The authors of this study developed a model to forecast the size of the public sector health workforce in Zambia over the next ten years to identify a combination of interventions that would expand the workforce to meet staffing targets. The key forecasting variables are training enrolment, graduation rates, public sector entry rates for graduates, and attrition of workforce staff. With no changes to current training, hiring, and attrition conditions, the total number of doctors, clinical officers, nurses, and midwives will increase from 44% to 59% of the minimum necessary staff by 2018. No combination of changes in staff retention, graduation rates, and public sector entry rates of graduates by 2010, without including training expansion, is sufficient to meet staffing targets by 2018 for any cadre except midwives. Training enrolment needs to increase by a factor of between three and thirteen for doctors, three and four for clinical officers, two and three for nurses, and one and two for midwives by 2010 to reach staffing targets by 2018. Necessary enrolment increases can be held to a minimum if the rates of retention, graduation, and public sector entry increase to 100% by 2010, but will need to increase if these rates remain at 2008 levels.
Human Resources
According to this review, researchers and policymakers in the past have paid little attention to the role of health workers in developing countries but a new generation of studies are providing a fuller understanding of these issues using more sophisticated data and research tools. The review refers to recent research that views health workers as active agents in dynamic labour markets who are faced with many competing incentives and constraints. Studies using this approach appear to provide greater insights into human resource requirements in health, the motivations and behaviours of health workers and health worker migration. The review urges for more high-quality research on the role of health workers in developing countries.
The objective of this paper was to understand the factors influencing health workers’ choice to work in rural areas as a basis for designing policies to redress geographic imbalances in health worker distribution. Data from a cohort survey of 412 nursing and medical students in Rwanda was used to examine the determinants of future health workers’ willingness to work in rural areas as measured by rural reservation wages. The data was combined with data from an identical survey in Ethiopia to enable a two-country analysis. The research found that health workers with higher intrinsic motivation – measured as the importance attached to helping the poor – as well as those who had grown up in a rural area and Adventists who had participated in a local bonding scheme were all significantly more willing to work in a rural area. The main result for intrinsic motivation in Rwanda was strikingly similar to the result obtained for Ethiopia and Rwanda combined. In conclusion, intrinsic motivation and rural origin play an important role in health workers’ decisions to work in a rural area, in addition to economic incentives, while faith-based institutions can also influence the decision.
This paper reviews available research evidence that links medical students’ characteristics with human resource imbalances and the contribution of medical schools in perpetuating an inequitable distribution of the health workforce. Existing literature on the determinants of the geographical imbalance of clinicians, with a special focus on the role of medical schools, is reviewed. Structured questionnaires collecting data on demographics, rural experience, working preferences and motivational aspects were administered to 130 fifth-year medical students at the medical faculties of MUCHS (University of Dar es Salaam), HKMU (Dar es Salaam) and KCMC (Tumaini University, Moshi campus) in the United Republic of Tanzania. The 130 students represented 95.6% of the Tanzanian finalists in 2005. The paper found that the lack of a primary interest in medicine among medical school entrants, biases in recruitment, the absence of rural related clinical curricula in medical schools, and a preference for specialisation not available in rural areas are among the main obstacles for building a motivated health workforce that could help correct the inequitable distribution of doctors in the United Republic of Tanzania. The paper suggests that there is a need to re-examine medical school admission policies and practices.
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.
South Africa has one of the highest rates of multidrug-resistant tuberculosis (MDR-TB), but a new study has found that many nurses have not been trained to handle this deadly, difficult-to-treat strain of the disease. The research, presented at the South African TB Conference, which was held from 1–4 June 2010 in Durban, found that only about 19% of the 16 health facilities surveyed in rural and urban areas of Limpopo and KwaZulu-Natal provinces had nurses with formal training in MDR-TB management. Dr Tsholofelo Mhlaba, of Health Systems Trust, a health research non-governmental organisation, said some nurses who had been trained to handle MDR-TB demonstrated similar levels of knowledge as those who were untrained. Some nurses tried to fill this knowledge gap with reading and internet research, but many considered MDR-TB a rare problem, even in KwaZulu-Natal, which has the highest incidence of drug-resistant TB in the country. Inadequate understanding of the disease led to poorly recorded patient histories and failure to follow up on people who had been in close contact with MDR-TB patients, such as household members.
This study aimed to identify the human resources for health (HRH) policy concerns and research priorities of key stakeholders in low- and middle-income countries; to assess the extent to which existing HRH research addresses these concerns and priorities; and to develop a prioritised list of core research questions requiring immediate attention to facilitate policy development and implementation. The study involved interviews with key informants, including health policy-makers, researchers and community and civil society representatives, in 24 low- and middle-income countries, and a literature search for relevant research reviews, from which research questions were prioritised. The questions ranked as most important at the consultative workshop were: To what extent do incentives work in attracting and retaining qualified health workers in underserviced areas? What is the impact of dual practice and multiple employment? How can incentives be used to optimise efficiency and the quality of health care? There was a clear consensus about the type of HRH policy problems faced by different countries and the nature of evidence needed to tackle them. The study concludes that co-ordinated action to support and implement research into the above questions could have a major impact on health worker policies and, ultimately, on the health of the poor.
This resolution of the 63rd World Health Assembly outlines a set of standards for the international recruitment of health personnel. The code of practice aims to establish and promote voluntary principles and practices for the ethical international recruitment of health personnel. It provides member states with ethical principles for international health worker recruitment that strengthen the health systems of developing countries. It discourages states from actively recruiting health personnel from developing countries that face critical shortages of health workers, and encourages them to facilitate the 'circular migration of health personnel' to maximise skills and knowledge sharing. It enshrines equal rights of both migrant and non-migrant health workers. The code sets the provisions for member states to monitor and report on the implementation of the code, for reporting back to the Assembly in 2012.
This review provides a comprehensive overview of the most important studies addressing the recruitment and retention of doctors to rural and remote areas. A comprehensive search of the English literature was conducted using the National Library of Medicine’s (PubMed) database and a total of 110 articles were included. The available evidence was classified into five intervention categories: selection, education, coercion, incentives and support. The main definitions used to define ‘rural and/or remote’ in the articles reviewed were summarised before the evidence in support of each of the five intervention categories was presented. The review argues for the formulation of universal definitions to assist study comparison and future collaborative research. Although coercive strategies address short-term recruitment needs, little evidence supports their long-term positive impact. Current evidence only supports the implementation of well-defined selection and education policies, although incentive and support schemes may have value. The review concludes that the impact of untested interventions needs to be evaluated in a scientifically rigorous fashion to identify winning strategies for guiding future practice and policy.
Compulsory service programmes have been used worldwide as a way to deploy and retain a professional health workforce within countries. Other names for these programmes include 'obligatory', 'mandatory', 'required' and 'requisite.' All these different programme names refer to a country’s law or policy that governs the mandatory deployment and retention of a heath worker in the underserved and/or rural areas of the country for a certain period of time. This study identified three different types of compulsory service programmes in 70 countries. These programmes are all governed by some type of regulation, ranging from a parliamentary law to a policy within the ministry of health. Depending on the country, doctors, nurses, midwives and all types of professional allied health workers are required to participate in the programme. Some of the compliance-enforcement measures include withholding full registration until obligations are completed, withholding degree and salary, or imposing large fines. This paper aims to explain these programmes more clearly, to identify countries that have or had such programmes, to develop a typology for the different kinds and to discuss the programmes in the light of important issues that are related to policy concepts and implementation. As governments consider the cost of investment in health professionals’ education, the loss of health professionals to emigration and the lack of health workers in many geographic areas, they are using compulsory service requirements as a way to deploy and retain the health workforce.