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Health Sector Issues

Subtopics on this page:

The importance of the management and administration of human resources (HR) to the success of the health sector in meeting its objectives has often been overlooked. This is particularly the case as countries attempt to reform their health sector, or undertake other efforts to focus on quality improvement and customer choice, structural change, and cost containment.

The health sector is labour-intensive. Staffing costs and wages represent usually about three quarters of recurrent health expenditure in most countries. The health sector workforce also usually comprises a significant element within the total public sector workforce. These workers are either directly employed by the public sector health system, or work in public sector funded agencies or organisations (i.e. social insurance funded). In many countries some additional elements of health care will also be delivered by organisations in the private sector and by voluntary organisations. The health sector workforce is thus highly complex, with several health-specific professional groups (e.g., doctors, nurses, etc.) with distinct roles and their own educational and regulatory structures.

Managing HR in health care is therefore a complex challenge, one that too often has been underestimated when reform and restructuring has been planned. Focusing on change during health sector reform may challenge the ways that health professionals and other staff are employed and deployed (see Saltman and von Otter 1995). The methods used to manage human resources in the health sector can in themselves be a major constraint or facilitator in achieving the objectives of effective delivery of health services and in meeting the aims of health sector reform (Martinez and Martineau 1996; Kolehmainen-Aiken 1998; Buchan 2000). The key to achieving effective HR is to recognise that it has to be an integral element of overall planning and management of the delivery of health services.

Developing an evidence base of HR management capacity                                                                                       

Health sector reform often brings with it an increased requirement for management capacity to support a decentralised system (Eggar and Adams 1999, Nigenda and Ruiz 1999). One major challenge is ensuring that lessons learnt contribute to a developing evidence base on management capacity in human resources in health care. A useful resource is the Human Resources for Health Development Journal.

Skill mix and new workers                                        

Determining the most effective mix of skills and workers to deliver care is a key requirement for cost effective health care services. Skill mix has to be addressed as an issue of long term change management, rather than a one off "quick fix" (Buchan, Ball, and O’May 2000).

New types of worker are being introduced into country health systems in response consumer need and efficiency/effectiveness requirements. Many of these "new" workers are cadres developed from within current health professions with advanced and enhanced skills, such as family health doctors and nurse practitioners. Others are generic or "multi-skilled" workers, as witnessed in Zambia (Chirwa 1996) and Ghana (Dovlo 1997).

Pay and incentives                                                     

Improving staff performance in health systems is a major factor in improving the quality and effectiveness of health services. Equitable and timely methods of paying staff are pre- requisites for developing an effective approach to managing HR in health care. It is equally important to recognise that the motivation of health workers relates to many factors other than pay. These include the provision of education and career development opportunities, flexibility in working schedules, and a safe working environment.

Employment relations                                                 

Health sector reform commonly has had the implicit or explicit goal of reducing labour costs and improving labour "flexibility"(see Saltman and von Otter 1995). These efforts include attempts to "outsource" some services and associated workers, or to re-deploy, retrain or "downsize" some elements within the health sector workforce. These changes have not always been initiated from a firm evidence base, or with a clear understanding of the objectives or likely outcomes. Managing a process of change of such magnitude requires communication and negotiating skills, and a well developed action plan. It must be recognised that such staffing changes also may be opposed by professional organisations and trade unions, unless it can be demonstrated that such changes will have a positive impact on the quality of care provided.

Often health sector reform has included an attempt to "de-link" employment conditions in the health sector from "civil service" type employment contracts. The rationale for this has been to improve cost effectiveness by increasing flexibility in the organisation of health services, and through greater local management autonomy. However, these changes can generate upward pressure on pay levels since conditions in the "new" system must be sufficiently attractive to encourage staff to transfer across (Cassels 1995). Higher pay may have to be offered to compensate for the loss of other real or perceived benefits such as pension entitlement and job security.

Good communications with staff, involving workers in the process of reform, and effective employment relations are vital elements of human resources in a pluralist model of management (see the ILO web page). In countries where employees can be represented collectively by trade unions and/or professional associations there is a need to involve them in partnership. Where trade unions have negotiating rights, any attempt to alter conditions of employment or shift the focus of negotiation activity from the national to local level may also engender opposition, as unions may perceive this move as a threat to their national power base (Kolehmainen-Aitken 1998).

Protected employment rights are sometimes granted to health sector employees during the transition phase of health sector reform to facilitate progress (e.g in the UK during the internal market reforms of the 1990’s) or to comply with legislation (e.g. in countries such as Bangladesh and Trinidad and Tobago where a Public Service Commission type of agency plays an independent role in ratifying public sector employment rights).

Key HR questions during health sector reform            

Any country engaging in reform of its health care system should consider the following questions:

  1. How can workforce planning be best integrated with practice patterns and with health service delivery to meet society needs?
  2. What communication strategies will be effective, and how can workers be involved in positive partnership? How can trade union and professional organisational support for reform be secured?
  3. How can the education sector which prepares health workers, and the employers who utilise their skills, be brought together in an effective planning framework to support and sustain the direction of reform? How can the potential for educational institutions to contribute to the reform process be maximised?
  4. New working patterns, contracting out services, and attempts to alter employment contracts may all be planned elements of reform. To what extent will these goals be desirable and achievable, given available management capacity and any legislative or regulatory constraints?
  5. If "protected" employment rights are to given to workers during the transition phase of reform, what impact will this have on the pace and direction of change?
  6. What additional resources and local management capacity will be required to support the implementation of reform?
  7. The emphasis on cost containment in health sector reform is likely to lead to a short-term perspective when local management is examining staffing levels and mix. How can a more evidence-based approach be stimulated?
  8. How can lifelong learning and continuing education for workers be delivered in a way which best sustains quality improvement and performance?
  9. Health sector reform, particularly in decentralised systems, is likely to be associated with an increased requirement for workforce information and labour cost data for performance management requirements. How will these data requirements be satisfied?


The majority of care giving workers in many health systems are women. They have often been the disadvantaged majority, in terms of access to equitable treatment in employment practices and in career opportunities. Whilst there continues to be gender specificity in some health professions in some countries, in many others these barriers are being broken down; for example more women are entering medical education. Career development opportunities for women are also increasing in some health services, but in many others there remains a need to break the "glass ceiling" preventing equal access to career development opportunities for women workers.

Recommended readings:                                            

  • Buchan, James. 2000 (forthcoming). "Health sector reform and human resources: lessons from the United Kingdom." Health Policy and Planning 15(3): 319-215.
  • Buchan, James, J. Ball, and F. O’May. 2000. "Skill Mix in the Health Workforce." Issues in Health Services Delivery, Discussion Paper No.3. Department of Organisation of Health Services Delivery (OSD), World Health Organisation, Geneva.
  • Cassels, A. 1995. "Health Sector Reform: Key Issues in Developing Countries." Journal of International Development 7(3): 329-347
  • Chirwa, B. 1996. "HRD and health reforms: the Zambian experience." In J. Martinez and T. Martineau, eds., "Workshop on Human Resources and Health Sector Reforms." Liverpool School of Tropical Medicine, Liverpool, England.
  • Dovlo, D. 1997. "Health Sector Reform and Deployment, Training and Motivation of Human Resources towards Equity in Health Care: Issues and Concerns in Ghana." Human Resources for Health Development Journal 1(3).
  • Eggar, D., and Orvill Adams. 1999. "Imbalances in Human Resources for Health: Can Policy Formulation and Planning Make a Difference?" Human Resources for Health Development Journal 3(1): 52-63.
  • Kolehmainen-Aitken, R. 1998. "Decentralization and Human Resources: Implications and Impact." Human Resources for Health Development Journal 2(1): 1-17.
  • Martinez J., and T. Martineau, eds. 1996. "Workshop on Human Resources and Health Sector Reforms." Liverpool School of Tropical Medicine, Liverpool, UK.
  • Saltman, R., and C. von Otter. 1995. "Implementing planned markets in health care: balancing social and economic responsibility." Open University Press, Milton Keynes.
  • Sen K., and M. Koivusalo. 1998. "Health Care Reforms and Developing Countries: A Critical Overview." International Journal of Health Planning and Management 13: 199-215.

Suggested  websites:                                                 


This page was developed by Orvill Adams and James Buchan of the World Health Organisation's Department of Organisation of Health Services Delivery. It was submitted on 5/28/00.

James Buchan is currently sitting as a Professor at the:

Queen Margaret University College
Clerwood Terrace EDINBURGH EH12 8TS
United Kingdom


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