Chapter six: formulating national health workforce strategies.

The ultimate goal of health workforce strategies is a delivery system that can guarantee universal access to health care and social protection to all citizens in every country. There is no global blueprint that describes how to get there--each nation must devise its own plan. Effective workforce strategies must be matched to a country's unique situation and based on a social consensus.

The workforce presents a set of interrelated problems that cannot be quickly tidied up or solved by a "magic bullet". Workforce problems are deeply embedded in changing contexts, fraught with uncertainty and exacerbated by a lack of information. Most significantly, the problems can be emotionally charged because of status issues and politically sensitive because of divergent interests. That is why workforce solutions require all stakeholders to be engaged together, both in diagnosing problems and in solving them.

The key is to mobilize political commitment to tackle workforce challenges. But this is difficult because achieving a health impact from an investment in the workforce takes time, extending well beyond election cycles. Disgruntled workers can paralyse a health system, stall health-sector reform, occasionally even bring down a government. Yet, successful strategies have been demonstrated that can energize the workforce and win public support. The political challenge is to apply known solutions, to craft new approaches, to monitor progress, and to make mid-course corrections.

Previous chapters have focused on dealing with workforce problems through the management of entry, workforce and exit. These aspects determine the performance of a health system and its ability to meet present and future challenges.

However, such problems cannot only be discussed in managerial and technical terms. The perspective of people who use the health care system must also be considered. Their expectations are not about the efficient delivery of cost-effective interventions to target populations; they are about getting help and care when faced with a health problem that they cannot cope with by themselves. In the relationship between individual health workers and individual clients, trust is of paramount importance, and it requires fair governing and effective regulations to build and sustain--which in turn involves leadership, strategic intelligence and capacity building in institutions, tools and training. These essential elements of national workforce strategies are the focus of this chapter.

BUILDING TRUST AND MANAGING EXPECTATIONS

To the general public, the term "health workers" evokes doctors and nurses. While this does not do justice to the multitude of people who make a health care system work, it does reflect the public's expectations: encounters with knowledgeable, skilled--and trustworthy--doctors and nurses who will help them to get better and who will act in their best interests.

Trust is not automatic: it has to be actively produced and negotiated. It is "slowly gained but easily lost in the face of confounded expectations" (1). In many countries the medical establishment has lost its aura of infallibility, even-handedness and dedication to the patient's interests. Fuelled by press reports of dysfunctional health care provision, public trust in health workers is eroding in the industrialized world (2) as well as in many developing countries (3-5). Poor people in particular may be sceptical or cynical when talking about their doctors, nurses or midwives: "We would rather treat ourselves than go to the hospital where an angry nurse might inject us with the wrong drug" (6). Trust is jeopardized each time patients do not get the care they need, or get care they do not need, or pay too much for the care they do receive. When patients experience violence, abuse or racketeering in health facilities their fragile trust is shattered.

The consequences of loss of trust go beyond the individual relationship between user and provider. A society that mistrusts its health workers discourages them from pursuing this career. The erosion of trust in health workers also affects those who manage and steer the health system (7). The administrations in charge of the health care system--governments, health-insurance institutions and professional organizations--have to make difficult trade-offs. They have to decide between competing demands: each citizen's entitlement of access to health care goods and services; the need to govern the cost of the uptake of these goods and services; and the needs of the professionals and other human resources who deliver these goods and services. The characteristics of the health sector with its large number of actors, asymmetry of information and conflicting interests make it particularly vulnerable to the abuse of entrusted power for private gain (8). The public no longer takes for granted that these trade-offs are always made fairly and effectively, nor do the front-line health workers.

Strategy 6.1 Design and implement a workforce strategy that fosters trust

The design of a strategy for a national health workforce might include measures actively to produce and negotiate trust in providers and managers of the health system (9, 10). This requires explicit measures that:

* address personal behaviour in the interaction between care providers and patients, between employers and employees, and between managers and institutions (this requires training as well as political leadership, and civil society organizations play a key role);

* set up managerial and organizational practices that give space for responsiveness, caring, interpersonal interaction and dialogue, and support the building of trust;

* take visible steps to eliminate exclusion and protect patients against mismanagement and financial exploitation;

* establish decision-making processes that are seen as fair and inclusive.

FAIR AND COOPERATIVE GOVERNING

Building and sustaining trust and protecting the public from harm require good governance and effective oversight, as well as fair regulation of the operations of health care facilities and the behaviour of health workers. The problem is that, in many countries, the regulatory environment is opaque and dysfunctional. All too often, weak professional and civil society organizations with few resources or little political clout exist alongside an equally weak state bureaucracy that lacks the structures, the people and the political will for the effective regulation of the health care sector.

Self-regulation

In many countries, professional organizations decide who can provide care and how providers should behave. Self-regulation can indeed be effective and positive: professional associations can promote professional ethics …