Health reforms that aim at increasing efficiency, quality and users' satisfaction need to take into consideration human resource issues, because the health sector is labor-intensive and the performance of health systems depends on qualified and motivated workers [1
]. At the same time, the support of the workforce is crucial to ensure successful implementation of reforms.
In Latin America, the need to improve the performance of the workforce had been pointed out in many health sector assessments conducted in the 1970s and 1980s by the United States Agency for International Development (USAID), the World Bank (WB), other agencies and independent researchers. (See for Argentina [5
], for Bolivia [8
], for Brazil [11
], for Chile [7
], for Colombia [12
], for Costa Rica [15
], for the Dominican Republic [16
], for Ecuador [19
], for El Salvador [21
], for Guatemala [22
], for Mexico [12
], for Nicaragua [27
], for Panama [28
], and for Uruguay [7
From these reports and studies, and notwithstanding the differences among the countries in the region, we can summarize the problems present during the 1970s and 1980s as follows:
• The skill mix of health personnel was often inadequate to meet the needs of the communities, and highly qualified staff often performed tasks that could be conducted by less-trained providers. The health systems of the region were characterized by an excess number of medical specialists and insufficient numbers of other professionals such as primary care providers, nurses, pharmacists, public health specialists, epidemiologists, health economists, accountants, social workers, administrators, communication experts, planners, health educators, nutritionists, physical therapists and sanitary engineers;
• There was an over-concentration of qualified health personnel in hospitals and urban centers, coupled with shortages in poor neighborhoods and rural areas;
• A large majority of physicians held at least two jobs, one in the government and one in the private sector. In countries with fragmented health systems, physicians could even have three jobs: they worked part time for the social security institute, they worked for the ministry of health, and also held a private practice. Dual or triple employment generated conflicts of interests; physicians used the public sector to draw patients for their private practice, and their productivity in the public post was low and absenteeism high;
• Human resources management systems were weak, largely due to dispersal of accountability: in many countries the terms and conditions of employment were under the control of the public service commission or the ministry of finance, and the education of human resources was under the control of the ministry of education or the private sector. Ministries of health did not have any input in determining the types and number of persons to be trained, and their involvement in hiring and managing the health workforce was limited. Health managers handled relations with the labor unions, had some limited supervisory roles, ensured organizational adherence to recruitment policies, and were responsible for some training.
• Salary increases were generally based on years of service. In the majority of countries, central labor unions negotiated working conditions directly with governments and signed collective agreements that left administrators with little room to compensate workers according to performance;
• Personnel decisions (hiring and promotion) were too often guided by favoritism, political dictates, and nepotism;
• Health professionals were insufficiently committed to the public system due to the conflict of interests mentioned above, poor personnel management systems and the perception that wages were low;
• The medical profession strongly dominated the definition of health sector policies and the regulation of the conditions of practice of all health professions;
• Communication between providers and patients was poor, and providers and service users had very different social and cultural backgrounds. In countries with Amerindian-speaking populations, providers did not speak their languages;
• The regulation of training institutions and conditions of practice was weak;
• The training of health promoters and other auxiliary personnel such as dental assistants, midwives, laboratory technicians, equipment maintenance and repair technicians, and pharmacy clerks was poor or non-existent, thus their performance was poor.
According to the literature reviewed, these conditions led to low productivity and efficiency; inadequate equipment; shortages of supplies and drugs; unmotivated and inadequately trained staff; questionable quality of care; and low users' satisfaction.
By the mid-1970s, the need to reform the human component of the health services was very urgent, and the urgency increased with the severe economic downturn that countries of the region suffered during in the early 1980s. The size of the Latin America health labor force (about nine million [30
]) implied that reformers attempting to resolve the human resources problems mentioned above needed to dedicate a large amount of time and resources to it.
This paper reviews the impact of the health reforms carried out under the leadership of the World Bank. Data come from a review of the literature including the leading Latin American and non-Latin American journals, monographs, documents found in ministries and reform offices, technical reports, papers presented at conferences and fieldwork carried out by the authors between 1980 and the present in Bolivia, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Honduras, Mexico and Peru.