Barbara McPake

How to bridge the gap in human resources for health

Human resources are the crucial core of a health system, but they have been a neglected component of health-system development. The demands on health systems have escalated in low income countries, in the form of the Millennium Development Goals and new targets for more access to HIV/AIDS treatment. Human resources are in very short supply in health systems in low and middle income countries compared with high income countries or with the skill requirements of a minimum package of health interventions. Equally serious concerns exist about the quality and productivity of the health workforce in low income countries. Among available strategies to address the problems, expansion of the numbers of doctors and nurses through training is highly constrained. This is a difficult issue involving the interplay of multiple factors and forces.

What can be done about the private health sector in low-income countries?

A very large private health sector exists in low-income countries. It consists of a great variety of providers and is used by a wide cross-section of the population. There are substantial concerns about the quality of care given, especially at the more informal end of the range of providers. This is particularly true for diseases of public health importance such as tuberculosis, malaria, and sexually transmitted infections. How can the activities of the private sector in these countries be influenced so that they help to meet national health objectives? Although the evidence base is not good, there is a fair amount of information on the types of intervention that are most successful in directly influencing the behaviour of providers and on what might be the necessary conditions for success. There is much less evidence, however, of effective approaches to interventions on the demand side and policies that involve strengthening the purchasing and regulatory roles of governments.

To Retain or Remove User Fees?: Reflections on the Current Debate in Low- and Middle-Income Countries

Many low- and middle-income countries continue to search for better ways of financing their health systems. Common to many of these systems are problems of inadequate resource mobilisation, as well as inefficient and inequitable use of existing resources. The poor and other vulnerable groups who need healthcare the most are also the most affected by these shortcomings. In particular, these groups have a high reliance on user fees and other out-of-pocket expenditures on health which are both impoverishing and provide a financial barrier to care.It is within this context, and in light of recent policy initiatives on user fee removal, that a debate on the role of user fees in health financing systems has recently returned. This paper provides some reflections on the recent user fees debate, drawing from the evidence presented and subsequent discussions at a recent UNICEF consultation on user fees in the health sector, and relates the debate to the wider issue of access to adequate healthcare. It is argued that, from the wealth of evidence on user fees and other health system reforms, a broad consensus is emerging. First, user fees are an important barrier to accessing health services, especially for poor people. They also negatively impact on adherence to long-term expensive treatments. However, this is offset to some extent by potentially positive impacts on quality. Secondly, user fees are not the only barrier that the poor face. As well as other cost barriers, a number of quality, information and cultural barriers must also be overcome before the poor can access adequate health services. Thirdly, initial evidence on fee abolition in Uganda suggests that this policy has improved access to outpatient services for the poor. For this to be sustainable and effective in reaching the poor, fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost fee revenue (as was the case in Uganda). Fourthly, implementation matters: if fees are to be abolished, this needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official fees are not replaced by informal fees, and appropriate management of the alternative financing mechanisms that are replacing user fees. Fifthly, context is crucial. For instance, immediate fee removal in Cambodia would be inappropriate, given that fees replaced irregular and often high informal fees. In this context, equity funds and eventual expansion of health insurance are perhaps more viable policy options. Conversely, in countries where user fees have had significant adverse effects on access and generated only limited benefits, fee abolition is probably a more attractive policy option.Removing user fees has the potential to improve access to health services, especially for the poor, but it is not appropriate in all contexts. Analysis should move on from broad evaluations of user fees towards exploring how best to dismantle the multiple barriers to access in specific contexts.

How to do (or not to do) ... Designing a discrete choice experiment for application in a low-income country.

Understanding the preferences of patients and health professionals is useful for health policy and planning. Discrete choice experiments (DCEs) are a quantitative technique for eliciting preferences that can be used in the absence of revealed preference data. The method involves asking individuals to state their preference over hypothetical alternative scenarios, goods or services. Each alternative is described by several attributes and the responses are used to determine whether preferences are significantly influenced by the attributes and also their relative importance. DCEs are widely used in high-income contexts and are increasingly being applied in low- and middle-income countries to consider a range of policy concerns. This paper aims to provide an introduction to DCEs for policy-makers and researchers with little knowledge of the technique. We outline the stages involved in undertaking a DCE, with an emphasis on the design considerations applicable in a low-income setting.

Salaries and incomes of health workers in sub-Saharan Africa

Public-sector health workers are vital to the functioning of health systems. We aimed to investigate pay structures for health workers in the public sector in sub-Saharan Africa; the adequacy of incomes for health workers; the management of public-sector pay; and the fiscal and macroeconomic factors that impinge on pay policy for the public sector. Because salary differentials affect staff migration and retention, we also discuss pay in the private sector. We surveyed historical trends in the pay of civil servants in Africa over the past 40 years. We used some empirical data, but found that accurate and complete data were scarce. The available data suggested that pay structures vary across countries, and are often structured in complex ways. Health workers also commonly use other sources of income to supplement their formal pay. The pay and income of health workers varies widely, whether between countries, by comparison with cost of living, or between the public and private sectors. To optimise the distribution and mix of health workers, policy interventions to address their pay and incomes are needed. Fiscal constraints to increased salaries might need to be overcome in many countries, and non-financial incentives improved.

Task shifting in health care in resource-poor countries.

There is good evidence and compelling logic to support the principle of task shifting—ie, the allocation of tasks in health-system delivery to the least costly health worker capable of doing that task reliably. Luis Huicho and colleagues,1 in today’s Lancet, provide the most comprehensive study of this topic to date. They compared results across four countries and found that health workers with a shorter duration of training performed at least as well and sometimes substantially better than those with a longer duration of training in assessing, classifying, and managing episodes of routine childhood illness, and in counselling the children’s carers.

Public autonomous hospitals in sub-Saharan Africa: trends and issues

Since the late 1980s, many countries in Africa have been granting increased autonomy to their main teaching hospitals. This policy has significant international support but has been evaluated little from either theoretical or empirical perspectives. This paper attempts to fill this gap by assembling evidence from policy documents, theoretical debates and empirical evidence of related policy changes in other contexts such as the development of trust hospitals in the UK NHS. The paper attempts to locate the policy in the broader context of the package of health sector reform measures proposed at international level, and to identify the role it is intended to play in the achievement of the implicit objectives of that package. The objectives identified are improvements in allocative efficiency and equity, improvements in internal efficiency and improvements in responsiveness, accountability and choice. Each of these objectives presents difficulties which suggest that only modest short-term expectations of the policy can be justified. Given the lack of evidence from existing experience, a research agenda is suggested, which aims to provide information to guide further implementation of the policy.

Removing user fees: learning from international experience to support the process

Removing user fees could improve service coverage and access, in particular among the poorest socio-economic groups, but quick action without prior preparation could lead to unintended effects, including quality deterioration and excessive demands on health workers. This paper illustrates the process needed to make a realistic forecast of the possible resource implications of a well-implemented user fee removal programme and proposes six steps for a successful policy change: (1) analysis of a countrys initial position (including user fee level, effectiveness of exemption systems and impact of fee revenues at facility level); (2) estimation of the impact of user fee removal on service utilization; (3) estimation of the additional requirements for human resources, drugs and other inputs, and corresponding financial requirements; (4) mobilization of additional resources (both domestic and external) and development of locally-tailored strategies to compensate for the revenue gap and costs associated with increased utilization; (5) building political commitment for the policy reform; (6) communicating the policy change to all stakeholders. The authors conclude that countries that intend to remove user fees can maximize benefits and avoid potential pitfalls through the utilization of the approach and tools described.

Private practitioners in the slums of Karachi : what quality of care do they offer?

Private health services have expanded in many developing countries over the last 10 yr. Qualified private practitioners provide basic health care for poorer groups in urban areas, although health care planners frequently criticize them for providing poor quality of care, charging high fees and failing to provide preventive health advice. In Karachi, a large city with more than 400 slums, private practitioners are important providers of care to the poor. This study assessed the nature and quality of care provided by 201 practitioners selected from four districts of the city. Vignettes of specific medical problems were used to assess their knowledge and their practice was measured by observing 658 doctor-patient contacts. The results show that knowledge was closer to accepted medical management than was their actual prescribing practice. On the other hand, their manners and interpersonal behaviour were good. Thus poor prescribing practice, which might equally stem from market influences as lack of knowledge, is the cause of low standards of care. In these circumstances, didactic in-service training to improve prescribing practice is unlikely to be successful.

Improving Maternal Health: Getting What Works To Happen

Maternal mortality reduction in many countries is unlikely despite the availability of inexpensive, efficacious interventions that are part of official policy. This article explores the reasons why, based on research on maternity services in Bangladesh, Russia, South Africa and Uganda. A simple dynamic responses model shows that the key to understanding challenges in implementation lies in the reflexive, complex and dynamic responses of health workers and community members to policies and programmes. These responses are “dynamic” in that they arise due to forces from within and outside the system, and in turn exert forces of their own. They result in the difference between the health system that is envisaged in policy, and what is implemented by health workers and experienced by users. Programmes aiming to improve maternal health are not only technical but also social interventions that need to be evaluated as such, using methodologies that have been developed for evaluating complex social interventions whose aim is to bring about change. The components of effective programmes have been defined globally. However, in getting what works to happen, context matters. Thus, technical advisors need to give “advice” more circumspectly, local programme managers must be capacitated to make programme-improving adjustments continuously, and the detail related to process, not just outcomes, must be documented in evaluations. Résumé Une réduction du taux de mortalité maternelle est improbable dans beaucoup de pays, malgré la disponibilité d’interventions efficaces et peu coûteuses incluses dans la politique officielle. Cet article cherche à comprendre pourquoi, avec des recherches en Afrique du Sud, au Bangladesh, en Fédération de Russie et en Ouganda. Un modèle simple de réponses dynamiques montre que pour comprendre les problèmes de mise en oeuvre, il faut étudier les réponses dynamiques, complexes et réfléchies des agents de santé et des membres de la communauté aux politiques et programmes. Ces réponses sont « dynamiques » en cela qu’elles sont créées par des forces à l’intérieur et à l’extérieur du système, et qu’elles exercent à leur tour une force. Leur résultat est la différence entre le système de santé envisagé dans la politique et celui qui est appliqué par les agents de santé et que connaissent les usagers. Les programmes d’amélioration de la santé maternelle sont des interventions techniques, mais aussi sociales qui doivent être évaluées comme telles, avec des méthodologies élaborées pour jauger des interventions sociales complexes destinées à déclencher un changement. Les composantes de programmes opérants ont été définies au niveau international. Néanmoins, le contexte est important pour appliquer des mesures efficaces. Les conseillers techniques doivent donc « conseiller » avec plus de circonspection, il faut que les directeurs de programmes locaux soient capables d’ajuster constamment les programmes pour les améliorer et que les évaluations informent des détails liés au processus, et non pas seulement des résultats. Resumen En muchos países, resulta improbable disminuir la tasa de mortalidad materna, pese a la disponibilidad de intervenciones eficaces y poco costosas que son parte de la política oficial. En este artículo se explora el porqué, a raíz de investigaciones sobre los servicios de maternidad en Bangladesh, Rusia, Sudáfrica y Uganda. Un simple modelo de respuestas dinámicas muestra que la clave para entender los retos de la implementación radica en las respuestas reflexivas, complejas y dinámicas de los trabajadores de la salud y miembros de la comunidad a las políticas y los programas. Estas respuestas son “dinámicas” en el sentido de que emergen debido a fuerzas dentro y fuera del sistema, y, a su vez emplean sus propias fuerzas. Tienen como resultado la diferencia entre el sistema de salud que es concebido en la política, y lo que es puesto en práctica por los trabajadores de la salud y experimentado por las usuarias. Los programas que procuran mejorar la salud materna no son sólo técnicos sino también intervenciones sociales que deben ser evaluadas como tal, utilizando metodologías que fueron creadas para evaluar intervenciones sociales complejas cuyo objetivo es promover cambios. Los elementos de los programas eficaces fueron definidos mundialmente. Sin embargo, para lograr que suceda lo que funciona, importa el contexto. Por tanto, los asesores técnicos deben dar “consejos” con más cautela, los administradores de programas locales deben recibir capacitación para realizar ajustes que mejoren los programas continuamente, y el detalle relacionado con el proceso, y no sólo los resultados, debe documentarse en las evaluaciones.