Barbara Stilwell

Human resources for health: overcoming the crisis

In this analysis of the global workforce, the Joint Learning Initiative-a consortium of more than 100 health leaders-proposes that mobilisation and strengthening of human resources for health, neglected yet critical, is central to combating health crises in some of the worlds poorest countries and for building sustainable health systems in all countries. Nearly all countries are challenged by worker shortage, skill mix imbalance, maldistribution, negative work environment, and weak knowledge base. Especially in the poorest countries, the workforce is under assault by HIV/AIDS, out-migration, and inadequate investment. Effective country strategies should be backed by international reinforcement. Ultimately, the crisis in human resources is a shared problem requiring shared responsibility for cooperative action. Alliances for action are recommended to strengthen the performance of all existing actors while expanding space and energy for fresh actors.

Migration of health-care workers from developing countries: strategic approaches to its management

Of the 175 million people (2.9% of the worlds population) living outside their country of birth in 2000, 65 million were economically active. The rise in the number of people migrating is significant for many developing countries because they are losing their better-educated nationals to richer countries. Medical practitioners and nurses represent a small proportion of the highly skilled workers who migrate, but the loss for developing countries of human resources in the health sector may mean that the capacity of the health system to deliver health care equitably is significantly compromised. It is unlikely that migration will stop given the advances in global communications and the development of global labour markets in some fields, which now include nursing. The aim of this paper is to examine some key issues related to the international migration of health workers and to discuss strategic approaches to managing migration.

Imbalance in the health workforce

Imbalance in the health workforce is a major concern in both developed and developing countries. It is a complex issue that encompasses a wide range of possible situations. This paper aims to contribute not only to a better understanding of the issues related to imbalance through a critical review of its definition and nature, but also to the development of an analytical framework. The framework emphasizes the number and types of factors affecting health workforce imbalances, and facilitates the development of policy tools and their assessment. Moreover, to facilitate comparisons between health workforce imbalances, a typology of imbalances is proposed that differentiates between profession/specialty imbalances, geographical imbalances, institutional and services imbalances and gender imbalances.

Developing evidence-based ethical policies on the migration of health workers: conceptual and practical challenges

It is estimated that in 2000 almost 175 million people, or 2.9% of the worlds population, were living outside their country of birth, compared to 100 million, or 1.8% of the total population, in 1995. As the global labour market strengthens, it is increasingly highly skilled professionals who are migrating. Medical practitioners and nurses represent a small proportion of highly skilled workers who migrate, but the loss of health human resources for developing countries can mean that the capacity of the health system to deliver health care equitably is compromised. However, data to support claims on both the extent and the impact of migration in developing countries is patchy and often anecdotal, based on limited databases with highly inconsistent categories of education and skills.The aim of this paper is to examine some key issues related to the international migration of health workers in order to better understand its impact and to find entry points to developing policy options with which migration can be managed.The paper is divided into six sections. In the first, the different types of migration are reviewed. Some global trends are depicted in the second section. Scarcity of data on health worker migration is one major challenge and this is addressed in section three, which reviews and discusses different data sources. The consequences of health worker migration and the financial flows associated with it are presented in section four and five, respectively. To illustrate the main issues addressed in the previous sections, a case study based mainly on the United Kingdom is presented in section six. This section includes a discussion on policies and ends by addressing the policy options from a broader perspective.

Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections

OBJECTIVE To draw up evidence-based guidelines to make injections safer. METHODS A development group summarized evidence-based best practices for preventing injection-associated infections in resource-limited settings. The development process included a breakdown of the WHO reference definition of a safe injection into a list of potentially critical steps, a review of the literature for each of these steps, the formulation of best practices, and the submission of the draft document to peer review. FINDINGS Eliminating unnecessary injections is the highest priority in preventing injection-associated infections. However, when intradermal, subcutaneous, or intramuscular injections are medically indicated, best infection control practices include the use of sterile injection equipment, the prevention of contamination of injection equipment and medication, the prevention of needle-stick injuries to the provider, and the prevention of access to used needles. CONCLUSION The availability of best infection control practices for intradermal, subcutaneous, and intramuscular injections will provide a reference for global efforts to achieve the goal of safe and appropriate use of injections. WHO will revise the best practices five years after initial development, i.e. in 2005.

Health professionals and migration

Migrant health workers are faced with a set of options that are a combination of economic, social and psychological factors and family choices (1). They trade decisions related to their career oppor-tunities — and to financial security for their families — against the psychological and social costs of leaving their country, family and friends. The comments of health workers themselves reflect the “push and pull” nature of the choices underpinning these “journeys of hope” as, for example, those collected in Ghana by Dovlo (2). Demotivating working conditions, coupled with low salaries, are set against the likelihood of prosperity for themselves and their families (by remit-tances), work in well-equipped hospitals, and the opportunity for professional development. In this issue of the Bulletin, Saravia & Miranda (pp. 608–615) point out that young, well-educated individuals are most likely to migrate, especially in pursuit of higher education.Employers in the countries of origin have their own perspective. They are unable to fulfil their mandates to provide equitable access to health care because the necessary health workers are not available. In many cases, the country is losing its investment in the education of health professionals, as well as losing the contribution of these workers to health care. Governments have to compete for health workers by making their condi-tions of work more attractive; they may also highlight the imbalance in com-petition between themselves and the receiving employers. Arguments from this perspective will inevitably include ethical and moral dimensions.Employers in receiving countries take a different position, driven by their need to provide sufficient health workers to meet the demand for services within the constraints of budget planning and the imperfections of the labour market. Kupfer et al. (pp. 616–619) discuss

Non-physician clinicians in sub-Saharan Africa

1578 www.thelancet.com Vol 371 May 10, 2008 to 11·5% in 2008. Schatz mentions the rural retention scheme, but what about the car loan scheme for doctors, regionally competi tive remunerations for staff, reten tion of lecturers in the school of medicine through WHO supplementation, infra structure re habilitation, improvement of diag nostic facilities through the ORET project (a joint programme of the Ministry of Health and Philips to revamp imaging equipment in hospitals in Zambia), the opening of the radiotherapy centre, two new centres of excellence in infection disease, and so on. The results have been a reversal in the brain drain and an increased retention of health professionals. This has all happened despite a freeze on employment in the public sector imposed until the comple tion points under the Heavily Indebted Poor Countries initiative were met in 2005, limitations imposed by multilateral partners to keep public-sector personal emoluments within 8% of GDP, and unwillingness by countries to which doctors migrate to com pensate the source coun try.

International health organisations and recruitment of health workers.

A telling phrase in David Southall and colleagues’ Comment is: “By off ering better salaries and working con ditions... international organis ations prevent government-trained doctors and nurses from contributing to their NHS.” International organisations are not preventing health workers from being employed in public systems, but are providing what public health systems often neglect—good working con ditions, on-time salaries, and recognition. From research on retention, we know that fi nancial and non-fi nancial factors aff ect health workers’ choices about where they work and whether they stay. In countries with weak health systems, non-state sectors might provide the bulk of health services. We cannot assume, therefore, that health workers employed by non-state sectors do not contribute to public health. Government health workers frustrated by poor working conditions might transfer to employers that provide salaries, equipment, and facilities, enabling them to perform well. Would they otherwise migrate externally and be lost as a resource to their countries? The objective of WHO’s guidelines is to promote retention in underserved areas (especially remote and rural areas) to meet community needs, not retention in government facilities. Private organisations might be better at retention and support than governments. If the goal of quality health care is met, working in nongovernment settings should not be problematic. We need more health workers everywhere. We need to make health workers’ jobs attractive and give them the right to choose where they sell their skills. To avoid critical shortages, we should ramp up recruitment and retention, not remove choice.