SeriesHow to bridge the gap in human resources for health
Introduction
Human resources have been described as “the heart of the health system in any country”,1 “the most important aspect of health care systems”,2 and “a critical component in health policies”.3 There is a consensus that despite their importance human resources have been a neglected component of health-system development in low income countries.
Much is needed of health sectors in the present decade. At least three and arguably all of the Millennium Development Goals will not be achieved without improvement in the functioning of health systems.4 Although substantial new resources are promised to health systems, many of the constraints cannot easily be resolved by money alone.5 A substantial portion of these new resources are earmarked for expanding access to HIV/AIDS treatment. For goals in this specialty to be achieved, primary care systems will need to provide a more complex intervention than has ever been expected of them, and partnership between primary and secondary levels of systems will have to become much more effective.
Section snippets
The present situation
A new, up-to-date, and complete country and international database of health workers has recently become available. A comparison of estimated ratios of health workers to population sheds some light on the issue (table 1). Disparities across countries are large.
These ratios should be interpreted carefully because the definition, training, and quality of professional groups differs from country to country. Nevertheless, these differences may mean that disparities in the data are underestimated
Factors causing present problems
A host of causes underpins this worsening situation. The HIV/AIDS epidemic is killing health workers. In 1997, Malawi lost 44 nurses as a result of AIDS, which is 44% of the annual number of nurses trained; in 1999 in Zambia 185 nurses died, which is 38% of the annual number of nurses trained in government institutions.19 Problems of absence from work and reduced productivity associated with the epidemic are also common. HIV/AIDS functions as a push factor in migration, increasing the numbers
Available strategies to address human resource difficulties
Although substantial emphasis is often put on training as a solution to human resource difficulties, the constraints to effective strategies based on training are many. Africa's paucity of medical schools points to the need for innovative approaches to improve training capacity in the short term. It is tempting to suggest that countries should invest in medical training infrastructure when this is unlikely to be feasible in the short term, and unlikely to be the most cost-effective strategy in
Staff retention and support
The way the health system is funded, organised, managed, and regulated affects heath workers' supply, retention, and performance. The contested policies of public and health sector reform can be construed as attempts to craft the incentive environment to produce improved performance.
There is some reported evidence that use of provider incentives and enablers can improve performance under specific circumstances. For example, Eichler and colleagues40 show that indicators of achievement that were
Which strategies offer the most promise?
There is an urgent need for more evidence to inform this debate. Although the volume of reported discussion in relation to human resources in health has risen over the past few years, funding for investigations that could provide new data to distinguish between more and less promising strategies has not been forthcoming.
On the basis of the available evidence, three areas seem to have the most scope to make advances. First, expansion of the numbers and roles of auxiliaries whose qualifications
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