Human resources for health in the Americas

Abstract

Many countries in Latin America and the Caribbean have too many specialists and too few primary care providers and community health workers. These countries need to overhaul their training and payment practices to address this imbalance, say human resources experts. Barbara Fraser reports.Until recently, Mauro Reyes' hospital, a jumble of pale blue buildings on the north side of Lima, was a neighbourhood health centre. Then the government added some wards and renamed the facility San Juan de Lurigancho Hospital.“They gave it the name, but they didn't give me the necessary budget”, Reyes, a gynaecologist and the new hospital's director, said. “They gave me two new wings, but they didn't give me the personnel I need.”Short-staffed and cash-strapped, Reyes must provide care for patients with the myriad of problems common among the urban poor of Latin America's teeming cities ranging from parasitic infections, tuberculosis and HIV/AIDS to teen pregnancy, depression, and drug addiction.Only half of Reyes' staff is on the payroll; the rest are contracted. A contracted physician earns less than $550 a month and receives no benefits. “They don't take home enough to support their families”, and most hold other jobs as well, Reyes said.Reyes is not alone. At a recent meeting on Observatories of Human Resources for Health in the Americas in Lima, experts said hiring and retaining qualified staff is a common problem for both the region's hospitals and community health programmes.In fact, human resource problems, the experts said, may keep many countries from reaching high priority targets, such as the Millennium Development Goals for reducing maternal and infant mortality. It's not just a question of pay, they acknowledge, it's also a question of matching human resources with real needs.Studies show a correlation between better health outcomes and the number of health-care workers. Between 1999 and 2004, Mexico, with an average of 26·4 health-care workers per 10 000 inhabitants, had an average infant mortality rate of 19·7 per 1000 livebirths. In comparison, Nicaragua—which is unlikely to meet its MDG for infant mortality—had 9·5 health care workers and an infant mortality rate of 35.The World Health Organization (WHO) suggests that countries need at least 20 to 25 health care workers—physicians, nurses, and midwives—for every 10 000 inhabitants. While 21 countries in the Americas and the Caribbean meet the threshold and 11 exceed it, 15 countries—with more than 163 million people—are below the minimum.Disparities also exist within countries. In Peru, the poorest regions—mainly the rural Andean highlands and Amazon basin—have the fewest health workers and highest maternal mortality rates.The region-wide human resources observatory system, which was launched in 1999 and now includes more than 20 countries in the Americas and the Caribbean, is a forum for research and planning of health care human resources.To some extent, the human resources crunch is a result of the economic adjustment policies of the 1980s and 1990s, when lenders pressured governments to trim budgets and bureaucracies. Social spending dropped and has been slow to recover. In recent years, Bolivia, Guatemala and Peru have spent less than the equivalent of 1·5% of their GDP on health care.The human resources picture is often paradoxical. In Colombia, where there are only 15·1 health workers per 10 000 inhabitants, 16·8 percent of the health work force is unemployed. One factor, international experts say, is that education and allocation of human resources have not been based on real needs. Among other things, medical schools turn out too many specialists and too few family and community health practitioners.Cuba has long been the exception. With a community-focused approach based on the concept that health is a human right, Cuba's health indicators have remained good despite the country's ongoing economic crisis. Its 134·6 health workers per 10 000 inhabitants gives it the highest density of human resources in the hemisphere—accompanied by nearly 100% immunisation coverage and an infant mortality rate of 7·2 per 1000 livebirths, one of the lowest in the region.Venezuela and Bolivia are beginning to retool their health-care systems to focus more on community medicine. Brazil has made a similar effort, with the formation of 25 000 primary care teams and a commitment to spend US$45 million to beef up family practice and community medicine programmes in 90 medical, nursing and dental schools, according to Francisco Campos, the Brazilian Health Ministry's secretary of education and labour management.Charles Godue, head of PAHO's Human Resources in Health Unit, says there is a growing awareness in the region that human resources management means more than just hiring, firing, and settling strikes—it means careful planning, anticipating changing needs due to demographic and epidemiological shifts.For example, until recently most Latin American countries were “young” with at least half the population under 25 years. Now, with fertility rates dropping and life expectancy increasing, the population is ageing and chronic diseases are becoming more common. But, because of lack of foresight and planning, there are not enough geriatricians in practice and too few in training.Many diseases, such as HIV/AIDS, tuberculosis, and malaria, are best tackled with community-based prevention programmes, the types of programs in which nurses can play a key role. But while there are three to four nurses for every physician in Canada, the United States and the English-speaking Caribbean, that ratio is reversed in most of the rest of the hemisphere, with four doctors per nurse in Brazil, Argentina, Paraguay, Uruguay, Costa Rica, and the Dominican Republic. One reason for the differences in ratios is that it is easier to get into a medical school in Latin American countries than it is in English-speaking Caribbean nations.But even when health workers are trained, there is no guarantee they will stay: although 5000 doctors and 9000 nurses graduated in Peru between 1995 and 2005, the country saw a net increase of only 1200 physicians—and a net loss of 3500 nurses. Peruvian immigration figures show that 4416 physicians emigrated in 1992, a figure that had risen to 14 130 by 2004. Over the same period, the number of emigrating nurses rose from 2726 to 7560.Between 21% and 32% of the health work force in the United States, Britain, Canada, and Australia is foreign born, and more than half of those workers are from low-income countries. So many health-care workers from Latin America and the Caribbean have moved to the United States, Canada, and Europe that even the destination countries are concerned about the effects on the countries of origin.“We're quite aware of the impact we can have on other countries. We're constantly trying to find the right line between meeting our own needs and not doing so in a way that compromises other countries that face even greater challenges”, said Dr Joshua Tepper, assistant deputy minister of health for Ontario, Canada.The complexity of the health human resources puzzle in Latin America calls for more comprehensive policies and planning. One challenge is to convince governments to see health care as an investment rather than an expense, said Felix Rígoli, PAHO regional adviser on human resources.In Peru, efforts to increase the wages of health workers have caused both legislators and citizens to complain that most health funding goes to salaries.“It's a paradox. If you ask finance ministers, they'll say a big part of their budgets goes to salaries. If you ask nurses, they'll say they can't stretch their pay to make ends meet”, Rígoli said.Government decentralisation poses another challenge, as local officials must be trained to allocate and manage health human resources effectively. Brazil, which has implemented successful family practice programmes and incentives for rural health workers, is providing human resources management training to health-care professionals in its Amazonian region and the countries along its western border.Both health officials and educators are becoming aware of the need for joint planning to ensure that the supply of graduates meets the country's health-care needs. The observatories have provided a forum for educators and health ministry officials to work together on long-range plans.Once doctors, nurses, obstetricians, dentists, and other health-care professionals graduate, plans must also be in place to encourage them to remain in their home country. Wages are only one factor. Many health-care professionals who have emigrated say they have found better career paths or opportunities to provide more effective care in their destination countries.According to Rígoli, policies and planning are key to meeting the challenges. “The functioning of health systems depends on the people who work in them”, he said. “It seems obvious, but it's not.” Many countries in Latin America and the Caribbean have too many specialists and too few primary care providers and community health workers. These countries need to overhaul their training and payment practices to address this imbalance, say human resources experts. Barbara Fraser reports. Until recently, Mauro Reyes' hospital, a jumble of pale blue buildings on the north side of Lima, was a neighbourhood health centre. Then the government added some wards and renamed the facility San Juan de Lurigancho Hospital. “They gave it the name, but they didn't give me the necessary budget”, Reyes, a gynaecologist and the new hospital's director, said. “They gave me two new wings, but they didn't give me the personnel I need.” Short-staffed and cash-strapped, Reyes must provide care for patients with the myriad of problems common among the urban poor of Latin America's teeming cities ranging from parasitic infections, tuberculosis and HIV/AIDS to teen pregnancy, depression, and drug addiction. Only half of Reyes' staff is on the payroll; the rest are contracted. A contracted physician earns less than $550 a month and receives no benefits. “They don't take home enough to support their families”, and most hold other jobs as well, Reyes said. Reyes is not alone. At a recent meeting on Observatories of Human Resources for Health in the Americas in Lima, experts said hiring and retaining qualified staff is a common problem for both the region's hospitals and community health programmes. In fact, human resource problems, the experts said, may keep many countries from reaching high priority targets, such as the Millennium Development Goals for reducing maternal and infant mortality. It's not just a question of pay, they acknowledge, it's also a question of matching human resources with real needs. Studies show a correlation between better health outcomes and the number of health-care workers. Between 1999 and 2004, Mexico, with an average of 26·4 health-care workers per 10 000 inhabitants, had an average infant mortality rate of 19·7 per 1000 livebirths. In comparison, Nicaragua—which is unlikely to meet its MDG for infant mortality—had 9·5 health care workers and an infant mortality rate of 35. The World Health Organization (WHO) suggests that countries need at least 20 to 25 health care workers—physicians, nurses, and midwives—for every 10 000 inhabitants. While 21 countries in the Americas and the Caribbean meet the threshold and 11 exceed it, 15 countries—with more than 163 million people—are below the minimum. Disparities also exist within countries. In Peru, the poorest regions—mainly the rural Andean highlands and Amazon basin—have the fewest health workers and highest maternal mortality rates. The region-wide human resources observatory system, which was launched in 1999 and now includes more than 20 countries in the Americas and the Caribbean, is a forum for research and planning of health care human resources. To some extent, the human resources crunch is a result of the economic adjustment policies of the 1980s and 1990s, when lenders pressured governments to trim budgets and bureaucracies. Social spending dropped and has been slow to recover. In recent years, Bolivia, Guatemala and Peru have spent less than the equivalent of 1·5% of their GDP on health care. The human resources picture is often paradoxical. In Colombia, where there are only 15·1 health workers per 10 000 inhabitants, 16·8 percent of the health work force is unemployed. One factor, international experts say, is that education and allocation of human resources have not been based on real needs. Among other things, medical schools turn out too many specialists and too few family and community health practitioners. Cuba has long been the exception. With a community-focused approach based on the concept that health is a human right, Cuba's health indicators have remained good despite the country's ongoing economic crisis. Its 134·6 health workers per 10 000 inhabitants gives it the highest density of human resources in the hemisphere—accompanied by nearly 100% immunisation coverage and an infant mortality rate of 7·2 per 1000 livebirths, one of the lowest in the region. Venezuela and Bolivia are beginning to retool their health-care systems to focus more on community medicine. Brazil has made a similar effort, with the formation of 25 000 primary care teams and a commitment to spend US$45 million to beef up family practice and community medicine programmes in 90 medical, nursing and dental schools, according to Francisco Campos, the Brazilian Health Ministry's secretary of education and labour management. Charles Godue, head of PAHO's Human Resources in Health Unit, says there is a growing awareness in the region that human resources management means more than just hiring, firing, and settling strikes—it means careful planning, anticipating changing needs due to demographic and epidemiological shifts. For example, until recently most Latin American countries were “young” with at least half the population under 25 years. Now, with fertility rates dropping and life expectancy increasing, the population is ageing and chronic diseases are becoming more common. But, because of lack of foresight and planning, there are not enough geriatricians in practice and too few in training. Many diseases, such as HIV/AIDS, tuberculosis, and malaria, are best tackled with community-based prevention programmes, the types of programs in which nurses can play a key role. But while there are three to four nurses for every physician in Canada, the United States and the English-speaking Caribbean, that ratio is reversed in most of the rest of the hemisphere, with four doctors per nurse in Brazil, Argentina, Paraguay, Uruguay, Costa Rica, and the Dominican Republic. One reason for the differences in ratios is that it is easier to get into a medical school in Latin American countries than it is in English-speaking Caribbean nations. But even when health workers are trained, there is no guarantee they will stay: although 5000 doctors and 9000 nurses graduated in Peru between 1995 and 2005, the country saw a net increase of only 1200 physicians—and a net loss of 3500 nurses. Peruvian immigration figures show that 4416 physicians emigrated in 1992, a figure that had risen to 14 130 by 2004. Over the same period, the number of emigrating nurses rose from 2726 to 7560. Between 21% and 32% of the health work force in the United States, Britain, Canada, and Australia is foreign born, and more than half of those workers are from low-income countries. So many health-care workers from Latin America and the Caribbean have moved to the United States, Canada, and Europe that even the destination countries are concerned about the effects on the countries of origin. “We're quite aware of the impact we can have on other countries. We're constantly trying to find the right line between meeting our own needs and not doing so in a way that compromises other countries that face even greater challenges”, said Dr Joshua Tepper, assistant deputy minister of health for Ontario, Canada. The complexity of the health human resources puzzle in Latin America calls for more comprehensive policies and planning. One challenge is to convince governments to see health care as an investment rather than an expense, said Felix Rígoli, PAHO regional adviser on human resources. In Peru, efforts to increase the wages of health workers have caused both legislators and citizens to complain that most health funding goes to salaries. “It's a paradox. If you ask finance ministers, they'll say a big part of their budgets goes to salaries. If you ask nurses, they'll say they can't stretch their pay to make ends meet”, Rígoli said. Government decentralisation poses another challenge, as local officials must be trained to allocate and manage health human resources effectively. Brazil, which has implemented successful family practice programmes and incentives for rural health workers, is providing human resources management training to health-care professionals in its Amazonian region and the countries along its western border. Both health officials and educators are becoming aware of the need for joint planning to ensure that the supply of graduates meets the country's health-care needs. The observatories have provided a forum for educators and health ministry officials to work together on long-range plans. Once doctors, nurses, obstetricians, dentists, and other health-care professionals graduate, plans must also be in place to encourage them to remain in their home country. Wages are only one factor. Many health-care professionals who have emigrated say they have found better career paths or opportunities to provide more effective care in their destination countries. According to Rígoli, policies and planning are key to meeting the challenges. “The functioning of health systems depends on the people who work in them”, he said. “It seems obvious, but it's not.”