Impact: What are three critical elements of the global health workforce that governments and donors must address to attain and sustain universal health coverage?
Tim Evans: The first element is to recognize the centrality of the health workforce in accelerating progress towards universal health coverage (UHC). Adequate numbers of appropriately trained and located health workers – be it for the provision of clinical services or the management of health insurance regimes – are mission critical to UHC. Too often, however, the health workforce is an after-thought or marginal consideration in policy and plans. Too many countries lack credible capacity to manage the workforce as an agent of change for UHC and it ends up being weighed down. Recognizing the value of the workforce and building capacity to manage more proactively are essential ingredients to UHC reforms.
Ensuring equal access to health care for all defines the second critical element: the recruitment and retention of qualified health workers to serve in areas of greatest need. This is more easily said than done and requires a multi-pronged solution that includes investing in education and training of students recruited from these under-served communities; developing curricula and training materials that reflect local needs; creating a safe work environment; and managing monetary and non-monetary incentives to attract and retain workers in the community.
A third critical element relates to developing greater awareness of and competency in managing health workforce labor markets. Health workers are sensitive to differences in remuneration, working conditions and career prospects. Disparities in these factors both within and across countries create powerful market forces for migration, often negatively impacting the provision of health services. Avoiding such fallout requires a better understanding of these market forces and effective interventions to counter their adverse consequences.
Impact: What are the biggest challenges in the adequacy of data on health workforce for policy decisions?
TE: The biggest data challenge relates to the absence of broadly accepted standards for counting and assessing the performance of the health workforce. The data that exists is usually incomplete, out-dated, skewed towards public sector medical professionals and away from private sector and public health workers. A new system that identifies the numbers, locations, productivity, inflows and outflows of health workers will help to provide the nature and magnitude of health worker challenges as essential inputs to policy.
Impact: How do economic, demographic and epidemiologic transitions in many low- and middle-income countries impact the demand for health workers?
TE: Overall, these trends are likely to accelerate the demand for health workers across the globe, although the magnitude and rate of increase in demand will vary from country to country. With economic growth, population aging and the information society, the public’s expectations for health care are increasing demand for quality health services everywhere. Together with urbanization and unregulated commercialization of health care, this demand skews the supply of health workers towards costly procedures and high-tech interventions in tertiary care hospitals. Achieving UHC will require shifting these expectations toward a greater demand for primary prevention and community/home-based models of care, supported by multi-disciplinary primary care teams of health workers.
Given the global shortage of health workers, the demand for high-skilled health professionals is likely to come under considerable competition from regional and global health labor market. National human resources for health strategies will need to take into account competing domestic and international interests. The challenge will not only be to increase the number of skilled health workers but to transform the way they are selected and educated.
Impact: PSI and IntraHealth will travel with a delegation to Tanzania in October to see our programs and meet health professionals. Can you talk about the Bank’s focus on health worker performance analysis in the country?
TE: In Tanzania, the World Bank and other partners support the health sector through a sector-wide approach and the Health Basket Fund, which helps with local government service delivery, health systems strengthening at the local level, and the procurement of medicines and other health commodities. The Bank also supports a capacity-building grant mechanism to improve the capacity of local governments to manage their health services, including human resource management. This is linked to activities through the Ministry of Health and Social Welfare and Prime Minister’s Regional Administration and Local Government, which support the performance management process and strengthen oversight structures.
One way to look at the results of improving health worker performance is through the analysis of service delivery indicators (SDI). The Bank has supported Tanzania and other African countries in this endeavor. At the policy level, the government has decided to introduce performance- or results-based financing as an approach to improve health worker performance by moving away from input-based financing, and focusing on performance or results. Following a successful Pay-for-Performance (P4P) pilot, funded by the Norwegian government, the Bank is assisting the Tanzanian government in redesigning a results-based financing system that will be pre-tested in one region this year, and starting the next financial year the new systems will be rolled out nationwide in a phased approach.
Impact: What is the role of the private sector in human resources for health?
TE: The private sector is growing rapidly in many health areas, including professional education and service delivery. This expansion is both a source of opportunity and concern for human resources for health (HRH). The growth of the private sector in health is creating new training and employment opportunities; however, without appropriate alignment with UHC objectives, it may create challenges to the access and quality of health professional education, and skew health workers towards facility-based, tertiary care. In many countries, public sector pay, support and supervision are such that health workers are often absent, low-performing and seeking work in the private sector. As such, it is necessary to manage the public-private mix with respect to education and employment to assure universal access to quality health services.
Photo credit: Gareth Bentley.