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

“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.

Sex partners as bystanders in HIV prevention trials: Two test cases for research ethics

Research involving human subjects can impose risk on some ‘bystanders’– people who are not themselves research subjects but whom the study may affect. We examine the consequences of research for a particular category of bystanders – research subjects’ sex partners – in trials testing interventions to reduce (1) HIV transmission (HIV treatment-asprevention trials) and (2) HIV acquisition (HIV pre-exposure prophylaxis trials). Both types of trials provide useful test cases for assessing whether bystanders to research deserve special consideration in ethics reviews, and potentially some of the benefits and protections that research subjects receive. In HIV treatment-as-prevention trials, there are two groups of people who are alike in many important respects but treated very differently by research ethics: research subjects who contribute data on the primary endpoint of the trial (because some of them have sex with the people receiving the treatment conditions of the trials) – and bystanders who are not enrolled in the trials but who could have contributed primary endpoint data in the same way as the first group. In pre-exposure trials, the sex partners of people participating in pre-exposure prophylaxis trials are bystanders, even though they are necessary for the success of the trial. Research subjects’ utonomy is fiercely protected by trial enrolment processes. Bystanders, by contrast, often have no choice but to be affected by the study, because of their relationship to a research subject. In HIV prevention trials, standing by can come with important risks, including the same ones on which the success of the research hinges. It is thus important to consider the ethical obligations to protect bystanders, and the related procedural responsibilities

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.

"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.

Health systems and HIV treatment in sub-Saharan Africa: Matching intervention and program evaluation strategies

Objectives International donors financing the delivery of antiretroviral treatment (ART) in developing countries have recently emphasized their commitment to rigorous evaluation of ART impact on population health. In the same time frame but different contexts, they have announced that they will shift funding from vertically-structured (i.e., disease-specific) interventions to horizontally-structured interventions (i.e., staff, systems and infrastructure that can deliver care for many diseases). We analyze likely effects of the latter shift on the feasibility of impact evaluation. Methods We examine the effect of the shift in intervention strategy on (i) outcome measurement, (ii) cost measurement, (iii) study-design options, and the (iv) technical and (v) political feasibility of program evaluation. Results As intervention structure changes from vertical to horizontal, outcome and cost measurement are likely to become more difficult (because the number of relevant outcomes and costs increases and the sources holding data on these measures become more diverse); study design options become more limited (because it is often impossible to identify a rigorously defined counterfactual in horizontal interventions); the technical feasibility of interventions is reduced (because lag times between intervention and impact increase in length and effect mediating and modifying factors increase in number); and political feasibility of evaluation is decreased (because national policymakers may be reluctant to support the evaluation). Conclusions In the choice of intervention strategy, policymakers need to consider the effect of intervention strategy on impact evaluation. Methodological studies are needed to identify the best approaches to evaluate the population health impact of horizontal interventions.Impact evaluation, health systems, HIV, antiretroviral treatment, Africa

Estimating health worker need to provide antiretroviral treatment in the developing world

Despite recent international efforts to increase antiretroviral treatment (ART) coverage, more than 5 million people who need ART in developing countries do not receive such treatment. Shortages of human resources to treat HIV/AIDS (referred to herein as HRHA) are one of the main constraints to further scaling up ART. Planning expansion of ART depends on the ability to predict how many HRHA will be needed in the future. We investigate whether taking into account positive feedback from the current supply of HRHA to future HRHA need substantially alters predictions. This feedback occurs because an increase in the number of HRHA implies an increase in the number of individuals receiving ART and – because ART is a lifelong treatment and is effective in prolonging the lives of HIV-positive people – a rise over time in the number of people requiring ART.Disease, control, global health, HIV/AIDS, Africa.

A Mathematical Model for Estimating the Number of Health Workers Required for Universal Antiretroviral Treatment

Despite recent international efforts to increase antiretroviral treatment (ART) coverage, it is estimated that more than 5 million people who need ART in developing countries do not receive such treatment. Shortages of human resources to treat HIV/AIDS (HRHA) are one of the main constraints to scaling up ART. We develop a discrete-time Markovian model to project the numbers of HRHA required to achieve universal ART coverage, taking into account the positive feedback from HRHA numbers to future HRHA need. Feedback occurs because ART is effective in prolonging the lives of HIVpositive people who need treatment, so that an increase in the number of people receiving treatment leads to an increase in the number of people needing it in future periods. We investigate the steady-state behavior of our model and apply it to different regions in the developing world. We find that taking into account the feedback from the current supply of HRHA to the future HRHA need substantially increases the projected numbers of HRHA required to achieve universal ART coverage. We discuss the policy implications of our model.Mathematical model, health workers, universal antiretroviral treatment

HIV Treatment-as-Prevention Research at a Crossroads

In light of changing WHO guidelines for HIV treatment, Till Bärnighausen and colleagues consider how large-scale HIV treatment-as-prevention trials can be adapted so that they can remain viable. Please see later in the article for the Editors' Summar