Addressing health workforce issues in developing countries
Tasleem Akhtar, Fatima Memorial System, Lahore, Pakistan
20 November 2006
I havee been concerned with health workforce force issues in Pakistan both in my previous assignment as Executive Director of the Pakistan Medical Research Council (PMRC) an autonomous organization under the federal ministry of health, Islamabad and now as Chief of Research and Academic Advancement in this private sector Academic Institution of Pakistan named Fatima Memorial System. In PMRC the concern was health research capacity in Pakistan, which is almost non existent and as a result whatever efforts are undertaken to promote research (which is the mandate of PMRC) there is not much impact. In my present assignment I am concerned by the overall lack of human resources in the health sector of Pakistan.
Pakistan is listed as one of 57 countries with critical health workforce deficiency by both the JLI 2004 report and the WHO World Health Report 2006. Our overall work force density and category wise densities are way below the threshold given in the JLI report. As a result despite establishing an elaborate infrastructure for Primary Health care and health services delivery we are far from achieving the ‘Health for All’ goal and have very poor health status indicators with little likelihood of achieving the Millennium Development Goals' Targets. The most worrying aspect however is that no one seems to be worried about the health workforce crisis in the country and at no forum is the issue under discussion. In a recent conference at the Aga Khan University Karachi on Child Health Research and Policy Interface, this was not mentioned even in passing and didn’t become part of the recommendations to government.
The need for scaling-up production of all the different categories of health professional in the country is immense. Along with numbers the quality of training needs to be improved. However institutional capacity is extremely limited. All the country has at present is undergraduate medical and some dental institutions, some postgraduate clinical medical training, and basic diploma level nursing training institutions. Institutions like the one I am working with are interested in diversifying their training programmes portfolios to include training of paramedics and allied health professional, health researchers and public health professionals but immediately face the problem of availability of qualified faculties. Another major issue is migration. Whatever number and category is trained, more than a third is lost through migration. Developing countries are literally bleeding and this has increased over the last few years especially for nurses, para –medics and allied health professionals .
The frameworks and principles presented in your editorial and the various reports are all very well but unless the issues in developing countries like Pakistan are really understood, the implementation and impact of these is going to be negligible. How can there be a country focus on Health Workforce development if the cash-strapped and capacity deficient developing countries are constantly losing the best of their health professionals to the developed world? I personally strongly feel that since the developed countries are filling their health workforce deficiencies with trained manpower from the developed countries, the least they can do is to help develop institutional capacities in the developing world so that sufficient numbers are trained by them for sharing with the rich countries. One way of doing this through implementation of joint training programmes of institutions of developed and developing countries funded by governments of the rich countries and international agencies. The institutions of the developed countries can provided technical experties for the development of the developing countries institutions and train faculties for the joint programmes to ensure their quality and sustainability after the period of collaboration is completed.
Competing interests
None
Applying the HRH Action Framework to the Proposed European Union Programme for Action on Human Resources for Health
Neil Squires, European Commission
6 June 2007
At a recent meeting of the Global Health Workforce Alliance (GHWA) and the Asian Pacific Action Alliance on Human Resources for Health (AAAH) held in Bangkok (28-31 October 2006) the HRH Action Framework was presented as a tool for analysing and supporting the strengthening of the national health policy response. The Action Framework has also proved a useful tool for assessing the policy completeness of the European Union's Programme for Action on addressing the Health Workforce Crisis, highlighting the utility of the framework as a tool for strengthening international as well as national analysis of key issues related to human resource planning.
In December 2005, the European Commission adopted a Communication entitled a European Strategy for Action to address the crisis in human resources for health in developing countries (COM(2005)642). The Strategy for Action was endorsed by the European Council in April 2006 and at the same time the European Union issued a statement of commitment, indicating the strong political will within Europe to help address the global crisis in human resources for health. The European Council asked the European Commission to develop a programme of action, identifying actions at country, regional and global level that might be supported by Europe to add value to the international response. Application of the HRH Action Framework to the European Programme for Action has helped to ensure that this EU Programme for Action addresses all the key policy areas and priorities.
The EU Programme for Action, which is clearly linked to the primary development objective of the EU of promoting progress towards the Millennium Development Goals (MDGs) proposes actions at country, regional and global level. Using the framework (illustrated below), it is apparent that the programme must address financing, education, partnership, leadership and policy actions as part of the process of strengthening Human Resource Management, promoting health system development and accelerating MDG progress. This work must be informed by a through situation analysis, including labour market surveys, and is intended to overcome clearly identified bottle necks to MDG progress, by overcoming human resource constraints which are undermining the effectiveness of the health system.
For example, under the EU programme for action should and indeed does, address the following issues:
Situation analysis: The EU Programme for Action (PfA) will support at global, regional and national level, research, analysis, and sharing of information and evidence on HRH planning, in order to inform strategy development.
Financing: The EU PfA highlights European commitment to promoting long term predictable financing, primarily through increasing the proportion of aid provided as budget support, but also by linking financing more closely to indicators which can measure MDG progress, and strengthening the link between financing and performance.
Education: The EU indicates that it will support the development of national training capacity and also regional sharing of capacity. The EU also proposes building training capacity through north-south and south-south partnerships and which include tapping in to the energy, and commitment of the health worker diaspora, who want to engage in their home countries health system development.
Partnership: The EU proposes a strong partnership between public and private sectors with active engagement of civil society and non government organisations as part of the national response.
Leadership: The EU recognises that effective policy planning and implementation requires strong national leadership. Government is viewed as being the steward of health policy development, developing policies which strengthen the public sector as well as engaging private and non state providers.
Policy: The EU recognises that a comprehensive, coherent and coordinated national response should be based upon a sound national policy development process, and aims to support this within the context of national poverty reduction and health sector development strategies.
Human Resource Management System: At the Regional level, the EU PfA proposes support for Regional Human Resource for Health Observatories, which could become Health System Observatories. These would work closely with equivalent agencies at the national level to ensure that national level policies are informed by solid evidence on what works and informed by experience in other countries within the region and globally.
The programme cycle of analysis, preparation and planning and monitoring and evaluation link these five elements together and should help to ensure that the critical success factors for improving HRH capacity are put in place.
The EU position on the purpose of action to address the health workforce crisis is clear. Whilst improved helath workforce outcomes are a necessary and important objective, the health workforce is being strengthened in order to increase the equity, effectiveness, efficiency and accessibility of health services, which will be critically important if progress is to be made towards the Millennium Development Goals.
The EU will be supporting actions at the Global and Regional levels which can add value to country level action. The intention of the EU Programme for Action is that it ensures that future support of the European Commission and of the European Member States at the country level are effectively harmonised and aligned with nationally defined priorities and policies. The HRH Framework has already proved a useful tool to ensure that the proposed EU actions are comprehensive.
Dr. Neil Squires
Human Development, Social Cohesion and Employment Unit
Human Resources for Health
Addressing health workforce issues in developing countries
20 November 2006
I havee been concerned with health workforce force issues in Pakistan both in my previous assignment as Executive Director of the Pakistan Medical Research Council (PMRC) an autonomous organization under the federal ministry of health, Islamabad and now as Chief of Research and Academic Advancement in this private sector Academic Institution of Pakistan named Fatima Memorial System. In PMRC the concern was health research capacity in Pakistan, which is almost non existent and as a result whatever efforts are undertaken to promote research (which is the mandate of PMRC) there is not much impact. In my present assignment I am concerned by the overall lack of human resources in the health sector of Pakistan.
Pakistan is listed as one of 57 countries with critical health workforce deficiency by both the JLI 2004 report and the WHO World Health Report 2006. Our overall work force density and category wise densities are way below the threshold given in the JLI report. As a result despite establishing an elaborate infrastructure for Primary Health care and health services delivery we are far from achieving the ‘Health for All’ goal and have very poor health status indicators with little likelihood of achieving the Millennium Development Goals' Targets. The most worrying aspect however is that no one seems to be worried about the health workforce crisis in the country and at no forum is the issue under discussion. In a recent conference at the Aga Khan University Karachi on Child Health Research and Policy Interface, this was not mentioned even in passing and didn’t become part of the recommendations to government.
The need for scaling-up production of all the different categories of health professional in the country is immense. Along with numbers the quality of training needs to be improved. However institutional capacity is extremely limited. All the country has at present is undergraduate medical and some dental institutions, some postgraduate clinical medical training, and basic diploma level nursing training institutions. Institutions like the one I am working with are interested in diversifying their training programmes portfolios to include training of paramedics and allied health professional, health researchers and public health professionals but immediately face the problem of availability of qualified faculties. Another major issue is migration. Whatever number and category is trained, more than a third is lost through migration. Developing countries are literally bleeding and this has increased over the last few years especially for nurses, para –medics and allied health professionals .
The frameworks and principles presented in your editorial and the various reports are all very well but unless the issues in developing countries like Pakistan are really understood, the implementation and impact of these is going to be negligible. How can there be a country focus on Health Workforce development if the cash-strapped and capacity deficient developing countries are constantly losing the best of their health professionals to the developed world? I personally strongly feel that since the developed countries are filling their health workforce deficiencies with trained manpower from the developed countries, the least they can do is to help develop institutional capacities in the developing world so that sufficient numbers are trained by them for sharing with the rich countries. One way of doing this through implementation of joint training programmes of institutions of developed and developing countries funded by governments of the rich countries and international agencies. The institutions of the developed countries can provided technical experties for the development of the developing countries institutions and train faculties for the joint programmes to ensure their quality and sustainability after the period of collaboration is completed.
Competing interests
None
Applying the HRH Action Framework to the Proposed European Union Programme for Action on Human Resources for Health
6 June 2007
At a recent meeting of the Global Health Workforce Alliance (GHWA) and the Asian Pacific Action Alliance on Human Resources for Health (AAAH) held in Bangkok (28-31 October 2006) the HRH Action Framework was presented as a tool for analysing and supporting the strengthening of the national health policy response. The Action Framework has also proved a useful tool for assessing the policy completeness of the European Union's Programme for Action on addressing the Health Workforce Crisis, highlighting the utility of the framework as a tool for strengthening international as well as national analysis of key issues related to human resource planning.
In December 2005, the European Commission adopted a Communication entitled a European Strategy for Action to address the crisis in human resources for health in developing countries (COM(2005)642). The Strategy for Action was endorsed by the European Council in April 2006 and at the same time the European Union issued a statement of commitment, indicating the strong political will within Europe to help address the global crisis in human resources for health. The European Council asked the European Commission to develop a programme of action, identifying actions at country, regional and global level that might be supported by Europe to add value to the international response. Application of the HRH Action Framework to the European Programme for Action has helped to ensure that this EU Programme for Action addresses all the key policy areas and priorities.
The EU Programme for Action, which is clearly linked to the primary development objective of the EU of promoting progress towards the Millennium Development Goals (MDGs) proposes actions at country, regional and global level. Using the framework (illustrated below), it is apparent that the programme must address financing, education, partnership, leadership and policy actions as part of the process of strengthening Human Resource Management, promoting health system development and accelerating MDG progress. This work must be informed by a through situation analysis, including labour market surveys, and is intended to overcome clearly identified bottle necks to MDG progress, by overcoming human resource constraints which are undermining the effectiveness of the health system.
For example, under the EU programme for action should and indeed does, address the following issues:
Situation analysis: The EU Programme for Action (PfA) will support at global, regional and national level, research, analysis, and sharing of information and evidence on HRH planning, in order to inform strategy development.
Financing: The EU PfA highlights European commitment to promoting long term predictable financing, primarily through increasing the proportion of aid provided as budget support, but also by linking financing more closely to indicators which can measure MDG progress, and strengthening the link between financing and performance.
Education: The EU indicates that it will support the development of national training capacity and also regional sharing of capacity. The EU also proposes building training capacity through north-south and south-south partnerships and which include tapping in to the energy, and commitment of the health worker diaspora, who want to engage in their home countries health system development.
Partnership: The EU proposes a strong partnership between public and private sectors with active engagement of civil society and non government organisations as part of the national response.
Leadership: The EU recognises that effective policy planning and implementation requires strong national leadership. Government is viewed as being the steward of health policy development, developing policies which strengthen the public sector as well as engaging private and non state providers.
Policy: The EU recognises that a comprehensive, coherent and coordinated national response should be based upon a sound national policy development process, and aims to support this within the context of national poverty reduction and health sector development strategies.
Human Resource Management System: At the Regional level, the EU PfA proposes support for Regional Human Resource for Health Observatories, which could become Health System Observatories. These would work closely with equivalent agencies at the national level to ensure that national level policies are informed by solid evidence on what works and informed by experience in other countries within the region and globally.
The programme cycle of analysis, preparation and planning and monitoring and evaluation link these five elements together and should help to ensure that the critical success factors for improving HRH capacity are put in place.
The EU position on the purpose of action to address the health workforce crisis is clear. Whilst improved helath workforce outcomes are a necessary and important objective, the health workforce is being strengthened in order to increase the equity, effectiveness, efficiency and accessibility of health services, which will be critically important if progress is to be made towards the Millennium Development Goals.
The EU will be supporting actions at the Global and Regional levels which can add value to country level action. The intention of the EU Programme for Action is that it ensures that future support of the European Commission and of the European Member States at the country level are effectively harmonised and aligned with nationally defined priorities and policies. The HRH Framework has already proved a useful tool to ensure that the proposed EU actions are comprehensive.
Dr. Neil Squires
Human Development, Social Cohesion and Employment Unit
European Commission
Directorate General for Development
Competing interests
None