Human Resources
Technical progress is often associated with sophisticated new equipment, such as MRI devices and CT scanners, or with new drugs, such as vaccines and anticoagulants, but technical progress is also embodied in improved skills to prevent, diagnose, and treat illnesses and injuries.3 Thus investments in the people who provide health care services are critical for achieving progress against disease and injury. Low- and middle-income countries face particular challenges in their efforts to mobilize and retain a skilled workforce in the health sector in all areas, from recruitment and training to payment policies, retention, rewards, motivation, and deployment. Unless countries can substantially increase the number and skills of health care workers, reaching the MDGs for health and nutrition will be difficult. Reducing maternal and neonatal mortality, in particular, requires substantial increases in skilled birth attendance; increasing the coverage of immunization programs may require more staff; and preventing and treating TB, HIV/AIDS, and malaria also demand skilled cadres.
". . . investments in the people who provide health care services are critical for achieving progress against disease and injury."
Part of the problem facing many low- and middle-income countries is an inadequate supply of health professionals. For example, while high-income countries average 283 physicians per 100,000 people and the global average is 146 physicians per 100,000 people, Peru has 10, Papua New Guinea has 7, and Nepal has 4, and 10 countries in Sub-Saharan Africa have fewer than 3 doctors per 100,000 people. Nurses are also scarce. While high-income countries have an average of 750 nurses per 100,000 people and the global average is 334, Papua New Guinea has 67, Peru has 6, and Nepal has 5 and 11 countries in Sub-Saharan Africa have fewer than 20 nurses per 100,000 people.
The relatively few health care professionals in many low- and middle-income countries are not distributed evenly across the population. In general, deploying doctors, and even nurses, to remote rural areas is difficult and health professionals tend to be concentrated in major urban areas. Public health systems find themselves competing to retain skilled staff against the pull of private practice and hiring by international agencies and aid programs. Many health professionals emigrate to higher-income countries with better pay and working conditions.
Health professionals who remain in their countries use a range of strategies to cope with low-paying jobs and poor working conditions. In many countries, absenteeism is a serious problem, often resulting from health care workers pursuing other remunerative activities within or outside the health sector. Among doctors, in particular, dual employment is common: they receive a salary from the public sector, but also earn fees though private practice. Those who remain at their public jobs may demand informal and illegal charges to supplement their low incomes. In addition, low productivity is compounded by lack of skills, poor supervision, little continuing education, dilapidated facilities, and lack of basic medical supplies.
Countries are grappling with these human resource issues in a variety of ways, including innovative staffing, changes in financial and non-financial incentives, and organizational reforms. DCP2 observes the great variety of these reforms, assessing the interventions themselves and also their degree of implementation and suitability to context.
Countries that seek to address shortages of skilled health care workers by training more doctors and nurses sometimes find that shortages persist because of high rates of attrition. To discourage health care workers from leaving for private practice or emigrating to countries with better pay, some countries have altered the skill mix in training programs to reduce the portability of professional degrees. Training can be adequate for particular domestic health care needs without necessarily being recognized internationally as an accepted medical program. In this way, countries can reduce the risk of losing trained staff to emigration.
Many innovations in human resource management in low-income countries involve creating new health professions, that is, categories of health care workers who perform a variety of functions that have traditionally been reserved for physicians or nurses. Professional associations often resist this process to protect their standards and positions, yet studies in developing countries have shown that in some cases nurses can perform many functions in primary care settings as safely and effectively as doctors. As a direct response to internal and external migration, Zimbabwe has introduced a new cadre known as primary health care nurses, who have fewer qualifications than general nurses. Malawi has created the profession of clinical officers, who do not receive a full medical education, but still obtain extensive training that permits them to carry out a number of medical procedures, including surgery and anesthesia. Emergency cesarean sections conducted by clinical officers are somewhat riskier than those doctors perform, but the risks are substantially lower than no timely treatment at all. Insisting on fully qualified doctors where they can be hired and retained and perform procedures is clearly preferable, but where no medical services exist, training and deploying less-skilled workers can make a substantial difference.
". . . nurses can perform many functions in primary care settings as safely and effectively as doctors."
The creation of new kinds of health care workers is a common theme in DCP2. Chapter 68 discusses how emergency care services can be extended to more people, addressing a substantial disease burden from trauma, by recruiting, training, and supporting bus and taxi drivers. Chapter 56 discusses the role that community health workers can play in monitoring children's growth and providing nutritional education and in screening and referral for many common conditions. Chapter 26 discusses the need for skilled birth attendants without full medical degrees. In some places, paying attention to the skills and technical methods that are needed rather than the title of the health care worker can mean the difference between providing a service or not.
Countries have also made changes in financial and nonfinancial incentives. Raising salaries is often costly, as payroll expenses account for 50 to 80 percent of recurrent costs, but when financial incentives are targeted toward specific aims, they can be effective. For example, Thailand improved service provision in rural areas by paying bonuses to doctors willing to work in more remote locations and providing nonfinancial incentives, including different contractual relationships, housing, peer review, and professional recognition.
"China has had some success with improving treatment of TB patients by paying village doctors for each case identified and treated . . ."
Other efforts have included increasing salaries by linking pay to performance. Some of these involve public administration reforms in which periodic performance reviews trigger pay raises or bonuses. In other cases, direct payments are linked to the numbers of services provided or the achievement of performance targets. China has had some success with improving treatment of TB patients by paying village doctors for each case identified and treated (box 7.6). In other cases, pay linked to performance may actually be harmful. For example, incentives to generate additional revenue at hospitals in Shandong province succeeded, in part, through the provision of unnecessary care.
[Box ]
Nonfinancial incentives can be as effective as financial incentives in altering staff behavior. Such incentives include giving productive workers access to special training and promotion opportunities, recognizing good performance publicly, awarding bonuses to be used for improving local working conditions, delegating responsibilities, and providing education for dependents and housing.
Many countries have used organizational reforms to alter the entire framework within which they recruit and employ human resources. Decentralizing health functions to local governments is a major trend worldwide. It is almost always introduced as a general political reform within which the health sector, like other public service sectors, has to find an accommodation. Decentralization can exacerbate problems of paying and retaining health workers unless an adequate assignment of revenues accompanies the assignment of responsibilities to local governments. Countries have also initiated broad civil service reforms to improve the salaries, supervision, and retention of public sector workers. Unfortunately, research has shown that few civil service reforms of this nature have led to decisive improvements. Efforts in Uganda and Zambia to separate health workers from the general civil service encountered substantial political resistance and were not implemented.
Finally, many governments are contracting health services from NGOs or private providers. Some of these efforts have been quite successful, leading to improved service coverage and quality. South Africa had successful experience with contracting out the management of several hospitals to a private company, and Cambodia has successfully used performance contracts with NGOs to provide primary health care services. In other cases, however, the same weaknesses of public administration in supervising public workers have simply transferred to weaknesses in the supervision of contracts, leaving NGOs or private providers to absorb resources without fulfilling their responsibilities.
"Addressing human resource management requires understanding that it operates in a competitive market."
Traditional planning models for human resources have tended to be mechanistic, assuming that people trained as doctors and nurses could be easily deployed to wherever they were needed. These models have ignored the wide range of opportunities available to health care workers within their own countries as well as overseas. Addressing human resource management requires understanding that it operates in a competitive market. Health care professionals continue to be motivated by their vocation, but are also swayed by financial and nonfinancial incentives, working conditions, and access to opportunities for professional advancement. Innovative staffing arrangements hold promise for meeting some of the need for trained health care workers. Experiments in personnel management and organizational reform may result in better ways to recruit, retain, and deploy health care workers in the future.
". . . mobilizing funds to finance public health interventions is difficult both because some health care is costly and because raising revenues in low-and middle-income countries is not easy."
