Gilles Dussault

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.

Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce

Access to good-quality health services is crucial for the improvement of many health outcomes, such as those targeted by the Millennium Development Goals (MDGs) adopted by the international community in 2000. The health-related MDGs cannot be achieved if vulnerable populations do not have access to skilled personnel and to other necessary inputs. This paper focuses on the geographical dimension of access and on one of its critical determinants: the availability of qualified personnel. The objective of this paper is to offer a better understanding of the determinants of geographical imbalances in the distribution of health personnel, and to identify and assess the strategies developed to correct them. It reviews the recent literature on determinants, barriers and the effects of strategies that attempted to correct geographical imbalances, with a focus on empirical studies from developing and developed countries. An analysis of determinants of success and failures of strategies implemented, and a summary of lessons learnt, is included.

Human resources for health policies: a critical component in health policies.

In the last few years, increasing attention has been paid to the development of health policies. But side by side with the presumed benefits of policy, many analysts share the opinion that a major drawback of health policies is their failure to make room for issues of human resources. Current approaches in human resources suggest a number of weaknesses: a reactive, ad hoc attitude towards problems of human resources; dispersal of accountability within human resources management (HRM); a limited notion of personnel administration that fails to encompass all aspects of HRM; and finally the short-term perspective of HRM.There are three broad arguments for modernizing the ways in which human resources for health are managed:• the central role of the workforce in the health sector;• the various challenges thrown up by health system reforms;• the need to anticipate the effect on the health workforce (and consequently on service provision) arising from various macroscopic social trends impinging on health systems.The absence of appropriate human resources policies is responsible, in many countries, for a chronic imbalance with multifaceted effects on the health workforce: quantitative mismatch, qualitative disparity, unequal distribution and a lack of coordination between HRM actions and health policy needs.Four proposals have been put forward to modernize how the policy process is conducted in the development of human resources for health (HRH):• to move beyond the traditional approach of personnel administration to a more global concept of HRM;• to give more weight to the integrated, interdependent and systemic nature of the different components of HRM when preparing and implementing policy;• to foster a more proactive attitude among human resources (HR) policy-makers and managers;• to promote the full commitment of all professionals and sectors in all phases of the process.The development of explicit human resources policies is a crucial link in health policies and is needed both to address the imbalances of the health workforce and to foster implementation of the health services reforms.

Responding to the global human resources crisis.

The global community is in the midst of a growing response to health crises in developing countries, which is focused on mobilising financial resources and increasing access to essential medicines. However, the response has yet to tackle the most important aspect of health-care systems--the people that make them work. Human resources for health--the personnel that deliver public-health, clinical, and environmental services--are in disarray and decline in much of the developing world, particularly in sub-Saharan Africa. The reasons behind this disorder are complex. For decades, efforts have focused on building training institutions. What is becoming increasingly clear, however, is that issues of supply, demand, and mobility (transnational, regional, and local) are central to the human-resource problem. Without substantial improvements in workforces, newly mobilised funds and commodities will not deliver on their promise. The global community needs to engage in four core strategies: raise the profile of the issue of human resources; improve the conceptual base and statistical evidence available to decision makers; collect, share, and learn from country experiences; and begin to formulate and enact policies at the country level that affect all aspects of the crisis.

Human resources for health and universal health coverage: fostering equity and effective coverage

Achieving universal health coverage (UHC) involves distributing resources, especially human resources for health (HRH), to match population needs. This paper explores the policy lessons on HRH from four countries that have achieved sustained improvements in UHC: Brazil, Ghana, Mexico and Thailand. Its purpose is to inform global policy and financial commitments on HRH in support of UHC. The paper reports on country experiences using an analytical framework that examines effective coverage in relation to the availability, accessibility, acceptability and quality (AAAQ) of HRH. The AAAQ dimensions make it possible to perform tracing analysis on HRH policy actions since 1990 in the four countries of interest in relation to national trends in workforce numbers and population mortality rates. The findings inform key principles for evidence-based decision-making on HRH in support of UHC. First, HRH are critical to the expansion of health service coverage and the package of benefits; second, HRH strategies in each of the AAAQ dimensions collectively support achievements in effective coverage; and third, success is achieved through partnerships involving health and non-health actors. Facing the unprecedented health and development challenges that affect all countries and transforming HRH evidence into policy and practice must be at the heart of UHC and the post-2015 development agenda. It is a political imperative requiring national commitment and leadership to maximize the impact of available financial and human resources, and improve healthy life expectancy, with the recognition that improvements in health care are enabled by a health workforce that is fit for purpose.

Nursing Workforce Policy and the Economic Crisis: A Global Overview

PURPOSE To assess the impact of the global financial crisis on the nursing workforce and identify appropriate policy responses. ORGANIZING CONSTRUCT AND METHODS This article draws from international data sources (Organisation for Economic Co-operation and Development [OECD] and World Health Organization), from national data sources (nursing regulatory authorities), and the literature to provide a context in which to examine trends in labor market and health spending indicators, nurse employment, and nurse migration patterns. FINDINGS A variable impact of the crisis at the country level was shown by different changes in unemployment rates and funding of the health sector. Some evidence was obtained of reductions in nurse staffing in a small number of countries. A significant and variable change in the patterns of nurse migration also was observed. CONCLUSIONS The crisis has had a variable impact; nursing shortages are likely to reappear in some OECD countries. Policy responses will have to take account of the changed economic reality in many countries. CLINICAL RELEVANCE This article highlights key trends and issues for the global nursing workforce; it then identifies policy interventions appropriate to the new economic realities in many OECD countries.Purpose To assess the impact of the global financial crisis on the nursing workforce and identify appropriate policy responses. Organizing Construct and Methods This article draws from international data sources (Organisation for Economic Co-operation and Development [OECD] and World Health Organization), from national data sources (nursing regulatory authorities), and the literature to provide a context in which to examine trends in labor market and health spending indicators, nurse employment, and nurse migration patterns. Findings A variable impact of the crisis at the country level was shown by different changes in unemployment rates and funding of the health sector. Some evidence was obtained of reductions in nurse staffing in a small number of countries. A significant and variable change in the patterns of nurse migration also was observed. Conclusions The crisis has had a variable impact; nursing shortages are likely to reappear in some OECD countries. Policy responses will have to take account of the changed economic reality in many countries. Clinical Relevance This article highlights key trends and issues for the global nursing workforce; it then identifies policy interventions appropriate to the new economic realities in many OECD countries.

Increasing access to health workers in underserved areas: a conceptual framework for measuring results.

Many countries have developed strategies to attract and retain qualified health workers in underserved areas, but there is only scarce and weak evidence on their successes or failures. It is difficult to compare lessons and measure results from the few evaluations that are available. Evaluation faces several challenges, including the heterogeneity of the terminology, the complexity of the interventions, the difficulty of assessing the influence of contextual factors, the lack of baseline information, and the need for multi-method and multi-disciplinary approaches for monitoring and evaluation. Moreover, the social, political and economic context in which interventions are designed and implemented is rarely considered in monitoring and evaluating interventions for human resources for health. This paper proposes a conceptual framework that offers a model for monitoring and evaluation of retention interventions taking into account such challenges. The conceptual framework is based on a systems approach and aims to guide the thinking in evaluating an intervention to increase access to health workers in underserved areas, from its design phase through to its results. It also aims to guide the monitoring of interventions through the routine collection of a set of indicators, applicable to the specific context. It suggests that a comprehensive approach needs to be used for the design, implementation, monitoring, evaluation and review of the interventions. The framework is not intended to be prescriptive and can be applied flexibly to each country context. It promotes the use of a common understanding on how attraction and retention interventions work, using a systems perspective.

Policies to sustain the nursing workforce: an international perspective

AIM Examine metrics and policies regarding nurse workforce across four countries. BACKGROUND International comparisons inform health policy makers. METHODS Data from the OECD were used to compare expenditure, workforce and health in: Australia, Portugal, the United Kingdom (UK) and the United States (US). Workforce policy context was explored. RESULTS Public spending varied from less than 50% of gross domestic product in the US to over 80% in the UK. Australia had the highest life expectancy. Portugal has fewer nurses and more physicians. The Australian national health workforce planning agency has increased the scope for co-ordinated policy intervention. Portugal risks losing nurses through migration. In the UK, the economic crisis resulted in frozen pay, reduced employment, and reduced student nurses. In the US, there has been limited scope to develop a significant national nursing workforce policy approach, with a continuation of State based regulation adding to the complexity of the policy landscape. The US is the most developed in the use of nurses in advanced practice roles. Ageing of the workforce is likely to drive projected shortages in all countries. LIMITATIONS There are differences as well as variation in the overall impact of the global financial crisis in these countries. CONCLUSION Future supply of nurses in all four countries is vulnerable. IMPLICATIONS FOR NURSING AND HEALTH POLICY Work force planning is absent or restricted in three of the countries. Scope for improved productivity through use of advanced nurse roles exists in all countries.

Recruitment and retention of health professionals across Europe: A literature review and multiple case study research

Many European countries are faced with health workforce shortages and the need to develop effective recruitment and retention (R&R) strategies. Yet comparative studies on R&R in Europe are scarce. This paper provides an overview of the measures in place to improve the R&R of health professionals across Europe and offers further insight into the evidence base for R&R; the interaction between policy and organisational levels in driving R&R outcomes; the facilitators and barriers throughout these process; and good practices in the R&R of health professionals across Europe. The study adopted a multi-method approach combining an extensive literature review and multiple-case study research. 64 publications were included in the review and 34 R&R interventions from 20 European countries were included in the multiple-case study. We found a consistent lack of evidence about the effectiveness of R&R interventions. Most interventions are not explicitly part of a coherent package of measures but they tend to involve multiple actors from policy and organisational levels, sometimes in complex configurations. A list of good practices for R&R interventions was identified, including context-sensitivity when implementing and transferring interventions to different organisations and countries. While single R&R interventions on their own have little impact, bundles of interventions are more effective. Interventions backed by political and executive commitment benefit from a strong support base and involvement of relevant stakeholders.

Medical theories and professional development: The theory of focal sepsis and dentistry in early twentieth century Britain

This paper traces the history of the theory of focal infection--which related a number of general conditions to septic foci from which toxic products spread to different parts of the body--and its application to dental diseases in early 20th century Britain. Bad teeth were said to be one of the major sources of infection and a cause of many diseases. The paper focuses on the social and professional context in which the theory emerged and flourished. It shows that in spite of its lack of scientific foundation, the theory of focal sepsis was readily accepted by the dental profession and used to advance its claims for professional recognition. Thus the paper attempts to illustrate the point that the acceptance of a medical theory by health practitioners is as much determined by social and economic factors as by its therapeutic potential or its scientific validity.