World Health & Population
Toward a Systemic Approach to the Global Health Workforce
There are several interrelated themes in the global health workforce literature. Some writers focus on broad issues of supply and metrics for assessing need and the adequacy of the health workforce. Attention is given to provider/population ratios, benchmarking, population and needs-based estimates of need, institutional staffing ratios, and other approaches to health workforce planning. The quantitative nature of this approach and presumed ease of measurement have made it popular with ministries of health and other governmental and non-governmental bodies. However, each approach is fraught with difficulties and drawbacks. Measurement is far more complex than appears at first glance, and interpreting numbers and ratios often presents more questions than answers (Ricketts 2008).
Another theme in global workforce writing and research deals with issues of recruitment, deployment and retention of the health workforce. That is, once need is established for health workers through some methodology, how do we recruit, deploy and retain health workers? It is here that the focus of attention moves from estimates of need to the development and implementation of effective management practices. Some of this literature also deals with alternative ways of organizing work, such as job sharing and task shifting. Among the themes addressed are questions of motivation and job satisfaction, training, reward systems, quality improvement and patient safety, organizational climate, performance management and emigration (Chopra et al. 2008).
More recently, another area of focus is on integrating various "vertical" interventions and programs with health system strengthening. This comes at a time when vast sums of money have been spent on disease-specific (e.g., HIV/AIDS) initiatives, but often without addressing the attendant needs for sustainable health system infrastructure improvement – including workforce development (Oliveira-Cruz et al. 2003).
This issue of World Health and Population provides a current sample of recent work in each of these thematic areas. We hope in this issue to convey the importance of addressing the complexity of the health workforce crisis through multiple perspectives and points of leverage.
In his article on the Global Health Initiative, Middleberg argues that US global health strategies have traditionally focused on specific disease programs but have neglected specific strategies to address broad health workforce problems. Middleberg argues that all health programs share a common need for a well-trained workforce, yet a measured way to address this issue has been absent from the current design of the Global Health Initiative. The development and implementation of a coordinated health workforce strategy is a key element in health system strengthening.
Massey takes a micro-level approach to health workforce planning through his description and analysis of how Geographic Information Systems (GIS) software can be used to identify more precisely high-priority areas for workforce development. His approach moves beyond traditional practitioner/population ratios, which do a poor job accounting for small area variations in need. Instead, his work focuses on linking maternal health indicators with the distribution of human resources. While his focus is on maternal mortality, use of GIS can be applied to virtually any area of health to more precisely identify areas of need.
In her article on workforce retention, Stilwell looks at the fundamental questions of how we attract and retain employees in our organizations. Although there are certainly differences among cultures in issues pertaining to employee satisfaction and motivation, Stilwell draws linkages between the classic literature on motivation and recent experiences with attracting and retaining health workers. She also emphasizes the gap between what we know about worker retention and implementation of proven strategies. Part of this gap is attributable to the lack of leadership and understanding in ministries of health in strategically managing human resources. I would argue as well that this is a problem that is not limited to healthcare or developing countries. While there is a substantial body of evidence on effective human resources management strategies, implementation continues to be inconsistent globally and across industries (Pfeffer and Sutton 2006). At its worse, our management practices are destructive to motivation and productivity.
When we solicited manuscripts for this issue, we were intrigued by the submission by Newman and others on discrimination and equal opportunity in Kenya's health-provider education system. Those of us familiar with human resources management in North America are well acquainted with the centrality of discrimination and equal employment opportunity. In the United States, this has been an important driver of workforce management since at least the mid-twentieth century. With the exception of a few countries, little global literature addresses discrimination in the health workplace and in health workforce training programs. Although there is a very substantial literature on gender and health, relatively little has been written about equal employment issues and discrimination in healthcare organizations and training programs. Discriminatory practices are persistent and usually deeply embedded in the culture – and thus difficult to change. We will be interested in seeing how the recommendations in the paper from Newman and colleagues are implemented and whether they can decrease gender discrimination.
Workforce issues extend from basic problems of recruitment and supply through to how we manage people once they choose to work in our organizations. Workforce issues will continue to present challenges in years to come, particularly as we see a global increase in the aging of the population and the need for not only a larger health workforce, but one that has the competency to work with a broad range of health issues. We hope that this issue of World Health and Population stimulates interest among our readership in the continuous search for new and innovative solutions.
About the Author
Bruce J. Fried, PhD Associate Professor & Director, Residential Masters Programs Department of Health Policy & Management University of North Carolina at Chapel Hill Chapel Hill, North Carolina
Chopra, M., S. Munro, J.N. Lavis and S. Bennett. 2008. "Effects of Policy Options for Human Resources for Health: An Analysis of Systematic Reviews." Lancet 371(9613): 668–74.
Oliveira-Cruz, V., C. Kurowski and A. Mills. 2003. "Delivery of Priority Health Services: Searching for Synergies within the Vertical versus Horizontal Debate. Journal of International Development 15: 67–86.
Pfeffer, J. and R.I. Sutton. 2006. Hard Facts, Dangerous Half-Truths, and Total Nonsense: Profiting from Evidence-Based Management. Boston: Harvard Business School Press.
Ricketts, R.R. 2008. "Healthcare Workforce Planning." In B.J. Fried and M.D. Fottler, eds., Human Resources in Healthcare: Managing for Success. Chicago: Health Administration Press.
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