Susan Sparkes

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.

Fiscal space for health in Uganda.

This report reviews performance of Ugandas health sector and assesses options for increasing total health spending and improving efficiency of health spending to improve health, nutrition, and population outcomes. Although Ugandas health outcomes are improving, the country is unlikely to achieve its national targets for health as well as the health related Millennium Development Goals (MDG) Uganda is faced with a high disease burden from communicable diseases; in addition, the country is witnessing a growing epidemic of non communicable diseases. The main conclusion of the report is that while Uganda needs to continue exploring ways to mobilize funding for health it needs to improve the efficiency of its health spending to maximize the health benefits for its population. Uganda could reap significant savings by improving management of human resources for health; strengthening procurement and logistics management for medicines and medical supplies; and by better programming of development assistance for health. Besides, Uganda needs to take proactive steps to mitigate growing pressure to increase health spending.

Health systems strengthening, universal health coverage, health security and resilience

Health system strengthening comprises the means (the policy instruments), while universal health coverage is a way of framing the objectives of policy. Without this distinction, there is a risk that instruments of reform become the objective, with the perception that “the problem” to be solved is the absence or presence of a particular policy instrument. When this occurs, policy dialogue shifts quickly away from where it needs to be – getting to consensus about the nature and causes of underperformance relative to universal health coverage goals – to what is often an ideologically polarized debate about the inherent merits or flaws of particular reform instruments. In health financing, for example, this has been observed in the debate on social or community-based health insurance, performance-based financing and user fees. Similarly, simply calling something a “universal health coverage reform” does not convey any meaning as to the actual content of what is being planned or implemented.

Protecting pro-poor health services during financial crises: lessons from experience.

OBJECTIVE This chapter assesses the extent to which previous economic and financial crises had a negative impact on health outcomes and health financing. In addition, we review evidence related to the effectiveness of different policy measures undertaken in past crises to protect access to health services, especially for the poor and vulnerable. The current global crisis is unique both in terms of its scale and origins. Unlike most previous instances, the current crisis has its origins in developed countries, initially the United States, before it spread to middle- and lower-income countries. The current crisis is now affecting almost all countries at all levels of income. This chapter addresses several key questions aimed at helping inform possible policy responses to the current crisis from the perspective of the health sector: What is the nature of the current crisis and in what ways does it differ from previous experiences? What are some of the key. lessons from previous crises? How have governments responded previously to protect health from such macroeconomic shocks? How can we improve the likelihood of positive action today? METHODOLOGY/APPROACH The chapter reviews the literature on the impact of financial crises on health outcomes and health expenditures and on the effectiveness of past policy efforts to protect human development during periods of economic downturn. It also presents analysis of household surveys and health expenditure data to track health seeking behavior and out-of-pocket expenditures by households during times of financial crisis. FINDINGS Evidence from previous crises indicates that health-related impacts during economic downturns can occur through various channels. The impact in households experiencing reductions in employment and income could be manifest in terms of poorer nutritional outcomes and lower levels of utilization of health care when needed. Households may become impoverished, reduce needed health services, and experience reductions in consumption as a result of health shocks occurring during a time when their economic vulnerability has increased. Women, children, the poor, and informal sector workers are likely to be most at risk of experiencing negative health-related consequences in a crisis. Real government spending per capita on health care could decline due to reduced revenues, currency devaluations, and potential reductions in external aid flows. Low-income countries with weak fiscal positions are likely to be the most vulnerable. IMPLICATIONS FOR POLICY Past crises can inform policy-making aimed at protecting health outcomes and reducing financial risk from health shocks. Evidence from previous crises indicates that broad-brush strategies that maintained overall levels of government health spending tended not to be successful, failing to protect access to quality health services especially for the poor. It is particularly vital to ensure access to essential health commodities, which in many low-income countries are imported, in the face of weakening exchange rates. Focused efforts to sustain the supply of lower-level basic services, combined with targeted demand-side approaches like conditional cash transfers may be more effective than broader sectoral approaches. Low-income countries may need specific short-term measures to ensure that health outcomes do not suffer.

The path to universal health coverage in Bangladesh : bridging the gap of human resources for health

Bangladesh is committed to achieving universal health coverage (UHC) by 2032; to this end, the government of Bangladesh is exploring policy options to increase fiscal space for health and expand coverage while improving service quality and availability. Despite Bangladeshs impressive strides in improving its economic and social development outcomes, the government still confronts health financing and service delivery challenges. In its review of the health system, this study highlights the limited fiscal space for implementing UHC in Bangladesh, particularly given low public spending for health and high out-of-pocket expenditure. The crisis in the countrys human resources for health (HRH) compounds public health service delivery inefficiencies. As the government explores options to finance its UHC plan, it must recognize that reform of its service delivery system with particular focus on HRH has to be the centerpiece of any policy initiative. The Path to Universal Health Coverage in Bangladesh assesses the current status of HRH in terms of production, recruitment, and deployment as well as related policy-making processes. It then explores policy options based on evidence from international experience that will help Bangladesh improve the availability and skill-mix of its health workforce. To reach its goal of UHC by 2032, the government will have to commit itself to policies to expand health financing options and, at the same time, tackle HRH challenges head on. This study presents an economic analysis model of different scenarios that accelerate closing the HRH gap for nurses and community midwives by 2020 within the governments fiscal space, thus improving the skill-mix of its health workforce. The study also presents detailed policy options to address HRH shortages, improve the skill mix, address geographic imbalances, retain health workers in rural areas, and adopt strategic payments and purchasing mechanisms. In presenting these options, the study provides evidence from literature as well as cogent cases from low- and middle-income countries, such as Afghanistan, Chile, Indonesia, Malawi, Nepal, Tanzania, and Thailand, to demonstrate the effect of these policies.

Political Strategies for Health Reform in Turkey: Extending Veto Point Theory

Abstract—This qualitative case study uses primary interview data to investigate the political processes of how Turkey established a unified and universal health coverage system. The goal of providing health coverage to all citizens through a unified system has been adopted by many low- and middle-income countries, but few have achieved it; Turkey is a notable exception. We use institutional veto point theory to identify four institutional obstacles to a unified and universal coverage system in Turkey between 2003 and 2008: (1) the Ministry of Finance and Treasury, (2) the Ministry of Labor and Social Security, (3) the Office of the President, and (4) the Constitutional Court. Our analysis shows how Minister of Health Recep Akdağ and his team of advisors used political strategies to address and overcome opposition at each veto point. Where possible they avoided institutional veto points by using ministerial authority to adopt policies. When adoption required approval of others with veto power, they delayed putting forward legislation while working to facilitate institutional change to remove opposition; persuaded or made strategic compromises to gain support; or overpowered opposition by calling on the prime minister to intervene. Our findings propose an extension to institutional veto point theory by showing how the exercise of political strategies can overcome opposition at institutional veto points to facilitate policy adoption.

Assessing Fiscal Space for Health in the SDG Era: A Different Story

Abstract—Initially defined for overall public purposes, the concept of fiscal space was subsequently developed and adapted for the health sector. In this context, it has been applied in research and policy in over 50 low- and middle-income countries over the past ten years. Building on this vast experience and against the backdrop of shifts in the global health financing landscape in the Sustainable Development Goals (SDG) era, the commentary highlights key lessons and challenges in the approach to assessing potential fiscal space for health. In looking forward, the authors recommend that future fiscal space for health analyses primarily focus on domestic sources, with specific attention to potential expansion from the improved use and performance of public resources. Embedding assessments in national health planning and budgeting processes, with due consideration of the political economy dynamics, will provide a way to inform and impact allocative decisions more effectively.

Can low-and-middle income countries increase domestic fiscal space for health: a mixed-methods approach to assess possible sources of expansion

Abstract—There has not been a systematic effort to synthesize findings of domestic fiscal space for health (DFSH) assessments, despite the existence of a commonly applied conceptual framework. To fill this gap and provide support to policy makers designing health financing policies toward universal health coverage (UHC), this study uses both qualitative and quantitative methods to assess the scope of possible sources of DFSH in low- and middle-income countries (LMICs). First, the findings of 28 studies assessing DFSH in LMICs were reviewed. A quantitative assessment was then conducted to assess potential expansion from increased tax revenues, a greater prioritization of health in the overall budget, and improved technical efficiency of health spending in a sample of 64 LMICs. The analysis found that macroeconomic conditions and budget prioritization are the key sources of DFSH expansion in 90% of the reviewed studies. Improved efficiency was referenced as having high potential for DFSH expansion in 60% of the studies. The quantitative analysis converged with these findings and further confirmed that an increase in tax revenues is, on average, the largest source of potential DFSH expansion (95% confidence interval [CI], 60%, 96%) in the studied countries. However, even without injecting new revenues, reprioritization of budget and technical efficiency improvements could significantly expand DFSH (95% CI, 77%, 102%). While highlighting the critical role played by fiscal conditions and tax policies, the study provides strong rationale for explicitly incorporating efficiency as a core source of DFSH in a more systematic manner in future assessments.

From silos to sustainability: transition through a UHC lens

The transition to higher-income status is a positive step forward for countries, but this transition brings with it the prospect of declining external assistance, both in general and in particular for health. Most health donor agencies rely at least in part on an income threshold to establish eligibility for support. Such a donor transition implies that government is increasingly responsible for the financing of a health programme and its supported interventions. However, focusing attention only on replacing external assistance with domestic revenues for the programmes concerned is problematic in two ways: firstly, this approach limits the sustainability question to revenues, and secondly, it limits the scope for action to the specific health programme that was receiving external support. The commitment countries have made to universal health coverage (UHC) is an opportunity to reframe the transition agenda towards sustaining coverage results rather than externally funded programmes per se. This perspective has implications for the overall approach to transition taken at both national and global levels. UHC embeds the goals of equity in service use, quality, and financial protection at the level of the entire health system and population. The way external resources are often channelled, as a legacy of the Millennium Development Goals era, creates or reinforces vertical struc tures focused on specific dis eases or interventions. In many countries, these subsystems operate independently of the rest of the health system, with separate plans, budgets, funding, procurement, supply chains, and information systems. When viewed through a UHC lens (ie, across the health system, within which programmes are embedded), it is apparent that these separate subsystems duplicate responsibilities, compromising efficiency in resource use and sometimes effective case management—eg, when service use data on a pregnant woman who has HIV is managed separately by the HIV programme and the maternal health programme. Consolidating underlying sub systems can help sustain progress. External assistance should support such real system-building actions. Purely financial solutions to the challenges posed by donor transi tion, such as blended financing arrangements, should not mask the need to address these efficiency challenges that are at the core of putting national health systems on more sustainable trajectories. There is no need to wait for transition; the time to initiate such change is now. The economic growth that triggers donor transition also provides an opportunity for a health financing transition—ie, reforms which, if effective, result in an increase in health spending per person and a decrease in the share of that spending that is paid out of pocket. Realising this in practice requires targeted policy measures. As with efficiency considerations, financing actions should be add ressed at the system rather than the programme level. Specifically, government-wide efforts to strengthen taxation capacity and increase priority for the health sector in public budgets are key. Within the health sector, actions are needed to reduce fragmentation in the way that funds are pooled, and to then allocate these funds strategically to improve health and drive efficiency gains. For example, the inclusion of currently programme-supported individual health services (eg, immunisation and HIV and tuberculosis treatment) within integrated benefit packages, pay ment systems, and service delivery arrange ments can be considered as part of building a more sustainable system. Finally, citizens and taxpayers (ie, those driving domestic funding) need to move this effort through collective action, as part of national health assemblies and parliamentary debates. Looking at transition through a UHC lens implies three shifts: building consensus that what is to be sustained is increased effective coverage of priority health interventions; that sustainability requires acting on both revenue and expenditure issues; and that such actions must be done system-wide rather than programme by programme. A UHC lens means looking at these challenges from the perspectives of the health and finance ministers rather than simply those of each programme manager. A minister’s perspective puts financing issues within the frame of funding for the entire sector, leading to an emphasis on strengthening overall taxation capacity and improving equity and efficiency, which are core principles for any health financing system, regard less of transition. It also means going beyond financing to carefully address inefficiencies through reforms and investments that might require donor support, to streamline the underlying administrative machinery of the entire health system. Focusing on UHC goals to drive consensus and the system-wide unit of analysis to frame actions better enables policy responses to build stronger health systems that address programmatic priorities, regardless of the source of funding.