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"Human resources, the different kinds of clinical and non-clinical staff who make each individual and public health intervention happen, are the most important of the health system's inputs. The performance of health care systems depends ultimately on the knowledge, skills and motivation of persons responsible for delivering services"
World Health Report 2000, p.77

The scope and dimensions of HRH policies and practices

The design and implementation of effective policies and management practices in relation to HRH are critical for the success of health sector reform (HSR). Even though this is increasingly recognized, much effort is still needed to encourage and support policy and decision makers in addressing the multiple dimensions of HRH problems in their countries .

HRH issues at different levels of the system

  • At the macro level (national health care system) the main issues relate to: (i) the size and composition of the work force, i.e., the stock of HRH; (ii) its distribution among service levels and across the country ; (iii) the regulation of education and professional practice; and (iv) the general parameters of working conditions, incentive systems , payment mechanisms, and labor relations; this website will focus on the macro level;
  • At the meso level (regional/local health authorities and health organizations), issues relate to the application of policies and decisions taken at a higher level, and which are addressed in a more or less autonomous manner, depending on the degree of decision-making and management decentralization;
  • At the micro level, HRH management is less concerned with groups and categories of personnel, as is the case at the other levels, but rather with individuals. Issues are more likely to be performance management, supervision, evaluation, conflict resolution, and so on. 

At all levels of the system, HRH decisions and practices impact the objectives of the health care system (HCS). For example, failure to train sufficient numbers of one category of providers ((such as is often the case with nurses in poor countries), reduces accessibility to, and efficiency of, services since physicians cannot delegate simpler tasks as they ordinarily would.. The absence of policies to encourage providers to work in remote or poorer regions of a country leads to inequities in access to services. Basic training which is not in tune with the needs of the population will result in the HCS being less effective in improving health status. Poor management of personnel and unsatisfactory working conditions, usually associated with a discouraged work force, make it difficult for the HCS to be responsive to consumers' expectations. In sum, the success of reforms depends on adjustments in the number, skills mix, distribution, education and training, management and working conditions (including incentive systems) of the work force. Paying attention to HRH implications of HSR is particularly important in poor countries, where the impact of effective and accessible health services on health status, and consequently on poverty reduction, can be significant.

A framework for analyzing HRH issues

HRH's contribution to HCS performance

Health systems carry out several critical functions: financing, input generation, and provision of services. These core functions are influenced by governments through their stewardship role and by the population through demand and markets. The joint effect of these five systemic factors, combined with health seeking behaviors of households and skilled clinical management of effective interventions, leads to either good or poor performance in health outcomes, financial protection, and responsiveness to consumer expectations -- the main objectives of health systems
(WHO World Health Report 2000.)

Health System objectives

§ Achieving better health outcomes means: "Improving the average level of population health (including fatal and non-fatal components) and reducing health inequalities or improving the distribution of health".
§ Increasing responsiveness includes, among other things, "respect for persons
§ , their dignity, autonomy and confidentiality" as well as increased "client orientation, including prompt attention, access to social support networks, quality of basic amenities, choice of provider".
§ Financial protection against the impact of ill health improves as risks are pooled and services made accessible through pre-payment mechanisms.

The World Bank's Health, Nutrition and Population (HNP)network has adopted a conceptual framework consistent with these views.

The performance of the health work force

HRH constitute the most costly (in terms of capital investment and, above all, of recurrent costs), and the most critical input in the HCS. HRH determine how effective the utilization of other inputs and capital investments (infrastructure, equipment, consumables, including drugs will be. [Note: drugs are consumables] The performance of the health work force has various dimensions each of which has a direct impact on the achievement of HCS objectives.

Dimensions of the performance of the health work force

  • Coverage refers to the extent to which the work force provides services to the various sub-groups of the population and supplies the whole range of services corresponding to their health needs.
  • Productivity corresponds to the output extracted from personnel, such as patients seen per doctor, number of procedures per provider.
  • Technical quality is the degree to which providers produce services which (1) respect the accepted technical norms, usually defined by professional associations, and (2) have a positive impact on the health status of users.
  • Socio-cultural or service quality refers to the degree to which providers produce services which are culturally and ethically acceptable to users, meet their expectations, and are organized in a way that makes them accessible.
  • Organizational sustainability is the degree to which the work force is utilized in a way that ensures (1) the maintenance of the capacity to provide needed services over time, both in quantitative and qualitative terms, and (2) the adaptation of services to changing needs and circumstances.

Each of these dimensions, individually or in combination, has an impact on health outcomes, responsiveness, even financial protection. For instance, poor technical quality has an obvious negative effect on health outcomes. Similarly, the failure to supply a type of services in a given region, for example obstetrical emergency surgery, also leads to poor health outcomes. Low productivity diminishes access which, in turn, has a negative impact on responsiveness, cost of services, and eventually on health outcomes.

The determinants of performance of the work force

HRH and Health Care System Objectives

The main factors determinants of HRH performance are:

  • The characteristics and behaviors of the individuals which compose the work force: age, sex, number, competencies (knowledge, skills, attitudes), motivation.
  • The processes which influence some of these characteristics and behaviors: (i) the planning of the stock of personnel; (ii) the development of competencies, through education and training (i.e., the process by which the appropriate number of each category of providers is produced and equipped with the knowledge, skills, and attitudes needed to achieve the health services objectives); (iii) the deployment of the work force (i.e., the process of allocating the work force among types and levels of services, and among the various regions and sub-regions of the country); (iv) the management of HRH (i.e., the process of creating an adequate organizational environment and ensuring that the work force performs adequately.
  • Policies and practices of the State in the health sector, as well as in other sectors, which influence both the characteristics of HRH (e.g., gender discrimination at the level of recruitment in education institutions influences the composition of the work force), and the processes influencing their performance. This refers to all decisions, actions, and non-actions which have an impact on how the work force is produced, deployed, and managed. Policies originate from the health sector itself where they are formulated by actors such as the Ministry of Health and its agencies, professional associations, councils and unions, accreditation agencies where they exist. They also originate from other sectors, which often carry even more weight than the health sector itself: education, finance, labor, planning ministries, and civil service commissions often play a central role in the definition of required competencies, working conditions, career structures, and incentive systems.
  • Resources, including financial resources, equipment, infrastructure, information (derived from data bases, surveys, research); these also include the human resources which are an input in policy-making or training (a pool of good candidates, a pool of well prepared teachers).
  • The health sector environment and the social, cultural, political, economic, legal, and institutional environment. For example, the distribution of political and social power between the numerous actors and stakeholders involved, their alliances and conflicts, determine their relative capacity to influence decisions and actions. They define who will have a greater say in the processes of work force utilization of the. Political and cultural traditions of patronage make the adoption of more rational and needs-based policies and practices more difficult. The absence of political will to support reform of HRH policies in general will make efforts to do so in the health sector ineffective. Similarly, weak institutional capacity to formulate and implement policies will limit the capacity of the State to play its stewardship role in improving the work force performance.

Why a framework?

A framework is helpful in analyzing HRH issues in a comprehensive manner. It also implicitly stresses the need for sets of coherent policies to address all the dimensions of HRH performance. For instance, it is useless to train doctors in great quantity if they are not adequately equipped, or if they become discouraged and leave the profession or the country altogether. A valid work force situation analysis is likely to show that work force problems are multidimensional and interconnected. Such an analysis is a prerequisite to successful HRH interventions; otherwise strategic decisions are less likely to hit their intended targets. A good situation diagnosis should make it possible to identify problems, measure their extent and dimension, and assess their probable evolution and potential impact. Such a diagnosis can then become a useful tool for planning and policy-making, helping to define policy objectives and assessing the feasibility of alternative strategies. It also provides a baseline for evaluation purposes. The rapid assessment tool-kit provided here in the near future aims to help gauge a country's HRH situation.

A sound diagnosis can also serve the important purpose of helping to sensitize key political and social actors to the importance of work force issues for the success of HCR and poverty reduction efforts. It can show that imbalances in the personnel deployment can create access problems which, in turn, generate inequities. A good diagnosis can put HRH issues on the public and political agendas. When the process of formulating a diagnosis is conducted with the participation of stakeholders, it can also serve to build consensus – a critical element for any policy debate Finally, the analysis can contribute to the development of an information database to support the policy-making and implementation process.

The usefulness of HRH situation analysis in the health sector: a summary

To inform the policy and decision-making process by helping to:
§ define objectives
§ assess alternative strategies
§ create a baseline for evaluation purposes
§ sensitize stakeholders
§ contribute to consensus building
§ put HRH problems on the public and political agendas

Main HRH issues and challenges

What are the main issues?

Planning the stock of health personnel: how many of each category are needed, now and in the future? What numbers can the country absorb, both in the public and private sectors? How to avoid surpluses or shortages? What is the appropriate mix of providers in terms of professional skills and gender balance? What is the impact of sector reforms and other reforms, such as administrative, civil service or higher education, on health personnel requirements?

Deployment of the work force by type and level of services and by region and sub-regions: How to avoid the concentration of HRH in the better-off regions, in the more specialized services, in hospitals? How to redeploy personnel when necessary? How to respond to new needs created by decentralization?

Education and training: How to adjust the contents of basic curricula and pedagogical strategies to the needs of the population? How to connect education and training to the objectives of the HCS? How to provide continuing education and in-service training to avoid "brain decay"? How to ensure the quality of education and training? How to regulate the opening of new training institutions?

Management: recruitment and retention (i.e., preventing losses of personnel which take years to train, avoiding their capture by international organizations and NGOs), regulation of access to practice (registration, licensing, certification), development of economic, professional and in-kind incentive systems, development of career streams ??, and of supervision and evaluation mechanisms, quality management, regulation and surveillance of professional practice, work organization, team building and management, labor relations.

What are the main challenges?

The policy process: Many of the policies and practices which affect HRH are not under the direct control of the health sector. Decisions on how many individuals will be trained in the various categories of personnel, and on the contents and strategies of education and training, are often made in an independent manner by educational institutions and agencies. The working conditions of health personnel, their level of remuneration, and their career plans are often determined by agencies such as civil service commissions, which do not necessarily take into account the specific requirements of the provision of health services. The practice norms for many categories of providers are defined by their professional bodies. And sometimes the goals of one sector may clash with those of another: for instance universities might want to train more providers whereas the Ministry of Health might want to diminish their numbers. One implication of this fragmented policy process is that what is seen as a problem by some is not necessarily perceived as such by others. Thus the design of multi-sectoral and coordinated policies represents an important challenge.

The stakeholders: The number and diversity of stakeholders involved, and the social and political strength of some of them (principally medical doctors and educators, who usually have the political capacity to resist policies which they disapprove of) create a particular challenge. Health care providers are not passive implementers of a government's decisions. Rather, they are active protagonists who can give or refuse their support to system objectives, and therefore need to be convinced to accept them. No HSR has been accomplished against the opposition of health care providers. This is why the formulation of HRH policies should be seen as a continuing process, conducted with the active participation of major stakeholders, among whom service providers play a paramount role. The challenge is to bring these stakeholders into the policy process, which many governments are reluctant to do.

The information: Information for better HRH policies is seriously lacking: few if any poor or middle-income country have reliable personnel information systems. There are no valid data on the number of staff available, let alone on their professional characteristics, which makes planning extremely difficult. The setting up of such systems and their maintenance require not only good technical capacities, but also the political will to deal with the problems which such systems reveal, such as the existence of ghost workers, mismatches (people assigned to jobs which do not correspond to their skills), distributive imbalances, and so on. Information is also lacking on trends with respect to HRH expectations, opinions and behavior, as well as on how the HSR environment impacts on HRH. The recent initiative of the PanAmerican Health Organization (PAHO) to create human resources observatories is a systematic effort to fill that gap (see or, in Spanish and Portuguese only). Finally, the time lag between decisions and their effect in HRH education requires that some information about future needs be made available, yet another tremendous challenge.

How can these challenges be met and the HRH problems addressed?

Traditional market responses are not usually effective when applied to the HRH issues identified above. Where the market is left to decide, HRH tend to concentrate in the most lucrative services and in the better-off regions; educational institutions tend to proliferate, creating surpluses of health personnel; and the quality of training is not always guaranteed. On the other hand, where the state controls the health labor supply and decrees working conditions, a black market of professional services and alternative practices, such as under-the-table payments or the sale of supposedly free drugs, tends to develop. Market and state failures call for policies which combine what market and regulation strategies can best contribute to improving HRH performance. For instance, as health work force availability is determined by decisions made years in advance in relation to the intake of training schools, and iby migrations of personnel, planning is likely to be more effective than the market in correcting work force imbalances. On the other hand, introducing market mechanisms to motivate staff to perform better might be a preferred strategy to decreeing levels of remuneration.

Appropriate strategies would recognize the specific requirements of HRH policies. For example, in health, factor substitution (capital for labor) has limited potential to improve efficiency. Substitution of labor inputs (nurses for doctors, psychologists for psychiatrists) is not easy either, because of professional regulations and barriers, which are among the hardest to remove. In sum, policies need to be designed with a view to changing the work force into a facilitating force, rather than its being an obstacle to reform.

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