In January, 2009, the World Health Organization’s (WHO) Executive Board considered the adoption of a global code of practice to address the movement of health workers from developing countries, the ‘WHO Draft Code of Practice for the International Recruitment of Health Workers’. This attention to brain drain is welcome, but the initiative does not begin to adequately address the consequences or roots of health-worker migration from sub-Saharan Africa to the rich developed world, especially to the United Kingdom, United States and Canada. The movement of skilled health workers constitutes a major transfer of riches from poor societies to the affluent, and the only appropriate redress is a bilaterally managed scheme of direct reimbursement of the value lost, along the lines proposed by Mensah and colleagues in 2005.
Human Resources
Although the Human Resources for Health (HRH) crisis is apparently not new in the public health agenda of many countries, not many low and middle income countries are using Primary Health Care (PHC) as a tool for planning and addressing the crisis in a comprehensive manner. The aim of this paper is to appraise the inadequacies of the existing planning approaches in addressing the growing HRH crisis in resource limited settings. A descriptive literature review of selected case studies in middle and low income countries reinforced with the evidence from Tanzania was used. Consultations with experts in the field were also made. In this review, we propose a conceptual framework that describes planning may only be effective if it is structured to embrace the fundamental principles of PHC. We place the core principles of PHC at the centre of HRH planning as we acknowledge its major perspective that the effectiveness of any public health policy depends on the degree to which it envisages to address public health problems multi-dimensionally and comprehensively. The proponents of PHC approach in planning have identified inter-sectoral action and collaboration and comprehensive approach as the two basic principles that policies and plans should accentuate in order to make them effective in realizing their pre-determined goals. Two conclusions are made: Firstly, comprehensive health workforce planning is not widely known and thus not frequently used in HRH planning or analysis of health workforce issues; Secondly, comprehensiveness in HRH planning is important but not sufficient in ensuring that all the ingredients of HRH crisis are eliminated. In order to be effective and sustainable, the approach need to evoke three basic values namely effectiveness, efficiency and equity.
Compulsory service programmes have been used worldwide as a way to deploy and retain a professional health workforce within countries. This study identified three different types of compulsory service programmes in 70 countries. These programmes are all governed by some type of regulation, ranging from a parliamentary law to a policy within the ministry of health. Depending on the country, doctors, nurses, midwives and all types of professional allied health workers are required to participate in the programme. Some of the compliance-enforcement measures include withholding full registration until obligations are completed, withholding degree and salary, or imposing large fines. This paper aims to explain these programmes more clearly, to identify countries that have or had such programmes, to develop a typology for the different kinds and to discuss the programmes in the light of important issues that are related to policy concepts and implementation. As governments consider the cost of investment in health professionals’ education, the loss of health professionals to emigration and the lack of health workers in many geographic areas, they are using compulsory service requirements as a way to deploy and retain the health workforce.
Compulsory service programmes have been used worldwide as a way to deploy and retain a professional health workforce within countries. Other names for these programmes include 'obligatory', 'mandatory', 'required' and 'requisite.' All these different programme names refer to a country’s law or policy that governs the mandatory deployment and retention of a heath worker in the underserved and/or rural areas of the country for a certain period of time. This study identified three different types of compulsory service programmes in 70 countries. These programmes are all governed by some type of regulation, ranging from a parliamentary law to a policy within the ministry of health. Depending on the country, doctors, nurses, midwives and all types of professional allied health workers are required to participate in the programme. Some of the compliance-enforcement measures include withholding full registration until obligations are completed, withholding degree and salary, or imposing large fines. This paper aims to explain these programmes more clearly, to identify countries that have or had such programmes, to develop a typology for the different kinds and to discuss the programmes in the light of important issues that are related to policy concepts and implementation. As governments consider the cost of investment in health professionals’ education, the loss of health professionals to emigration and the lack of health workers in many geographic areas, they are using compulsory service requirements as a way to deploy and retain the health workforce.
Participatory research approaches such as the Health Workers for Change (HWC) initiative have been successful in improving provider-client relationships in various developing country settings, but have not yet been reported in the complex environment of hospital wards. This study evaluated the HWC approach for improving the relationship between nurses and parents on a paediatric ward in a busy regional hospital in Tanzania. Six workshops were held, attended by 29 of 31 trained nurses and nurse attendants working on the paediatric ward. Two focus-group discussions were held with the workshop participants six months after the intervention. Some improvement was reported in the responsiveness of nurses to client needs (41.2% of parents were satisfied, up from 38.9%). But nurses felt hindered by persisting problems in their working environment, including poor relationships with other staff and a lack of response from hospital administration to their needs.
Access to well trained and motivated health workers is the major rural health issue. Without local access, it is unlikely that people in rural and remote communities will be able to achieve the Millennium Development Goals. Studies in many countries have shown that the three factors most strongly associated with entering rural practice are: a rural background; positive clinical and educational experiences in rural settings as part of undergraduate medical education; and targeted training for rural practice at the postgraduate level. This paper presents evidence for policy initiatives involving the training of medical students from, in and for rural and remote areas. It gives examples of medical schools in different regions of the world that are using an evidence-based and context-driven educational approach to producing skilled and motivated health workers. It demonstrates how context influences the design and implementation of different rural education programmes. Successful programmes have overcome major obstacles including negative assumptions and attitudes, and limitations of human, physical, educational and financial resources. Training rural health workers in the rural setting is likely to result in greatly improved recruitment and retention of skilled health-care providers in rural underserved areas with consequent improvement in access to health care for the local communities.
Young women in Malawi face many challenges in accessing family planning, including distance to the health facility and partner disapproval. The author’s primary objective was to assess if training Health Surveillance Assistants in couples counselling would increase modern family planning uptake among young women. In this cluster randomised controlled trial, 30 Health Surveillance Assistants from Lilongwe, Malawi received training in family planning. The Health Surveillance Assistants were then randomised 1:1 to receive or not receive additional training in couples counselling. All Health Surveillance Assistants were asked to provide family planning counselling to women in their communities and record their contraceptive uptake over 6 months. Sexually-active women <30 years of age who had never used a modern family planning method were included in this analysis. Generalised estimating equations with an exchangeable correlation matrix to account for clustering by Health Surveillance Assistants were used to estimate risk differences and 95% confidence intervals. 430 (53%) young women were counselled by the 15 Health Surveillance Assistants who received couples counselling training, and 378 (47%) were counselled by the 15 Health Surveillance Assistants who did not. 115 (26%) from the couples counselling group had male partners present during their first visit, compared to only 6 (2%) from the other group. Nearly all (99.5%) initiated a modern family planning method, with no difference between groups. Women in the couples counselling group were 8% more likely to receive male condoms and 8% more likely to receive dual methods. Training Health Surveillance Assistants in family planning led to high modern family planning uptake among young women who had never used family planning. Couples counselling training increased male involvement with a trend towards higher male condom uptake.
This case study describes how Kenya created an inter-county, multi-stakeholder coordination framework that promotes consensus, commitment, and cooperation in devolved human resources management. The coordination framework has been instrumental in expediting development, customization, and dissemination of policies, enabling national human resources for health officers to mentor their county counterparts, and providing collaborative platforms for multiple stakeholders to resolve challenges and harmonize practices nationwide. Successes catalyzed through the inter-county forums include hiring over 20 000 health workers to address shortages; expanding the national human resources information system to all 47 counties; developing guidelines for sharing specialist providers; and establishing professionalized human resources for health units in all 47 counties. The coordination framework supports alignment of county health operations with national goals while enabling national policy responses to health gaps in the counties.
The Health and Human Rights Programme at the University of Cape Town, South Africa, in conjunction with the Health Professions Council of South Africa, the South African Nursing Coulncil, the South African Medical Association and the Democratic Nurses Organisation, hosted a conference exploring what are Core Competencies in Human Rights for graduates in the health professions. The conference aimed to provide guidance to those bodies setting standards for our graduates as to what kinds of competencies and skills should be expected of doctors, nurses and other health professionals once they graduate from our training institutions. The conference took place from Wednesday 5th to Friday 7th July and helped to develop recommendations for curriculum standards for graduates in the health professions in South Africa.
This paper reports on two separate experiences of costing for Human Resources Development Plans (HRDP) costing in Mozambique and Guinea Bissau, with the objective of providing an insight into the practice of costing exercises in information-poor settings, as well as to contribute to the existing debate on human resources costing methodologies. The study adopts a case-study approach to analyse the methodologies developed in the two countries, their contexts, policy processes and actors involved. From the analysis of the two cases, it emerged that the costing exercises represented an important driver of the HRDP elaboration, which lent credibility to the process, and provided a financial framework within which HRH policies could be discussed. In both cases, bottom-up and country-specific methods were designed to overcome the countries' lack of cost and financing data, as well as to interpret their financial systems. Such an approach also allowed the costing exercises to feed directly into the national planning and budgeting process. The authors conclude that bottom-up and country-specific costing methodologies have the potential to serve adequately the multi-faceted purpose of the exercise. However, adopting pre-defined and insufficiently flexible tools may undermine the credibility of the costing exercise, and reduce the space for policy negotiation opportunities within the HRDP elaboration process.