Health Care Provision and Associated Human Resource Needs
Studies on developing services to meet the Millennium Development Goals emphasize the importance of making health workers with the appropriate skills available and motivating them (Jha and Mills 2002). The problems include lack of technical skills, low motivation, and poor support networks (Kurowski and others 2003). This chapter, therefore, focuses on HR planning, training and professional development, incentives for workers to accept and stay in posts and to deliver services, and alternatives to conventional professional groups.
Incentives and Motivation
The labor market model outlined earlier provides a framework for analyzing the role of incentives. A health worker will accept a job if the benefits of doing so outweigh the opportunity cost. Improving recruitment and retention requires either offering higher rewards that make alternative employment less attractive or making qualifications less "portable"—that is, less likely to be recognized in other countries. The development of new health professions in many countries is a way of reducing the portability of qualifications, thereby reducing the opportunity cost of jobs at home. Another advantage is that training can be more specific to local health system needs, but ensuring quality and safety are important issues.
Health workers will choose to train and increase their skills if the rewards of doing so exceed the cost. In general, the supply of skilled professionals rises as rewards increase, because more will seek training, more will return to the workforce, and fewer will move to other jobs or other countries. Because health workers value both financial and nonfinancial rewards, they will work for lower salaries if other job characteristics are attractive.
The causes of health HR problems in developing countries are complex, and attempts to address them must reflect this complexity. Table 71.2 suggests a framework for exploring links between factors at individual, organizational, and health system levels. The framework is inspired by a systems approach, which gives prominence to the roles of and relationships between different component parts in influencing the whole.
[Table .]
The individual health worker level serves as a starting point for exploring the determinants of health worker behavior and performance (Kyaddondo and White 2003). Performance here means productivity and quality of services. Individuals respond to individual concerns through coping strategies, such as informal and dual practices, with associated consequences. There are multiple links between individual health worker behavior and organizational and systemic factors. Organizational and system arrangements define the incentive context for health workers and influence both organizational and individual performance.
Therefore, the configuration of the health system must create incentives for appropriate supply and deployment of health workers. HR development experts tend to focus more on problems encountered in the lower tiers of this framework. Political pressure for short-term solutions partly explains why many countries do not address HR problems comprehensively. The wider context can also be important. Good governance at the national level is necessary to make policy interventions at the health system level or below effective.
Financial Incentives
Most of the comparatively scarce evidence on the relative importance of financial and other incentives for health workers at the individual level comes from developed countries. Two findings emerge from recruitment and turnover studies. First, at extremely low salaries, financial incentives are particularly important (Normand and Thompson 2000). Second, at least half of the variation in turnover can be attributed to financial incentives (Gray and Phillips 1996). These findings leave considerable scope for improving retention using organizational changes, but such changes will be only partially successful if much better financial rewards are available elsewhere.
International migration has increased as restrictions on moves to high-income countries have been eased (Bach 2000). Many developed countries have shortages of health professionals and actively recruit from low-income countries, thereby raising the opportunity cost of remaining at home.
Health Care Systems' Responses to Health Worker Issues
Health sector reforms have been widespread in recent years, often with international support. These reforms tended to focus more on structures and financing and less on resource issues (Martineau and Buchan 2000). Other government reforms aimed mainly at improving efficiency and reducing the cost of government administration have often had large effects on the health workforce (Adams and Hicks 2000; Corkery 2000). Some changes have attempted to introduce better incentives, such as performance-related pay and renewable contracts, and to remove underperformers and ghost workers. Evidence on the effects of these reforms suggests that more emphasis should have been placed on designing incentives to improve performance and retention and on moving further away from workforce quotas and norms. Using the three levels of analysis, the following sections consider policies, management, and incentives and how they can help match skills to needs.
