Public health workforce: challenges and policy issues

This paper reviews the challenges facing the public health workforce in developing countries and the main policy issues that must be addressed in order to strengthen the public health workforce. The public health workforce is diverse and includes all those whose prime responsibility is the provision of core public health activities, irrespective of their organizational base. Although the public health workforce is central to the performance of health systems, very little is known about its composition, training or performance. The key policy question is: Should governments invest more in building and supporting the public health workforce and infrastructure to ensure the more effective functioning of health systems? Other questions concern: the nature of the public health workforce, including its size, composition, skills, training needs, current functions and performance; the appropriate roles of the workforce; and how the workforce can be strengthened to support new approaches to priority health problems. The available evidence to shed light on these policy issues is limited. The World Health Organization is supporting the development of evidence to inform discussion on the best approaches to strengthening public health capacity in developing countries. WHO's priorities are to build an evidence base on the size and structure of the public health workforce, beginning with ongoing data collection activities, and to map the current public health training programmes in developing countries and in Central and Eastern Europe. Other steps will include developing a consensus on the desired functions and activities of the public health workforce and developing a framework and methods for assisting countries to assess and enhance the performance of public health training institutions and of the public health workforce

Sub-national assessment of inequality trends in neonatal and child mortality in Brazil

<p>Abstract</p> <p>Objective</p> <p>Brazil's large socioeconomic inequalities together with the increase in neonatal mortality jeopardize the MDG-4 child mortality target by 2015. We measured inequality trends in neonatal and under five mortality across municipalities characterized by their socio-economic status in a period where major pro poor policies were implemented in Brazil to infer whether policies and interventions in newborn and child health have been successful in reaching the poor as well as the better off.</p> <p>Methods</p> <p>Using data from the 5,507 municipalities in 1991 and 2000, we developed accurate estimates of neonatal mortality at municipality level and used these data to investigate inequality trends in neonatal and under five mortality across municipalities characterized by socio-economic status.</p> <p>Results</p> <p>Child health policies and interventions have been more effective in reaching the better off than the worst off. Reduction of under five mortality at national level has been achieved by reducing the level of under five mortality among the better off. Poor municipalities suffer from worse newborn and child health than richer municipalities and the poor/rich gaps have increased.</p> <p>Conclusion</p> <p>Our analysis highlights the importance of monitoring progress on MDGs at sub-national level and measuring inequality gaps to accurately target health and inter-sectoral policies. Further efforts are required to improve the measurement and monitoring of trends in neonatal and under five mortality at sub-national level, particularly in developing countries and countries with large socioeconomic inequalities.</p

Skill mix in the health care workforce : reviewing the evidence

This paper discusses the reasons for skill mix among health workers being important for health systems. It examines the evidence base (identifying its limitations), summarizes the main findings from a literature review, and highlights the evidence on skill mix that is available to inform health system managers, health professionals, health policy-makers and other stakeholders. Many published studies are merely descriptive accounts or have methodological weaknesses. With few exceptions, the published analytical studies were undertaken in the USA, and the findings may not be relevant to other health systems. The results from even the most rigorous of studies cannot necessarily be applied to a different setting. This reflects the basis on which skill mix should be examined-identifying the care needs of a specific patient population and using these to determine the required skills of staff. It is therefore not possible to prescribe in detail a ''universal'' ideal mix of health personnel. With these limitations in mind, the paper examines two main areas in which investigating current evidence can make a significant contribution to a better understanding of skill mix. For the mix of nursing staff, the evidence suggests that increased use of less qualified staff will not be effective in all situations, although in some cases increased use of care assistants has led to greater organizational effectiveness. Evidence on the doctor-nurse overlap indicates that there is unrealized scope in many systems for extending the use of nursing staff. The effectiveness of different skill mixes across other groups of health workers and professions, and the associated issue of developing new roles remain relatively unexplored.sch_nur1. The World Health Report, 2000 - Health systems: improving performance. Geneva: World Health Organization; 2000. 2. WHO estimates of health personnel: physicians, nurses, midwives, dentists and pharmacists (around 1998). Geneva: World Health Organization. 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International Journal of Nursing Studies 2000;37:185-97. 9. Anderson RA, Hsieh P, Su H. Resource allocation and resident outcomes in nursing homes: comparisons between the best and worst. Research in Nursing and Health 1998;21: 297-313. 10. Bond CA, Raehl CL, Pitterle M E, Franke T. Health care professional staffing, hospital characteristics, and hospital mortality rates Pharmacotherapy 1999;19:130-8. 11. Kovner C, Gergen PJ. Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image: Journal of Nursing Scholarship 1998;30:315-21. 12. Aiken L, Sloane D. Advances in hospital outcomes research. Journal of Health Services Research & Policy 1998;3:249-50. 13. Sochalski J, Estabrooks C, Humphrey C. Nurse staffing and patient outcomes: evolution of an international study. Canadian Journal of Nursing Research 1999;31:69-88. 14. Carpenter GI, Ikegami N, Ljunggren G, Carrillo E, Fries BE. RUG-III and resource allocation: comparing the relationship of direct care time with patient characteristics in five countries. Resource Utilization Groups. Age and Ageing 1997;26. Suppl. 2:61-5. 15. Wharrad H, Robinson J. The global distribution of physicians and nurses. Journal of Advanced Nursing 1999;1:109-20. 16. Hoff W.Traditional practitioners as primary health care workers. Geneva: World Health Organization; 1995. Unpublished document WHO/SHS/DHS/TRM/95.6. 17. Taylor B. Parents as partners in care. Paediatric Nursing 1996;8:24-7. 18. Ukanda U, Sharma U, Saini K. Care provided by 'skill mix' and 'informal care givers' to critically ill patients. Nursing Journal of India 1999;90:53-4. 19. Wasserbauer LI, Arrington DT, Abraham IL. Using elderly volunteers to care for the elderly: opportunities for nursing, Nursing Economics 1996;14:232-8. 20. Ellis B, Connell NAD, Ellis HC. Role, training and job satisfaction of physiotherapy assistants. Physiotherapy 1998;84:608-16. 21. Edwards M. The health care assistant: usurper of nursing? British Journal of Community Health Nursing 1997;10:490-4. 22. Orne RM, Garland D, O'Hara M, Perfetto L, Stielau J. Caught in the cross fire of change: nurses' experience with unlicensed assistive personnel. Applied Nursing Research 1998;11:101-10. 23. Gardner DL. Issues related to the use of nurse extenders. Journal of Nursing Administration 1991;21:40-5. 24. Krapohl G, Larson E. The impact of unlicensed assistive personnel on nursing care delivery. Nursing Economics 1996;14:99-112. 25. Siehoff AM. Impact of unlicensed assistive personnel on patient satisfaction: an integrative review of the literature. Journal of Nursing Care Quality 1998; 13:1-10. 26. Hesterly SC, Robinson M. Alternative caregivers: cost effective utilisation of RNs. Nursing Administration Quarterly 1990;14:45-57. 27. Bostrom J, Zimmerman J. Restructuring nursing for a competitive health care environment. Nursing Economics 1993;11:35-41,54. 28. Powers P, Dickey C, Ford A. Evaluating an RN/co-worker model. Journal of Nursing Administration 1990;20:11-15. 29. Garfink C, Kirby KK, Bachman SS. The University Hospital nurse extender program: Part IV. Nursing Management 1991;21:26-31. 30. Carr-Hill RA, Dixon P, Griffiths M, Higgins M, McCaughan D, Rice N, Wright K. The impact of nursing grade on the quality and outcome of nursing care. Health Economics 1995;4:57-72. 31. Castillo A, Manfredi M. Estudio sobre la situacio n de la formacio n de personal te cnico en salud: algunos pases de la regio n [Study on the training of health technicians' situation in some countries of Latin American and Caribbean]. Washington (DC): Pan American Health Organzation;1999. 32. Holt MR, Hand MM. The pharmacist's role in reducing patient delay in seeking treatment for acute myocardial infarction. Journal of the American Pharmaceutical Association 1999;39:752-7. 33. Rodgers S, Avery A, Meecham D, Briant S, Geraghty M, Doran K et al. Controlled trial of pharmacist intervention in general practice: the effect on prescribing costs. British Journal of General Practice 1999;49:717-20. 34. Bogden PE, Abbot R, Williamson P, Onopa J, Koontz L. Comparing standard care with a physician and pharmacist team approach for uncontrolled hypertension. Journal of General Internal Medicine 1998;13:740-5. 35. Chant A. A confusion of roles: manpower in the National Health Service. Journal of the Royal Society of Medicine 1998;91:63-5. 36. Calpin-Davies PJ, Akehurst RL. Doctor-nurse substitution: the workforce equation. Journal of Nursing Management 1999;7:71. 37. Shum C, Humphreys A, Wheeler D, Cochrane M, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: a multi centre randomised control trial. BMJ 2000;320:1038-43. 38. Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P, et al. Randomised control trial of nurse practitioner versus general practitioner care for patients requesting same day consultation in primary care. BMJ 2000;320:1043-48. 39. Venning P, Durie A, Roland M, Roberst C, Leese B. Randomised control trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. BMJ 2000;320:1048-53. 40. Svitone EC, Garfield R, Vasconcelos MI, Craveiro VA. Primary health care lessons from the northeast of Brazil: the Agentes de Sau de Program. Pan-American Journal of Public Health 2000;7:293-302. 41. Buchan J, Ball J, O'May F. If changing skill mix is the answer, what is the question? Journal of Health Services Research and Policy 2002;6:233-8. 58080pub92pub

Addressing the health workforce crisis: towards a common approach

The challenges in the health workforce are well known and clearly documented. What is not so clearly understood is how to address these issues in a comprehensive and integrated manner that will lead to solutions. This editorial presents – and invites comments on – a technical framework intended to raise awareness among donors and multisector organizations outside ministries of health and to guide planning and strategy development at the country level

The practice of physicians and nurses in the Brazilian Family Health Programme – evidences of change in the delivery health care model

The article analyzes the practice of physicians and nurses working on the Family Health Programme (Programa de Saúde da Família or PSF, in Portuguese). A questionnaire was used to assess the evidences of assimilation of the new values and care principles proposed by the programme. The results showed that a great number of professionals seem to have incorporated the practice of home visits, health education actions and planning of the teams' work agenda to their routine labour activities

The health workforce crisis in TB control: a report from high-burden countries

BACKGROUND: Human resources (HR) constraints have been reported as one of the main barriers to achieving the 2005 global tuberculosis (TB) control targets in 18 of the 22 TB high-burden countries (HBCs); consequently we try to assess the current HR available for TB control in HBCs. METHODS: A standard questionnaire designed to collect information on staff numbers, skills, training activities and current staff shortages at different health service levels was sent to national TB control programme managers in all HBCs. RESULTS: Nineteen HBCs (86%) replied, and 17 (77%) followed the questionnaire format to provide data. Complete information on staff numbers at all service levels was available from nine countries and data on skill levels and training were complete in six countries. Data showed considerable variations in staff numbers, proportions of trained staff, length of courses and quality of training activities. Eleven HBCs had developed training materials, many used implementation guidelines for training and only three used participatory educational methods. Two countries reported shortages of staff at district health facility level, whereas 14 reported shortages at central level. There was no apparent association between reported staff numbers (and skills) and the country's TB burden or current case detection rates (CDR). CONCLUSION: There were few readily available data on HR for TB control in HBCs, particularly in the larger ones. The great variations in staff numbers and the poor association between information on workforce, proportion of trained staff, and length and quality of courses suggested a lack of valid information and/or poor data reliability. There is urgent need to support HBCs to develop a comprehensive HR strategy involving short-term and long-term HR development plans and strengthening their HR planning and management capabilities

"More money for health - more health for the money": a human resources for health perspective

<p>Abstract</p> <p>Background</p> <p>At the MDG Summit in September 2010, the UN Secretary-General launched the Global Strategy for Women's and Children's Health. Central within the Global Strategy are the ambitions of "more money for health" and "more health for the money". These aim to leverage more resources for health financing whilst simultaneously generating more results from existing resources - core tenets of public expenditure management and governance. This paper considers these ambitions from a human resources for health (HRH) perspective.</p> <p>Methods</p> <p>Using data from the UK Department for International Development (DFID) we set out to quantify and qualify the British government's contributions on HRH in developing countries and to establish a baseline.. To determine whether activities and financing could be included in the categorisation of 'HRH strengthening' we adopted the Agenda for Global Action on HRH and a WHO approach to the 'working lifespan' of health workers as our guiding frameworks. To establish a baseline we reviewed available data on Official Development Assistance (ODA) and country reports, undertook a new survey of HRH programming and sought information from multilateral partners.</p> <p>Results</p> <p>In financial year 2008/9 DFID spent £901 million on direct 'aid to health'. Due to the nature of the Creditor Reporting System (CRS) of the Organisation for Economic Co-operation and Development (OECD) it is not feasible to directly report on HRH spending. We therefore employed a process of imputed percentages supported by detailed assessment in twelve countries. This followed the model adopted by the G8 to estimate ODA on maternal, newborn and child health. Using the G8's model, and cognisant of its limitations, we concluded that UK 'aid to health' on HRH strengthening is approximately 25%.</p> <p>Conclusions</p> <p>In quantifying DFID's disbursements on HRH we encountered the constraints of the current CRS framework. This limits standardised measurement of ODA on HRH. This is a governance issue that will benefit from further analysis within more comprehensive programmes of workforce science, surveillance and strategic intelligence. The Commission on Information and Accountability for Women's and Children's Health may present an opportunity to partially address the limitations in reporting on ODA for HRH and present solutions to establish a global baseline.</p

Monitoring and evaluation of human resources for health: an international perspective

BACKGROUND: Despite the undoubted importance of human resources to the functions of health systems, there is little consistency between countries in how human resource strategies are monitored and evaluated. This paper presents an integrated approach for developing an evidence base on human resources for health (HRH) to support decision-making, drawing on a framework for health systems performance assessment. METHODS: Conceptual and methodological issues for selecting indicators for HRH monitoring and evaluation are discussed, and a range of primary and secondary data sources that might be used to generate indicators are reviewed. Descriptive analyses are conducted drawing primarily on one type of source, namely routinely reported data on the numbers of health personnel and medical schools as covered by national reporting systems and compiled by the World Health Organization. Regression techniques are used to triangulate a given HRH indicator calculated from different data sources across multiple countries. RESULTS: Major variations in the supply of health personnel and training opportunities are found to occur by region. However, certain discrepancies are also observed in measuring the same indicator from different sources, possibly related to the occupational classification or to the sources' representation. CONCLUSION: Evidence-based information is needed to better understand trends in HRH. Although a range of sources exist that can potentially be used for HRH assessment, the information that can be derived from many of these individual sources precludes refined analysis. A variety of data sources and analytical approaches, each with its own strengths and limitations, is required to reflect the complexity of HRH issues. In order to enhance cross-national comparability, data collection efforts should be processed through the use of internationally standardized classifications (in particular, for occupation, industry and education) at the greatest level of detail possible

A realist synthesis of randomised control trials involving use of community health workers for delivering child health interventions in low and middle income countries

<p>Abstract</p> <p>Background</p> <p>A key constraint to saturating coverage of interventions for reducing the burden of childhood illnesses in Low and Middle Income Countries (LMIC) is the lack of human resources. Community health workers (CHW) are potentially important actors in bridging this gap. Evidence exists on effectiveness of CHW in management of some childhood illnesses (IMCI). However, we need to know how and when this comes to be. We examine evidence from randomized control trials (RCT) on CHW interventions in IMCI in LMIC from a realist perspective with the aim to see if they can yield insight into the working of the interventions, when examined from a different perspective.</p> <p>Methods</p> <p>The realist approach involves educing the mechanisms through which an intervention produced an outcome in a particular context. 'Mechanisms' are reactions, triggered by the interaction of the intervention and a certain context, which lead to change. These are often only implicit and are actually hypothesized by the reviewer. This review is limited to unravelling these from the RCTs; it is thus a hypothesis generating exercise.</p> <p>Results</p> <p>Interventions to improve CHW performance included 'Skills based training of CHW', 'Supervision and referral support from public health services', 'Positioning of CHW in the community'. When interventions were applied in context of CHW programs embedded in local health services, with beneficiaries who valued services and had unmet needs, the interventions worked if following mechanisms were triggered: anticipation of being valued by the community; perception of improvement in social status; sense of relatedness with beneficiaries and public services; increase in self esteem; sense of self efficacy and enactive mastery of tasks; sense of credibility, legitimacy and assurance that there was a system for back-up support. Studies also showed that if context differed, even with similar interventions, negative mechanisms could be triggered, compromising CHW performance.</p> <p>Conclusion</p> <p>The aim of this review was to explore if RCTs could yield insight into the working of the interventions, when examined from a different, a realist perspective. We found that RCTs did yield some insight, but the hypotheses generated were very general and not well refined. These hypotheses need to be tested and refined in further studies.</p