Marko Vujicic

Health workforce skill mix and task shifting in low income countries: a review of recent evidence.

BackgroundHealth workforce needs-based shortages and skill mix imbalances are significant health workforce challenges. Task shifting, defined as delegating tasks to existing or new cadres with either less training or narrowly tailored training, is a potential strategy to address these challenges. This study uses an economics perspective to review the skill mix literature to determine its strength of the evidence, identify gaps in the evidence, and to propose a research agenda.MethodsStudies primarily from low-income countries published between 2006 and September 2010 were found using Google Scholar and PubMed. Keywords included terms such as skill mix, task shifting, assistant medical officer, assistant clinical officer, assistant nurse, assistant pharmacist, and community health worker. Thirty-one studies were selected to analyze, based on the strength of evidence.ResultsFirst, the studies provide substantial evidence that task shifting is an important policy option to help alleviate workforce shortages and skill mix imbalances. For example, in Mozambique, surgically trained assistant medical officers, who were the key providers in district hospitals, produced similar patient outcomes at a significantly lower cost as compared to physician obstetricians and gynaecologists. Second, although task shifting is promising, it can present its own challenges. For example, a study analyzing task shifting in HIV/AIDS in sub-Saharan Africa noted quality and safety concerns, professional and institutional resistance, and the need to sustain motivation and performance. Third, most task shifting studies compare the results of the new cadre with the traditional cadre. Studies also need to compare the new cadres results to the results from the care that would have been provided--if any care at all--had task shifting not occurred.ConclusionsTask shifting is a promising policy option to increase the productive efficiency of the delivery of health care services, increasing the number of services provided at a given quality and cost. Future studies should examine the development of new professional cadres that evolve with technology and country-specific labour markets. To strengthen the evidence, skill mix changes need to be evaluated with a rigorous research design to estimate the effect on patient health outcomes, quality of care, and costs.

Working in Health : Financing and Managing the Public Sector Health Workforce

The health workforce plays a key role in increasing access to health services for the poor in developing countries. Recent evidence has demonstrated an important link between staffing levels and both service delivery and health outcomes. Various global and country-level estimates have also shown that current staffing levels in developing countries, particularly in Sub-Saharan Africa, are often well below those required to deliver essential health services. This study focuses on two main aspects of health workforce policy. First, it examines how overall government wage bill policies affect the size of the health wage bill, the hiring of health workers in the public sector, and the related policy options. This focus is important because despite the importance of fiscal constraints on the wage bill, and the persistent debate at the global level, very little documented evidence describes how health wage bill budgets in the public sector are determined, how this action is linked to overall wage bill policies, and how it affects the ability of governments to increase staffing levels in the health sector. Second, this report looks at how well health wage bill resources are used in the public sector.

A decade in dental care utilization among adults and children (2001-2010).

OBJECTIVE To decompose the change in pediatric and adult dental care utilization over the last decade. DATA 2001 through 2010 Medical Expenditure Panel Survey. STUDY DESIGN The Blinder-Oaxaca decomposition was used to explain the change in dental care utilization among adults and children. Changes in dental care utilization were attributed to changes in explained covariates and changes due to movements in estimated coefficients. Controlling for demographics, overall health status, and dental benefits variables, we estimated year-specific logistic regression models. Outputs from these models were used to compute the Blinder-Oaxaca decomposition. PRINCIPAL FINDINGS Dental care utilization decreased from 40.5 percent in 2001 to 37.0 percent in 2010 for adults and increased from 43.2 percent in 2001 to 46.3 percent in 2010 for children (p<.05). Among adults, changes in insurance status, race, and income contributed to a decline in adult dental care utilization (-0.018, p<.01). Among children, changes in controlled factors did not substantially change dental care utilization, which instead may be explained by changes in policy, oral health status, or preferences. CONCLUSIONS Dental care utilization for adults has declined, especially among the poor and uninsured. Without further policy intervention, disadvantaged adults face increasing barriers to dental care.

An analysis of GAVI, the Global Fund and World Bank support for human resources for health in developing countries

Shortages, geographic imbalances and poor performance of health workers pose major challenges for improving health service delivery in developing countries. In response, multilateral agencies have increasingly recognized the need to invest in human resources for health (HRH) to assist countries in achieving their health system goals. In this paper we analyse the HRH-related activities of three agencies: the Global Alliance for Vaccines and Immunisation (GAVI); the Global Fund for Aids, Tuberculosis, and Malaria (the Global Fund); and the World Bank. First, we reviewed the type of HRH-related activities that are eligible for financing within each agency. Second, we reviewed the HRH-related activities that each agency is actually financing. Third, we reviewed the literature to understand the impact that GAVI, Global Fund and World Bank investments in HRH have had on the health workforce in developing countries. Our analysis found that by far the most common activity supported across all agencies is short-term, in-service training. There is relatively little investment in expanding pre-service training capacity, despite large health worker shortages in developing countries. We also found that the majority of GAVI and the Global Fund grants finance health worker remuneration, largely through supplemental allowances, with little information available on how payment rates are determined, how the potential negative consequences are mitigated, and how payments are to be sustained at the end of the grant period. Based on the analysis, we argue there is an opportunity for improved co-ordination between the three agencies at the country level in supporting HRH-related activities. Existing initiatives, such as the International Health Partnership and the Health Systems Funding Platform, could present viable and timely vehicles for the three agencies to implement this improved co-ordination.

Physician shortages in rural Vietnam: Using a labor market approach to inform policy

This paper investigates labor market dynamics for physicians in Vietnam, paying particular attention to geographic distribution and dual job holding. The analysis is based on a survey of a random sample of physicians in 3 regions in 2009-10. We found that the labor market for physicians in Vietnam is characterized by very little movement among both facility levels and geographic areas. Dual practice is also prominent, with over one-third of physicians holding a second job. After taking account of the various sources of income for physicians and controlling for key factors, there is a significant wage premium associated with locating in an urban area. This premium is driven by much higher earnings from dual job holding rather than official earnings in the primary job. There are important policy implications that emerge. With such low job turnover rates, policies to increase the number of physicians in rural areas could focus on initial recruitment. Once in place, physicians tend to remain in their jobs for a very long time. Lastly, findings from an innovative discrete choice experiment suggest that providing long-term education and improving equipment are the most effective instruments to recruit physicians to work in rural areas.

The Effect of Chairside Chronic Disease Screenings by Oral Health Professionals on Health Care Costs

OBJECTIVES We estimated short-term health care cost savings that would result from oral health professionals performing chronic disease screenings. METHODS We used population data, estimates of chronic disease prevalence, and rates of medication adherence from the literature to estimate cost savings that would result from screening individuals aged 40 years and older who have seen a dentist but not a physician in the last 12 months. We estimated 1-year savings if patients identified during screening in a dental setting were referred to a physician, completed their referral, and started pharmacological treatment. RESULTS We estimated that medical screenings for diabetes, hypertension, and hypercholesterolemia in dental offices could save the health care system from

A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health

42.4 million (

Health Reform In Massachusetts Increased Adult Dental Care Use, Particularly Among The Poor

13.51 per person screened) to

The Impact of Medicaid Reform on Children’s Dental Care Utilization in Connecticut, Maryland, and Texas

102.6 million (

The effect of the Affordable Care Act's expanded coverage policy on access to dental care.

32.72 per person screened) over 1 year, dependent on the rate of referral completion from the dental clinic to the physicians office. CONCLUSIONS Oral health professionals can potentially play a bigger role in detecting chronic disease in the US population. Additional prevention and monitoring activities over the long term could achieve even greater savings and health benefits.