Changing Research Perspectives on the Global Health Workforce

Past research on the health workforce can be structured into three perspectives – “health workforce planning” (1960 through 1970s); “the health worker as economic actor” (1980s through 1990s); and “the health worker as necessary resource” (1990s through 2000s). During the first phase, shortages of health workers in developed countries triggered the development of four approaches to project future health worker requirements. We discuss each approach and show that modified versions are experiencing a resurgence in current studies estimating health worker requirements to meet population health goals, such as the United Nations’ health-related Millennium Development Goals. A perceived “cost explosion” in many health systems shifted the focus to the study of the effect of health workers’ behavior on health system efficiency during the second phase. We review the literature on one example topic: health worker licensure. In the last phase, regional health worker shortages in developing countries and local shortages in developed countries led to research on international health worker migration and programs to increase the supply of health workers in underserved areas. Based on our review of existing studies, we suggest areas for future research on the health workforce, including the transfer of existing approaches from developed to developing countries.Research perspectives, Global Health Workforce

Universal antiretroviral treatment: the challenge of human resources

WHO’s Towards Universal Access 2009 report documents a remarkable worldwide increase in the number of people receiving antiretrviral treatment (ART) – from 3 million in 2007 to 4 million in 2008 – creating hope that with sustained energy, universal ART coverage might be achievable (1). At the same time, the report emphasizes many challenges in delivering ART on a more massive scale. One challenge – the number and types of human resources that will be required to achieve universal coverage – deserves attention from a new perspective.  In particular, we discuss the effect of feedback from current ART coverage to future ART human resources need on the sustainability of high lvels of ART coverage. But in order to think about the future, we first try to understand the past.Antiretroviral treatment, human resources

“Conditional scholarships” for HIV/AIDS health workers: educating and retaining the workforce to provide antiretroviral treatment in sub- Saharan Africa

In spite of recent large-scale efforts to roll out ART in developing countries, millions of people who need ART currently do not receive it. Without large increases in the number of health workers to treat HIV/AIDS (HAHW) in the next few years, most developing countries will be unable to achieve universal coverage with ART, leading to large numbers of potentially avoidable deaths. We investigate the economic value of a scholarship for health care education that is conditional on the recipient entering into a contract to work for a number of years after graduation delivering ART in sub-Saharan Africa. Such a scholarship could address two of the main reasons for the low numbers of health workers in developing countries. First, the “scholarship” could increase the number of health workers educated in the country. Second, the “condition” could decrease the probability of emigration of HAHW. We use Markov Monte Carlo microsimulation to estimate the expected net present value (eNPV) of “conditional scholarships” in sub-Saharan Africa. We find that under a wide range of plausible assumptions the scholarships are highly eNPV positive. “Conditional scholarships” for a team of health workers sufficient to provide ART for 500 patients have an eNPV of 1.23 million year-2000 US dollars, assuming that the scholarship recipients are in addition to the health workers who would have been educated without scholarships and that the scholarships reduce annual HAHW emigration probabilities from 15% to 5% for five years. When individual variable values are varied from this base case within plausible bounds suggested by the literature, eNPV of the “conditional scholarships” never falls below 0.5 million year-2000 US dollars. When we assume that the scholarships do not increase HAHW education output, but merely reduce annual HAHW emigration probabilities from 15% to 5% for five years, their eNPV remains highly positive at 0.29 million year-2000 US dollars. Although the “conditional scholarships” are a socially desirable investment, implementation success will likely depend on the sources of finance, selection of candidates, specification of the condition, enforcement mechanisms, and supporting interventions.AIDS, ART.

Financial incentives for return of service in underserved areas: a systematic review

Of the 42 reviewed studies 33 investigated financial-incentive programs in the US. The remaining studies evaluated programs in Japan (five studies), Canada (two), New Zealand (one) and South Africa (one). The programs started between 1930 and 1998. We identified five different types of programs (service-requiring scholarships, educational loans with service requirements, service-option educational loans, loan repayment programs, and direct financial incentives). Financial incentives ranged from year-2000 United States dollars 1,358 to 28,470. All reviewed studies were observational. The random-effects estimate of the pooled proportion of all eligible program participants who had either fulfilled their obligation or were fulfilling it at the time of the study was 71% (95% confidence interval 60-80%). Seven studies compared retention in the same underserved area between program participants and non-participants. Six studies found that participants were less likely to remain in the same underserved area (five studies reported the difference to be statistically significant, while one study did not report a significance level); one study did not find a significant difference in retention in the same area. Twelve studies compared provision of care/retention in any underserved area between participants and non-participants. Ten studies found that participants were more likely to continue to practice in any underserved area (eight studies reported the difference to be statistically significant, while two studies did not provide the results of significance tests); two studies found that program participants were significantly less likely than non-participants to remain in any underserved area. Seven studies investigated the satisfaction of participants with aspects of their enrolment in financial-incentive programs; three studies examined the satisfaction of members of participants’ families with their lives in the undeserved area.Financial incentives, underserved areas,review

"Conditional scholarships" for HIV/AIDS Health Workers: Educating and Retaining the Workforce to Provide Antiretroviral Treatment in Sub-Saharan Africa

Without large increases in the number of health workers to treat HIV/AIDS (HAHW), most developing countries will be unable to achieve universal coverage with antiretroviral treatment (ART), leading to large numbers of potentially avoidable deaths among people living with HIV/AIDS. We use Markov Monte Carlo microsimulation to estimate the expected net present value (eNPV) of a scholarship for health care education that is conditional on the recipient entering into a contract to work for a number of years after graduation delivering ART in sub-Saharan Africa. Such a scholarship could increase the number of health workers educated in the region and decrease the probability of HAHW emigration. "Conditional scholarships" for a team of health workers sufficient to provide ART for 500 patients have an eNPV of 1.23 million year-2000 US dollars, assuming that the scholarship recipients are in addition to the health workers who would have been educated without scholarships and that the scholarships reduce annual HAHW emigration probabilities from 15% to 5% for five years. When individual variable values are varied from this base case within plausible bounds suggested by the literature, eNPV of the "conditional scholarships" never falls below 0.5 million year-2000 US dollars.

Financial incentives for return of service in underserved areas: a systematic review

In many geographical regions, both in developing and in developed countries, the number of health workers is insufficient to achieve population health goals. Financial incentives for return of service are intended to alleviate health worker shortages: A (future) health worker enters into a contract to work for a number of years in an underserved area in exchange for a financial pay-off. The authors of this paper carried out a systematic literature search of PubMed for studies evaluating outcomes of financial-incentive programs published between 1957 and 2007.Disease, control, global health, financial-incentive programs.

Designing financial-incentive programmes for return of medical service in underserved areas of sub-Saharan Africa

In many countries in sub-Saharan Africa health worker shortages are one of the main constraints in achieving population health goals. Financial-incentive programmes for return of service, whereby participants receive payments in return for a commitment to practice for a period of time in a medically underserved area, can alleviate local and regional health worker shortages through two mechanisms. First, they can redirect the flow of those health workers who would have been educated without financial incentive from well-served to underserved areas. Second, they can add health workers to the pool of workers who would have been educated without financial incentives and place them in underserved areas. While financial-incentive programmes are an attractive option to increase the supply of health workers to medically underserved areas – they offer students who otherwise would not have the means to finance a health care education an opportunity to do so, establish legally enforceable commitments to work in underserved areas, and work without compulsion – these programmes may be difficult to implement.Disease, control, global health, financial-incentive programs, Africa.