This paper reports on two separate experiences of costing for Human Resources Development Plans (HRDP) costing in Mozambique and Guinea Bissau, with the objective of providing an insight into the practice of costing exercises in information-poor settings, as well as to contribute to the existing debate on human resources costing methodologies. The study adopts a case-study approach to analyse the methodologies developed in the two countries, their contexts, policy processes and actors involved. From the analysis of the two cases, it emerged that the costing exercises represented an important driver of the HRDP elaboration, which lent credibility to the process, and provided a financial framework within which HRH policies could be discussed. In both cases, bottom-up and country-specific methods were designed to overcome the countries' lack of cost and financing data, as well as to interpret their financial systems. Such an approach also allowed the costing exercises to feed directly into the national planning and budgeting process. The authors conclude that bottom-up and country-specific costing methodologies have the potential to serve adequately the multi-faceted purpose of the exercise. However, adopting pre-defined and insufficiently flexible tools may undermine the credibility of the costing exercise, and reduce the space for policy negotiation opportunities within the HRDP elaboration process.
Human Resources
This review of human resources in the health sector indicates that the African Region is faced with severe shortages of doctors and nurses, with only 590,198 health workers against an estimated requirement of 1,408,190 health workers. This situation is compounded by inappropriate skill mixes and gaps in service coverage. The estimated critical shortages of doctors, nurses and midwives is over 800,000. The problem is more severe in rural and remote areas where most people typically live in the countries in the African Region. This review provides information about the efforts and commitments by World Health Organization Member States and the various opportunities created by regional and global partners, including the progress made. The paper also explores issues and challenges related to the underlying factors of the health worker crisis, such as chronic underinvestment in health systems development in general, and specifically in human resources for health development, migration of skilled health personnel as a result of poor working conditions and remuneration, lack of evidence-based strategic planning, insufficient production of health workers and poor management systems.
According to this paper, about 59 million people make up the health workforce of paid full-time health workers world-wide. However, enormous gaps remain between the potential of health systems and their actual performance, and there are far too many inequities in the distribution of health workers between countries and within countries. Sub-Saharan Africa, with about 11% of the world’s population, bears over 24% of the global disease burden, is home to only 3% of the global health workforce, and spends less than 1% of the world’s financial resources on health. In most developing countries, the health workforce is concentrated in the major towns and cities, while rural areas can only boast of about 23% and 38% of the country’s doctors and nurses respectively. The imbalances exist not only in the total numbers and geographical distribution of health workers, but also in the skills mix of available health workers. Countries in sub-Saharan Africa would need to increase their health workforce by about 140% to achieve enough coverage for essential health interventions to make a positive difference in the health and life expectancy of their populations. The paper argues that the global health workforce crisis can be tackled if there is global responsibility, political will, financial commitment and public-private partnership for country-led and country-specific interventions that seek solutions beyond the health sector. Only when enough health workers can be trained, sustained and retained in sub-Saharan African countries will there be meaningful socio-economic development and the faintest hope of attaining the Millennium Development Goals in the sub-continent.
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.
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.