Editorial: Human resources in health: putting the right agenda back to the front

It has taken unusually long for international efforts in health systems development to give human resources the special attention they rightly deserve given the unique and complex circumstances under which health workers operate in the developing world. Health workers continue to be underpaid, demoralized and underproductive. This has given rise to various forms of informal activities and dual practice with implications for equity of access to quality services (Killingsworth et al. 1999; McPake et al. 1999). Problems of health worker training, deployment and, most importantly, retention, remain ubiquitous. Migration of health workers to greener pastures within regions or to richer countries is emerging as a serious global problem. Imbalances in the skill mix of those health workers who remain present further challenges for efficient health service delivery. There are many reasons why we need to focus on human resources capacity in health of developing countries: HIV/AIDS and related diseases, increasing poverty, rapid epidemiological and demographic changes, continuous (and sometimes inappropriate) health sector reforms, technological changes and governance problems. A plethora of global initiatives has emerged in response, but as it relies on constructive and energetic health workers, solutions need to be found to the issues of morale, motivation and distribution of basic and specialist skills. Traditional approaches to human resource capacity building have largely centred around availability (numbers and norms) and distribution, with the popular solution being training and re-training of health workers. This appears to have been driven by the notion that human resource capacity is determined more by the quantity and quality of inputs than by attending to the processes that determine how and how well those inputs are used. This has not succeeded, even on its own terms. To some extent this reflects the insufficiency of past investments especially at the periphery of developing countries, but also questions the value of investments made. Once trained, staff have left the system altogether, or engaged in ‘dual practice’, or preferred low-priority roles, or failed to work productively in high-priority roles. All these suggest that a strategy which focuses on input volume alone is misguided. Two lessons can be drawn from this experience: First, training policies need to be reviewed in the light of changes in global economics and politics, health sector reforms, epidemiological transition, and new diseases that operate within national boundaries. Secondly, equal emphasis should be put on improving health worker availability and retention. The latter is a function of incentives in terms of all those factors that influence a health worker's choices rather than merely monetary inducements, such as: career opportunities, the ability to work in an environment conducive to the effectiveness of that work, features of the location of work (opportunities for children's schooling or engaging in private practice). Training and re-training is a necessary but insufficient strategy to address human resource capacity problems. The focus should not only be on planning for the right numbers of each cadre, but on ensuring that training places are taken up by those most likely to fulfil the role and that incentives reinforce the job choice and location decisions. This requires innovative and concerted efforts by all major players in health system development, something that current policy debates on human resources in developing countries are virtually devoid of. For example there are a number of countries which have instituted rural and non-private practice allowances but failed to carefully evaluate their effects. Lack of interest on the part of research funders in these areas is one important reason, and a tendency to respond to human resource issues at the programme level is another. Each subsectoral programme tries to solve its own problems, on occasions, in ways that undermine the efforts of other programmes. Anecdotal examples (e.g. outreach allowances undermining the activities of static units) abound, but again research to estimate the scale and implications of the problem is largely absent. New Public Management thinking offers useful insights into this area. Some sources distinguish between internal and external human resource capacity, defining internal capacity as the ability of individuals to perform linked to their knowledge, skills and experience, and external capacity as the organizational, institutional and governance environment in which they are located (Mills et al. 2000). By these definitions, external capacity encompasses macro-health system factors and wider non-health system factors such as the socio-economic and political environment. Internal capacity is a function of external capacity; hence it is crucial to identify and address the systemic constraints to develop the incentive structures that will bring about the desired health worker performance. Factors such as modes of financing, regulation, organization and management of the health system influence the development of individual skills and competencies, training and experience, motivation and performance. However, the relationships between these factors are not obvious and likely to vary from one context to another. What is the pattern-of-use of skilled health workers? In most countries, we do not know the scale of external migration, the extent of dual practice, the distribution of publicly trained staff between the public and private sectors, or the actual working time, or the proportion of productive working time of staff employed in the public sector. Anecdotal evidence implies that problems in all these areas abound. How does staff performance respond to changes in modes of financing, regulation, organization and management? For example, Martinez and Martineau (1998) point out that the move towards empowering consumers of health services might concomitantly disempower health workers. Issues of staff training, deployment, retention, motivation and performance need separate consideration. How have personnel policies to address these problems fared? The lack of evaluation of the effects of rural and non-private practice allowances is one example, and the potential conflict between uncoordinated attempts to resolve human resource issues at programme level is another. Any attempts to answer these difficult and multi-faceted questions require a multidisciplinary approach. For instance, health worker behaviour can be influenced as much by non-monetary as by financial incentives (Kingman 2003), and the question is: what is the optimal mix, in which context? In conclusion, the issue of human resources in health deserves more attention today than ever before because of the rapidly changing demographic, epidemiological, geo-political and economic landscape. If health systems are to better respond to people's needs, and if more poor patients are to gain access to health services, we need productive, well-qualified health workers in sufficient numbers. It is therefore essential to develop policies and interventions that are both evidence-based and sensitive to human resource issues.