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1.  The decentralisation-centralisation dilemma: recruitment and distribution of health workers in remote districts of Tanzania 
The implementation of decentralisation reforms in the health sector of Tanzania started in the 1980s. These reforms were intended to relinquish substantial powers and resources to districts to improve the development of the health sector. Little is known about the impact of decentralisation on recruitment and distribution of health workers at the district level. Reported difficulties in recruiting health workers to remote districts led the Government of Tanzania to partly re-instate central recruitment of health workers in 2006. The effects of this policy change are not yet documented. This study highlights the experiences and challenges associated with decentralisation and the partial re-centralisation in relation to the recruitment and distribution of health workers.
An exploratory qualitative study was conducted among informants recruited from five underserved, remote districts of mainland Tanzania. Additional informants were recruited from the central government, the NGO sector, international organisations and academia. A comparison of decentralised and the reinstated centralised systems was carried out in order to draw lessons necessary for improving recruitment, distribution and retention of health workers.
The study has shown that recruitment of health workers under a decentralised arrangement has not only been characterised by complex bureaucratic procedures, but by severe delays and sometimes failure to get the required health workers. The study also revealed that recruitment of highly skilled health workers under decentralised arrangements may be both very difficult and expensive. Decentralised recruitment was perceived to be more effective in improving retention of the lower cadre health workers within the districts. In contrast, the centralised arrangement was perceived to be more effective both in recruiting qualified staff and balancing their distribution across districts, but poor in ensuring the retention of employees.
A combination of centralised and decentralised recruitment represents a promising hybrid form of health sector organisation in managing human resources by bringing the benefits of two worlds together. In order to ensure that the potential benefits of the two approaches are effectively integrated, careful balancing defining the local-central relationships in the management of human resources needs to be worked out.
PMCID: PMC2688480  PMID: 19405958
2.  Assessing the implementation of performance management of health care workers in Uganda 
The performance management concept is relatively new to the Ugandan health sector. Uganda has been implementing health sector reforms for nearly two decades. The reforms included the introduction of the results-oriented management in the public sector and the decentralisation of the management of health care workers from central to local governments. This study examined the implementation of performance management of health care workers in order to propose strategies for improvement.
The study was a descriptive survey carried out in the Kumi, Mbale, Sironko and Tororo districts and utilising mixed research methodology. A self-administered questionnaire was used to collect quantitative data from the health care workers. A semi-structured interview guide was used to collect qualitative data from the health service managers. The sample for the quantitative method was selected using stratified random sampling. Purposive sampling was used to select health service managers. Quantitative data were analysed using Statistical Package for Social Sciences (version 18.0). Qualitative data were categorised according to the themes and analysed manually.
The findings show that to some extent performance management is implemented in the health sector; however, there were loopholes in its implementation. There were inadequacies in setting performance targets and performance management planning was hardly done. Although many health care workers had job descriptions, the performance indicators and standards were not clearly defined and known to all workers and managers. Additionally the schedules for performance assessments were not always adhered to. There were limited prospects for career progression, inadequate performance feedback and poor rewarding mechanisms.
Performance management of health care workers is inadequately done in the districts. Performance management is a key component of attempts to improve health sector outcomes. As a result of this study, suggestions to enhance health sector performance management in the districts have been put forward. The authors are optimistic that if these suggestions are implemented, the performance of health care workers is likely to improve.
PMCID: PMC3849262  PMID: 24044774
Health care workers; Performance management; Performance review; Performance measurement; Performance improvement
3.  Gaps in universal health coverage in Malawi: A qualitative study in rural communities 
In sub-Saharan Africa, universal health coverage (UHC) reforms have often adopted a technocratic top-down approach, with little attention being paid to the rural communities’ perspective in identifying context specific gaps to inform the design of such reforms. This approach might shape reforms that are not sufficiently responsive to local needs. Our study explored how rural communities experience and define gaps in universal health coverage in Malawi, a country which endorses free access to an Essential Health Package (EHP) as a means towards universal health coverage.
We conducted a qualitative cross-sectional study in six rural communities in Malawi. Data was collected from 12 Focus Group Discussions with community residents and triangulated with 8 key informant interviews with health care providers. All respondents were selected through stratified purposive sampling. The material was tape-recorded, fully transcribed, and coded by three independent researchers.
The results showed that the EHP has created a universal sense of entitlements to free health care at the point of use. However, respondents reported uneven distribution of health facilities and poor implementation of public-private service level agreements, which have led to geographical inequities in population coverage and financial protection. Most respondents reported affordability of medical costs at private facilities and transport costs as the main barriers to universal financial protection. From the perspective of rural Malawians, gaps in financial protection are mainly triggered by supply-side access-related barriers in the public health sector such as: shortages of medicines, emergency services, shortage of health personnel and facilities, poor health workers’ attitudes, distance and transportation difficulties, and perceived poor quality of health services.
Moving towards UHC in Malawi, therefore, implies the introduction of appropriate interventions to fill the financial protection gaps in the private sector and the access-related gaps in the public sector and/or an effective public-private partnership that completely integrates both sectors. Current universal health coverage reforms need to address context specific gaps and be carefully crafted to avoid creating a sense of universal entitlements in principle, which may not be effectively received by beneficiaries due to contextual and operational bottlenecks.
PMCID: PMC4051374  PMID: 24884788
Universal health coverage; Financial protection; Access to health care; Gaps in coverage; Geographical inequities; Community perspective; Qualitative study; Malawi
4.  Public sector reform and demand for human resources for health (HRH) 
This article considers some of the effects of health sector reform on human resources for health (HRH) in developing countries and countries in transition by examining the effect of fiscal reform and the introduction of decentralisation and market mechanisms to the health sector.
Fiscal reform results in pressure to measure the staff outputs of the health sector. Financial decentralisation often leads to hospitals becoming "corporatised" institutions, operating with business principles but remaining in the public sector. The introduction of market mechanisms often involves the formation of an internal market within the health sector and market testing of different functions with the private sector. This has immediate implications for the employment of health workers in the public sector, because the public sector may reduce its workforce if services are purchased from other sectors or may introduce more short-term and temporary employment contracts.
Decentralisation of budgets and administrative functions can affect the health sector, often in negative ways, by reducing resources available and confusing lines of accountability for health workers. Governance and regulation of health care, when delivered by both public and private providers, require new systems of regulation.
The increase in private sector provision has led health workers to move to the private sector. For those remaining in the public sector, there are often worsening working conditions, a lack of employment security and dismantling of collective bargaining agreements.
Human resource development is gradually being recognised as crucial to future reforms and the formulation of health policy. New information systems at local and regional level will be needed to collect data on human resources. New employment arrangements, strengthening organisational culture, training and continuing education will also be needed.
PMCID: PMC538275  PMID: 15560841
5.  The interface between health sector reform and human resources in health 
The relationship between health sector reform and the human resources issues raised in that process has been highlighted in several studies. These studies have focused on how the new processes have modified the ways in which health workers interact with their workplace, but few of them have paid enough attention to the ways in which the workers have influenced the reforms.
The impact of health sector reform has modified critical aspects of the health workforce, including labor conditions, degree of decentralization of management, required skills and the entire system of wages and incentives. Human resources in health, crucial as they are in implementing changes in the delivery system, have had their voice heard in many subtle and open ways – reacting to transformations, supporting, blocking and distorting the proposed ways of action.
This work intends to review the evidence on how the individual or collective actions of human resources are shaping the reforms, by spotlighting the reform process, the workforce reactions and the factors determining successful human resources participation. It attempts to provide a more powerful way of predicting the effects and interactions in which different "technical designs" operate when they interact with the human resources they affect. The article describes the dialectic nature of the relationship between the objectives and strategies of the reforms and the objectives and strategies of those who must implement them.
PMCID: PMC305361  PMID: 14613523
6.  Human resources: the Cinderella of health sector reform in Latin America 
Human resources are the most important assets of any health system, and health workforce problems have for decades limited the efficiency and quality of Latin America health systems. World Bank-led reforms aimed at increasing equity, efficiency, quality of care and user satisfaction did not attempt to resolve the human resources problems that had been identified in multiple health sector assessments. However, the two most important reform policies – decentralization and privatization – have had a negative impact on the conditions of employment and prompted opposition from organized professionals and unions. In several countries of the region, the workforce became the most important obstacle to successful reform.
This article is based on fieldwork and a review of the literature. It discusses the reasons that led health workers to oppose reform; the institutional and legal constraints to implementing reform as originally designed; the mismatch between the types of personnel needed for reform and the availability of professionals; the deficiencies of the reform implementation process; and the regulatory weaknesses of the region.
The discussion presents workforce strategies that the reforms could have included to achieve the intended goals, and the need to take into account the values and political realities of the countries. The authors suggest that autochthonous solutions are more likely to succeed than solutions imported from the outside.
PMCID: PMC548503  PMID: 15659241
7.  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
8.  Paris on the Mekong: using the aid effectiveness agenda to support human resources for health in the Lao People's Democratic Republic 
This study examines the potential of aid effectiveness to positively influence human resources for health in developing countries, based on research carried out in the Lao People's Democratic Republic (Lao PDR). Efforts to make aid more effective – as articulated in the 2005 Paris Declaration and recently reiterated in the 2008 Accra Agenda for Action – are becoming an increasingly prominent part of the development agenda. A common criticism, though, is that these discussions have limited impact at sector level. Human resources for health are characterized by a rich and complex network of interactions and influences – both across government and the donor community. This complexity provides a good prism through which to assess the potential of the aid effectiveness agenda to support health development and, conversely, possibilities to extend the impact of aid-effectiveness approaches to sector level.
The research adopted a case study approach using mixed research methods. It draws on a quantitative analysis of human resources for health in the Lao People's Democratic Republic, supplementing this with a documentary and policy analysis. Qualitative methods, including key informant interviews and observation, were also used.
The research revealed a number pathways through which aid effectiveness is promoting an integrated, holistic response to a range of human resources for health challenges, and has identified further opportunities for stronger linkages. The pathways include: (1) efforts to improve governance and accountability, which are often central to the aid effectiveness agenda, and can be used as an entry point for reforming workforce planning and regulation; (2) financial management reforms, typically linked to provision of budget support, that open the way for greater transparency and better management of health monies and, ultimately, higher salaries and revenues for health facilities; (3) commitments to harmonization that can be used to improve coherence of donor support in areas such as salary supplementation, training and health information management.
If these opportunities are to be fully exploited, a number of constraints will need to be overcome: limited awareness of the aid effectiveness agenda beyond a core group in government; a perception that this is a donor-led agenda; and different views among partners as to the optimal pace of aid management reforms. In conclusion, we recommend strategic engagement of health stakeholders in the aid effectiveness agenda as one means of strengthening the health workforce.
PMCID: PMC2669799  PMID: 19239716
9.  Strategic management of the health workforce in developing countries: what have we learned? 
The study of the health workforce has gained in prominence in recent years, as the dynamic interconnections between human resource issues and health system effectiveness have come into sharper focus. This paper reviews lessons relating to strategic management challenges emerging from the growing literature in this area. Workforce issues are strategic: they affect overall system performance as well as the feasibility and sustainability of health reforms. Viewing workforce issues strategically forces health authorities to confront the yawning gaps between policy and implementation in many developing countries.
Lessons emerge in four areas. One concerns imbalances in workforce structure, whether from a functional specialization, geographical or facility lens. These imbalances pose a strategic challenge in that authorities must attempt to steer workforce distribution over time using a limited range of policy tools. A second group of lessons concerns the difficulties of central-level steering of the health workforce, often critically weak due to the lack of proper information systems and the complexities of public sector decentralization and service commercialization trends affecting the grassroots.
A third cluster examines worker capacity and motivation, often shaped in developing countries as much by the informal norms and incentives as by formal attempts to support workers or to hold them accountable. Finally, a range of reforms centering on service contracting and improvements to human resource management are emerging. Since these have as a necessary (but not sufficient) condition some flexibility in personnel practices, recent trends towards the sharing of such functions with local authorities are promising.
The paper identifies a number of current lines of productive research, focusing on the relationship between health policy reforms and the local institutional environments in which the workforce, both public and private, is deployed.
PMCID: PMC1808474  PMID: 17319973
10.  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
11.  Human resources for health policies: a critical component in health policies 
In the last few years, increasing attention has been paid to the development of health policies. But side by side with the presumed benefits of policy, many analysts share the opinion that a major drawback of health policies is their failure to make room for issues of human resources. Current approaches in human resources suggest a number of weaknesses: a reactive, ad hoc attitude towards problems of human resources; dispersal of accountability within human resources management (HRM); a limited notion of personnel administration that fails to encompass all aspects of HRM; and finally the short-term perspective of HRM.
There are three broad arguments for modernizing the ways in which human resources for health are managed:
• the central role of the workforce in the health sector;
• the various challenges thrown up by health system reforms;
• the need to anticipate the effect on the health workforce (and consequently on service provision) arising from various macroscopic social trends impinging on health systems.
The absence of appropriate human resources policies is responsible, in many countries, for a chronic imbalance with multifaceted effects on the health workforce: quantitative mismatch, qualitative disparity, unequal distribution and a lack of coordination between HRM actions and health policy needs.
Four proposals have been put forward to modernize how the policy process is conducted in the development of human resources for health (HRH):
• to move beyond the traditional approach of personnel administration to a more global concept of HRM;
• to give more weight to the integrated, interdependent and systemic nature of the different components of HRM when preparing and implementing policy;
• to foster a more proactive attitude among human resources (HR) policy-makers and managers;
• to promote the full commitment of all professionals and sectors in all phases of the process.
The development of explicit human resources policies is a crucial link in health policies and is needed both to address the imbalances of the health workforce and to foster implementation of the health services reforms.
PMCID: PMC166115  PMID: 12904254
12.  Human resource management in the Georgian National Immunization Program: a baseline assessment 
Georgia's health care system underwent dramatic reform after gaining independence in 1991. The decentralization of the health care system was one of the core elements of health care reform but reports suggest that human resource management issues were overlooked. The Georgian national immunization program was affected by these reforms and is not functioning at optimum levels. This paper describes the state of human resource management practices within the Georgian national immunization program in late 2004.
Thirty districts were selected for the study. Within these districts, 392 providers and thirty immunization managers participated in the study. Survey questionnaires were administered through face-to-face interviews to immunization managers and a mail survey was administered to immunization providers. Qualitative data collection involved four focus groups. Analysis of variance (ANOVA) and Chi-square tests were used to test for differences between groups for continuous and categorical variables. Content analysis identified main themes within the focus groups.
Weak administrative links exist between the Centres of Public Health (CPH) and Primary Health Care (PHC) health facilities. There is a lack of clear management guidelines and only 49.6% of all health providers had written job descriptions. A common concern among all respondents was the extremely inadequate salary. Managers cited lack of authority and poor knowledge and skills in human resource management. Lack of resources and infrastructure were identified as major barriers to improving immunization.
Our study found that the National Immunization Program in Georgia was characterized by weak organizational structure and processes and a lack of knowledge and skills in management and supervision, especially at peripheral levels. The development of the skills and processes of a well-managed workforce may help improve immunization rates, facilitate successful implementation of remaining health care reforms and is an overall, wise investment. However, reforms at strategic policy levels and across sectors will be necessary to address the systemic financial and health system constraints impeding the performance of the immunization program and the health care system as a whole.
PMCID: PMC1950878  PMID: 17672907
13.  A descriptive study on health workforce performance after decentralisation of health services in Uganda 
Uganda, like many developing countries, is committed to achieving the Millennium Development Goals (MDGs) by 2015. However, serious challenges prove to hamper the attainment of these goals, particularly the health related MDGs. A major challenge relates to the human resources for health. The health system in Uganda was decentralised in the 1990s. Despite the health sector reforms, the services have remained significantly deficient and performance of health workers is thought to be one of the contributing factors. The purpose of this study was, therefore, to investigate the performance of health workers after decentralisation of the health services in Uganda in order to identify and suggest possible areas for improvement.
A cross-sectional descriptive survey, using quantitative research methods was utilised. A structured self-administered questionnaire was used to collect quantitative data from 276 health workers in the districts of Kumi, Mbale, Sironko and Tororo in Eastern Uganda. The health workers included doctors, clinical officers, professional nurses and midwives. The sample was selected using stratified random sampling. The data was analysed using SPSS version 18.0 and included both univariate and bivariate analysis. The results were presented in tabular and text forms.
The study revealed that even though the health workers are generally responsive to the needs of their clients, the services they provide are often not timely. The health workers take initiatives to ensure that they are available for work, although low staffing levels undermine these efforts. While the study shows that the health workers are productive, over half (50.4%) of them reported that their organisations do not have indicators to measure their individual performance. The findings indicate that the health workers are skilled and competent to perform their duties. In general, the results show that health workers are proficient, adaptive, proactive and client-oriented.
Although Uganda is faced with a number of challenges as regards human resources for health, the findings show that the health workers that are currently working in the health facilities are enthusiastic to perform. This may serve as a motivator for the health workers to improve their performance and that of the health sector.
PMCID: PMC3506521  PMID: 23134673
Health workers; Health workforce; Decentralisation; Performance; Health sector reforms
14.  Health services reform in Bangladesh: hearing the views of health workers and their professional bodies 
BMC Health Services Research  2011;11(Suppl 2):S8.
In Bangladesh, widespread dissatisfaction with government health services did not improve during the Health and Population Sector Programme (HPSP) reforms from 1998-2003. A 2003 national household survey documented public and health service users' views and experience. Attitudes and behaviour of health workers are central to quality of health services. To investigate whether the views of health workers influenced the reforms, we surveyed local health workers and held evidence-based discussions with local service managers and professional bodies.
Some 1866 government health workers in facilities serving the household survey clusters completed a questionnaire about their views, experience, and problems as workers. Field teams discussed the findings from the household and health workers' surveys with local health service managers in five upazilas (administrative sub-districts) and with the Bangladesh Medical Association (BMA) and Bangladesh Nurses Association (BNA).
Nearly one half of the health workers (45%) reported difficulties fulfilling their duties, especially doctors, women, and younger workers. They cited inadequate supplies and infrastructure, bad behaviour of patients, and administrative problems. Many, especially doctors (74%), considered they were badly treated as employees. Nearly all said lack of medicines in government facilities was due to inadequate supply, not improved during the HPSP. Two thirds of doctors and nurses complained of bad behaviour of patients. A quarter of respondents thought quality of service had improved as a result of the HPSP.
Local service managers and the BMA and BNA accepted patients had negative views and experiences, blaming inadequate resources, high patient loads, and patients' unrealistic expectations. They said doctors and nurses were demotivated by poor working conditions, unfair treatment, and lack of career progression; private and unqualified practitioners sought to please patients instead of giving medically appropriate care. The BMA considered it would be dangerous to attempt to train and register unqualified practitioners.
The continuing dissatisfaction of health workers may have undermined the effectiveness of the HPSP. Presenting the views of the public and service users to health managers helped to focus discussions about quality of services. It is important to involve health workers in health services reforms.
PMCID: PMC3332567  PMID: 22375856
15.  Contextual influences on health worker motivation in district hospitals in Kenya 
Organizational factors are considered to be an important influence on health workers' uptake of interventions that improve their practices. These are additionally influenced by factors operating at individual and broader health system levels. We sought to explore contextual influences on worker motivation, a factor that may modify the effect of an intervention aimed at changing clinical practices in Kenyan hospitals.
Franco LM, et al's (Health sector reform and public sector health worker motivation: a conceptual framework. Soc Sci Med. 2002, 54: 1255–66) model of motivational influences was used to frame the study Qualitative methods including individual in-depth interviews, small-group interviews and focus group discussions were used to gather data from 185 health workers during one-week visits to each of eight district hospitals. Data were collected prior to a planned intervention aiming to implement new practice guidelines and improve quality of care. Additionally, on-site observations of routine health worker behaviour in the study sites were used to inform analyses.
Study settings are likely to have important influences on worker motivation. Effective management at hospital level may create an enabling working environment modifying the impact of resource shortfalls. Supportive leadership may foster good working relationships between cadres, improve motivation through provision of local incentives and appropriately handle workers' expectations in terms of promotions, performance appraisal processes, and good communication. Such organisational attributes may counteract de-motivating factors at a national level, such as poor schemes of service, and enhance personally motivating factors such as the desire to maintain professional standards.
Motivation is likely to influence powerfully any attempts to change or improve health worker and hospital practices. Some factors influencing motivation may themselves be influenced by the processes chosen to implement change.
PMCID: PMC2727485  PMID: 19627590
16.  The African Health Profession Regulatory Collaborative for Nurses and Midwives 
More than thirty-five sub-Saharan African countries have severe health workforce shortages. Many also struggle with a mismatch between the knowledge and competencies of health professionals and the needs of the populations they serve. Addressing these workforce challenges requires collaboration among health and education stakeholders and reform of health worker regulations. Health professional regulatory bodies, such as nursing and midwifery councils, have the mandate to reform regulations yet often do not have the resources or expertise to do so. In 2011, the United States of America Centers for Disease Control and Prevention began a four-year initiative to increase the collaboration among national stakeholders and help strengthen the capacity of health professional regulatory bodies to reform national regulatory frameworks. The initiative is called the African Health Regulatory Collaborative for Nurses and Midwives. This article describes the African Health Regulatory Collaborative for Nurses and Midwives and discusses its importance in implementing and sustaining national, regional, and global workforce initiatives.
The African Health Profession Regulatory Collaborative for Nurses and Midwives convenes leaders responsible for regulation from 14 countries in East, Central and Southern Africa. It provides a high profile, south-to-south collaboration to assist countries in implementing joint approaches to problems affecting the health workforce. Implemented in partnership with Emory University, the Commonwealth Secretariat, and the East, Central and Southern African College of Nursing, this initiative also supports four to five countries per year in implementing locally-designed regulation improvement projects. Over time, the African Health Regulatory Collaborative for Nurses and Midwives will help to increase the regulatory capacity of health professional organizations and ultimately improve regulation and professional standards in this region of Africa. The African Health Regulatory Collaborative for Nurses and Midwives will measure the progress of country projects and conduct an annual evaluation of the initiative’s regional impact, thereby contributing to the global evidence base of health workforce interventions.
The African Health Regulatory Collaborative for Nurses and Midwives is designed to address priority needs in health workforce development and improve regulation of the health workforce. This model may assist others countries and regions facing similar workforce challenges.
PMCID: PMC3447670  PMID: 22931501
Health workforce; Regulation; Health profession; Human resources for health; Collaborative; Global health; Regional approach; Strengthening; Nursing; Midwifery
17.  Decentralization's impact on the health workforce: Perspectives of managers, workers and national leaders 
Designers and implementers of decentralization and other reform measures have focused much attention on financial and structural reform measures, but ignored their human resource implications. Concern is mounting about the impact that the reallocation of roles and responsibilities has had on the health workforce and its management, but the experiences and lessons of different countries have not been widely shared. This paper examines evidence from published literature on decentralization's impact on the demand side of the human resource equation, as well as the factors that have contributed to the impact. The elements that make such an impact analysis exceptionally complex are identified. They include the mode of decentralization that a country is implementing, the level of responsibility for the salary budget and pay determination, and the civil service status of transferred health workers.
The main body of the paper is devoted to examining decentralization's impact on human resource issues from three different perspectives: that of local health managers, health workers themselves, and national health leaders. These three groups have different concerns in the human resource realm, and consequently, have been differently affected by decentralization processes. The paper concludes with recommendations regarding three key concerns that national authorities and international agencies should give prompt attention to. They are (1) defining the essential human resource policy, planning and management skills for national human resource managers who work in decentralized countries, and developing training programs to equip them with such skills; (2) supporting research that focuses on improving the knowledge base of how different modes of decentralization impact on staffing equity; and (3) identifying factors that most critically influence health worker motivation and performance under decentralization, and documenting the most cost-effective best practices to improve them. Notable experiences from South Africa, Ghana, Indonesia and Mexico are shared in an annex.
PMCID: PMC420260  PMID: 15144558
18.  Evaluation of the effects of comprehensive reform on primary healthcare institutions in Anhui Province 
In 2009, the Chinese Central Communist Party and the China State Council started to implement comprehensive healthcare reforms. The first round of reforms, involving Anhui province, was from 2009 to 2011, and focused on primary healthcare institutions. This study conducts an initial assessment of the effects of specific parts of the reforms in Anhui.
Mixed quantitative and qualitative methods were adopted for data collection. Seven hundred and three health institutions from 15 counties were randomly chosen. The practices, development, effects, problems, and other relevant information related to the reform were classified into four aspects: medicine management; personnel systems and income distribution mechanisms; compensation mechanisms for primary healthcare institutions; and strengthening the primary healthcare system. The effects of reform were analyzed by evaluating changes in compensation channels, visit costs, diagnosis and treatment structure, hardware, structures, efficiency, and behavior.
A new system for authorizing drugs resulted in a total of 857 new drugs being accessible at agreed prices through primary healthcare institutions in Anhui. The cost of the average outpatient visit decreased from 35.29 RMB to 31.64 RMB, although for inpatients, the average cost increased from 799.05 RMB to 992.60 RMB. The number of healthcare personnel decreased, but their workloads increased. The total revenue from government sources increased by 41.09%, and the proportion of revenue from drugs decreased by 25.19%. The rate of diagnosis and treatment visits and outpatient visits to primary healthcare institutions increased. Finally, between 2008 and 2010, 1,195 standardized township hospitals, 14,134 village clinics, and 1,234 community health service institutions were constructed.
The reform of primary healthcare institutions in Anhui has improved the personnel structures surrounding frontline healthcare workers, increased their incomes, improved work efficiency, and changed the compensation patterns of primary healthcare institutions, improved hardware, reduced drug prices, and, to some extent, improved the diagnosis and treatment structure. However, the reforms have not radically changed the behavior of medical workers or the visit patterns of patients. Approaches such as strengthening performance evaluation, and carrying out initiatives to further mobilize frontline healthcare workers, enhance rational drug use through improved training and educate patients, should be undertaken in the future.
PMCID: PMC4105389  PMID: 24942901
Health reform; Primary healthcare institutions; Anhui province
19.  Developing the national community health assistant strategy in Zambia: a policy analysis 
In 2010, the Ministry of Health in Zambia developed the National Community Health Assistant strategy, aiming to integrate community health workers (CHWs) into national health plans by creating a new group of workers, called community health assistants (CHAs). The aim of the paper is to analyse the CHA policy development process and the factors that influenced its evolution and content. A policy analysis approach was used to analyse the policy reform process.
Data were gathered through review of documents, participant observation and key informant interviews with CHA strategic team members in Lusaka district, and senior officials at the district level in Kapiri Mposhi district where some CHAs have been deployed.
The strategy was developed in order to address the human resources for health shortage and the challenges facing the community-based health workforce in Zambia. However, some actors within the strategic team were more influential than others in informing the policy agenda, determining the process, and shaping the content. These actors negotiated with professional/statutory bodies and health unions on the need to develop the new cadre which resulted in compromises that enabled the policy process to move forward. International agencies also indirectly influenced the course as well as the content of the strategy. Some actors classified the process as both insufficiently consultative and rushed. Due to limited consultation, it was suggested that the policy content did not adequately address key policy content issues such as management of staff attrition, general professional development, and progression matters. Analysis of the process also showed that the strategy might create a new group of workers whose mandate is unclear to the existing group of health workers.
This paper highlights the complex nature of policy-making processes for integrating CHWs into the health system. It reiterates the need for recognising the fact that actors’ power or position in the political hierarchy may, more than their knowledge and understanding of the issue, play a disproportionate role in shaping the process as well as content of health policy reform.
PMCID: PMC3724745  PMID: 23870454
Human resources; National community health assistant strategy; Policy analysis; Zambia
20.  Health equity in an unequal country: the use of medical services in Chile 
A recent health reform was implemented in Chile (the AUGE reform) with the objective of reducing the socioeconomic gaps to access healthcare. This reform did not seek to eliminate the private insurance system, which coexists with the public one, but to ensure minimum conditions of access to the entire population, at a reasonable cost and with a quality guarantee, to cover an important group of health conditions. This paper’s main objective is to enquire what has happened with the use of several healthcare services after the reform was fully implemented.
Concentration and Horizontal Inequity indices were estimated for the use of general practitioners, specialists, emergency room visits, laboratory and x-ray exams and hospitalization days. The change in such indices (pre and post-reform) was decomposed, following Zhong (2010). A “mean effect” (how these indices would change if the differential use in healthcare services were evenly distributed) and a “distribution effect” (how these indices would change with no change in average use) were obtained.
Changes in concentration indices were mainly due to mean effects for all cases, except for specialists (where “distribution effect” prevailed) and hospitalization days (where none of these effects prevailed over others). This implies that by providing more services across socioeconomic groups, less inequality in the use of services was achieved. On the other hand, changes in horizontal inequity indices were due to distribution effects in the case of GP, ER visits and hospitalization days; and due to mean effect in the case of x-rays. In the first three cases indices reduced their pro-poorness implying that after the reform relatively higher socioeconomic groups used these services more (in relation to their needs). In the case of x-rays, increased use was responsible for improving its horizontal inequity index.
The increase in the average use of healthcare services after the AUGE reform has not always led to improved equity in the use of such services in most services. This indicates that there are still barriers to the equitable use of healthcare services (e.g. insufficient medical human resources, financial barriers, capacity constraints, etc.) that have remained after the reform.
PMCID: PMC3544610  PMID: 23249481
Equity; Inequality; Healthcare use; Chile; Household surveys
21.  Health system challenges to integration of mental health delivery in primary care in Kenya- perspectives of primary care health workers 
Health system weaknesses in Africa are broadly well known, constraining progress on reducing the burden of both communicable and non-communicable disease (Afr Health Monitor, Special issue, 2011, 14-24), and the key challenges in leadership, governance, health workforce, medical products, vaccines and technologies, information, finance and service delivery have been well described (Int Arch Med, 2008, 1:27). This paper uses focus group methodology to explore health worker perspectives on the challenges posed to integration of mental health into primary care by generic health system weakness.
Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 20 health workers drawn from a randomised controlled trial to evaluate the impact of a mental health training programme for primary care, 10 from the intervention group clinics where staff had received the training programme, and 10 health workers from the control group where staff had not received the training).
These focus group discussions suggested that there are a number of generic health system weaknesses in Kenya which impact on the ability of health workers to care for clients with mental health problems and to implement new skills acquired during a mental health continuing professional development training programmes. These weaknesses include the medicine supply, health management information system, district level supervision to primary care clinics, the lack of attention to mental health in the national health sector targets, and especially its absence in district level targets, which results in the exclusion of mental health from such district level supervision as exists, and the lack of awareness in the district management team about mental health. The lack of mental health coverage included in HIV training courses experienced by the health workers was also striking, as was the intensive focus during district supervision on HIV to the detriment of other health issues.
Generic health system weaknesses in Kenya impact on efforts for horizontal integration of mental health into routine primary care practice, and greatly frustrate health worker efforts.
Improvement of medicine supplies, information systems, explicit inclusion of mental health in district level targets, management and supervision to primary care are likely to greatly improve primary care health worker effectiveness, and enable training programmes to be followed by better use in the field of newly acquired skills. A major lever for horizontal integration of mental health into the health system would be the inclusion of mental health in the national health sector reform strategy at community, primary care and district levels rather than just at the higher provincial and national levels, so that supportive supervision from the district level to primary care would become routine practice rather than very scarce activity.
Trial registration
Trial registration ISRCTN 53515024
PMCID: PMC3852631  PMID: 24079756
Health system challenges; Health sector reform; Mental health; Primary care; Kenya
22.  An approach to classifying human resources constraints to attaining health-related Millennium Development Goals 
For any wide-ranging effort to scale up health-related priority interventions, human resources for health (HRH) are likely to be a key to success. This study explores constraints related to human resources in the health sector for achieving the Millennium Development Goals (MDGs) in low-income countries.
Methods and framework
The analysis drew on information from a variety of publicly-available sources and principally on data presented in published papers in peer-reviewed journals. For classifying HRH constraints an analytical framework was used that considers constraints at five levels: individual characteristics, the health service delivery level, the health sector level, training capacities and the sociopolitical and economic context of a country.
Results and discussion
At individual level, the decision to enter, remain and serve in the health sector workforce is influenced by a series of social, economic, cultural and gender-related determinants. For example, to cover the health needs of the poorest it is necessary to employ personnel with specific social, ethnic and cultural characteristics. At health-service level, the commitment of health staff is determined by a number of organizational and management factors. The workplace environment has a great impact not only on health worker performance, but also on the comprehensiveness and efficiency of health service delivery. At health-sector level, the use of monetary and nonmonetary incentives is of crucial importance for having the accurate skill mix at the appropriate place. Scaling up of priority interventions is likely to require significant investments in initial and continuous training. Given the lead time required to produce new health workers, such investments must occur in the early phases of scaling up. At the same time coherent national HRH policies are required for giving direction on HRH development and linking HRH into health-sector reform issues, the scaling-up of priority interventions, poverty reduction strategies, and training approaches. Multisectoral collaboration and the sociopolitical and economic context of a country determine health sector workforce development and potential emigration.
Key determinants of success for achieving international development goals are closely related to human-resource development.
PMCID: PMC471573  PMID: 15238166
23.  Players and processes behind the national health insurance scheme: a case study of Uganda 
Uganda is the last East African country to adopt a National Health Insurance Scheme (NHIS). To lessen the inequitable burden of healthcare spending, health financing reform has focused on the establishment of national health insurance. The objective of this research is to depict how stakeholders and their power and interests have shaped the process of agenda setting and policy formulation for Uganda’s proposed NHIS. The study provides a contextual analysis of the development of NHIS policy within the context of national policies and processes.
The methodology is a single case study of agenda setting and policy formulation related to the proposed NHIS in Uganda. It involves an analysis of the real-life context, the content of proposals, the process, and a retrospective stakeholder analysis in terms of policy development. Data collection comprised a literature review of published documents, technical reports, policy briefs, and memos obtained from Uganda’s Ministry of Health and other unpublished sources. Formal discussions were held with ministry staff involved in the design of the scheme and some members of the task force to obtain clarification, verify events, and gain additional information.
The process of developing the NHIS has been an incremental one, characterised by small-scale, gradual changes and repeated adjustments through various stakeholder engagements during the three phases of development: from 1995 to 1999; 2000 to 2005; and 2006 to 2011. Despite political will in the government, progress with the NHIS has been slow, and it has yet to be implemented. Stakeholders, notably the private sector, played an important role in influencing the pace of the development process and the currently proposed design of the scheme.
This study underscores the importance of stakeholder analysis in major health reforms. Early use of stakeholder analysis combined with an ongoing review and revision of NHIS policy proposals during stakeholder discussions would be an effective strategy for avoiding potential pitfalls and obstacles in policy implementation. Given the private sector’s influence on negotiations over health insurance design in Uganda, this paper also reviews the experience of two countries with similar stakeholder dynamics.
PMCID: PMC3849368  PMID: 24053551
Health insurance; Stakeholder analysis; Context analysis; Policy reform; Health financing; Case study; Uganda
24.  Workplace violence and gender discrimination in Rwanda's health workforce: Increasing safety and gender equality 
Workplace violence has been documented in all sectors, but female-dominated sectors such as health and social services are at particular risk. In 2007-2008, IntraHealth International assisted the Rwanda Ministries of Public Service and Labor and Health to study workplace violence in Rwanda's health sector. This article reexamines a set of study findings that directly relate to the influence of gender on workplace violence, synthesizes these findings with other research from Rwanda, and examines the subsequent impact of the study on Rwanda's policy environment.
Fifteen out of 30 districts were selected at random. Forty-four facilities at all levels were randomly selected in these districts. From these facilities, 297 health workers were selected at random, of whom 205 were women and 92 were men. Researchers used a utilization-focused approach and administered health worker survey, facility audits, key informant and health facility manager interviews and focus groups to collect data in 2007. After the study was disseminated in 2008, stakeholder recommendations were documented and three versions of the labor law were reviewed to assess study impact.
Thirty-nine percent of health workers had experienced some form of workplace violence in year prior to the study. The study identified gender-related patterns of perpetration, victimization and reactions to violence. Negative stereotypes of women, discrimination based on pregnancy, maternity and family responsibilities and the 'glass ceiling' affected female health workers' experiences and career paths and contributed to a context of violence. Gender equality lowered the odds of health workers experiencing violence. Rwandan stakeholders used study results to formulate recommendations to address workplace violence gender discrimination through policy reform and programs.
Gender inequality influences workplace violence. Addressing gender discrimination and violence simultaneously should be a priority in workplace violence research, workforce policies, strategies, laws and human resources management training. This will go a long way in making workplaces safer and fairer for the health workforce. This is likely to improve workforce productivity and retention and the enjoyment of human rights at work. Finally, studies that involve stakeholders throughout the research process are likely to improve the utilization of results and policy impact.
PMCID: PMC3154143  PMID: 21767411
25.  South Africa’s protracted struggle for equal distribution and equitable access – still not there 
The purpose of this contribution is to analyse and explain the South African HRH case, its historical evolution, and post-apartheid reform initiatives aimed at addressing deficiencies and shortfalls. HRH in South Africa not only mirrors the nature and diversity of challenges globally, but also the strategies pursued by countries to address these challenges. Although South Africa has strongly developed health professions, large numbers of professional and mid-level workers, and also well-established training institutions, it is experiencing serious workforce shortages and access constraints. This results from the unequal distribution of health workers between the well-resourced private sector over the poorly-resourced public sector, as well as from distributional disparities between urban and rural areas. During colonial and apartheid times, disparities were aggravated by policies of racial segregation and exclusion, remnants of which are today still visible in health-professional backlogs, unequal provincial HRH distribution, and differential access to health services for specific race and class groups.
Since 1994, South Africa’s transition to democracy deeply transformed the health system, health professions and HRH establishments. The introduction of free-health policies, the district health system and the prioritisation of PHC ensured more equal distribution of the workforce, as well as greater access to services for deprived groups. However, the HIV/AIDS epidemic brought about huge demands for care and massive patient loads in the public-sector. The emigration of health professionals to developed countries and to the private sector also undermines the strength and effectiveness of the public health sector. For the poor, access to care thus remains constrained and in perpetual shortfall.
The post-1994 government has introduced several HRH-specific strategies to recruit, distribute, motivate and retain health professionals to strengthen the public sector and to expand access and coverage. Of great significance among these is the NHI Plan that aims to bridge the structural divide and to redistribute material and human resources more equally. Its success largely hinges on HRH and the balanced deployment of the national workforce.
Low- and middle-income countries have much to learn from South African HRH experiences. In turn, South Africa has much to learn from other countries, as this case study shows.
PMCID: PMC4029937  PMID: 24885691
South Africa; HRH policies; reforms; shortages; access; distribution; retention; inequalities; disparities

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