PHM-Exch> HIFA2015: Priorities in Human Resources for Health - Background information

[Neil Pakenham-Walsh, UK]

HIFA2015: Priorities in Human Resources for Health - Background information
Global conversation starts Monday 9th September, 
through September and October, sponsored by the 
Global Health Workforce Alliance

Join here: www.hifa2015.org

The text below is intended to provide a brief 
introduction to some of the issues in Human 
Resources for Health. Please keep it as a 
reference for the discussions over the coming 
weeks. It is based on a GHWA fact sheet, 
available here: http://www.who.int/workforcealliance/media/KeyMessages_3GF.pdf

THE GLOBAL HEALTH WORKFORCE IS IN CRISIS. 
Billions of people are denied access to safe, 
effective healthcare as a result of workforce 
shortages and lack of support to teh existing 
workforce. Here are just a few of the consequences:
- 48 million women give birth each year without a skilled health worker present
- 6.9 million children under 5 die from treatable 
& preventable diseases every year
- Ninety percent of all maternal deaths and 80 
percent of stillbirths happen in just 58 
countries. These countries have only 17 percent 
of the worlds midwives and physicians.

Below are some of the cross-cutting issues of the 
Global Health Workforce Crisis. All of these 
issues need to be addressed to realise 
progressively the GHWA vision: Every person 
everywhere will have access to an informed, 
supported and motivated health worker. For 
further reading, please use the links below, or 
browse the GHWA Knowledge Centre, a collection of 
resources on HRH issues, organised by theme: 
http://www.who.int/workforcealliance/knowledge/en/

HIFA members and others are invited to share 
their experience and expertise on any of the 
issues below, or indeed any other issue that you 
perceive to be important. Let us know what you 
think have been the Human Resources for Health 
achievements of the past 10 years, globally and 
in individual countries. Such achievements may be 
in any domain: research, policy, and/or 
implementation. What have been the failures or 
disappointments of the past 10 years? Are we 
making progress or are we falling behind? What 
can be done to improve the situation, globally or 
in individual countries, over the next 10 years. 
Please send your messages to: hifa2015 at dgroups.org

1. URGENT ACTION IS NEEDED: Global commitments to 
the health-related Millennium Development Goals 
and efforts to increase access, coverage and 
equity of health services will not be met unless 
action is taken now to increase human resources 
capacity in health services. Addressing shortages 
and inequitable distribution so that the right 
health personnel will be in the right place at 
the right time must be made a global health priority.

Further reading:
Human resources for health: critical for 
effective universal health coverage. (GHWA, 2013)
http://www.who.int/workforcealliance/knowledge/resources/hrhforuhcpost2015/en/index.html

2. THIS MUST BE RECOGNISED UNIVERSALLY AS A 
GLOBAL CRISIS: More than a quarter of the worlds 
countries do not have enough health workers. The 
world needs 4 million new health workers to 
address global workforce shortages. The urgency 
to address the health worker crisis is a 
challenge for all high-, middle- and low-income 
countries alike. Health worker shortages affect 
Germany and the USA, just like they affect India 
or Uganda. Western countries import workers from 
developing countries, because they are also short 
of trained health workers. Aging populations are exacerbating the problem.

3. IMPROVE URBAN/RURAL DISPARITY: The acute 
shortages and inequitable distribution of health 
workers within countries are also major barriers 
to increasing coverage of health interventions to 
those most in need. Fifty percent of the worlds 
population lives in rural areas, but 75 percent 
of doctors and 62 percent of nurses serve urban 
populations. For instance, the capital city of 
Cameroon, Yaounde has 4.5 times more health 
workers than the poorest province in the 
country.1 Approximately 80 percent of the 
Malawian population lives in rural areas, yet 
only 30 percent of the countrys health staff work there.

Further reading: How to Recruit and Retain Health 
Workers in Rural and Remote Areas in Developing 
Countries (World Bank Guidance note, Health, 
Nutrition and Population Discussion Paper)
http://www.who.int/workforcealliance/knowledge/resources/wb_retentionguidancenote/en/index.html

4. MANAGE MIGRATION: Developing countries lose 
some of their most valuable health workers to 
richer countries. For example, 75 percent of 
doctors trained in Mozambique now work abroad. 
The majority work in Portugal (1,218) and the 
rest work in South Africa (61), US (20) and UK 
(16).2 When significant numbers of doctors and 
nurses leave, the countries that financed their 
education lose a return on their investment. 
Geographical and financial barriers that prevent 
people from accessing a health worker when they need care must be removed.

Further reading: WHO Global Code of Practice on 
the International Recruitment of Health Personnel (2010)
http://www.who.int/hrh/migration/code/full_text/en/

5. IMPROVE RETENTION: Effective management of 
trained health workforce is fundamental. To 
expand coverage of essential interventions to 
those who need them the most, health workers must 
be incentivized with improved working conditions 
(adequate equipment, facilities, supervision, 
opportunities for advancement and fair 
remuneration) to retain them to serve in their 
home countries/regions or undeserved areas. In 
Zambia, health workers receive an extra 25% 
recruitment and retention allowance to their 
basic monthly salary; those that serve in rural 
areas receive an additional 25% rural and remote 
hardship allowance. These policies have been 
effective in decreasing the migration of nurses.

Further reading: Rapid Retention Survey Toolkit: 
Designing Evidence-Based Incentives for Health Workers
Health worker retention toolkit (Dec 2012, PDF 
3Mb): 
http://www.who.int/workforcealliance/knowledge/resources/retentiontoolkit/en/index.html

6. USE A HOLISTIC APPROACH: Countries must 
develop innovative solutions for strengthening 
their health systems, based on priority health 
needs and concrete strategies for achieving 
better health outcomes. Adopting a holistic 
approach to the crisis, recognizing the 
inter-dependence and the inter-connectedness of 
the different areas of health workforce 
development is critical. Stand-alone 
interventions will not be effective, nor 
sustainable. Strengthening health systems means 
not just making changes within individual or 
vertical disease-specific programs but extending 
that change across the system. For instance, when 
an investment is made in training new health 
workers, parallel efforts must be made to ensure 
that adequate resources, management systems and 
incentives are put in place so to ensure that the 
new graduates can find employment in the health sector.

Further reading: Third Global Forum: new template 
for eliciting HRH commitments (2013).
http://www.who.int/workforcealliance/en/

7. SCALE-UP TRAINING: Countries must work to 
increase the quantity of health workers while 
maximizing the potential of existing health 
workers, including community health workers who 
play an important role in reaching remote and 
excluded populations. Government-wide support is 
critical in order to strengthen health workforce 
policy, planning, financing, management, 
monitoring and reporting. Through the Ministrys 
implementation of the Emergency Human Resource 
Plan (EHRP 2004-2010), Malawi extended the health 
workforce by 53%, from 5,453 in 2004 to 8,369 in 
2009 across 11 priority cadres.

Education and training of health workers is an 
immediate priority, bearing in mind that training 
a doctor, for example, requires 5-8 years, so the 
effects of actions taken today will not be felt 
instantly. The health workforce must be 
responsive and respectful to the populations they 
serve, taking into account socio-cultural needs. 
This means educating the health workforce, 
ensuring an appropriate gender balance and skills 
mix and having oversight, supervision and 
regulatory mechanisms. Building capacity to 
enable countries to retain and absorb newly 
trained health professionals is also crucial.

Further reading: Scaling Up, Saving Lives (2008)
http://www.who.int/workforcealliance/knowledge/themes/training/en/index.html

8. INTRODUCE TASK SHARING where appropriate. 
While initially driven by the urgency of 
conquering the HIV/AIDS epidemic, task sharing 
holds the potential of enabling countries to 
build sustainable, cost-effective and equitable 
health care systems, thus moving closer not only 
to the MDGs, but also the Universal Health 
Coverage goal. It is safe and effective for 
health workers in communities to carry out a 
variety of healthcare tasks if they receive 
training which emphasis a team based approach to 
the delivery of care, supported by the necessary 
regulatory frameworks that authorize them to 
operate within the full scope of their profession.

Further reading: WHO Recommendations – Optimizing 
health worker roles for maternal and newborn health
http://www.optimizemnh.org/

9. FOSTER LEADERSHIP: An effective response to 
the health workforce challenges entails 
collaboration among multiple sectors of 
Governments (including health, education, 
finance, labour, science and research), and 
multiple constituencies including also the 
private sector, professional associations, 
international organizations, development 
partners, foundations and civil society.

Further reading: Governance and human resources 
for health (Article in Human Resources for Health journal, 2011)
http://www.who.int/workforcealliance/knowledge/resources/hrhgovernance/en/index.html

10. INCREASE FINANCING: Funding must be long-term 
and sustainable if it is to contribute in a 
sustainable and effective manner to strengthening 
national health systems. Financing is not just 
about raising funds, but also about how the funds 
are used to increase efficiency, effectiveness, 
and equity ("making the money work"). Every 
country with critical shortage of health workers 
should develop and implement a budgeted, national 
health workforce strengthening plan, integrated 
in the national health strategy. This plan should 
include a special focus on covering the poor and 
most excluded segments of society, and strategies 
to train and retain skilled health workers as 
well as maximize health worker productivity and 
performance. Development partners should maintain 
and increase health resources and technical 
support to respond to countries demand, while 
national governments should strive to sustain and 
increase domestic health spending and use 
resources effectively to move towards UHC.

Further reading: "More money for HRH: more HRH 
for the money" (Global Health Workforce Alliance, 
TOPIC BRIEF: Financing Human Resources, 2012)
http://www.who.int/workforcealliance/knowledge/resources/hrhfinancingbrief2012/en/index.html

11. WORK TOGETHER. Partnership is critical to 
success. Cross-government support and 
partnerships must ensure that health workers have 
the necessary skills, competencies and incentives 
to provide an effective service. There should be 
mechanisms to measure, reward and sustain 
high-quality service provision. Within 
governments, responses to this cross-sectoral 
problem should involve national Ministries of 
Health, Labour, Education, Public Service and 
Finance .The only way forward is to work 
together--North and South, East and West, rich 
and poor. Everyone has a part to play in the solution to this crisis.

Further reading: Third Global Forum: new template 
for eliciting HRH commitments (2013).
http://www.who.int/workforcealliance/en/

With thanks,

HIFA profile: Neil Pakenham-Walsh is the 
coordinator of the HIFA2015 campaign and 
co-director of the Global Healthcare Information 
Network. He is also currently chair of the 
Dgroups Foundation (www.dgroups.info), a 
partnership of 18 international development 
organisations promoting dialogue for 
international health and development. He started 
his career as a hospital doctor in the UK, and 
has clinical experience as an isolated health 
worker in rural Ecuador and Peru.  For the last 
20 years he has been committed to the global 
challenge of improving the availability and use 
of relevant, reliable healthcare information for 
health workers and citizens in low- and 
middle-income countries. He is particularly 
interested in the potential of inclusive, 
interdisciplinary communication platforms to help 
address global health and international 
development challenges. He has worked with the 
World Health Organization, the Wellcome Trust, 
Medicine Digest and INASP (International Network 
for the Availability of Scientific Publications). 
He is based near Oxford, UK. 
www.hifa2015.org  neil.pakenham-walsh AT ghi-net.org