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1.  Health sector reforms and human resources for health in Uganda and Bangladesh: mechanisms of effect 
Despite the expanding literature on how reforms may affect health workers and which reactions they may provoke, little research has been conducted on the mechanisms of effect through which health sector reforms either promote or discourage health worker performance. This paper seeks to trace these mechanisms and examines the contextual framework of reform objectives in Uganda and Bangladesh, and health workers' responses to the changes in their working environments by taking a 'realistic evaluation' approach.
The study findings were generated by triangulating both qualitative and quantitative methods of data collection and analysis among policy technocrats, health managers and groups of health providers. Quantitative surveys were conducted with over 700 individual health workers in both Bangladesh and Uganda and supplemented with qualitative data obtained from focus group discussions and key interviews with professional cadres, health managers and key institutions involved in the design, implementation and evaluation of the reforms of interest.
The reforms in both countries affected the workforce through various mechanisms. In Bangladesh, the effects of the unification efforts resulted in a power struggle and general mistrust between the two former workforce tracts, family planning and health. However positive effects of the reforms were felt regarding the changes in payment schemes. Ugandan findings show how the workforce responded to a strong and rapidly implemented system of decentralisation where the power of new local authorities was influenced by resource constraints and nepotism in recruitment. On the other hand, closer ties to local authorities provided the opportunity to gain insight into the operational constraints originating from higher levels that health staff were dealing with.
Findings from the study suggest that a) reform planners should use the proposed dynamic responses model to help design reform objectives that encourage positive responses among health workers b) the role of context has been underestimated and it is necessary to address broader systemic problems before initiating reform processes, c) reform programs need to incorporate active implementation research systems to learn the contextual dynamics and responses as well as have inbuilt program capacity for corrective measures d) health workers are key stakeholders in any reform process and should participate at all stages and e) some effects of reforms on the health workforce operate indirectly through levels of satisfaction voiced by communities utilising the services.
PMCID: PMC1800303  PMID: 17270042
2.  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
3.  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
4.  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
5.  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
6.  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
7.  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
8.  Lithuanian health care in transitional state: ethical problems 
BMC Public Health  2005;5:117.
Throughout the economic and political reforms in post-communist countries, significant changes have also occurred in public morality. One of the tasks of the Lithuanian health policy is to create mechanisms for strengthening the significance of ethical considerations in the decision-making processes concerning health care of individuals and groups of individuals, as well as considering the positions of physicians and the health care system itself in a general way. Thus, health care ethics could be analyzed at two levels: the micro level (the ethics of doctor-patient relationships) and the macro level (the ethics of health policy-making, which can be realized by applying the principles of equal access, reasonable quality, affordable care and shared responsibilities). To date, the first level remains dominant, but the need arises for our attention to refocus now from the micro level to the patterns of managing and delivering care, managing the health care resources, and conducting business practices.
In attempting to increase the efficiency of health services in Lithuania, a common strategy has been in place for the last fifteen years. Decentralization and privatization have been implemented as part of its policy to achieve greater efficiency. Although decentralization in theory is supposed to improve efficiency, in practice the reform of decentralization has still to be completely implemented in Lithuania. Debates on health policy in Lithuania also include the issue of private versus public health care. Although the approach of private health care is changing in a positive way, it is obvious that reduced access to health services is the most vulnerable aspect. In the Lithuanian Health Program adopted in July 1998, the target of equity was stressed, stating that by 2010, differences in health and health care between various socio-economic groups should be reduced by 25%.
The restructuring of health care system in Lithuania should be based on a balance between decentralization and centralization, and between public and private health care sectors. Successful transition requires a balanced role of the government. Today it is obvious in Lithuania that continuous encouragement to make sacrifices was not enough to induce the system to function well, and in an ethical manner.
PMCID: PMC1310618  PMID: 16281969
9.  A systematic assessment of the current capacity to act in nutrition in West Africa: cross-country similarities and differences 
Global Health Action  2014;7:10.3402/gha.v7.24763.
Although it is widely accepted that lack of capacity is one of the barriers to scaling up nutrition in West Africa, there is a paucity of information about what capacities exist and the capacities that need to be developed to accelerate progress toward improved nutrition outcomes in the region.
To systematically assess the current capacity to act in nutrition in the West Africa region and explore cross-country similarities and differences.
Data were collected from 13 West African countries through interviews with government officials, key development partners, tertiary-level training institutions, and health professional schools. The assessment was based on a conceptual framework of four interdependent levels (tools; skills; staff and infrastructure; and structures, systems and roles). In each of the surveyed countries, we assessed capacity assets and gaps at individual, organizational, and systemic levels.
Important similarities and differences in capacity assets and gaps emerged across all the surveyed countries. There was strong momentum to improve nutrition in nearly all the surveyed countries. Most of the countries had a set of policies on nutrition in place and had set up multisectoral, multi-stakeholder platforms to coordinate nutrition activities, although much remained to be done to improve the effectiveness of these platforms. Many initiatives aimed to reduce undernutrition were ongoing in the region, but there did not seem to be clear coordination between them. Insufficient financial resources to implement nutrition activities were a major problem in all countries. The bulk of financial allocations for nutrition was provided by development partners, even though some countries, such as Niger, Nigeria, and Senegal, had a national budget line for nutrition. Sporadic stock-outs of nutrition supplies were reported in most of the countries as a result of a weak logistic and supply chain system. They also had a critical shortage of skilled nutrition professionals. There was limited supervision of nutrition activities, especially at lower levels. Nigeria and Ghana emerged as the countries with the greatest capacities to support the expansion of a nutrition workforce, although a significant proportion of their trained nutritionists were not employed in the nutrition sector. None of the countries had in place a unified nutrition information system that could guide decision-making processes across the different sectors.
There is an urgent need for a shift toward wider reforms for nutrition capacity development in the West Africa region. Addressing these unmet needs is a critical first step toward improved capacity for action in nutrition in the region.
PMCID: PMC4102835  PMID: 25034256
capacity development; nutrition; undernutrition; nutrition workforce; West Africa
10.  Integration of care systems in Portugal: anatomy of recent reforms 
Integrated care is increasingly present in the agenda of policy-makers, health professionals and researchers as a way to improve care services in relation to access, quality, user satisfaction and efficiency. These are overarching objectives of most sectoral reforms. However, health care and social care services and systems are more and more dependent on the performance of each other, imposing the logic of network. Demographic, epidemiologic and cultural changes result in pressure to increase efficiency and efficacy of services and organisations in both sectors and that is why integrated care has become so relevant in the last years.
We first used concept maps to organise and systematise information that we had gathered through deep literature review in order to set a framework where to base the subsequent work. Then, we interviewed informants at several levels of the health and social care systems and we built a list of major recent reforms addressing integrated care in Portugal. In a third step, we conducted two independent focus groups where those reforms were discussed and evaluated within the context of the concepts and frameworks identified from the literature. Results were confronted and reconciled, giving place to a list of requisites and guidelines that oriented further search for documentation on those reforms.
Several important health reforms are in course in primary and hospital care in Portugal, while a so-called third level of care has been introduced with the launch of the National Network of Long-Term Integrated Care (RNCCI – Rede Nacional de Cuidados Continuados Integrados). The social care sector has itself been a subject of alternative models springing from opposite political orientations. All these changes are having repercussions on the way the systems work with each other as they are leading to ongoing and ill-evaluated reformulations on the way they are governed, financed, structured and operated.
Care integration is not absent from policy-making and implementation endeavour in Portugal. However, recurrent issues seem to be consistently hampering the efforts regarding the integration of care in the country. It is urgent to assess current situation as experienced by those closely involved and directly affected.
PMCID: PMC4113913  PMID: 25114663
care systems integration; health care reform; social care reform; Portugal
11.  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
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.  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
14.  Inequities in the Global Health Workforce: The Greatest Impediment to Health in Sub-Saharan Africa 
Health systems played a key role in the dramatic rise in global life expectancy that occurred during the 20th century, and have continued to contribute enormously to the improvement of the health of most of the world’s population. The health workforce is the backbone of each health system, the lubricant that facilitates the smooth implementation of health action for sustainable socio-economic development. It has been proved beyond reasonable doubt that the density of the health workforce is directly correlated with positive health outcomes. In other words, health workers save lives and improve health. About 59 million people make up the health workforce of paid full-time health workers world-wide. However, enormous gaps remain between the potential of health systems and their actual performance, and there are far too many inequities in the distribution of health workers between countries and within countries. The Americas (mainly USA and Canada) are home to 14% of the world’s population, bear only 10% of the world’s disease burden, have 37% of the global health workforce and spend about 50% of the world’s financial resources for health. Conversely, sub-Saharan Africa, with about 11% of the world’s population bears over 24% of the global disease burden, is home to only 3% of the global health workforce, and spends less than 1% of the world’s financial resources on health. In most developing countries, the health workforce is concentrated in the major towns and cities, while rural areas can only boast of about 23% and 38% of the country’s doctors and nurses respectively. The imbalances exist not only in the total numbers and geographical distribution of health workers, but also in the skills mix of available health workers. WHO estimates that 57 countries world wide have a critical shortage of health workers, equivalent to a global deficit of about 2.4 million doctors, nurses and midwives. Thirty six of these countries are in sub-Saharan Africa. They would need to increase their health workforce by about 140% to achieve enough coverage for essential health interventions to make a positive difference in the health and life expectancy of their populations. The extent causes and consequences of the health workforce crisis in Sub-Saharan Africa, and the various factors that influence and are related to it are well known and described. Although there is no “magic bullet” solution to the problem, there are several documented, tested and tried best practices from various countries. The global health workforce crisis can be tackled if there is global responsibility, political will, financial commitment and public-private partnership for country-led and country-specific interventions that seek solutions beyond the health sector. Only when enough health workers can be trained, sustained and retained in sub-Saharan African countries will there be meaningful socio-economic development and the faintest hope of attaining the Millennium Development Goals in the sub-continent.
PMCID: PMC3728573  PMID: 17617671
Health workforce; human resources for health; health worker; crisis; skills mix
15.  (Re)form with Substance? Restructuring and governance in the Australian health system 2004/05 
The Australian health system has been the subject of multiple reviews and reorganisations over the last twenty years or more. The year 2004–2005 was no different.
This paper reviews the reforms, (re)structures and governance arrangements in place at both the national and state/territory levels in the last year. At the national level some progress has been made in 2004/05 through the Australian Health Ministers' Council and there is now a national health reform agenda, albeit not a comprehensive one, endorsed by the Council of Australian Governments (COAG) in June 2005. Quality and safety was an increasing focus in 2004–2005 at both the national and jurisdictional levels, as was the need for workforce reform. Although renewed policy attention was given to the need to better integrate and coordinate health care, there is little evidence of any real progress this last year. More progress was made on a national approach to workforce reform.
At the jurisdictional level, the usual rounds of reviews and restructuring occurred in several jurisdictions and, in 2005, they are organisationally very different from each other. The structure and effectiveness of jurisdictional health authorities are now more important. All health authorities are being expected to drive an ambitious set of national and local reforms. At the same time, most have now blurred the boundary between policy and service delivery and are devoting significant resources to centrally 'crisis managing' their service systems. These same reasons led to decentralisation in previous restructuring cycles. While there were many changes in 2004–2005, and a new national report to COAG on health reform is expected at the end of 2005, based on current evidence there is little room for optimism about the prospects for real progress.
PMCID: PMC1208850  PMID: 16120207
16.  Development Prospects of Health and Reform of the Fiscal System in Bosnia and Herzegovina 
Materia Socio-Medica  2011;23(4):221-226.
The functions of the health system, according to the key objectives and relationships within the sub-systems that are available to the policy makers and managers in the Health Care system in Bosnia and Herzegovina – B&H, have been elaborated in detail, with the analytical overview of relevant indicators, thus confirming the limitations of the health promotion in B&H. The ability to overcome the expressed problems is in the startup of process for structural adjustment of the health sector, reform of the health care system and its financing. The reform in health system implies fundamental changes that need to take place, in B&H, as a state in health policy and institutions in the health care system, in order to improve the functioning of health systems with the aim of ensuring better health of the population. Reform implies the existence of documents with clearly formulated health policy objectives, for which the state stands, and for which a consensus was reached on the national level with all key actors in the political structure: public promotion of the basic principles for carrying out the reform, its implementation within a reasonable time frame, the corresponding effects for providers and customer satisfaction, as well as improving health services’ efficacy (i.e. micro and macro) and the quality of healthcare. In this article, we elaborated the criteria for the classification of health systems, whereby the scientifically-based and empirical analysis is conducted on the health system in B&H and elaborated the key levers of the system. Leveraged organizational arrangements relating to the economic and political environment, organization and management functions, in connection with the services of finance, funds, customers and service providers, from which it follows the framework of state legislation related to health policy and health institutions at the state level are responsible for finance, planning, the organization, payment, regulation and conduct. If we start from the administrative criteria for the classification of “health sub-systems” in B&H, it is difficult to fit them in a pluralistic, decentralized or monistic, because in the system for each organization, there should be health policy at the state level, which is in the most countries represents the Ministry of Health.
PMCID: PMC3633535  PMID: 23678300
Health Insurance Fund of the Tuzla Canton; Services of finance; payment of health services.
17.  Oral Health Care Reform in Finland – aiming to reduce inequity in care provision 
BMC Oral Health  2008;8:3.
In Finland, dental services are provided by a public (PDS) and a private sector. In the past, children, young adults and special needs groups were entitled to care and treatment from the public dental services (PDS). A major reform in 2001 – 2002 opened the PDS and extended subsidies for private dental services to all adults. It aimed to increase equity by improving adults' access to oral health care and reducing cost barriers. The aim of this study was to assess the impacts of the reform on the utilization of publicly funded and private dental services, numbers and distribution of personnel and costs in 2000 and in 2004, before and after the oral health care reform. An evaluation was made of how the health political goals of the reform: integrating oral health care into general health care, improving adults' access to care and lowering cost barriers had been fulfilled during the study period.
National registers were used as data sources for the study. Use of dental services, personnel resources and costs in 2000 (before the reform) and in 2004 (after the reform) were compared.
In 2000, when access to publicly subsidised dental services was restricted to those born in 1956 or later, every third adult used the PDS or subsidised private services. By 2004, when subsidies had been extended to the whole adult population, this increased to almost every second adult. The PDS reported having seen 118 076 more adult patients in 2004 than in 2000. The private sector had the same number of patients but 542 656 of them had not previously been entitled to partial reimbursement of fees.
The use of both public and subsidised private services increased most in big cities and urban municipalities where access to the PDS had been poor and the number of private practitioners was high. The PDS employed more dentists (6.5%) and the number of private practitioners fell by 6.9%. The total dental care expenditure (PDS plus private) increased by 21% during the study period. Private patients who had previously not been entitled to reimbursements seemed to gain most from the reform.
The results of this study indicate that implementation of a substantial reform, that changes the traditionally defined tasks of the public and private sectors in an established oral health care provision system, proceeds slowly, is expensive and probably requires more stringent steering than was the case in Finland 2001 – 2004. However, the equity and fairness of the oral health care provision system improved and access to services and cost-sharing improved slightly.
PMCID: PMC2268684  PMID: 18226197
18.  Capacity-building in family health 
Canadian Family Physician  2009;55(6):613-613.e6.
Brazil, Chile, and Canada are among the countries where development and deployment of human resources have been central to health reform; however, it is unclear how the education and training of primary care workers is best accomplished.
To implement a model of in-service training in primary health care for interdisciplinary teams of primary health care professionals from Brazil and Chile.
This 5-module program targeted primary care providers from various disciplines who had at least 3 months of front-line experience. The program was offered in 2 formats: intermittent “in-country” training or an intensive course taught in Canada. In Brazil, the in-country training took place over a period of 8 to 12 months, during which 5 modules of 2 to 3 days each were interspersed with 2-month “action periods.” The intensive course taught in Canada was delivered to Chilean participants in Toronto, Ont, where 3 modules were offered to a group of 12 to 20 primary health care professionals over a 6-week period. The educational methodology combined short didactic presentations, whole group learning exercises, and small group problem-based learning sessions, including team projects that were completed in between each module and presented at the beginning of the next one. During the course, the participants learned how to perform computer database searches and assess the best evidence in the management of common problems.
Pretests, posttests, and evaluations of student projects demonstrated that participants had increased knowledge, as well as increased capacity to use the best evidence to address common problems in their communities. This is a promising model, adapted to the context of primary care reform in Latin America, with strong potential to support health human resource development and multidisciplinary care by front-line providers in other countries.
PMCID: PMC2694088  PMID: 19509207
19.  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
20.  Health care reform in the USA: Recommendations from USA and non-USA radiologists 
World Journal of Radiology  2012;4(2):44-47.
AIM: To compare the opinions and recommendations of imaging specialists from United States (USA) and non-USA developed nations for USA health care reform.
METHODS: A survey was emailed out to 18 imaging specialists from 17 non-USA developed nation countries and 14 radiologists within the USA regarding health care reform. The questionnaire contained the following questions: what are the strengths of your health care system, what problems are present in your nation’s health care system, and what recommendations do you have for health care reform in the USA. USA and non-USA radiologists received the same questionnaire.
RESULTS: Strengths of the USA health care system include high quality care, autonomy, and access to timely care. Twelve of 14 (86%) USA radiologists identified medicolegal action as a major problem in their health care system and felt that medicolegal reform was a critical aspect of health care reform. None of the non-USA radiologists identified medicolegal aspects as a problem in their own country nor identified it as a subject for USA health care reform. Eleven of 14 (79%) USA radiologists and 16/18 (89%) non-USA radiologists identified universal health care coverage as an important recommendation for reform.
CONCLUSION: Without full universal coverage, meaningful health care reform will likely require medicolegal reform as an early and important aspect of improved and efficient health care.
PMCID: PMC3304092  PMID: 22423317
Health care reform; Health care policy
21.  Hospital Performance, the Local Economy, and the Local Workforce: Findings from a US National Longitudinal Study 
PLoS Medicine  2010;7(6):e1000297.
Blustein and colleagues examine the associations between changes in hospital performance and their local economic resources. Locationally disadvantaged hospitals perform poorly on key indicators, raising concerns that pay-for-performance models may not reduce inequality.
Pay-for-performance is an increasingly popular approach to improving health care quality, and the US government will soon implement pay-for-performance in hospitals nationwide. Yet hospital capacity to perform (and improve performance) likely depends on local resources. In this study, we quantify the association between hospital performance and local economic and human resources, and describe possible implications of pay-for-performance for socioeconomic equity.
Methods and Findings
We applied county-level measures of local economic and workforce resources to a national sample of US hospitals (n = 2,705), during the period 2004–2007. We analyzed performance for two common cardiac conditions (acute myocardial infarction [AMI] and heart failure [HF]), using process-of-care measures from the Hospital Quality Alliance [HQA], and isolated temporal trends and the contributions of individual resource dimensions on performance, using multivariable mixed models. Performance scores were translated into net scores for hospitals using the Performance Assessment Model, which has been suggested as a basis for reimbursement under Medicare's “Value-Based Purchasing” program. Our analyses showed that hospital performance is substantially associated with local economic and workforce resources. For example, for HF in 2004, hospitals located in counties with longstanding poverty had mean HQA composite scores of 73.0, compared with a mean of 84.1 for hospitals in counties without longstanding poverty (p<0.001). Hospitals located in counties in the lowest quartile with respect to college graduates in the workforce had mean HQA composite scores of 76.7, compared with a mean of 86.2 for hospitals in the highest quartile (p<0.001). Performance on AMI measures showed similar patterns. Performance improved generally over the study period. Nevertheless, by 2007—4 years after public reporting began—hospitals in locationally disadvantaged areas still lagged behind their locationally advantaged counterparts. This lag translated into substantially lower net scores under the Performance Assessment Model for hospital reimbursement.
Hospital performance on clinical process measures is associated with the quantity and quality of local economic and human resources. Medicare's hospital pay-for-performance program may exacerbate inequalities across regions, if implemented as currently proposed. Policymakers in the US and beyond may need to take into consideration the balance between greater efficiency through pay-for-performance and socioeconomic equity.
Please see later in the article for the Editors' Summary
Editors' Summary
These days, many people are rewarded for working hard and efficiently by being given bonuses when they reach preset performance targets. With a rapidly aging population and rising health care costs, policy makers in many developed countries are considering ways of maximizing value for money, including rewarding health care providers when they meet targets, under “pay-for-performance.” In the UK, for example, a major pay-for-performance initiative—the Quality and Outcomes Framework—began in 2004. All the country's general practices (primary health care facilities that deal with all medical ailments) now detail their achievements in terms of numerous clinical quality indicators for common chronic conditions (for example, the regularity of blood sugar checks for people with diabetes). They are then rewarded on the basis of these results.
Why Was This Study Done?
In the US, the government is poised to implement a nationwide pay-for-performance program in hospitals within Medicare, the government program that provides health insurance to Americans aged 65 years or older, as well as people with disabilities. However, some observers are concerned about the effect that the proposed pay-for-performance program might have on the distribution of health care resources in the US. Pay-for-performance assumes that health care providers have the economic and human resources that they need to perform or to improve their performance. But, if a hospital's capacity to perform depends on local resources, payment based on performance might worsen existing health care inequalities because hospitals in under-resourced areas might lose funds to hospitals in more affluent regions. In other words, the government might act as a reverse Robin Hood, taking from the poor and giving to the rich. In this study, the researchers examine the association between hospital performance and local economic and human resources, to explore whether this scenario is a plausible result of the pending change in US hospital reimbursement.
What Did the Researchers Do and Find?
US hospitals have voluntarily reported their performance on indicators of clinical care (“process-of-care measures”) for acute myocardial infarction (AMI, heart attack), heart failure (HF), and pneumonia under the Hospital Quality Alliance (HQA) program since 2004. The researchers identified 2,705 hospitals that had fully reported process-of-care measures for AMI and HF in both 2004 and 2007. They then used the “Performance Assessment Model” (a methodology developed by the US Centers for Medicare and Medicaid Services to score hospital performance) to calculate scores for each hospital. Finally, they looked for associations between these scores and measures of the hospital's local economic and human resources such as population poverty levels and the percentage of college graduates in the workforce. Hospital performance was associated with local and economic workforce capacity, they report. Thus, hospitals in counties with longstanding poverty had lower average performance scores for HF and AMI than hospitals in affluent counties. Similarly, hospitals in counties with a low percentage of college graduates in the workforce had lower average performance scores than hospitals in counties where more of the workforce had been to college. Finally, although performance improved generally over the study period, hospitals in disadvantaged areas still lagged behind hospitals in advantaged areas in 2007.
What Do These Findings Mean?
These findings indicate that hospital performance (as measured by the clinical process measures considered here) is associated with the quantity and quality of local human and economic resources. Thus, the proposed Medicare hospital pay-for-performance program may exacerbate existing US health care inequalities by leading to the transfer of funds from hospitals in disadvantaged locations to those in advantaged locations. Although further studies are needed to confirm this conclusion, these findings have important implications for pay-for-performance programs in health care. They suggest that US policy makers may need to modify how they measure performance improvement—the current Performance Assessment Model gives hospitals that start from a low baseline less credit for improvements than those that start from a high baseline. This works against hospitals in disadvantaged locations, which start at a low baseline. Second and more generally, they suggest that there may be a tension between the efficiency goals of pay-for-performance and other equity goals of health care systems. In a world where resources vary across regions, the expectation that regions can perform equally may not be realistic.
Additional Information
Please access these Web sites via the online version of this summary at is an online resource for learning about the US health care system. It includes educational modules on such topics as the Medicare program and efforts to improve the quality of care
The Hospital Quality Alliance provides information on the quality of care in US hospitals
Information about the UK National Health Service Quality and Outcomes Framework pay-for-performance initiative for general practice surgeries is available
PMCID: PMC2893955  PMID: 20613863
22.  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
23.  Health sector reform in the Occupied Palestinian Territories (OPT): targeting the forest or the trees? 
Health policy and planning  2003;18(1):59-67.
Since the signing of the Oslo Peace Accords and the establishment of the Palestinian Authority in 1994, reform activities have targeted various spheres, including the health sector. Several international aid and UN organizations have been involved, as well as local and international non-governmental organizations, with considerable financial and technical investments. Although important achievements have been made, it is not evident that the quality of care has improved or that the most pressing health needs have been addressed, even before the second Palestinian Uprising that began in September 2000. The crisis of the Israeli re-invasion of Palestinian-controlled towns and villages since April 2002 and the attendant collapse of state structures and services have raised the problems to critical levels. This paper attempts to analyze some of the obstacles that have faced reform efforts. In our assessment, those include: ongoing conflict, frail Palestinian quasi-state structures and institutions, multiple and at times inappropriate donor policies and practices in the health sector, and a policy vacuum characterized by the absence of internal Palestinian debate on the type and direction of reform the country needs to take. In the face of all these considerations, it is important that reform efforts be flexible and consider realistically the political and economic contexts of the health system, rather than focus on mere narrow technical, managerial and financial solutions imported from the outside.
PMCID: PMC1457109  PMID: 12582108
health sector reform; conflict; Occupied Palestinian Territories
24.  Realizing universal health coverage for maternal health services in the Republic of Guinea: the use of workforce projections to design health labor market interventions 
Universal health coverage requires a health workforce that is available, accessible, and well-performing. This article presents a critical analysis of the health workforce needs for the delivery of maternal and neonatal health services in Guinea, and of feasible and relevant interventions to improve the availability, accessibility, and performance of the health workforce in the country.
A needs-based approach was used to project human resources for health (HRH) requirements. This was combined with modeling of future health sector demand and supply. A baseline scenario with disaggregated need and supply data for the targeted health professionals per region and setting (urban or rural) informed the identification of challenges related to the availability and distribution of the workforce between 2014 and 2024. Subsequently, the health labor market framework was used to identify interventions to improve the availability and distribution of the health workforce. These interventions were included in the supply side modeling, in order to create a “policy rich” scenario B which allowed for analysis of their potential impact.
In the Republic of Guinea, only 44% of the nurses and 18% of the midwives required for maternal and neonatal health services are currently available. If Guinea continues on its current path without scaling up recruitment efforts, the total stock of HRH employed by the public sector will decline by 15% between 2014 and 2024, while HRH needs will grow by 22% due to demographic trends. The high density of HRH in urban areas and the high number of auxiliary nurses who are currently employed pose an opportunity for improving the availability, accessibility, and performance of the health workforce for maternal and neonatal health in Guinea, especially in rural areas.
Guinea will need to scale up its recruitment efforts in order to improve health workforce availability. Targeted labor market interventions need to be planned and executed over several decades to correct entrenched distortions and mismatches between workforce need, supply, and demand. The case of Guinea illustrates how to design and operationalize HRH interventions based on workforce projections to accompany and facilitate universal health coverage reforms.
Video abstract
PMCID: PMC4243577  PMID: 25429245
human resources for health; workforce projections
25.  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

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