Rising to the grand challenge of human resources for health
The Third Global Forum on Human Resources for Health (the Forum) will be one of the main global health events in 2013, bringing together over 1500 policy makers, experts and advocates in the health workforce field, and frontline health workers. The event theme is Human Resources for Health: foundation for Universal Health Coverage and the post-2015 development agenda. The Global Health Workforce Alliance (GHWA) organized the Forum in Recife, Brazil, from 10-13 November 2013, under the patronage of the Government of Brazil, World Health Organization (WHO) and the Pan American Health Organization (PAHO).
CHW Central Blog Posts from the Conference:
1. Discussing the way forward…
My first session was on CHWs and other Frontline Workers: Moving from Fragmentation to Synergy to Achieve Universal Health Care. The meeting discussed findings from three key reports meant to reduce fragmentation and duplication of services and emphasizing the importance of integrating CHWs into the country health systems in an effort to reach Universal Health Care (UHC). The main recommendations from the report were to get NGOs, donors and civil society to commit to partnership and follow the three ones (used for PEPFAR) and modified here:
- One national strategy
- One lead authority respected by all partners
- One monitoring and accountability framework
To do this, emphasis needs to be placed on measuring results, scaling up and sustainability, economic evaluation and increased capacity building for LMIC investigations. They also presented an agenda for research studies, such as comparing the effectiveness of CHWs who provide curative vs. preventive care and looking at the quality of CHWs with multiple tasks compared to those with fewer tasks.
CHWs can do so much more; in fact, they do work that no else can. Reorganizing and optimizing CHWs can make them even stronger: first we need to ensure they have the right support, motivation, training and tools to do their job better. CHW AIM2 was touted as a tool that could help CHW programs assess and improve the functionality of their programs and CHW Central was highlighted as a platform for sharing information and resources.
Donors also need to help reduce duplication, improve transparency and accountability. Questions were raised about how they were going to do that. Indeed, there was also emphasis on the need to strengthen national leadership.
Finally the partners in the session and those at the conference and around the world are being asked to sign a commitment to work together to meet the three ones. Mohammed Azul, director of GHWA ended the session by looking forward, “Partners working together now need to know how to implement what we have agreed to.”
2. Looking at evidence for staffing decisions…
The second session focused on the Workload Indicators of Staffing Need (WISN) TOOL developed by WHO to help assess staffing needs. 15 years old, the tool was updated in 2008. It answers the questions: Why do you need so many staff? – where do you find evidence to back this up? The tool looks at the 7 rights:
- Right number of health workers and
- the Right number of cadres
- in the Right place
- with the Right skills
- in the Right time
- doing the Right things
- and, as importantly, having the Right HIS data.
By calculating the availability of working time, standards, activities and looking at the additional administrative tasks, it is possible to determine the gaps, the shortages and the overstaffing or inadequate distribution that can then be addressed. More information can be found through WHO.
3. Improving Performance Through Results Based Financing (RBF)
Next – RBF was explained as a motivating and retaining process to assist Universal Health Care. Started in the private sector, RBF, funded by the Work Bank Innovation Fund, is being used in the public sector in 40 countries. The RBF fund is available to reward health workers/facilities who reach targets; the bonuses are allocated based on health facility staff discussion among staff and a portion is reinvested in the health facility. Staff also works on improving performance using a modified PDSA. Some of the best practices are strengthened supervision, timely payment, capacity building in CQI, transparency, verification and when done right – intrinsic motivation. Some of the outcomes based on the indicators included improved attendance, improved productivity due to incentives, improved or new equipment, openness to discussion and an ability to make decisions as a team and retention.
1Sponsored by the Global Health Workforce Alliance (GHWA), the United States Agency for international Development (USAID), the Frontline Health Worker Coalition (FLWHC) and the Norwegian Agency for Development (NORAD)
2Community Health Worker Assessment and Improvement Matrix (CHW AIM): A Toolkit for Improving CHW Programs and Services MARCH 2013 Lauren Crigler, Initiatives Inc. Kathleen Hill, University Research Co., LLC
Rebecca Furth, Initiatives Inc. Donna Bjerregaard, Initiatives Inc.
On November 12, it is 83 degrees in Recife and Santa Claus and Christmas trees are beginning to populate the city along with the 2,000 people who are filling the halls of the Pernambuco Convention Center in Old Town to discuss Human Resources for Health (HRH).
The goal of this conference is to attain, sustain and accelerate progress on Universal Health Coverage for all (UHC). Pape Gaye (IntraHealth) reminded participants that, “Community health workers and frontline health workers are the best investment a country can make. It is the most sustainable and the right thing to do. They are the link between heath systems and communities.” Argentina proposed that “Health is a right and should not be viewed as a charity.”
I attended an interesting session on the balancing act of regulating HRH migration. How do you assess the right to leave a country vs. the right to health care that is affected by outmigration?
Ireland pointed out it didn’t plan well enough to meet the health needs of its population. The country relied on international recruitment when it had shortages, but didn’t fully comprehend the effect on the source country and this made it hard for Ireland, faced with too many medical immigrants, to plan for their own workforce needs. Using the WHO Global Code of Practice on the International Recruitment of Health Personnel, Ireland took steps to change their approach. They focused on new models of care, clinical programs, task shifting and training of doctors and nurses. They further entered into agreements with select developing countries to reduce emigration of medical staff to Ireland by strengthening the systems of other countries to improve care, retention, and training. They also developed a program for two-year placements for medical emigrants in the Irish hospital system to enable more exposure to care models and specialty areas.
According to a study by Irene Glinos of WHO, international recruitment has its benefits: it is quick, immediate, and cheap, increases cultural diversity, frees up senior capacity to do other tasks and keeps salaries low and competitive. But it also has disadvantages: volatility – economic ups and downs make countries importers at one point and exporters at other points, unemployment, geographical distribution problems remain and the recurring cycles of brain drain – all impact the health system.
The session pointed out how difficult planning for HRH and UHC can be when there are so many factors to address. But it left me with a message about how interdependent the world is and how important planning is to ensure universal health coverage in all countries
Last night, GHWA and WHO launched their new report on how to attain, sustain and accelerate progress on Universal Health Coverage (UHC). The report includes workforce data on 36 countries, including the United States showing statistics on population, health and HRH coverage data.
It proposes 3 questions:
- What health workforce is required to ensure effective coverage of an agreed package of health care benefits?
- What health workforce is required to progressively expand coverage over time?
- How does a country produce, deploy and sustain a health workforce that is both fit for the purpose and fit to practice in support of UHC?
In response, it looks at four dimensions: availability (supply, competent HWs); accessibility (equitability and referral); acceptability (respectful treatment) and quality (skills, knowledge and proper behavior).
In the last 10 years there have been changes. But common themes for most countries are still:
- Shortages of some categories of staff
- Aging workforce affects staff replacement possibilities
- Inadequate pre-service education content
- Motivation issues
- Insufficient prioritization of Quality
- Varying capability to estimate HR needs
- Lack and poor use of HR data for planning
WHO presents a 10-point integrated agenda to move us forward: assessing gaps, developing HR policies, focusing on data, building technical capacity and political support, assessing costs, and addressing transnational issues.
The final message: HRH is now in the hands of governments and stakeholders to make sure that every country and individual has access to a quality health workforce.
This report provides important data on where we were and where have come but one hopes that the next global conference on HRH will focus more on research, best practices and country examples and allow more inter-country dialogue to guide the way forward.
Just how do you get health services to every woman and every child? By Helen Morton, The Guardian News
Community recruits can plug the shortage of qualified health workers and help the UN deliver on its promise to save 16 million women and children by 2015.
Read the article here.
Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis. By Glenton et al.
Lay health workers (LHWs) perform functions related to healthcare delivery, receive some level of training, but have no formal professional or paraprofessional certificate or tertiary education degree. They provide care for a range of issues, including maternal and child health. For LHW programmes to be effective, we need a better understanding of the factors that influence their success and sustainability. This review addresses these issues through a synthesis of qualitative evidence and was carried out alongside the Cochrane review of the effectiveness of LHWs for maternal and child health. The overall aim of the review is to explore factors affecting the implementation of LHW programmes for maternal and child health. Rather than being seen as a lesser trained health worker, LHWs may represent a different and sometimes preferred type of health worker. The close relationship between LHWs and recipients is a programme strength. However, programme planners must consider how to achieve the benefits of closeness while minimizing the potential drawbacks. Other important facilitators may include the development of services that recipients perceive as relevant; regular and visible support from the health system and the community; and appropriate training, supervision and incentives.
Read the article here.
Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. By Lewin et al.
Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. Little is known, however, about the effectiveness of LHW interventions. To assess the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases. LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care. For other health issues, evidence is insufficient to draw conclusions about the effects of LHWs.
Read the article here.