In light of global attention on the achievement of Universal Health Coverage by 2030 as described in the Sustainable Development Goals (SDGs),5 many international organizations have focused on the global availability of human resources. The WHO has developed a global strategy on human resources for health for planners and policy-makers, informed by a multi-year consultation process. The document is framed around six objectives and global milestones for both 2020 and 2030 and may be a useful resource for understanding global objectives related to human resources for health.4 These global and national strategies relevant to human resources for health will be discussed in greater detail in the Workforce module, though we present a few relevant considerations here.
Worldwide, nurses and midwives represent the largest proportion of the health workforce. In fact, the density of nurses, but not doctors, is found to have a significant impact on maternal mortality, and a well-regulated nursing staff has been found to improve patient satisfaction and health outcomes.7 Therefore, bolstering the nursing and midwifery workforce can have a considerable positive impact on health in certain contexts. It is important to note that the responsibilities and training for nurses and midwives as well as the definitions of the professions may differ between countries, and it is important to match their skills with other types of providers to meet population needs.8 A rapid review exploring the effectiveness and cost-effectiveness of nursing and midwifery interventions found that while some studies show positive impact, the findings across all identified studies are mixed and often there is insufficient data to draw a clear conclusion.8 Additionally, much of the identified evidence is from high-income countries and acute care rather than LMIC or PHC, respectively. A systematic review of 36 papers on nurse and midwifery workforce interventions found that national and state policies to strengthen the workforce have been successful in improving access and equity. These interventions were generally focused on increased education and training, deployment to underserved areas, and task shifting of services typically delivered by doctors to nurses and midwives.7 A few tangible lessons from this review include:
- When nurses assume new roles and responsibilities, it may be effective and necessary to also shift some of their lower-skilled responsibilities to other cadres, while ensuring adequate training and support during this transition.
- Workforce policy interventions must be supported by adequate infrastructure, training, incentives, and working conditions.
- It is important to ensure that nurses have adequate, supportive supervision. However, this should not be confused with burdensome reporting structures.
- When introducing new responsibilities and tasks, it is important that health workers receive increased incentives.
- Nurses and midwives are often most effective in their roles when they collaborate with community health workers or other such community-based cadres to better understand important community needs and cultural considerations.
Improving workforce in rural areas
Strategies to retain, recruit, and station providers – commonly called Posting and Transfer (P&T) - include:
- Expanding medical education and capacity targeted at specific cadres or regions in order to train and deploy more qualified providers;
- Providing core training closer to the service environment as well as greater continuing education and professional development opportunities locally;
- Strengthening primary and pre-service training programs in existing institutions in areas where there is an inadequate supply;
- Providing incentives and support for providers working in rural areas;
- Instituting mandatory civil service in rural areas; and
- Developing methods for improving provider motivation and satisfaction such as supportive supervision, access to career development and continuing education, ensuring an adequate workload, providing psychosocial support, and improving facility infrastructure so as to promote provider retention. 6 9 10 11 12
The WHO has developed a set of strategies to improve recruitment and retention of health workers in rural areas. The document addresses: national policies to improve retention; recommendations for improving attraction, recruitment, and retention related to education, incentives, and professional support; suggestions for evaluation of rural retention; and research gaps and agendas.13
Workforce optimization and roles and responsibilities
The WHO Global Strategy on Human Resources for Health: Workforce 2030 focuses on workforce optimization and roles and responsibilities. Often times, the skills of providers are underutilized, and access to high-quality care could be improved by better matching tasks and responsibilities to provider competencies. For instance, midwives have the potential to provide nearly 90% of care for sexual, reproductive, maternal, and newborn services, but often their scope is significantly more limited. By expanding roles and responsibilities with adequate training, incentives, remuneration, and supervision, facilities may be able to provide more comprehensive and available care.6
A similar strategy used to strengthen the availability of competent providers is optimizing the skill-mix of providers. Often called task shifting, this entails moving responsibilities from one type of health worker to another who may have less specific training but still has the competencies to deliver the given service.14 Often, optimizing the workforce by shifting responsibilities to cadres that are in greater supply can be an effective strategy for increasing capacity and improving provider availability, ultimately improving patient access to high-quality care. Optimizing responsibilities within an adequately staffed team can allow a team of health care workers each with an individually narrower range of skills to provide the more comprehensive approach required in primary care. Successful task shifting has been demonstrated extensively for HIV and maternal health services in low and middle-income countries, and growing evidence suggests that it may be a suitable approach for managing the growing burden of non-communicable diseases in these settings as well.15 16 17
However, it is crucial to ensure that providers who gain responsibilities have adequate training in their new responsibilities the ensure that the health workforce is able to deliver high-quality and safe care. The following general steps should be taken to implement changing roles and responsibilities:
- Identify or inventory the existing skills within the workforce at the national, regional, district, and/or facility level.
- Identification of skills within the workforce or tasks within the facility that a certain cadre is either trained to do but not yet doing or could be trained to do.
- Conduct training to enable providers to deliver new skills.
- Support these providers with the necessary management support and infrastructure to carry out their new tasks.
- Involve communities throughout to ensure acceptability of services and providers.
A few resources from the WHO may be useful to stakeholders exploring how they can best optimize the health workforce in a given context:
It is important to note briefly that some countries have strengthened the health workforce through targeted recruitment of international health workers. While this strategy may be effective in the short term, it may be to the detriment of developing sustainable national health workforce strategies in the long-term. The sixty-third World Health Assembly adopted the Global Code of Practice on the International Recruitment of Health Personnel to guide policy-makers considering international recruitment.
Health workers in the private sector
Health workers in the private sector make up a significant portion of the health workforce in many countries.20 21 The private sector includes providers working at either “formal” and “informal” health institutions, with the former including legally recognized for-profit and not-for-profit organizations and the later comprising non-legally recognized individuals such as informal drug sellers, shop keepers, and lay health workers.20 The size of the private health workforce, their regulation and credentialing, and the population’s access to these providers can all affect overall provider availability. Particularly in the informal sector, there is often little quality regulation of health workers in the private sector, and private sector institutions and health workers differ significantly in training and scope between and within countries.22 While there is increasing attention to and research on regulation of the formal private sector, there is limited literature or normative guidance on the informal sector. Often, strategies intended to improve quality or availability of primary care services focus exclusively on the public sector, overlooking a major source of care for a significant portion of the population.
A systematic review of the literature comparing quality of care between formal public and private providers found 80 quantitative analyses and two qualitative ones, primarily from Sub-Saharan Africa and Asia and the Pacific.22 The review found that structure, competence, and clinical practice were relatively similar between the public and private sector, and both were quite poor with a computed median quality score – a summary of structural, delivery, and technical quality – of 50/100. However, the formal private sector had slightly better drug availability, responsiveness, and effort, perhaps due to more flexible use of funds.
Often, it is the competence of both public and private providers – not availability – that prevents improvements in health status. For instance, a study in the poor, rural state of Madhya Pradesh, India, found that on average, a household had access to more than five medical providers in their village, but 67% of these had no medical training.23 One of the goals outlined in the WHO’s Global Strategy on Human Resources for Health: Workforce 2030 is “by 2020, all countries will have a regulatory mechanism to promote patient safety and adequate oversight of the private sector,” highlighting the global importance of private sector regulation.6 Policy options and recommendations relevant to this goal can be found in the document. Thus, understanding the variation in both public and private provider availability, competence, regulation, and utilization is a crucial first step when designing interventions to strengthen the health workforce.