At the first Global Forum on Human Resources for Health in Kampala, Uganda, delegates endorsed a Global Agenda for Action on the alarming imbalances in the availability and distribution of health workers worldwide. One component of the Agenda was a pledge to "accelerate negotiations for a code of practice on the international recruitment of health workers". The first step was taken on March 31 with the launch of a 3-week online global dialogue convened by the Health Worker Migration Policy Initiative. The global dialogue provided a unique opportunity for anyone affected by the vast complexities of health-worker migration, in whatever capacity, to share experiences and knowledge on the realities of migration, on effective strategies to retain health workers where they are needed most, and on what the key principles of a global code of practice should be. The paper questions whether another code of practice really required.
Despite a global recognition from all stakeholders of the gravity and urgency of health worker shortage in Africa, little progress has been achieved to improve health worker coverage in many of the African human resources for health (HRH) crisis countries. The problem consists in how policy is made, how leaders are accountable, how the World Health Organization (WHO) and foreign funders encourage (or distort) health policy, and how development objectives are prioritized in these countries. The paper uses political economy analysis, which stems from a recognition that the solution to the shortage of health workers across Africa involves more than a technical response. A number of institutional arrangements dampen investments in HRH, including a mismatch between officials’ tenure in office and program results, the vertical nature of health programming, the modalities of Overseas Development Assistance in health, the structures of the global health community, and the weak capacity in HRH units within Ministries of Health. A major change in policy-making would only occur with a disruption to the political or institutional order. The case study of Ethiopia, who has increased its health workforce dramatically over the last 20 years, disrupted previous institutional arrangements through the power of ideas—HRH as a key intermediate development objective. The framing of HRH created the rationale for the political commitment to investment in health workers. The authors argue that Ethiopia demonstrates that political will coupled with strong state capacity and adequate resource mobilization can overcome the institutional hurdles above.
Most African countries lack the required workforce to deliver basic health care, including care for mothers and children. This is especially acute in rural areas and has limited countries' abilities to meet maternal, newborn, and child health (MNCH) targets outlined by Millennium Development Goals 4 and 5. To address the challenges, evidence-based deployment and training policies are required. However, the resources available to country-level policy makers to create such policies are limited. A scoping review was conducted to identify the type, extent, and quality of evidence that exists on workforce policies for rural MNCH in Africa. Fourteen electronic health and health education databases were searched for peer-reviewed papers specific to training and deployment policies for doctors, nurses, and midwives for rural MNCH in African countries with English, Portuguese, or French as official languages. Non-peer reviewed literature and policy documents were also identified through systematic searches of selected international organizations and government websites. There was an overall paucity of information on workforce training and deployment policies for MNCH in rural Africa. Policies focusing exclusively on training or deployment were limited; most documents focused on both training and deployment or were broader with embedded implications for workforce management or MNCH. Relevant government websites varied in functionality and in the availability of policy documents.
The Sub-Saharan African Medical Schools Study (SAMSS) survey is a descriptive survey study of sub-Saharan African medical schools. Surveys were distributed to 146 medical schools in 40 of 48 sub-Saharan African countries. One hundred and five responses were received (72% response rate). Enrolments for medical schools ranged from 2 to 1,800 and graduates ranged from 4 to 384. Seventy-three percent of respondents increased first-year enrolments in the past five years. On average, 26% of respondents’ graduates were reported to migrate out of the country within five years of graduation. The most significant reported barriers to increasing the number of graduates and improving quality were related to infrastructure and faculty limitations, respectively. Significant correlations were seen between schools implementing increased faculty salaries and bonuses, and lower levels of loss of faculty staff. Strengthened institutional research tools and funded faculty research time were also linked to greater faculty involvement in research. The results of the SAMSS survey are intended to serve as a baseline for future research, policies and investment in the health care workforce in the region.
This study conducted a systematic literature review of task shifting and found 2,960 articles, of which 84 were included in the core review. Fifty-one articles reported outcomes, including research from ten countries in sub-Saharan Africa. The most common type of task shifting studied was the delegation of tasks from doctors to nurses and other non-physician clinicians, especially initiating and monitoring highly active anti-retroviral therapy (HAART). Five studies showed increased access to HAART through expanded clinical capacity; four concluded task shifting is cost effective; nine showed staff could deliver equal or better quality of care; and studies on whether non-physicians and physicians were in agreement with their clinical decisions offered mixed results, with most showing good agreement. The study argues that task shifting is an effective strategy for addressing shortages of health workers in HIV treatment and care and believes it offers high-quality, cost-effective care to more patients than a physician-centered model could. The main challenges to implementation include adequate and sustainable training, support and pay for staff in new roles, the integration of new members into healthcare teams, and the compliance of regulatory bodies. The study recommends that task shifting should be considered for careful implementation where health worker shortages threaten rollout programmes.
Task shifting, or delegating tasks performed by physicians to staff with lower-level qualifications, is considered a means of expanding rollout in resource-poor or HRH-limited settings. This literature review aimed to assess task-shifting for HIV treatment and care in Africa. Of a total of 2,960 articles, 84 were included in the core review, including research from ten countries in sub-Saharan Africa. The most common intervention studied was the delegation of tasks from doctors to nurses and other non-physician clinicians. Five studies showed that task-shifting allowed for expansion of health services, while two concluded task shifting was cost effective and nine reported equal or better quality of care. The review concludes that task shifting offers high-quality, cost-effective care to more patients than a physician-centred model. The main challenges to implementation include adequate and sustainable training, support and pay for staff in new roles, the integration of new members into health-care teams, and the compliance of regulatory bodies.
This paper proposes a framework for carrying out a costing analysis of interventions to increase the availability of health workers in rural and remote areas with the aim to help policy decision makers. The authors review the evidence on costing interventions to improve health workforce recruitment and retention in remote and rural areas, provide guidance to undertake a costing evaluation of such interventions and investigates the role and importance of costing to inform the broader assessment of how to improve health workforce planning and management. They show show that while the debate on the effectiveness of policies and strategies to improve health workforce retention is gaining impetus and attention, there is still a significant lack of knowledge and evidence about the associated costs. To address the concerns stemming from this situation, key elements of a framework to undertake a cost analysis are proposed and discussed, which should help policy makers gain insight into the costs of policy interventions, to clearly identify and understand their financing sources and mechanisms, and to ensure their sustainability.
This report is intended to inform proceedings at the Third Global Forum on Human Resources for Health and to inform a global audience and trigger momentum for action. It aims to consolidate what is known on human resources for health and how to attain, sustain and accelerate progress on universal health coverage. The report uses mixed methods in selecting, collating and analysing country data. This includes analysing the workforce data in the WHO Global Health Observatory, searches of human resources for health progress in 36 countries and horizon-scanning of “big picture” challenges in the immediate future. The report presents a case that the health workforce is central to attaining, sustaining and accelerating progress on universal health coverage and suggests three guiding questions for decision-makers. What health workforce is required to ensure effective coverage of an agreed package of health care benefits? What health workforce is required to progressively expand coverage over time? How does a country produce, deploy and sustain a health workforce that is both fit for purpose and fit to practice in support of universal health coverage?
Zimbabwe is experiencing a debilitating flight of professional and skilled people escaping the country's economic crisis, a study funded by the UN Development Programme (UNDP) has found. A large number of Zimbabweans had taken up South African citizenship and there were probably more Zimbabweans in South Africa than in the United Kingdom, the country with the highest official tally of expatriate Zimbabweans.
Developing mid-level health professionals who can complement existing staff is an additional strategy that has been debated since 1994 and incorporated into the government’s recent human resources policy. Yet progress in the production of mid-level health workers has been slow. Reasons for this are likely to include competing priorities, the practical difficulties associated with setting up and implementing new training programmes, constraints on absorbing new cadres into the existing health system, tensions between different cadres over role definition and working conditions, and the brain drain into the private sector. More fundamentally, concerns remain about whether mid-level workers are the correct choice for South Africa’s health system. The author discusses how the design and early implementation of a new programme to develop South Africa’s first mid-level medical health professionals took account of these concerns and realities. Also highlighted are the issues that need to be addressed by government in order to ensure that this new programme has a substantial impact on the quality of care delivered in public hospitals. The author concludes that clinical associates have the potential to bring good quality hospital care closer to communities in a way that is affordable for the country.