Chapter seven: working together, within and across countries.(world health)

There are five broad areas of concern that impel countries to look beyond their borders and work together with others in order to address issues of human resources for health more effectively:

* The profound lack of information, tools and measures, the limited amount of evidence on what works, and the absence of shared standards, technical frameworks and research methodologies are all imperatives for regional and international collaboration.

* The scarcity of technical expertise available to develop better metrics, monitor performance, set standards, identify research priorities, and validate methodologies means that a collective global effort is the only way to accelerate progress in these areas.

* The changes in demographics, demand for care, and technological advances cut across borders and are manifested in increasingly global labour markets. Cooperative arrangements and agreements between countries are essential to manage these flows and minimize adverse effects.

* The reality that a violent conflict, an outbreak of an infectious disease, or an unexpected catastrophic event can lay waste even to the most well-prepared national health system demonstrates that no country will ever have the human resource capacity to be able always to mount an effective response entirely on its own.

* The enormous workforce crisis that constrains health development so profoundly in the world's poorest countries requires an international response.

This chapter focuses on the rationale for working together and concludes with a plan of action that is based on national leadership and global solidarity.

CATALYSING KNOWLEDGE AND LEARNING

As has been pointed out in this report, basic information on the workforce that is required in order to inform, plan and evaluate resources is in very short supply in virtually all countries. The scant information that does exist is difficult to aggregate and compare over time and across sources and countries (1-4). This limitation is reflected not only in the challenges inherent in coordinating information flows across sectors--education, health, labour/employment--but more fundamentally in the absence of agreed frameworks and standards for health workforce assessment. Investment should be made in developing these frameworks and standards so that better tools to understand and respond to health workforce challenges can be made widely available more quickly and at lower cost.

A firm foundation for information

An important first step towards strengthening the foundations of information about health workers is to develop a clear conceptual framework that describes the boundaries and make-up of the workforce. Encouragingly, there is a global effort under way to develop a common technical framework (see Box 7.1). Even with such a framework, however, there remain a number of fundamental challenges related to health workforce information that must be taken up.

Box 7.1 Seeking a common technical framework for human resources
for health: a public good useful to all countries?

Could a common technical framework help governments and
national planners understand the myriad and complex problems
of human resources for health--and find feasible solutions?
Could such a framework address all sides of the issue in a
comprehensive manner, be collaboratively developed, and be universally
used--a public good of benefit to all countries?

A common framework would have several benefits. First, it
would define the key dimensions of technical competence needed
to develop and implement a strategy for human resources. This
is particularly important given the limited pool of expertise available
globally. Second, it would help inform the growing number
of groups interested in this area of the complexities of the health
workforce and prevent the spread of simplistic and limited views
on what is involved (e.g. that developing human resources for
health is simply about training and increasing salaries). Third,
it would be a common reference point for all health workforce
stakeholders and save policy-makers, implementers, donors,
academics and others the effort of "re-inventing the wheel".

An attempt to develop a common technical framework began
in December 2005, when WHO and USAID invited 35 representatives
from multilateral and bilateral agencies, donor countries,
nongovernmental organizations and the academic community to
meet at the Pan American Health Organization in Washington, DC.
They drew on 11 technical frameworks that had been developed
over the years by researchers and human resources professionals
in various parts of the world. Some of these applied to very
specific contexts; others offered broad conceptual roadmaps for
thinking through the issues. Many focused on just one aspect of
the health workforce, for example human resources planning.

The participants agreed that the desired common framework
needed to be scientifically-based, operationally useful
(field-tested), and useful in a multisectoral and multi-stakeholder
context. It had to capture the content and processes involved in
developing and implementing a national strategy for human resources
for health, be simple but comprehensive, and show the

interdependencies among the various players, institutions and
labour markets involved in the health workforce.

The figure below shows the framework that was produced
at the meeting. All seven interlinking thematic areas--human
resource management systems, policy, finance, education, partnership
and leadership--must be taken into account in dealing
with health workforce development, and this calls for multisector
involvement. However, the diagram shows only the upper layer of
a conceptual orientation that also has underlying secondary and
tertiary levels.

Work continues to develop and complete the framework. The
goal is to produce an interactive CD-ROM that will convey the
detailed content and processes underlying each thematic area.
In the meantime, more information on the elements in each thematic
area, on action that can be taken, and on the overall process
for using the framework to develop a national strategy can
be found in the WHO publication Tools for planning and developing
human resources for HIV/AIDS and other health services (available
at: http://www.who.int/hrh/tools/en/).

One problem area is the classification of the health workforce. Until 2006, WHO reported only on health professionals--doctors, nurses, midwives, pharmacists and dentists--thus rendering invisible other important service providers as well as all health management and support workers (who account for around one third of the workforce). This oversight reflects the shortcomings of using instruments whose primary purpose is not the collection of information on the health workforce. It underlines the need to develop special health workforce classification tools that can be more effectively integrated into existing census, survey and occupational reporting instruments.

Another important information need is for metrics to assess performance. Policymakers and donors are increasingly demanding evidence showing that their decisions and investments are indeed strengthening the health workforce. In the area of health information systems, a performance assessment instrument has been developed that permits cross-country comparisons (see Figure 7.1). A similar instrument for human resources could lead to more and wiser investments in the health workforce. Among the indicators that can be used in the development of health workforce performance metrics are sufficient numbers, equitable distribution, good competencies, appropriate sociocultural and linguistic background, responsiveness to clients, and productivity.

[FIGURE 7.1 OMITTED]

Human resource information is also needed to understand global labour markets, migratory flows of health workers, and the activities of multinational companies that employ significant numbers of health workers. In addition to good country data, an accurate, consistent and coherent view of the big picture also requires effective regional and global aggregation and analytical capacities. Reaching agreement on what information will be collected, how data will be aggregated and the necessary institutional arrangements is an important priority for concerned international partners.

Generation and management of knowledge

Strongly linked to building a foundation for health workforce information are challenges related to both the generation and management of knowledge. Given that close to half of health expenditure is spent on the health workforce, it seems incredible that there is so little research investment or solid evidence in this area. The evidence base within and across countries related to the health workforce is perilously weak, especially when compared with the strength of evidence in other domains of the health sector (6). The absence of a formal designation of the health workforce as a research priority has resulted in a patchy knowledge base. There is considerable research on curricula and teaching methods (see Box 3.8), rural retention schemes and various …