By Oscar Abello
Imagine Sara. She’s a younger woman, newly married to a taxi driver in an emerging market, less defined by her age than she is by her stage in life. She’s at a crucial moment, weighing whether or not it’s worth it to finish her last year of university and start a career in health care, something she’s dreamed about since she was a young girl watching her mother give birth to her younger sister.
She could drop out and choose a safer option, like a job in the garment industry, or perhaps return to working on her family farm. Maybe she has an aunt or uncle who offered to invest in setting her up in a small shop selling groceries and beauty products. Or maybe she has heard that a global health insurance company is hiring sales people in the capital, and if she completes her studies she may be qualified for a position there instead of on the frontlines of health care.
Sara’s decision represents a challenge for global health actors. How can they be better equipped to avoid losing her to other, less risky or more promising career opportunities for her and her future family? What can health systems do to better attract top-level talent like Sara? And even if she does follow through to start her professional life in the global health workforce, how equipped are global health actors to keep her there?
“This is indeed a very important question,” says Dr. Vera Cordeira, founder and president of Associaçao Saúde Criança, which has faced similar workforce challenges as it has scaled up its multi-dimensional approach for improving family health to reach more than 40,000 people per month in Brazil. “For us and for most of the social organizations mainly based in the global south, this is one of our main challenges.
“We are lucky to have great people working with us who are extremely dedicated to our cause,” Cordeira continues. For a career as a global health actor to remain viable option for Sara, the field will have to counter with more than just the promise of fulfillment through a life of service to others.
The private sector has demonstrated that employers can use employee-level data to improve employee retention, incentivization, training and skill development, and productivity. How can global health leaders apply similar data analyses to improve health systems? Will these analyses better position global health systems to attract and retain the best and the brightest?
Multinational corporations have adopted the practice of analyzing employee data in order to determine how to improve the overall productivity and cost-effectiveness of their workforces. Companies can now make data-driven decisions about what stage in the workforce to focus their recruiting and hiring, and what practices they can internally invest in to improve employee retention.
“People management has moved beyond viewing workforce spending as an expense to a more expansive view that it’s also an investment,” says Haig Nalbantian, senior partner at Mercer and co-lead of the company’s Workforce Sciences Institute.
Nalbantian, a labor and organizational economist, has spent years with his team examining the data that workforces generate, drawing inferences based on the available evidence on what investments prove to be key drivers in improving employee productivity while reducing overall long-term costs to the business. The past five years, he observes, have been transformational. “We don’t spend time any more talking about value of workforce investments to clients. Now we talk more about what kind of workforce analytics to measure.
“Just as marketing functions apply heavy duty analytics to understand consumer behavior, corporations understand they need to do the same for their workforce,” says Nalbantian. “Cost-based or qualitative methods for deciding workforce investments are not good enough anymore. You need to understand the return on recruitment, training, compensation and supervision.”
On recruitment and training, global health systems face key challenges. In Nigeria, for example, 60 percent of Sara’s peers on track for a career in health care drop out, according to a study by CapacityPlus, USAID’s flagship health workforce project. “Just an investment of $300 to $500 each would be enough to see them through that final year,” says Kate Tulenko, senior director at IntraHealth International and director of CapacityPlus, referring to investments mainly in the form of targeted scholarships for students at risk of financial dropout.
Global health actors can also take a page from corporations and use data to determine the right benefits packages or other programs to attract and retain Sara and her peers. “One company noted in one of their growth markets workers were lacking education,” Nalbantian says. “So compensation packages included tuition reimbursement, they worked on building schools in partnership with local government, and did other complementary work.”
Then, of course, there’s the issue of wages. Tulenko spoke of another study in Uganda that compared wages in public and private sectors for workers with equivalent years of experience. In general, she says, health workers were getting paid less than others across all sectors with equivalent experience. What does that mean for Sara’s long-term career prospects in health as compared with other sectors?
Continual workforce development is important for career growth, as Sara and her peers will always take an interest in growing professionally. Coupled with data to inform what new skills and knowledge are needed in a given context, continuous workforce development is also vital for addressing the rise of new challenges, such as the rising burden of non-communicable diseases.
“Facilities may be over-staffed for some services while lacking staff for other needs,” says Dr. Tom Achoki, global health professor at the University of Washington and director of African Initiatives at the Institute for Health Metrics and Evaluation. “You find a place where there is only one nurse trained to deal with diabetes, but there are a growing number of diabetes patients.”
“The biggest problem that we have is there is not harmonization in how we collect information in these different areas. There’s not alignment between the workforce and the staffing norms and service they provide,” Achoki says.
Achoki also believes that having data on continuous workforce development can help to identify opportunities for task-shifting – moving less complicated procedures like administering diagnostic tests or injecting common medications previously prescribed by more qualified staff – which can help employers to save money over time and implement solutions at greater scale. “We have to be able to know that more can be shifted to lower cadres of health workers while being able to monitor and maintain quality and efficiency,” Achoki says.
Employee incentives are crucial to evaluate in order to develop health systems. Much data exist on the incen-tives that systems used in different workforces, which can assist health leaders in improving talent recruitment and retention where it is most needed.
“Let’s think about very clear incentives about how to retain the highly trained skilled professionals we have,” Achoki adds.
Full-time versus part-time status is one important incentive that’s often taken for granted in global health programs. Yet that combination can have dramatic effects on the bottom line – measured by finance as well as by quality of delivery.
Nalbantian and his Workforce Sciences Institute looked at eight years of data from 25 facilities in a regional hospital system, covering everything from inner-city communities to wealthy suburbs and remote rural locations. In a previous attempt to cut costs, the system had dramatically shifted toward hiring part-time instead of full- time workers, thinking that the savings in compensation and benefits would improve their bottom lines. The data contradicted that intuition. The system average was 44 percent full-time workers, but the optimum ratio that would provide the best value for money was
63 percent full-time workers.
“That’s not quite an argument against part-time workers, which have their advantages in terms of flexibility to respond to volume or sudden shifts in disease burdens,” Nalbantian says. “It’s just an argument that you can’t just look at compensation as a way to determine value for money.”
But is this type of analysis really applicable to NGOs? “We’ve done this work with NGOs,” Nalbantian says. “They’ve been some of the most fun and rewarding projects I’ve been involved in.” He mentioned work with the Organisation for Economic Co-operation and Development, studying its retention and performance of technical staff, as well as work with the Boys & Girls Clubs of America on local chapter leadership factors as standout examples of using the analysis outside of the traditional corporate realm.
There’s no telling exactly how high the stakes are for understanding what can recruit and retain Sara and her peers as health workers in emerging economies. But one can look to other service industries for a sense of what’s possible.
Think about the potential implications on global health systems if we thought about workforce development in the same way that Nalbantian does across the private sector.
Working with a regional retail bank, Nalbantian and his team gathered data at the branch level – market share, customer retention, growth of premium accounts, and other measures of customer acquisition and revenue growth. Their analysis found that the single big-gest predictor of business success was an employee’s average length of service in a position as a frontline worker – in the bank’s case, tellers, customer service reps and assistant managers. They were able to predict that by increasing the average length of service across all frontline branch staff by one year on aggregate, it would be worth $40 million more to the bank’s bottom line annually.
Meanwhile, the potential for the average tenure for a health worker in an internationally supported health program remains a mystery. If it were known which incentives could recruit and retain Sara and her peers for longer careers in key global health workforce positions, what might that do to the bottom-line social impact?
Oscar Abello is online editor, Impact, The magazine of PSI
Photo: A new mother at Gondar University Hospital.