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1.  Issues facing the future health care workforce: the importance of demand modelling 
This article examines issues facing the future health care workforce in Australia in light of factors such as population ageing. It has been argued that population ageing in Australia is affecting the supply of health care professionals as the health workforce ages and at the same time increasing the demand for health care services and the health care workforce.
However, the picture is not that simple. The health workforce market in Australia is influenced by a wide range of factors; on the demand side by increasing levels of income and wealth, emergence of new technologies, changing disease profiles, changing public health priorities and a focus on the prevention of chronic disease. While a strong correlation is observed between age and use of health care services (and thus health care workforce), this is mediated through illness, as typified by the consistent finding of higher health care costs in the months preceding death.
On the supply side, the health workforce is highly influenced by policy drivers; both national policies (eg funded education and training places) and local policies (eg work place-based retention policies). Population ageing and ageing of the health workforce is not a dominant influence. In recent years, the Australian health care workforce has grown in excess of overall workforce growth, despite an ageing health workforce. We also note that current levels of workforce supply compare favourably with many OECD countries. The future of the health workforce will be shaped by a number of complex interacting factors.
Market failure, a key feature of the market for health care services which is also observed in the health care labour market – means that imbalances between demand and supply can develop and persist, and suggests a role for health workforce planning to improve efficiency in the health services sector. Current approaches to health workforce planning, especially on the demand side, tend to be highly simplistic. These include historical allocation methods, such as the personnel-to-population ratios which are essentially circular in their rationale rather than evidence-based. This article highlights the importance of evidence-based demand modelling for those seeking to plan for the future Australian health care workforce. A model based on population health status and best practice protocols for health care is briefly outlined.
PMCID: PMC2685808  PMID: 19422686
2.  How evidence-based workforce planning in Australia is informing policy development in the retention and distribution of the health workforce 
Australia’s health workforce is facing significant challenges now and into the future. Health Workforce Australia (HWA) was established by the Council of Australian Governments as the national agency to progress health workforce reform to address the challenges of providing a skilled, innovative and flexible health workforce in Australia. HWA developed Australia’s first major, long-term national workforce projections for doctors, nurses and midwives over a planning horizon to 2025 (called Health Workforce 2025; HW 2025), which provided a national platform for developing policies to help ensure Australia’s health workforce meets the community’s needs.
A review of existing workforce planning methodologies, in concert with the project brief and an examination of data availability, identified that the best fit-for-purpose workforce planning methodology was the stock and flow model for estimating workforce supply and the utilisation method for estimating workforce demand. Scenario modelling was conducted to explore the implications of possible alternative futures, and to demonstrate the sensitivity of the model to various input parameters. Extensive consultation was conducted to test the methodology, data and assumptions used, and also influenced the scenarios selected for modelling. Additionally, a number of other key principles were adopted in developing HW 2025 to ensure the workforce projections were robust and able to be applied nationally.
The findings from HW 2025 highlighted that a ‘business as usual’ approach to Australia’s health workforce is not sustainable over the next 10 years, with a need for co-ordinated, long-term reforms by government, professions and the higher education and training sector for a sustainable and affordable health workforce. The main policy levers identified to achieve change were innovation and reform, immigration, training capacity and efficiency and workforce distribution.
While HW 2025 has provided a national platform for health workforce policy development, it is not a one-off project. It is an ongoing process where HWA will continue to develop and improve health workforce projections incorporating data and methodology improvements to support incremental health workforce changes.
PMCID: PMC3922608  PMID: 24490586
Workforce planning; Workforce projections
3.  Australian public health policy in 2003 – 2004 
In Australia, compared with other developed countries the many and varied programs which comprise public health have continued to be funded poorly and unsystematically, particularly given the amount of publicly voiced political support.
In 2003, the major public health policy developments in communicable disease control were in the fields of SARS, and vaccine funding, whilst the TGA was focused on the Pan Pharmaceutical crisis. Programs directed to health maintenance and healthy ageing were approved. The tertiary education sector was involved in the development of programs for training the public health workforce and new professional qualifications and competencies. The Abelson Report received support from overseas experts, providing a potential platform for calls to improve national funding for future Australian preventive programs; however, inconsistencies continued across all jurisdictions in their approaches to tackling national health priorities. Despite 2004 being an election year, public health policy was not visible, with the bulk of the public health funding available in the 2004/05 federal budget allocated to managing such emerging risks as avian flu. We conclude by suggesting several implications for the future.
PMCID: PMC1087471  PMID: 15811192
4.  CAM practitioners in the Australian health workforce: an underutilized resource 
CAM practitioners are a valuable but underutilizes resource in Australian health care. Despite increasing public support for complementary and alternative medicine (CAM) little is known about the CAM workforce. Apart from the registered professions of chiropractic, osteopathy and Chinese medicine, accurate information about the number of CAM practitioners in the workforce has been difficult to obtain. It appears that many non-registered CAM practitioners, although highly qualified, are not working to their full capacity.
Increasing public endorsement of CAM stands in contrast to the negative attitude toward the CAM workforce by some members of the medical and other health professions and by government policy makers. The marginalisation of the CAM workforce is evident in prejudicial attitudes held by some members of the medical and other health professions and its exclusion from government policy making. Inconsistent educational standards has meant that non-registered CAM practitioners, including highly qualified and competent ones, are frequently overlooked. Legitimising their contribution to the health workforce could alleviate workforce shortages and provide opportunities for redesigned job roles and new multidisciplinary teams. Priorities for better utilisation of the CAM workforce include establishing a guaranteed minimum education standard for more CAM occupation groups through national registration, providing interprofessional education that includes CAM practitioners, developing courses to upgrade CAM practitioners' professional skills in areas of indentified need, and increasing support for CAM research.
Marginalisation of the CAM workforce has disadvantaged those qualified and competent CAM practitioners who practise evidence-informed medicine on the basis of many years of university training. Legitimising and expanding the important contribution of CAM practitioners could alleviate projected health workforce shortages, particularly for the prevention and management of chronic health conditions and for health promotion.
PMCID: PMC3528465  PMID: 23116374
5.  The Australian preventive health agenda: what will this mean for workforce development? 
The formation of the National Health and Hospitals Reform Commission (NHHRC) and the National Preventative Task Force in 2008, demonstrate a renewed Australian Government commitment to health reform. The re-focus on prevention, bringing it to the centre of health care has significant implications for health service delivery in the primary health care setting, supportive organisational structures and continuing professional development for the existing clinical and public health workforce. It is an opportune time, therefore, to consider new approaches to workforce development aligned to health policy reform. Regardless of the actual recommendations from the NHHRC in June 2009, there will be an emphasis on performance improvements which are accountable and aligned to new preventive health policy, organisational priorites and anticipated improved health outcomes.
To achieve this objective there will be a need for the existing population health workforce, primary health care and non-government sectors to increase their knowledge and understanding of prevention, promotion and protection theory and practice within new organisational frameworks and linked to the community. This shift needs to be part of a national health services research agenda, infrastructure and funding which is supportive of quality continuing professional development.
This paper discusses policy and practice issues related to workforce development as part of an integrated response to the preventive agenda.
PMCID: PMC2696455  PMID: 19463159
6.  Working in disadvantaged communities: What additional competencies do we need? 
Residents of socioeconomically disadvantaged locations are more likely to have poor health than residents of socioeconomically advantaged locations and this has been comprehensively mapped in Australian cities. These inequalities present a challenge for the public health workers based in or responsible for improving the health of people living in disadvantaged localities. The purpose of this study was to develop a generic workforce needs assessment tool and to use it to identify the competencies needed by the public health workforce to work effectively in disadvantaged communities.
A two-step mixed method process was used to identify the workforce needs. In step 1 a generic workforce needs assessment tool was developed and applied in three NSW Area Health Services using focus groups, key stakeholder interviews and a staff survey. In step 2 the findings of this needs assessment process were mapped against the existing National Health Training Package (HLT07) competencies, gaps were identified, additional competencies described and modules of training developed to fill identified gaps.
There was a high level of agreement among the AHS staff on the nature of the problems to be addressed but less confidence indentifying the work to be done. Processes for needs assessments, community consultations and adapting mainstream programs to local needs were frequently mentioned as points of intervention. Recruiting and retaining experienced staff to work in these communities and ensuring their safety were major concerns. Workforce skill development needs were seen in two ways: higher order planning/epidemiological skills and more effective working relationships with communities and other sectors. Organisational barriers to effective practice were high levels of annual compulsory training, balancing state and national priorities with local needs and giving equal attention to the population groups that are easy to reach and to those that are difficult to engage. A number of additional competency areas were identified and three training modules developed.
The generic workforce needs assessment tool was easy to use and interpret. It appears that the public health workforce involved in this study has a high level of understanding of the relationship between the social determinants and health. However there is a skill gap in identifying and undertaking effective intervention.
PMCID: PMC2684114  PMID: 19393091
7.  Assessment of graduate public health education in Nepal and perceived needs of faculty and students 
Despite the large body of evidence suggesting that effective public health infrastructure is vital to improving the health status of populations, many universities in developing countries offer minimal opportunities for graduate training in public health. In Nepal, for example, only two institutions currently offer a graduate public health degree. Both institutions confer only a general Masters in Public Health (MPH), and together produce 30 graduates per year. The objective of this assessment was to identify challenges in graduate public health education in Nepal, and explore ways to address these challenges.
The assessment included in-person school visits and data collection through semi-structured in-depth interviews with primary stakeholders of Nepal’s public health academic sector. The 72 participants included faculty, students, alumni, and leaders of institutions that offered MPH programs, and the leadership of one government-funded institution that is currently developing an MPH program. Data were analyzed through content analysis to identify major themes.
Six themes characterizing the challenges of expanding and improving graduate public health training were identified: 1) a shortage of trained public health faculty, with consequent reliance on the internet to compensate for inadequate teaching resources; 2) teaching/learning cultures and bureaucratic traditions that are not optimal for graduate education; 3) within-institution dominance of clinical medicine over public health; 4) a desire for practice–oriented, contextually relevant training opportunities; 5) a demand for degree options in public health specialties (for example, epidemiology); and 6) a strong interest in international academic collaboration.
Despite an enormous need for trained public health professionals, Nepal’s educational institutions face barriers to developing effective graduate programs. Overcoming these barriers will require: 1) increasing the investment in public health education and 2) improving the academic environment of educational institutions. Long term, committed academic collaborations with international universities may be a realistic way to: 1) redress immediate inadequacies in resources, including teachers; 2) encourage learning environments that promote inquiry, creativity, problem-solving, and critical thinking; and 3) support development of the in-country capacity of local institutions to produce a cadre of competent, well-trained public health practitioners, researchers, teachers, and leaders.
PMCID: PMC3640966  PMID: 23621945
Public health; Graduate public health education; Nepal; Collaboration; Global health; E-learning
8.  Human resource governance: what does governance mean for the health workforce in low- and middle-income countries? 
Research on practical and effective governance of the health workforce is limited. This paper examines health system strengthening as it occurs in the intersection between the health workforce and governance by presenting a framework to examine health workforce issues related to eight governance principles: strategic vision, accountability, transparency, information, efficiency, equity/fairness, responsiveness and citizen voice and participation.
This study builds off of a literature review that informed the development of a framework that describes linkages and assigns indicators between governance and the health workforce. A qualitative analysis of Health System Assessment (HSA) data, a rapid indicator-based methodology that determines the key strengths and weaknesses of a health system using a set of internationally recognized indicators, was completed to determine how 20 low- and middle-income countries are operationalizing health governance to improve health workforce performance.
The 20 countries assessed showed mixed progress in implementing the eight governance principles. Strengths highlighted include increasing the transparency of financial flows from sources to providers by implementing and institutionalizing the National Health Accounts methodology; increasing responsiveness to population health needs by training new cadres of health workers to address shortages and deliver care to remote and rural populations; having structures in place to register and provide licensure to medical professionals upon entry into the public sector; and implementing pilot programs that apply financial and non-financial incentives as a means to increase efficiency. Common weaknesses emerging in the HSAs include difficulties with developing, implementing and evaluating health workforce policies that outline a strategic vision for the health workforce; implementing continuous licensure and regulation systems to hold health workers accountable after they enter the workforce; and making use of health information systems to acquire data from providers and deliver it to policymakers.
The breadth of challenges facing the health workforce requires strengthening health governance as well as human resource systems in order to effect change in the health system. Further research into the effectiveness of specific interventions that enhance the link between the health workforce and governance are warranted to determine approaches to strengthening the health system.
PMCID: PMC3584723  PMID: 23414237
Health governance; Health workforce; Human resources for health; Health system strengthening; Human resource management
9.  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.
PMCID: PMC179882  PMID: 12904251
10.  Human resource management in post-conflict health systems: review of research and knowledge gaps 
Conflict and Health  2014;8:18.
In post-conflict settings, severe disruption to health systems invariably leaves populations at high risk of disease and in greater need of health provision than more stable resource-poor countries. The health workforce is often a direct victim of conflict. Effective human resource management (HRM) strategies and policies are critical to addressing the systemic effects of conflict on the health workforce such as flight of human capital, mismatches between skills and service needs, breakdown of pre-service training, and lack of human resource data. This paper reviews published literatures across three functional areas of HRM in post-conflict settings: workforce supply, workforce distribution, and workforce performance. We searched published literatures for articles published in English between 2003 and 2013. The search used context-specific keywords (e.g. post-conflict, reconstruction) in combination with topic-related keywords based on an analytical framework containing the three functional areas of HRM (supply, distribution, and performance) and several corresponding HRM topic areas under these. In addition, the framework includes a number of cross-cutting topics such as leadership and governance, finance, and gender. The literature is growing but still limited. Many publications have focused on health workforce supply issues, including pre-service education and training, pay, and recruitment. Less is known about workforce distribution, especially governance and administrative systems for deployment and incentive policies to redress geographical workforce imbalances. Apart from in-service training, workforce performance is particularly under-researched in the areas of performance-based incentives, management and supervision, work organisation and job design, and performance appraisal. Research is largely on HRM in the early post-conflict period and has relied on secondary data. More primary research is needed across the areas of workforce supply, workforce distribution, and workforce performance. However, this should apply a longer-term focus throughout the different post-conflict phases, while paying attention to key cross-cutting themes such as leadership and governance, gender equity, and task shifting. The research gaps identified should enable future studies to examine how HRM could be used to meet both short and long term objectives for rebuilding health workforces and thereby contribute to achieving more equitable and sustainable health systems outcomes after conflict.
PMCID: PMC4187016  PMID: 25295071
Human resource management; Health workforce; Post-conflict; Fragile; Health systems; Reconstruction
11.  Building capacity to develop an African teaching platform on health workforce development: a collaborative initiative of universities from four sub Saharan countries 
Health systems in many low-income countries remain fragile, and the record of human resource planning and management in Ministries of Health very uneven. Public health training institutions face the dual challenge of building human resources capacity in ministries and health services while alleviating and improving their own capacity constraints. This paper reports on an initiative aimed at addressing this dual challenge through the development and implementation of a joint Masters in Public Health (MPH) programme with a focus on health workforce development by four academic institutions from East and Southern Africa and the building of a joint teaching platform.
Data were obtained through interviews and group discussions with stakeholders, direct and participant observations, and reviews of publications and project documents. Data were analysed using thematic analysis.
Case description
The institutions developed and collaboratively implemented a ‘Masters Degree programme with a focus on health workforce development’. It was geared towards strengthening the leadership capacity of Health ministries to develop expertise in health human resources (HRH) planning and management, and simultaneously build capacity of faculty in curriculum development and innovative educational practices to teach health workforce development. The initiative was configured to facilitate sharing of experience and resources.
The implementation of this initiative has been complex, straddling multiple and changing contexts, actors and agendas. Some of these are common to postgraduate programmes with working learners, while others are unique to this particular partnership, such as weak institutional capacity to champion and embed new programmes and approaches to teaching.
The partnership, despite significant inherent challenges, has potential for providing real opportunities for building the field and community of practice, and strengthening the staff and organizational capacity of participant institutions. Key learning points of the paper are:
• the need for long-term strategies and engagement;
• the need for more investment and attention to developing the capacity of academic institutions;
• the need to invest specifically in educational/teaching expertise for innovative approaches to teaching and capacity development more broadly; and
• the importance of increasing access and support for students who are working adults in public health institutions throughout Africa.
PMCID: PMC4049409  PMID: 24886267
African teaching platform; Institutional capacity development; Health workforce development; Partnership; Sustainability; Flexible delivery; South-South cooperation
12.  Australian experts' perspectives on a curriculum for psychologists working in primary health care: implication for Indonesia 
In Indonesia there is a pressing need to scale up mental health services due to a substantial unmet need for mental health care. Integrating psychologists into primary health care can potentially deliver affordable mental health services to communities and help to close the treatment gap. Australia is one of the pioneers in integrating mental health into primary health care, and the mental health reforms in Australia may have some implications for Indonesia. The aim of this paper is to examine the Australian experience and to reflect in particular on lessons that may be learnt to inform the development of curriculum for psychologists working in primary health care in Indonesia. Data were collected through semi-structured interviews with 12 Australian experts in primary mental health care. The focus of the interview was on the roles and skills of psychologists working in primary health care with a particular focus on the appropriate curriculum for psychologists. Overall, the Australian experts agreed that psychologists' roles and training should include both clinical skills and public mental health skills. The experts also agreed that psychologists should be able to educate the community about mental health issues and be capable of undertaking research and evaluation of programs. A central theme was the need for strong collaborations with general practitioners and existing agencies in the community so that psychologists are able to make appropriate referrals and also accept referrals. The lessons learnt from the Australian experience, which are most applicable to the Indonesian setting are: (1) the importance of adequate government funding of psychologists; (2) the value of evidence-based treatments such as Cognitive Behavioural Therapy; (3) the need to specifically train psychologists for primary care; (4) the need for flexibility in the psychologist workforce (e.g. location); and (5) the value of continuing supervision for psychologists to support them in their role.
PMCID: PMC4346017  PMID: 25750829
psychologists; primary mental health care; Indonesia; curriculum development; Australian experts
13.  Public health human resources: a comparative analysis of policy documents in two Canadian provinces 
Amidst concerns regarding the capacity of the public health system to respond rapidly and appropriately to threats such as pandemics and terrorism, along with changing population health needs, governments have focused on strengthening public health systems. A key factor in a robust public health system is its workforce. As part of a nationally funded study of public health renewal in Canada, a policy analysis was conducted to compare public health human resources-relevant documents in two Canadian provinces, British Columbia (BC) and Ontario (ON), as they each implement public health renewal activities.
A content analysis of policy and planning documents from government and public health-related organizations was conducted by a research team comprised of academics and government decision-makers. Documents published between 2003 and 2011 were accessed (BC = 27; ON = 20); documents were either publicly available or internal to government and excerpted with permission. Documentary texts were deductively coded using a coding template developed by the researchers based on key health human resources concepts derived from two national policy documents.
Documents in both provinces highlighted the importance of public health human resources planning and policies; this was particularly evident in early post-SARS documents. Key thematic areas of public health human resources identified were: education, training, and competencies; capacity; supply; intersectoral collaboration; leadership; public health planning context; and priority populations. Policy documents in both provinces discussed the importance of an educated, competent public health workforce with the appropriate skills and competencies for the effective and efficient delivery of public health services.
This policy analysis identified progressive work on public health human resources policy and planning with early documents providing an inventory of issues to be addressed and later documents providing evidence of beginning policy development and implementation. While many similarities exist between the provinces, the context distinctive to each province has influenced and shaped how they have focused their public health human resources policies.
PMCID: PMC3936858  PMID: 24564931
Public health human resources; Public health workforce; Policy analysis; Public health systems renewal; Public health systems research
14.  Analysis of the Literature Pertaining to the Education of Public Health Professionals 
A well-educated workforce is essential to the infrastructure of a public health system (1). At a time when global focus on public health is increasing, a severe shortage of public health professionals is projected (2). A strong educational framework is thus imperative to ensure the capacity and capability of the worldwide public health workforce for the future. The education of those who work in public health is spread across disciplines, subject-specific training programs and types of academic institutions. In the 2011 report on the Health Professionals for a New Century, Frenk and Chen comment that, compared to medicine and nursing, public health has done the least to examine what and how it teaches (3). This does not bode well for meeting the demands of the public health workforce for the future. The purpose of the study reported here is to analyze the state of pedagogy pertaining to the education of the public health workforce as evidenced by published literature. The focus is on “professionals,” defined as those who have formal education, are self-governing, and can work independently.
PMCID: PMC3859983  PMID: 24350216
education of the public health workforce; public health workforce pedagogy; literature on public health pedagogy; literature on education of public health professionals; public health professionals’ education
15.  Practice nursing in Australia: A review of education and career pathways 
BMC Nursing  2009;8:5.
Nurses in Australia are often not educated in their pre registration years to meet the needs of primary care. Careers in primary care may not be as attractive to nursing graduates as high-tech settings such as intensive or acute care. Yet, it is in primary care that increasingly complex health problems are managed. The Australian government has invested in incentives for general practices to employ practice nurses. However, no policy framework has been developed for practice nursing to support career development and post-registration education and training programs are developed in an ad hoc manner and are not underpinned by core professional competencies. This paper reports on a systematic review undertaken to establish the available evidence on education models and career pathways with a view to enhancing recruitment and retention of practice nurses in primary care in Australia.
Search terms describing education models, career pathways and policy associated with primary care (practice) nursing were established. These search terms were used to search electronic databases. The search strategy identified 1394 citations of which 408 addressed one or more of the key search terms on policy, education and career pathways. Grey literature from the UK and New Zealand internet sites were sourced and examined. The UK and New Zealand Internet sites were selected because they have well established and advanced developments in education and career pathways for practice nurses.
Two reviewers examined titles, abstracts and studies, based on inclusion and exclusion criteria. Disagreement between the reviewers was resolved by consensus or by a third reviewer.
Significant advances have been made in New Zealand and the UK towards strengthening frameworks for primary care nursing education and career pathways. However, in Australia there is no policy at national level prepare nurses to work in primary care sector and no framework for education or career pathways for nurses working in that sector.
There is a need for national training standards and a process of accreditation for practice nursing in Australia to support the development of a responsive and sustainable nursing workforce in primary care and to provide quality education and career pathways.
PMCID: PMC2698919  PMID: 19473493
16.  Financing Universal Coverage in Malaysia: a case study 
BMC Public Health  2012;12(Suppl 1):S7.
One of the challenges to maintain an agenda for universal coverage and equitable health system is to develop effective structuring and management of health financing. Global experiences with different systems of health financing suggests that a strong public role in health financing is essential for health systems to protect the poor and health systems with the strongest state role are likely the more equitable and achieve better aggregate health outcomes. Using Malaysia as a case study, this paper seeks to evaluate the progress and capacity of a middle income country in terms of health financing for universal coverage, and also to highlight some of the key underlying health systems challenges.
The WHO Health Financing Strategy for the Asia Pacific Region (2010-2015) was used as the framework to evaluate the Malaysian healthcare financing system in terms of the provision of universal coverage for the population, and the Malaysian National Health Accounts (2008) provided the latest Malaysian data on health spending. Measuring against the four target indicators outlined, Malaysia fared credibly with total health expenditure close to 5% of its GDP (4.75%), out-of-pocket payment below 40% of total health expenditure (30.7%), comprehensive social safety nets for vulnerable populations, and a tax-based financing system that fundamentally poses as a national risk-pooled scheme for the population.
Nonetheless, within a holistic systems framework, the financing component interacts synergistically with other health system spheres. In Malaysia, outmigration of public health workers particularly specialist doctors remains an issue and financing strategies critically needs to incorporate a comprehensive workforce compensation strategy to improve the health workforce skill mix. Health expenditure information is systematically collated, but feedback from the private sector remains a challenge. Service delivery-wise, there is a need to enhance financing capacity to expand preventive care, in better managing escalating healthcare costs associated with the increasing trend of non-communicable diseases. In tandem, health financing policies need to infuse the element of cost-effectiveness to better manage the purchasing of new medical supplies and equipment. Ultimately, good governance and leadership are needed to ensure adequate public spending on health and maintain the focus on the attainment of universal coverage, as well as making healthcare financing more accountable to the public, particularly in regards to inefficiencies and better utilisation of public funds and resources.
PMCID: PMC3381695  PMID: 22992444
17.  Physician Emigration from Sub-Saharan Africa to the United States: Analysis of the 2011 AMA Physician Masterfile 
PLoS Medicine  2013;10(9):e1001513.
Siankam Tankwanchi and colleagues used the AMA Physician Masterfile and the WHO Global Health Workforce Statistics on physicians in sub-Saharan Africa to determine trends in physician emigration to the United States.
Please see later in the article for the Editors' Summary
The large-scale emigration of physicians from sub-Saharan Africa (SSA) to high-income nations is a serious development concern. Our objective was to determine current emigration trends of SSA physicians found in the physician workforce of the United States.
Methods and Findings
We analyzed physician data from the World Health Organization (WHO) Global Health Workforce Statistics along with graduation and residency data from the 2011 American Medical Association Physician Masterfile (AMA-PM) on physicians trained or born in SSA countries who currently practice in the US. We estimated emigration proportions, year of US entry, years of practice before emigration, and length of time in the US. According to the 2011 AMA-PM, 10,819 physicians were born or trained in 28 SSA countries. Sixty-eight percent (n = 7,370) were SSA-trained, 20% (n = 2,126) were US-trained, and 12% (n = 1,323) were trained outside both SSA and the US. We estimated active physicians (age ≤70 years) to represent 96% (n = 10,377) of the total. Migration trends among SSA-trained physicians increased from 2002 to 2011 for all but one principal source country; the exception was South Africa whose physician migration to the US decreased by 8% (−156). The increase in last-decade migration was >50% in Nigeria (+1,113) and Ghana (+243), >100% in Ethiopia (+274), and >200% (+244) in Sudan. Liberia was the most affected by migration to the US with 77% (n = 175) of its estimated physicians in the 2011 AMA-PM. On average, SSA-trained physicians have been in the US for 18 years. They practiced for 6.5 years before US entry, and nearly half emigrated during the implementation years (1984–1999) of the structural adjustment programs.
Physician emigration from SSA to the US is increasing for most SSA source countries. Unless far-reaching policies are implemented by the US and SSA countries, the current emigration trends will persist, and the US will remain a leading destination for SSA physicians emigrating from the continent of greatest need.
Please see later in the article for the Editors' Summary
Editors' Summary
Population growth and aging and increasingly complex health care interventions, as well as existing policies and market forces, mean that many countries are facing a shortage of health care professionals. High-income countries are addressing this problem in part by encouraging the immigration of foreign health care professionals from low- and middle-income countries. In the US, for example, international medical graduates (IMGs) can secure visas and permanent residency by passing examinations provided by the Educational Commission of Foreign Medical Graduates and by agreeing to provide care in areas that are underserved by US physicians. Inevitably, the emigration of physicians from low- and middle-income countries undermines health service delivery in the emigrating physicians' country of origin because physician supply is already inadequate in those countries. Physician emigration from sub-Saharan Africa, which has only 2% of the global physician workforce but a quarter of the global burden of disease, is particularly worrying. Since 1970, as a result of large-scale emigration and limited medical education, there has been negligible or negative growth in the density of physicians in many countries in sub-Saharan Africa. In Liberia, for example, in 1973, there were 7.76 physicians per 100,000 people but by 2008 there were only 1.37 physicians per 100,000 people; in the US, there are 250 physicians per 100,000 people.
Why Was This Study Done?
Before policy proposals can be formulated to address global inequities in physician distribution, a clear picture of the patterns of physician emigration from resource-limited countries is needed. In this study, the researchers use data from the 2011 American Medical Association Physician Masterfile (AMA-PM) to investigate the “brain drain” of physicians from sub-Saharan Africa to the US. The AMA-PM collects annual demographic, academic, and professional data on all residents (physicians undergoing training in a medical specialty) and licensed physicians who practice in the US.
What Did the Researchers Do and Find?
The researchers used data from the World Health Organization (WHO) Global Health Workforce Statistics and graduation and residency data from the 2011 AMA-PM to estimate physician emigration rates from sub-Saharan African countries, year of US entry, years of service provided before emigration to the US, and length of time in the US. There were 10,819 physicians who were born or trained in 28 sub-Saharan African countries in the 2011 AMA-PM. By using a published analysis of the 2002 AMA-PM, the researchers estimated that US immigration among sub-Saharan African-trained physicians had increased over the past decade for all the countries examined except South Africa, where physician emigration had decreased by 8%. Overall, the number of sub-Saharan African IMGs in the US had increased by 38% since 2002. More than half of this increase was accounted for by Nigerian IMGs. Liberia was the country most affected by migration of its physicians to the US—77% of its estimated 226 physicians were in the 2011 AMA-PM. On average, sub-Saharan African IMGs had been in the US for 18 years and had practiced for 6.5 years before emigration. Finally, nearly half of the sub-Saharan African IMGs had migrated to US between 1984 and 1995, years during which structural adjustment programs, which resulted in deep cuts to public health care services, were implemented in developing countries by international financial institutions as conditions for refinancing.
What Do These Findings Mean?
Although the sub-Saharan African IMGs in the 2011 AMA-PM only represent about 1% of all the physicians and less than 5% of the IMGs in the AMA-PM, these findings reveal a major loss of physicians from sub-Saharan Africa. They also suggest that emigration of physicians from sub-Saharan Africa is a growing problem and is likely to continue unless job satisfaction for physicians is improved in their country of origin. Moreover, because the AMA-PM only lists physicians who qualify for a US residency position, more physicians may have moved from sub-Saharan Africa to the US than reported here and may be working in other jobs incommensurate with their medical degrees (“brain waste”). The researchers suggest that physician emigration from sub-Saharan Africa to the US reflects the complexities in the labor markets for health care professionals in both Africa and the US and can be seen as low- and middle-income nations subsidizing the education of physicians in high-income countries. Policy proposals to address global inequities in physician distribution will therefore need both to encourage the recruitment, training, and retention of health care professionals in resource-limited countries and to persuade high-income countries to train more home-grown physicians to meet the needs of their own populations.
Additional Information
Please access these websites via the online version of this summary at
The Foundation for Advancement of International Medical Education and Research is a non-profit foundation committed to improving world health through education that was established in 2000 by the Educational Commission for Foreign Medical Graduates
The Global Health Workforce Alliance is a partnership of national governments, civil society, international agencies, finance institutions, researchers, educators, and professional associations dedicated to identifying, implementing and advocating for solutions to the chronic global shortage of health care professionals (available in several languages)
Information on the American Medical Association Physician Masterfile and the providers of physician data lists is available via the American Medical Associations website
The World Health Organization (WHO) annual World Health Statistics reports present the most recent health statistics for the WHO Member States
The Medical Education Partnership Initiative is a US-sponsored initiative that supports medical education and research in sub-Saharan African institutions, aiming to increase the quantity, quality, and retention of graduates with specific skills addressing the health needs of their national populations
CapacityPlus is the USAID-funded global project uniquely focused on the health workforce needed to achieve the Millennium Development Goals
Seed Global Health cultivates the next generation of health professionals by allying medical and nursing volunteers with their peers in resource-limited settings
"America is Stealing the Worlds Doctors", a 2012 New York Times article by Matt McAllester, describes the personal experience of a young doctor who emigrated from Zambia to the US
Path to United States Practice Is Long Slog to Foreign Doctors, a 2013 New York Times article by Catherine Rampell, describes the hurdles that immigrant physicians face in practicing in the US
PMCID: PMC3775724  PMID: 24068894
18.  Strengthening health workforce capacity through work-based training 
Although much attention has been given to increasing the number of health workers, less focus has been directed at developing models of training that address real-life workplace needs. Makerere University School of Public Health (MakSPH) with funding support from the Centers for Disease Control and Prevention (CDC) developed an eight-month modular, in-service work-based training program aimed at strengthening the capacity for monitoring and evaluation (M&E) and continuous quality improvement (CQI) in health service delivery.
This capacity building program, initiated in 2008, is offered to in-service health professionals working in Uganda. The purpose of the training is to strengthen the capacity to provide quality health services through hands-on training that allows for skills building with minimum work disruptions while encouraging greater involvement of other institutional staff to enhance continuity and sustainability. The hands-on training uses practical gaps and challenges at the workplace through a highly participatory process. Trainees work with other staff to design and implement ‘projects’ meant to address work-related priority problems, working closely with mentors. Trainees’ knowledge and skills are enhanced through short courses offered at specific intervals throughout the course.
Overall, 143 trainees were admitted between 2008 and 2011. Of these, 120 (84%) from 66 institutions completed the training successfully. Of the trainees, 37% were Social Scientists, 34% were Medical/Nursing/Clinical Officers, 5.8% were Statisticians, while 23% belonged to other professions. Majority of the trainees (80%) were employed by Non-Government Organizations while 20% worked with the public health sector. Trainees implemented 66 projects which addressed issues such as improving access to health care services; reducing waiting time for patients; strengthening M&E systems; and improving data collection and reporting. The projects implemented aimed to improve trainees’ skills and competencies in M&E and CQI and the design of the projects was such that they could share these skills with other staff, with minimal interruptions of their work.
The modular, work-based training model strengthens the capacity of the health workforce through hands-on, real-life experiences in the work-setting and improves institutional capacity, thereby providing a practical example of health systems strengthening through health workforce capacity building.
PMCID: PMC3565877  PMID: 23347473
Work-based; Health workforce development; Capacity building; Training; Uganda
19.  Prioritising public health: a qualitative study of decision making to reduce health inequalities 
BMC Public Health  2011;11:821.
The public health system in England is currently facing dramatic change. Renewed attention has recently been paid to the best approaches for tackling the health inequalities which remain entrenched within British society and across the globe. In order to consider the opportunities and challenges facing the new public health system in England, we explored the current experiences of those involved in decision making to reduce health inequalities, taking cardiovascular disease (CVD) as a case study.
We conducted an in-depth qualitative study employing 40 semi-structured interviews and three focus group discussions. Participants were public health policy makers and planners in CVD in the UK, including: Primary Care Trust and Local Authority staff (in various roles); General Practice commissioners; public health academics; consultant cardiologists; national guideline managers; members of guideline development groups, civil servants; and CVD third sector staff.
The short term target- and outcome-led culture of the NHS and the drive to achieve "more for less", combined with the need to address public demand for acute services often lead to investment in "downstream" public health intervention, rather than the "upstream" approaches that are most effective at reducing inequalities. Despite most public health decision makers wishing to redress this imbalance, they felt constrained due to difficulties in partnership working and the over-riding influence of other stakeholders in decision making processes. The proposed public health reforms in England present an opportunity for public health to move away from the medical paradigm of the NHS. However, they also reveal a reluctance of central government to contribute to shifting social norms.
It is vital that the effectiveness and cost effectiveness of all new and existing policies and services affecting public health are measured in terms of their impact on the social determinants of health and health inequalities. Researchers have a vital role to play in providing the complex evidence required to compare different models of prevention and service delivery. Those working in public health must develop leadership to raise the profile of health inequalities as an issue that merits attention, resources and workforce capacity; and advocate for central government to play a key role in shifting social norms.
PMCID: PMC3206485  PMID: 22014291
20.  A global perspective on the education and training of primary care and public health professionals 
London Journal of Primary Care  2012;4(2):116-119.
Key messages
The global shortage of health workers and the global epidemic of non-communicable diseases require shared solutions which will involve job and role redesign and fundamental changes in education and training.
Why this matters to me
After 20 years in the NHS – the last 6 years as Chief Executive of the service – I have spent 5 years working in health in low- and middle-income countries in Africa and Asia with a particular emphasis on the preservice education and training of health workers. As a result, it has become clear to me that whilst there are many differences between these countries and the UK, there are also many similarities, and that new approaches to workforce design and education and training need to be adopted globally.
Background There is a critical shortage of health workers globally, which is not just a problem for low- and middle-income countries, but needs to be tackled through shared action. At the same time, public policy around the world is responding to changing health needs, social trends and technological possibilities by placing ever greater emphasis on primary care and public health, the interconnections between them and their relationships with other disciplines. All these themes mean that a new approach to the education and training of health workers is required.
Setting Global, but with relevance to the UK.
Question The education and training of professionals in public health and primary care need to adapt to the changing epidemiological, social, technological and policy environment, as well as to health worker shortages and resource constraints.
Methods This article brings together the results of reviews undertaken by the Global Health Workforce Alliance taskforce on scaling up the education and training of the health workforce and the Lancet Commission ‘Health professionals for a new century – transforming education to strengthen health systems in an interdependent world’ (of both of which the author was a member) with the author's own experiences working in Africa, Asia and North America as well as in the UK.
Results There are obvious differences in the needs and capabilities of health systems in different countries, but whatever the context – and whether they are high-, low- or middle-income countries – there are many similarities in the approach that is needed to educate and train professional and non-professional health workers, and a great deal that all countries can learn from each other.
Conclusion/discussion As the NHS enters a new phase in the continuing development of general practitioners as commissioners and providers there is a need to look for insights from around the world and to develop a new approach to educating and training primary care and public health professionals which takes account of this global perspective and global learning.
PMCID: PMC4461107  PMID: 26265947
education and training; global health; health workforce crisis
21.  Course experiences, satisfaction and career intent of final year pre-registration Australian pharmacy students 
Pharmacy Practice  2014;12(2):392.
In Australia, the profession of pharmacy has undergone many changes to adapt to the needs of the community. In recent years, concerns have been raised with evidence emerging of workforce saturation in traditional pharmacy practice sectors. It is not known how current final year pharmacy students’ perceive the different pharmacy career paths in this changing environment. Hence investigating students’ current experiences with their pharmacy course, interaction with the profession and developing an understanding of their career intentions would be an important step, as these students would make up a large proportion of future pharmacy workforce.
The objective of this study was thus to investigate final year students’ career perspectives and the reasons for choosing pharmacy, satisfaction with this choice of pharmacy as a tertiary course and a possible future career, factors affecting satisfaction and intention of future career paths.
A quantitative cross sectional survey of final year students from 3 Australian universities followed by a qualitative semi-structured interview of a convenience sample of final year students from the University of Sydney.
‘Interest in health and medicine’ was the most important reason for choosing pharmacy (n=238). The majority of students were ‘somewhat satisfied’ with the choice of pharmacy (35.7%) as a course and possible future career. Positive associations were found between satisfaction and reasons for joining pharmacy such as ‘felt pharmacy is a good profession’ (p=0.003) while negative associations included ‘joined pharmacy as a gateway to medicine or dentistry’ (p=0.001). Quantitate and qualitative results showed the most frequent perception of community pharmacy was ‘changing’ while hospital and pharmaceutical industry was described as ‘competitive’ and ‘research’ respectively. The highest career intention was community followed by hospital pharmacy.
Complex factors including university experiences are involved in shaping students’ satisfaction and perception of career. This may relate to challenges in the community pharmacy sector, job opportunities in hospital and limited understanding of the pharmaceutical industry. The results offer insight for the profession in terms of entry into various roles and also to pharmacy educators for their roles in shaping curricula and placement experiences that attract future graduates to defined career pathways in pharmacy.
PMCID: PMC4100949  PMID: 25035715
Students; Pharmacy; Career Choice; Personal Satisfaction; Pharmacists; Pharmaceutical Services; Australia
22.  Using the World Health Organization's 4S-Framework to Strengthen National Strategies, Policies and Services to Address Mental Health Problems in Adolescents in Resource-Constrained Settings 
Most adolescents live in resource-constrained countries and their mental health has been less well recognised than other aspects of their health. The World Health Organization's 4-S Framework provides a structure for national initiatives to improve adolescent health through: gathering and using strategic information; developing evidence-informed policies; scaling up provision and use of health services; and strengthening linkages with other government sectors. The aim of this paper is to discuss how the findings of a recent systematic review of mental health problems in adolescents in resource-constrained settings might be applied using the 4-S Framework.
Analysis of the implications of the findings of a systematic search of the English-language literature for national strategies, policies, services and cross-sectoral linkages to improve the mental health of adolescents in resource-constrained settings.
Data are available for only 33/112 [29%] resource-constrained countries, but in all where data are available, non-psychotic mental health problems in adolescents are identifiable, prevalent and associated with reduced quality of life, impaired participation and compromised development. In the absence of evidence about effective interventions in these settings expert opinion is that a broad public policy response which addresses direct strategies for prevention, early intervention and treatment; health service and health workforce requirements; social inclusion of marginalised groups of adolescents; and specific education is required. Specific endorsed strategies include public education, parent education, training for teachers and primary healthcare workers, psycho-educational curricula, identification through periodic screening of the most vulnerable and referral for care, and the availability of counsellors or other identified trained staff members in schools from whom adolescents can seek assistance for personal, peer and family relationship problems.
The predominant endorsed action is not that dedicated mental health services for adolescents are required, but that mental health care should be integrated using cross-sectoral strategies into the communities in which adolescents live, the institutions they attend and the organisations in which they participate.
PMCID: PMC3182992  PMID: 21923901
23.  The societal benefits of reducing six behavioural risk factors: an economic modelling study from Australia 
BMC Public Health  2011;11:483.
A large proportion of disease burden is attributed to behavioural risk factors. However, funding for public health programs in Australia remains limited. Government and non-government organisations are interested in the productivity effects on society from reducing chronic diseases. We aimed to estimate the potential health status and economic benefits to society following a feasible reduction in the prevalence of six behavioural risk factors: tobacco smoking; inadequate fruit and vegetable consumption; high risk alcohol consumption; high body mass index; physical inactivity; and intimate partner violence.
Simulation models were developed for the 2008 Australian population. A realistic reduction in current risk factor prevalence using best available evidence with expert consensus was determined. Avoidable disease, deaths, Disability Adjusted Life Years (DALYs) and health sector costs were estimated. Productivity gains included workforce (friction cost method), household production and leisure time. Multivariable uncertainty analyses and correction for the joint effects of risk factors on health status were undertaken. Consistent methods and data sources were used.
Over the lifetime of the 2008 Australian adult population, total opportunity cost savings of AUD2,334 million (95% Uncertainty Interval AUD1,395 to AUD3,347; 64% in the health sector) were found if feasible reductions in the risk factors were achieved. There would be 95,000 fewer DALYs (a reduction of about 3.6% in total DALYs for Australia); 161,000 less new cases of disease; 6,000 fewer deaths; a reduction of 5 million days in workforce absenteeism; and 529,000 increased days of leisure time.
Reductions in common behavioural risk factors may provide substantial benefits to society. For example, the total potential annual cost savings in the health sector represent approximately 2% of total annual health expenditure in Australia. Our findings contribute important new knowledge about productivity effects, including the potential for increased household and leisure activities, associated with chronic disease prevention. The selection of targets for risk factor prevalence reduction is an important policy decision and a useful approach for future analyses. Similar approaches could be applied in other countries if the data are available.
PMCID: PMC3146859  PMID: 21689461
24.  Equity in health personnel financing after Universal Coverage: evidence from Thai Ministry of Public Health’s hospitals from 2008–2012 
Shortage and maldistribution of the health workforce is a major problem in the Thai health system. The expansion of healthcare access to achieve universal health coverage placed additional demand on the health system especially on the health workers in the public sector who are the major providers of health services. At the same time, the reform in hospital payment methods resulted in a lower share of funding from the government budgetary system and higher share of revenue from health insurance. This allowed public hospitals more flexibility in hiring additional staff. Financial measures and incentives such as special allowances for non-private practice and additional payments for remote staff have been implemented to attract and retain them. To understand the distributional effect of such change in health workforce financing, this study evaluates the equity in health workforce financing for 838 hospitals under the Ministry of Public Health across all 75 provinces from 2008–2012.
Data were collected from routine reports of public hospital financing from the Ministry of Public Health with specific identification on health workforce spending. The components and sources of health workforce financing were descriptively analysed based on the geographic location of the hospitals, their size and the core hospital functions. Inequalities in health workforce financing across provinces were assessed. We calculated the Gini coefficient and concentration index to explore horizontal and vertical inequity in the public sector health workforce financing in Thailand. Separate analyses were carried out for funding from government budget and funding from hospital revenue to understand the difference between the two financial sources.
Health workforce financing accounted for about half of all hospital non-capital expenses in 2012, about a 30 % increase from the level of spending in 2008. Almost one third of the workforce financing came from hospital revenue, an increase from only one fourth 5 years earlier. The study reveals a big difference in health workforce expenditure per capita across provinces. Health workforce spending from government budget was less equal than that from hospital revenues as shown by the higher Gini coefficient. The concentration indices show that the financing of hospital workforce was higher per capita in lower resource provinces.
Our analysis of equalities in health workforce spending shows an improving trend in equity across provinces from 2008–2012. Expansion of healthcare and health insurance coverage and financing reform towards a demand-side financing helped improve the distribution of funding for health workforce across the provinces. The findings from this study can be useful for other countries with ongoing reform towards universal health coverage.
PMCID: PMC4506592  PMID: 26187375
Equity; Health personnel; Health financing; Compensation; Thailand
25.  Veterinary Public Health Capacity in the United States: Opportunities for Improvement 
Public Health Reports  2011;126(6):868-874.
In 2006, the Association of American Veterinary Medical Colleges reported that the shortage (≥1,500) of public health veterinarians is expected to increase tenfold by 2020. In 2008, the Centers for Disease Control and Prevention (CDC) Preventive Medicine Fellows conducted a pilot project among CDC veterinarians to identify national veterinary public health workforce concerns and potential policy strategies.
Fellows surveyed a convenience sample (19/91) of public health veterinarians at CDC to identify veterinary workforce recruitment and retention problems faced by federal agencies; responses were categorized into themes. A focus group (20/91) of staff veterinarians subsequently prioritized the categorized themes from least to most important. Participants identified activities to address the three recruitment concerns with the highest combined weight.
Participants identified the following three highest prioritized problems faced by federal agencies when recruiting veterinarians to public health: (1) lack of awareness of veterinarians' contributions to public health practice, (2) competitive salaries, and (3) employment and training opportunities. Similarly, key concerns identified regarding retention of public health practice veterinarians included: (1) lack of recognition of veterinary qualifications, (2) competitive salaries, and (3) seamless integration of veterinary and human public health.
Findings identified multiple barriers that can affect recruitment and retention of veterinarians engaged in public health practice. Next steps should include replicating project efforts among a national sample of public health veterinarians. A committed and determined long-term effort might be required to sustain initiatives and policy proposals to increase U.S. veterinary public health capacity.
PMCID: PMC3185323  PMID: 22043103

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