Viewing the health workforce through a governance lens of overall strategic planning capacity, accountability, transparency, information systems, efficiency, equity and fairness, responsiveness, and citizen voice and participation provides a framework for assessing how to strengthen the health workforce holistically and sustainably. While the eight principles presented here are by no means comprehensive of all the many complex ways that health governance impacts the health workforce, they serve to further the conversation on the types of activities that should be researched for health systems strengthening.
We recognize several limitations to this study. First and foremost, the HSA approach was not developed to assess how health governance is operationalized to improve health workforce performance. As a result, additional indicators that could inform this topic were not collected and therefore leave many issues related to HRH and governance unanswered here. Second, not all HSA reports provide comparable information for each indicator because implementation of the HSA approach varied slightly by each assessment team. This was particularly true for the indicator on commitment of high-level government officials to HRH issues, which teams did not routinely assess. Third, given that the HSAs reviewed for this study were completed as long ago as 2007, they do not reflect more recent HRH governance activities. Last, the HSA countries were selected based on the demand of USAID missions, not on a set of more scientific criteria. Despite these limitations, we believe that the HSA findings provide valuable insight into the main strengths of, and challenges to, governance and the health workforce, which are summarized below.
Main governance strengths
The study identified country-specific interventions that improve governance of the health workforce in many countries. Four strengths are most common. First, routine resource tracking methodologies like NHA are increasing the transparency of financing of the health workforce and broader health system, and countries have been moving towards institutionalization of the methodology so that they are less dependent on external assistance. Kenya and Tanzania have been particularly successful at increasing in country capacity to produce routine NHA estimations, as each country has multiple NHAs.
Second, many countries have been training new cadres of health workers to address critical HRH shortages and ensure that the health workforce is responsive to population health needs. The HSAs for Angola, Kenya, Lesotho, and Uganda discuss how community health workers have become a means to increase access to primary health care.
Third, registration and licensure of health workers is a common practice in most of the countries examined. While few countries have the capacity to re-register or update licensure of health workers, most ensure that certain qualifications are met before medical professionals can begin practicing. Having this initial structure in place to register and license health workers is a foundation from which to expand in the future.
Finally, many countries, including Angola, Kenya, Lesotho, and Mozambique are experimenting with some type of financial or non-financial incentive to increase health worker efficiency and improve health outcomes of patients. As countries implement incentive programs, it is imperative that results are monitored and lessons learned are disseminated to other countries.
Main governance challenges
Three key challenges were identified in countries examined. First, although many countries recognized the importance of strategic plans, a significant number of countries were still struggling to develop HRH-focused plans and then implement them. Given the financial and human resource investment required for the implementation, it is no surprise that the countries have experienced difficulty moving from plan to action.
Second, overcoming the financial and human resource shortages to improve licensure, regulation, and supervision is a major challenge. The rise of private providers in LMIC has added a new dimension to the quality assurance process that will require adaptation of regulations and systems in countries that have previously focused entirely on public sector systems. In resource-limited settings, resources are easily redirected to direct service delivery expenses. However, the importance of ensuring quality of the workforce, and therefore of services delivered, should not be undervalued.
Third, moving from paper-based to automated health information systems is a challenge. Existing country information systems are limited in their ability to provide timely and relevant information to policymakers, providers, and patients. Common obstacles to implementation include lack of a coordinating body to manage the information systems, lack of an up-to-date health information strategic plan, and lack of standard definitions for data elements collected; having multiple parallel information systems for NGO-led interventions; and having only limited infrastructure for information communication technology and limited demand for health data.
Possible strategies to improve governance of the health workforce
Several documents exist to guide best practices for developing HRH strategic plans [35, 36]. Key messages from these documents include: the importance of creating a steering committee to oversee the development of the strategic plan; the importance of using evidence to inform the plan; and the importance of bringing a wide range of stakeholders to the table to ensure that the plan is relevant to the public, NGO, and private sectors. To ensure that countries are equipped with approaches that work, more research is needed on the specific challenges to implementing a strategic plan and solutions that have been applied to confront these challenges. Furthermore, systems to monitor implementation and evaluate impact of HRH strategies must be developed. For a monitoring and evaluation plan to be effective, it needs to be built into the strategic plan from the beginning, and incorporate indicators that can be easily tracked and are relevant to plan objectives. A recent study by Altman et al. applies a standardized set of 60 indicators in five case countries and presents information concerning the availability, relevance, and ability of indicators that track health system performance . Building off of lessons learned from existing country experiences along with a country’s own specific evaluation can inform the types of indicators to be included in the monitoring and evaluation plan. However, further research into how to effectively integrate monitoring and evaluation into strategic planning for HRH is needed.
To ensure that limited resources devoted to licensure, regulation, and supervision are used efficiently, countries can learn from existing interventions. For example, mentorship programs in Angola consider using foreign doctors to improve supervision of newly trained health workers and some countries are make progress in standardizing their supervisory visits through the use of checklists. Efforts documented in the literature, such as the use of smart phone technology for improving the supervision of tuberculosis patients, can help to provide more regular and consistent follow up with health workers . These types of interventions should be explored in more detail to increase health worker accountability.
As countries build their health information systems, there is a need to ensure that overlapping systems are not produced. The goal of an information system should be to collect relevant and timely information in a manner that requires minimal effort from data reporters and data analysts. Data demands of the national government, district governments, development partners, and civil society need to first be considered. Next, when developing a standardized set of comprehensive indicators, countries need to be cognizant that the effort required to collect data is relative to their ability to inform policy and planning and that the data collection method is feasible. Where possible, existing information systems should be harmonized, and any new system should be flexible so that it can adapt to the dynamic nature of the health system.
Finally, this paper presents multiple examples of innovative country examples that improve governance of the health workforce: in Uganda, the government uses criteria such as the level of care provided and the number of health care providers in a region to determine health worker salaries; in Lesotho, the government is providing health services through a PPP; in Ukraine, in-service training is incentivized through a points-based system; and in Vietnam, community feedback is gained through regular and structured meetings with facility leaders. Further research is required to evaluate the impact of country-specific interventions, and to determine how they can be scaled up within their own country, or used in other countries to improve governance of the health workforce.