More than half way towards the Millennium Development Goals (MDGs), there is
an urgent need to respond to the global human resource crisis in health. Despite
a fast moving 21st century which has brought about a wide range of technological
and medical advances and tremendous efforts to create global alliances for international
health, the health needs of many populations remain far from being met. The
gap between rich and poor countries is widening. Many health systems remain
inadequate and at the brink of failing, life expectancies in some of the poorer
countries are decreasing, preventable diseases such as Malaria, TB and HIV/AIDS
are causing a heavy death toll and even the most basic health services are not
being provided. The precarious health resources situation further adds to this
crisis situation and is the result of numerous factors: sheer shortage of staff,
low salary levels, low motivation and productivity, lacking incentives, geographic
imbalances, a lack of suitable education, pre-service and continuous training
opportunities, the impact of HIV/AIDS and a one-way South-North migration of
health personnel. The full implications of these facts and figures are complex,
but at the bottom line there is a global shortage of more than 4 million doctors,
nurses, midwives and other cadres of health staff with 57 countries suffering
from a critical health personnel shortage (WHO 2006).
A Symposium “Human Resources for Health – Beyond the Declarations” was hosted
by the Swiss Tropical Institute (STI) in Basel on 21st March 2007 to take up
the current debate and to point out potential ways forward. Several speakers
from the World Health Organisation (WHO), Swiss Agency for Development and Cooperation
(SDC), Council on Health Research for Development (COHRED), Special Program
for Research and Training in Tropical Diseases (TDR), Community Health Department
of the University Hospital Geneva (HUG) as well as international guests from
Zambia and the Ivory Coast contributed to the discussion. As the presentations
showed, the key issues coincide with those raised in the ongoing human resource
discussions at the global level. There is a need for action!
The raw material for health systems
A strong and well-functioning health system is a prerequisite to reach the
MDGs goals and health system strengthening should therefore be seen as an integral
part of national health policies. Only efficient and equitable health systems
are able to successfully deliver treatment for those infected with HIV, to meet
reproductive health needs, implement immunisation programmes and to channel
aid investments in a sound manner. But the raw material for health systems is
made up of those people who make it work on a daily basis - those who treat
and care for patients and those who work at the managerial and support level.
It is therefore not surprising that the distribution and density of skilled
health staff coincide with a country’s health outcome. Specific examples were
highlighted during the Symposium discussion; high density of health staff strongly
correlated with a low child mortality in countries like Norway or the UK, whereas
the opposite trend is observed in many African countries such as Sierra Leone,
Ethiopia and Uganda. Efforts to maximise the best mix of skills that can be
achieved from the limited numbers of the various health cadres available need
considerable back up and support from decision-makers and planners as well as
from those providing the funding. Unfortunately there is no standardised approach
to solving the human resources problematic. Each country has to define its own
strategies.
So why do so many countries, especially in the African region, experience chronic
shortages of health staff? The reasons are manifold and can best be highlighted
through the country-level examples presented at the Symposium. While a decade
ago, migration of health staff in Zambia was insignificant it has nowadays reached
extremely high levels. Today, 5% of the total Zambian nurse workforce is practicing
in European countries. Many more decide to migrate to the neighbouring countries
South Africa and Botswana or continue their profession in the private sector
or in other organisations. Further figures that give rise to concern were presented
for Ghana and Zimbabwe where 13% and 34% of nurses respectively are already
working in foreign countries. The main forces serving to drive health staff
from Zambia in search of a brighter future abroad include higher salary levels
(especially for nurses), better working conditions, enhanced educational possibilities
and a future oriented career development. A regional maldistribution of skilled
professionals adds to this crisis leading to a disproportionably high number
of health personnel being found in the urban environment whereas rural areas
experience immense deficits.
Besides migration, the largest cause of attrition of health service staff is
death due to HIV/AIDS. In Zambia, 2 nurses out of 1000 died of AIDS in the 1980s
while figures climbed to 27 deaths out of 1000 in 2001. Such a development is
alarming as it not only implies that health workforce numbers are declining
in overall terms but also that the very staff who are needed to deliver antiretroviral
treatment are themselves succumbing to the disease. Only functioning health
systems which have sufficient staff are able to provide the health services
- including antiretroviral treatment - that save lives! This needs to be kept
in mind when considering the strong interrelationship between the number of
service providers and plans to achieve Universal Access to antiretroviral treatment
by 2010.
WHO has recently set up a new programme which follows a triple strategy to
strengthen HRH for different disease programmes, especially HIV/AIDS. The initiative
is known as Treat, Train, Retain (TTR). ‘Treat’ stands for a package of HIV
treatment, prevention, care and support services for health workers, who may
be infected or affected by HIV or AIDS. WHO will hereby collaborate with the
International Labour Organisation (ILO) to support the roll-out of the workplace
programmes. For ‘Train’ WHO will support standardised training and certifying
of all cadres to deliver HIV services. ‘Retain’ covers financial and other incentives
and occupational health and safety. Migration issues will be taken up together
with the International Organisation for Migration (IOM). The efforts are promising
and mark an important way forward.
In many countries, investments in health staff pre-service training and continuous
education have so far been limited, thus constricting the supply of young professionals.
A global snapshot of the availability of medical education facilities draws
a bleak picture. Great disparities exist concerning the distribution and number
of medical educational facilities. Whereas the USA has more than 500 medical
schools with a yearly graduate output of 68,500, Africa lags far behind with
less than 100 medical schools and an average of 5,100 graduates per year only.
A major step forward would thus be to invest in the establishment of high quality
training institutions which assure the coverage of the health needs of the population
and satisfy the labour market in countries suffering from serve health shortages.
As was commented at the Symposium, “if millions are invested in individual diseases,
the responsibility also exists to invest in HR development”. The results of
such investments are most likely not as measurable, rewarding and presentable
in the short term but would significantly contribute to long-term health system
strengthening. The aim should be to achieve the right mix of health worker numbers,
professional skills and competencies through qualitative and accredited curricula
which target practice based teaching, problem based learning and patient focused
services. Supported through a higher level of financing, political commitment,
development partner support and combined efforts of decision making bodies,
changes towards better coverage of essential interventions can be achieved.
At the symposium a successful example for capacity building was presented for
a project led by a consortium of “Partnerships in Health” and the University
hospital of Geneva (HUG) in the former Yugoslavia. During the war between 1992/1995,
major parts of the health infrastructure of Bosnia Herzegovina were destroyed
and many health workers migrated abroad. Years of isolation and a lack of training
of health care personnel lead to the break-down of prevention programmes and
a general deterioration of health conditions and outcomes. The project of the
HUG, aimed at training and retraining primary care doctors and nurses and offering
capacity building for the health tutors themselves in curriculum development
and family medicine. Starting in 1998, the FaMi project has seen ever increasing
interest amongst health staff to take part in the trainings being offered. In
1988 there were just 38 participants. Last year the number had risen to 220.
Specific project outcomes include the training of 810 doctors and nurses, 120
“Training of Trainer” courses (TOT), creation of 4 family medicine training
centres and 70 medical practices rebuilt and newly equipped. The family medicine
training programme placed great emphasis on sustainability through joint training
of doctors and nurses, empowerment of nurses, interactive training methods,
gradual replacement of the Swiss trainers by their Bosnian counterparts, development
of local responsibility and ownership, progress monitoring, supervision and
coaching on the job and systematic involvement of local institutions. In addition,
organizational changes were implemented for patient registration, appointment
systems, patient files, task division, team meetings, telephone advices, health
promotion activities, continuity of care and home and palliative care.
New efforts for capacity building are, however, not enough! Access to quality
teaching materials and technologies (computerised systems including e-learning
possibilities etc.) as well as access to research programmes and data in general
represent additional challenges. Despite the widespread acknowledgement that
research and development is key to health, equity and economic development,
there is no clear approach as to who, where and how research for health should
be addressed. As a result, almost all new research efforts for the South are
still concentrated in the North. If this development is not explicitly targeted,
developing countries will remain spectators while the North continues to act
on their behalf by identifying the country problems, deciding on the amount
and type of funding and conducting the research. It must be clearly stated here
that the South needs to become actively involved in research for health in order
to drive development forward. From a national perspective, development is a
key outcome which requires research capacity strengthening at national level
to become better understood, studied and addressed. Human resources for health
research (HR-HR) remains an area that lacks clear strategies and monitoring.
As a consequence HR-HR is not living up to its expectation and there is no common
scaling-up. In order to change the invisible and implicit character of HR-HR,
a multilevel approach needs to be initiated, involving the individual, institutional,
system, economic and political level. A strong political leadership combined
with the establishment of research alliances alongside health research priorities,
the creation of institutions and a targeted investment in science technology
and innovation is called for. Country empowerment involving local institutions
and addressing local health priorities is a further must!
Well-targeted HR-HR would generate the long-strived for data on human resources
in health. Efforts to strengthen the use of basic modern communication technology
such as telephones, computers and access to internet could also be made to improve
the efficiency of data management. Vital basic information on the number and
distribution of important diseases, child mortality and vaccination programmes
could be used more effectively as the basis of planning. No matter how well-trained
and motivated health staff are, inadequate health infrastructure and health
information management systems will hamper their performance.
There is no single, blueprint approach
A common conclusion of the Symposium showed, that Global health initiatives
have taken off, but a blueprint approach will never be achieved. On the contrary,
effective workforce strategies have to be adapted to each and every individual
country context as workforce dynamics are deeply embedded in the history and
the present political situation of a country. Until recently, development partners
and health planners concentrated more on their own disease priority assuming
that such interventions would also benefit the health systems. GHIs are only
recognising now, that well functioning health systems are fundamental for effective
aid interventions and successful disease programme implementation. Thus, awareness
about the global human resource crisis is increasing among major institutions
and international organisations and they are starting to address the problem.
One example presented at the STI Symposium refers to combined efforts of the
German development cooperation, mainly consisting of the German Technical Cooperation(GTZ),
German Development Bank (KfW), Centre for International Migration and Development
(CIM), German Development Service (DED), German Academic Exchange Service (DAAD),
Capacity Building International (InWEnt) and the Centre for International Migration
and Development (CIM). The German Development Cooperation has long-term experience
in providing health system support, at national, regional and district level.
Concrete strategies need to be adapted to the context in question and require
involvement at macro level with a strong linkage to the national decision making
bodies - including the ministries of finance and other social sectors. The German
Development Cooperation acts increasingly through a programme approach that
draws on the individual competencies and strengths of each organisation. The
GTZ, has a strong focus on strategic human resources planning, capacity building
and supporting closer collaboration between public and private health providers.
Budget support and infrastructural improvements form the – often indirect -
contribution of KfW, whereas the DED ensures that the linkage to the district
level is maintained. Capacity building and continuous personnel development
such as through e-learning courses and provision of health learning materials
has long been a priority area of InWEnt and will be further continued. Complementary
to this, the DAAD facilitates academic and research possibilities in Germany
for scholars from around the world while encouraging them to return and practice
in their home countries upon qualifying. In line with this approach, CIM takes
on a twofold strategy by actively organising the return of health professionals
to their country of origin and enabling senior and well-qualified professionals
from Europe to work in resource poor settings with the aim to transfer skills
and know-how.
International support needs to go hand in hand with national leadership and
priority-setting and be underpinned by well formulated national HRH policies.
Social Sector Ministries have to take up the issue as part of their national
leadership. In other words, it is their duty to act as stewards of the health
or education system and lobby for health system and HR strengthening.
The way forward?
We observe that there are many initiatives already underway, but no quick fit
solution for all. Initiatives do already exist as the German and the Bosnia
Herzegovina examples have shown, but their full potential can only be reached
when structural changes are made and these can only be instigated at the highest
political level. It is widely acknowledged that the health workforce is at the
heart of each and every health systems and central for improving health. In
order to tackle the human resource challenge, the supply of health workers needs
to be increased, and those in place need to be offered appropriate payment levels
comprising monetary and non-monetary incentives, access to well equipped and
functioning health infrastructures, acceptable working conditions and high quality
training opportunities to strengthen their professional skills. As long as not
even the basic health infrastructure exists and the rights of the individual
health worker are not respected, the exodus of health professionals can only
be expected to continue.
A strong national leadership and stewardship is of utmost important. A stable
political, regulatory and strategic framework needs to be put in place by national
authorities in order to lay the groundwork for ways out of the HR crisis. The
involvement of multiple national actors including ministries of health, labour,
trade and immigration is needed together with support from health professionals
and health training and regulatory institutions. An interlinkage to the policy
level and to other reform processes is a prerequisite.
For this most crucial of issues national leadership needs the exceptional support
of global solidarity – be this in regard to health system strengthening, capacity
building, scientific knowledge support and well-targeted funding. The Bosnia
Herzegovina example has shown a successful approach for capacity building where
various medical professionals were brought together, local involvement was emphasised
and a reward based system under supportive supervision was introduced. There
is a need to train beyond academic capacity and enhance the skills of leadership,
planning and management. The catalysation of knowledge e.g. through research
collaboration according to a research agenda set by the South, based in the
South and with the South requesting technical support from the North where it
sees a need, rather than the other way around would be another step forward.
Operations research that looks for simple solutions to locally identified problems
would pave the way for data generation for decision making and strategies that
work. A coordinated and harmonised response from the donor side is also vital
for setting up immediate and sustainable financing mechanisms for human resource
development. A considerable part of the investments need ultimately to be directed
towards structural change and to bear in mind that human resources lie at the
heart of every health system.
*This article is based on the presentations and discussions made at the
Spring Symposium “Human Resources for Health – Beyond the Declarations” on 21
March, 2007. It can be described as symposium review embedded in the current
HR context with a focus on HR and Global Health Initiatives, health system and
HR strengthening and capacity building. The views and ideas expressed herein
are those of the authors and do not necessarily imply or reflect the opinion
of the individual presenters.
Svenja Weiss is a public health specialist with focus on health systems
and human resources. She is involved in various consultancy and evaluation services
and studies in the field of public health at the STI. All authors work at the
Swiss Centre for International Health, a department of the Swiss Tropical Institute,
“Improving Health Systems Worldwide”. Contact: www.sti.ch,
Kaspar.Wyss@unibas.ch
Key Reference
Working together for Health - The World Health Report 2006. The World Health
Organisation, Geneva, Switzerland, www.who.int/whr/2006
