.

Innovative approaches to scaling-up the training of health workers are being promoted in a number of countries. Some examples include the utilization of e-learning approaches, telemedicine and distance learning. Providing faculty exchanges, networking and twinning with training institutions abroad and within the Region are used as ways to increase capacity.

Planning for human resources for health

Countries in the WHO African Region with shortages of human resources (physicians, nurses and midwives, 2005–2009) are shown in the figure.

Fig7section34regionalhealth wfdistrib.jpg

Migration of health workers

The World Health Assembly, through a number of resolutions,[3] has recognized the consequences of migration of skilled health workers, examined various possibilities of offsetting its negative impact on health care delivery, and urged countries to motivate and retain health workers.

In response, WHO has developed global guidelines and recommendations for retention of health workers in rural and remote areas. A methodology on documenting and monitoring the trends and impact of migration on African health systems has also been developed, and further research is in preparation.

Priorities and ways forward

Most African countries have made efforts to develop policies and plans on human resources for health within the context of health sector reforms. These have met with varying degrees of success and in the absence of reliable and validated data and information it has been difficult to establish evidence-based comparable analyses. In addition, the policy imperatives of these national initiatives, as well as other specific strategies to strengthen health systems, call for robust monitoring and evaluation mechanisms to assess the extent to which countries are making progress. The African Health Workers Observatory will be one way of meeting this need. Other approaches to the planning, production and management of human resources for health will include improving information systems and conducting evidence-based research in this domain.

For real progress to be achieved, countries will need to open a dialogue between their ministry of health and all other related ministries to ensure the appropriate coordination of decision-making concerning the training and production of health workers. It is particularly important that countries should undertake a process to identify the competencies required and identify gaps in skill mixes, through thorough task analyses and prioritization of country needs.

Additional measures now being encouraged include innovative training approaches such as the combination of preservice and in-service training that involves trainees in hands-on service delivery. Training of lower-level and mid-level health care workers must be geared to meet specific needs in service delivery, with systematic monitoring and evaluation of impact.

In summary, African countries need assistance in their endeavours to increase the number of training institutions and the supply of health workers, as well as the modernization of curricula and teaching methods. Human resource management training needs to be modernized and integrated into health management and public health training institutions. Capacity for systematic assessment of training institutions regarding fitness for purpose needs to be ensured. Equally, the pressing need for more, and more relevant, materials for health sciences education and training in the WHO African Region must become a priority.

Others

Partnerships for workforce financing

Collaboration and partnerships with stakeholders interested in strengthening health systems, and in particular human resources for health, has gained momentum, starting with the recognition that unless there is a radical and substantial increase in health worker numbers where the need is greatest, Millennium Development Goal targets are unlikely to be reached. Since then, collaboration with a wide variety of partners such as the African Union, the Economic Commission for Africa, the European Commission, the Global Health Workforce Alliance, bilateral donors, and private foundations such as the Bill & Melinda Gates Foundation, has greatly enhanced financial and technical support to countries for this purpose.

Through partnerships of this kind, training of health workers is being scaled-up in line with the requirements of national strategic plans. Support includes measures such as:

  • capacity assessments
  • evaluation of training programmes and updating of curricula
  • skills upgrading
  • promoting innovative training approaches.

To establish what proportion of health resources (both national and external) are allocated to human resources for health development by countries, a study was carried out in 2009 in four countries – Ethiopia, Liberia, Mozambique and Sierra Leone. The results of this exercise will be published in 2011.

Endnotes: sources, methods, abbreviations, etc.

The English content will be available soon.

Références

[1] Organisation mondiale de la Santé, 2006. Travailler ensemble pour la santé. World Health Report, Genève, Suisse.

[2] La résolution WHA 57.19 : Les migrations internationales des personnels de santé:. un défi pour les systèmes de santé dans les pays en développement, OMS, Genève, 22 mai 2004 la résolution WHA 59. 23 : Accélération de la production de personnels de santé: l'OMS, Genève, 27 mai 2006. Résolution WHA 59.27 : Renforcement des soins infirmiers et obstétricaux: OMS, Genève, 27 mai 2007.

Liste des tableaux / figures

[3] Pays avec une pénurie de ressources humaines (médecins, infirmières et sages-femmes) de 2005 à 2009. (non référencées, mais l'usage recommandé, si la source fourni).

[4] Les médecins, infirmières sages-femmes et le ratio (p4). Plus détaillée que l'Atlas Fig. 46 qui ne couvre que ratio médecin.

[5]Atlas Fig. 46: Rapport des médecins à la population dans la Région africaine, 2000-2009.

References

  1. The world health report 2006: working together for health (7.11Mb). Geneva, World Health Organization, 2008
  2. 2.0 2.1 The world health report 2006: working together for health (7.11Mb). Geneva, World Health Organization, 2008 http://www.who.int/whr/2006/whr06_en.pdf
  3. Resolution WHA 57.19: International migration of health personnel: a challenge for health systems in developing countries, Geneva, 22 May 2004; Resolution WHA 59. 23 : Rapid scaling up of health workforce production: Geneva, 27 May 2006; Resolution WHA 59.27: Strengthening nursing and midwifery: Geneva, 27 May 2007.